[Elbow arthroscopy]. / L'arthroscopie du coude.

This symposium of the French Arthroscopic Society is the 2005 state of the art of elbow arthrosocpy in France. A survey reports 499 cases during 2 years with a rate of complication higher than the arthroscopies of other joints (6% of minor and 1% of major complications). The main indication is the removal of loose bodies. They can come from arthritis, chondromatosis, osteochondritis or fracture. The most accurate radiologic examination is an arthroCTscan. The main pronostic factor is the cartilage status. Arthrolysis is the second indication. We performed a retrospective and a prospective studies to compare open and arthroscopic surgery. Results are almost similar with a significant higher improvement in flexion (7 degrees ) in the open group. Open surgery seems more efficient but with a franck loss of motion in the postoperative course. However, in this group elbows were preoperatively stiffer in relation with a trauma event instead of sport related microtrauma in the arthroscopically treated group. Removal of necrotic fragment combined with abrasion in osteochondritis of the capitulum yields to good results with 82% of patients resuming to sports. Long term prognosis is unknown as the joint line is narrowed at a 3 years follow up. Arthroscopy is usefull in synovial diseases as resection of synovial folds or removal of tumors like villonodular synovitis. In the treatment of epicondylitis, the results of our retrospective study are not so good as those reported in the literature. But in our comparative study the results are similar to the open surgery group. The numerous procedures and the different follow up in these two groups did not allow to give statistical analysis. Elbow arthroscopy is a hyper specialty with more and more advanced procedures.

Influence of medial meniscectomy on tibiofemoral joint space width.

OBJECTIVE: The aim of this study was to evaluate the influence of partial medial meniscectomy on tibiofemoral joint space width (JSW). DESIGN: Thirty-seven patients (mean age: 51 years), suffering from medial meniscal lesions, (post-traumatic (n=22) or degenerative (n=15)), and requiring arthroscopic partial meniscectomy, were enrolled in a prospective, controlled study. Bilateral weight-bearing radiographs in extended and flexed position were performed in the same Radiology Unit just before and 2 days after meniscectomy. During arthroscopy, the extent of meniscectomy was evaluated in percentage and medial chondropathy was quantified using the Société Française d'Arthroscopie (SFA) scoring system (SFA score: 0-100). Medial chondropathy was absent or mild (mean SFA score: 8+/-13). Meniscectomy removed an average of 61% of the posterior third of the medial meniscus, 51% of the middle third and 22% of the anterior third. Radiographs, before and after meniscectomy, were read singly and were analyzed by a single reader unaware of patient identity and date of radiographs. Medial JSW was measured at the narrowest point of the medial compartment using a 0.1mm graduated magnifying glass. RESULTS: Comparison of JSW before and after meniscectomy did not show any statistically significant difference (mm): 0.01+/-0.43 (p=0.83) and -0.05+/-0.56 (p=0.66) in the extended and flexed views, respectively. CONCLUSION: This preliminary study suggests that partial medial meniscectomy does not influence tibiofemoral JSW on weight-bearing X-rays. Consequently, joint space narrowing appearing after partial meniscectomy should lead to seeking postmeniscectomy cartilage degradation rather than being attributed to removal of the meniscus.

Arthroscopic evaluation of post-traumatic patellofemoral chondropathy.

OBJECTIVE: To evaluate clinically and arthroscopically post-traumatic patellofemoral chondropathy. METHODS: Fifty-nine patients with post-traumatic patellofemoral chondropathy were included in a cross sectional study and 46 of them completed a 6 month longitudinal study. Evaluation of the disease, performed once in the cross sectional study and twice (at entry and after 6 months) in the longitudinal study, included clinical and arthroscopic variables evaluating disease activity and severity. Arthroscopy was performed under local anesthesia in an outpatient procedure using a small arthroscope. Chondropathy was evaluated by the overall assessment of the investigator using a visual analog scale, and by the Société Française d'Arthroscopie (SFA) scoring system (SFA score: 0-100). Synovitis was assessed by the "synovitis score," which represents a composite index taking into account intensity, extent and location of synovial abnormalities. RESULTS: In the cross sectional study, severity of chondropathy correlated with age, body mass index, disease duration, functional impairment (Lequesne's index and maximum number of steps descended), patellofemoral crepitus on active motion, limitation of flexion, and presence and amount of synovitis. Knee effusion correlated with the presence of synovitis, but no correlation was found between pain or functional impairment and presence or amount of synovitis. In the longitudinal study, no statistically significant change in chondropathy was observed after 6 months followup despite a statistically significant improvement in pain, function, and knee effusion after this period. However, a statistically significant correlation was found between the progression of patellofemoral chondropathy and the presence and amount of synovitis at baseline. Synovitis was present at baseline in 10 patients. Changes in SFA scores were 1.2 +/- 1.6 and -0.1 +/- 1.0 in the groups of patients with and without synovitis, respectively (p = 0.0062). CONCLUSION: These data suggest that synovitis might have a deleterious effect on the evolution of post-traumatic patellofemoral chondropathy or might be a marker for active cartilage breakdown.

Inter-observer reliability of the arthroscopic quantification of chondropathy of the knee.

BACKGROUND: Several scoring systems have been proposed in order to quantify the degree of cartilage damage observed by arthroscopy of the knee in patients with osteoarthritis. OBJECTIVE: To evaluate the inter-observer reliability of five different scoring systems of arthroscopic evaluation for chondropathy in osteoarthritis of the knee and to evaluate the utility of a training session between different observations on these scoring systems. METHODS: Videotapes of knee arthroscopies on five patients with osteoarthritis demonstrating different levels of severity of cartilage damage of the medial tibiofemoral compartment were analyzed by nine observers prior to (pre-training evaluation) and 2 months after a 6 h training session (post-training evaluation) by the following scoring systems: (1) cartilage deterioration by a 100 mm visual analogue scale (VAS), (2) overall assessment of degeneration in the entire medial compartment (cartilage, meniscus, osteophyte) using a 100 mm VAS, (3) French Society of Arthroscopy (SFA) Scoring System, (4) SFA Grading System, (5) American College of Rheumatology (ACR) Scoring System. RESULTS: At the pre-training evaluation, the SFA grading system produced the highest coefficient of reliability (r = 0.94), the other systems recording levels of < or = 0.80. At the post-training evaluation, the coefficient of reliability was r > 0.80 for four of the five scoring systems, with lack of improvement in the ACR Scoring System. CONCLUSION: There was an improved and acceptable inter-observer reliability for at least 2 months follow-up in four of five evaluated scoring systems of arthroscopically graded osteoarthritis of the knee following a training session. A scoring system using a 100 mm VAS may produce the best inter-observer reliability. These results show that scoring chondropathy is possible and demonstrate the importance of training in the analysis of articular cartilage breakdown.

Arthroscopic evaluation of potential structure modifying activity of hyaluronan (Hyalgan) in osteoarthritis of the knee.

OBJECTIVE: Several reported studies suggest that repeated intra-articular injections of hyaluronan result in sustained relief from pain and functional disability in patients with knee osteoarthritis. Several in vivo data suggest that hyaluronan might have a beneficial structural effect in osteoarthritis. The objective of the study was to evaluate the potential structure-modifying effects of Hyalgan (500-730 kDa molecular weight), a highly-purified sodium hyaluronate. DESIGN: Patients with painful knee osteoarthritis (ACR criteria) were enrolled in a prospective, controlled study of 1-year duration. After randomization, either conventional therapy or three cycles (every 3 months) of three intra-articular injections of Hyalgan (once a week during 2 weeks) were given. Clinical outcome was added using pain visual analog score (VAS), functional impairment: Lequesne's index, quality of life: arthritis impact measurement scale (AIMS2) and structural outcome using X-rays: joint space narrowing and arthroscopy: global assessment using VAS, SFA scoring and grading systems. RESULTS: Of the 39 recruited patients, 36 completed the 1-year trial (19 in the Hyalgan group and 17 in the control group). There was no difference between groups at entry. Between-group comparison for changes in clinical parameters reached statistical significance for the quality of life index (AIMS2: -0.4 +/- 0.7 vs 0.2 +/- 0.9 in the Hyalgan and control groups respectively, P < 0.05). Deterioration in the structural parameters was less in the Hyalgan group, with a statistically significant difference for two of the three evaluated parameters (overall assessment of chondropathy: +5.1 +/- 12.7 vs 16.7 +/- 18.3, P = 0.016; SFA scoring system: +3.7 +/- 7.3 vs +9.0 +/- 11.5, P = 0.05) in the Hyalgan and control groups, respectively. CONCLUSIONS: This study supports existing data concerning the favorable symptomatic effect of intra-articular injections of Hyalgan in osteoarthritis of the knee and suggests that repeated intra-articular injections of Hyalgan might delay the structural progression of the disease. Other studies are required to confirm these results and to determine the long-term monitoring of osteoarthritic patients using such local therapy.

Arthroscopy-assisted synovectomy in the treatment of chronic synovitis of the knee.

The place of arthroscopy-assisted synovectomy in the treatment of inflammatory synovitis of the knee was evaluated by studying 26 patients who underwent this procedure between November 1992 and September 1995. Half the patients had rheumatoid arthritis. Twenty-three patients (28 knees) were reevaluated after a mean follow-up of 32 months (range, 4-50 months). The arthroscopic synovectomy was done either as the first-line synovectomy procedure, after failure of triamcinolone hexacetonide injection into the joint, or as the second-line synovectomy procedure, after failure of osmic acid or yttrium-90 synovectomy. Except in one patient with severe arthritis, arthroscopic synovectomy produced statistically significant improvements regarding pain (visual scale), function (Lequesne's index), range of flexion, amount of joint fluid and knee circumference. The range of extension of the knee was normal at baseline and remained so after the procedure. Overall efficacy was similar for first-line and second-line procedures. Results were rated good to very good by 71% of the patients and 61% of the physicians overall and the overall improvement in knee arthritis as perceived by the patients was 60%. The procedure was well tolerated in 93% of cases. The mean time needed to achieve a stable improvement was 3.2 weeks for pain, 4.7 weeks for swelling and 3.6 weeks for range of motion. One case each of hemarthrosis and stiffness of the knee were recorded, with a full recovery in both cases. Arthroscopic synovectomy is effective and safe but more burdensome and expensive than osmic acid or radiation synovectomy, and consequently deserves a place of choice in patients who have failed to respond to either of the last two methods.

Arthroscopic evaluation of chondropathy in osteoarthritis of the knee.

OBJECTIVE: To evaluate arthroscopic findings as a potential measurement of severity and outcome of chondropathy. METHODS: 110 patients with knee osteoarthritis (OA) were included in a cross sectional study and 41 of them in a one year longitudinal study. The evaluation of OA performed once in the cross sectional study and twice (at entry and after one year) in the longitudinal study, included clinical, radiological and arthroscopic variables evaluating disease activity and severity. Arthroscopy was performed. under local anesthesia in an outpatient procedure using a small arthroscope. Chondropathy was evaluated by the overall assessment of the investigator by visual analog scale and the Société Française d'Arthroscopie (SFA) scoring and grading systems, which represent a composite index taking into account depth, size, and localization of the articular cartilage lesions. RESULTS: The intrinsic validity of the arthroscopic variables was suggested by highly significant correlation (R2 = 80-85%) between the overall assessment of the investor and the SFA systems. There was also highly significant correlation (p < 0.01) between the arthroscopic and radiological variables. Intraobserver reliability of the arthroscopic quantification of chondropathy was better than interobserver reliability. In the cross sectional study, severity of chondropathy correlated with both age and body mass index. In the longitudinal study there was statistically significant worsening in the severity of chondropathy and statistically significant correlation between the changes in the severity of chondropathy and changes in functional impairment. CONCLUSION: We conclude that arthroscopy might be considered a relevant measurement of OA outcome for research purposes.

[Chondroscopy: a new method for measuring osteoarthritis?]. / La chondroscopie: un nouvel intrument de mesure de l'arthrose?

Arthroscopy allows direct visual examination of joint cavity components and is useful for the diagnosis, treatment and evaluation of lesions. We investigated the contribution of arthroscopy to the evaluation of joint cartilage. The severity of cartilage lesions can be assessed using a total 100-mm visual analog scale (0 = no chondropathy; 100 = the worst possible lesions) or a more objective system based on the site, depth, and surface area of the lesions. This latter system was developed by the French Society for Arthroscopy (Société Française d'Arthroscopie) and provides a score and a class (SFA score and SFA grade). We investigated whether this system has the characteristics required of an evaluation tool, i.e., simplicity, reproducibility, clinical relevance, sensitivity to change, and discriminant capacity. Arthroscopy is an invasive procedure. However, we introduced several simplifications, including use of local rather than general anesthesia, performance on an outpatient basis, elimination of the tourniquet (to avoid muscular dysfunction), and use of a small arthroscope. This simplified technique is called chondroscopy. Intra-observer reproducibility is far better than inter-observer reproducibility. We found a good correlation between the two arthroscopy scales (visual analog scale and SFA scale). Chondroscopy and roentgenographic evaluations of cartilage lesions were closely correlated. Changes in the severity of cartilage lesions were correlated with changes in functional impairment. Chondroscopy proved capable of demonstrating statistically significant changes in cartilage lesions due to knee osteoarthritis between two evaluations done only one year apart, even in a small sample of patients (less than 20). A preliminary study of repeated hyaluronic acid injections suggested that chondroscopy may be capable of identifying truly chondromodulating agents.

The SFA system for assessing articular cartilage lesions at arthroscopy of the knee.

We proposed to establish a system of assessing severity of chondropathy taking into account localization, size, and depth of cartilage lesions. The design of the study was prospective and multicenter. The subjects were 755 patients who had undergone arthroscopy of the knee. Criteria for assessment of severity of chondropathy were as follows: (a) Physician's overall assessment using a 100-mm-long Visual Analogue Scale, and (b) size, grade, and localization of cartilage lesions recorded on a diagram. We used multivariate parametric and nonparametric analyses. The analyses resulted in two systems of assessing severity of chondropathy: SFA scoring for the three compartments of the knee, which is a continuous variable, and SFA grading, which is a semiquantitative variable. These systems seem to be of clinical relevance. However, more studies are required to further validate them and their capacity to detect changes in severity of chondropathy.

Chondroscopy: a new method for scoring chondropathy.

The purpose of this study was to evaluate the performance (simplicity, reproducibility, relevance) of chondroscopy as a method for evaluating cartilage damage. Chondroscopy consisted in endoscopic evaluation of the knee using a 2.7-mm Storz arthroscope under local anesthesia and recorded on videotape. Scoring of chondropathy was based on physician's overall assessment using a 100-mm-length visual analogue scale (VAS) and size and grade of cartilage lesions. Reproducibility was evaluated by variability (coefficient of variation [CV]) in the reading of chondroscopic evaluations of five patients five times by one physician and one time each by four different physicians. The correlations between scoring of chondropathy (VAS) and radiological articular joint space narrowing, demographic data (sex, age, weight), and disease characteristics (localization, etiology, activity) were studied in 84 outpatients fulfilling the American College of Rheumatology criteria for the diagnosis of osteoarthritis of the knee. The grade and size of the lesions were both correlated with the physician's overall assessment (r = 0.713 and r = 0.816, respectively). These two variables accounted for 72% of the variance of the VAS (multiple regression analysis). Intraobserver reproducibility was better than interobserver reproducibility (CV, 9% and 37%, respectively). There was a strong correlation between the scoring of chondropathy (VAS) and radiological joint space narrowing (r = .646, P < .0001). Moreover, in 17 of 33 patients without radiological joint space narrowing, VAS was > 20 mm. At variance, the body mass index was the single clinical variable found to correlate with the scoring of chondropathy (r = .282, P < .001).(ABSTRACT TRUNCATED AT 250 WORDS)

Arthroscopic treatment of synovial chondromatosis of the knee.

Between 1971 and 1987, arthroscopy was performed in 39 patients with synovial chondromatosis of the knee; 29 of these patients (32 knees) were followed an average of 3.5 years. A good result was obtained in 78% of the cases. Removal of loose bodies was the only treatment in 31 of the 32 knees. A synovectomy was performed in one case. No synovectomies were performed secondarily. Only three patients required a second arthroscopic procedure. The essential prognostic factor for a good functional result is the condition of the femorotibial cartilage. We concluded that simple arthroscopic removal of cartilaginous bodies without synovectomy is the treatment of choice for synovial chondromatosis of the knee.

[Arthroscopy of degenerative lesions of the internal meniscus. Classification and treatment]. / Lésions dégénératives du ménisque interne en arthroscopie. Classification et traitement.

In reference to 310 degenerative meniscal lesions (DML), we are proposing to classify these lesions into five types. They must be differentiated from arthrosis to which they are not automatically associated, even if the presence of cartilaginous lesions appears to be an important prognostic factor. Likewise, studies by age groups mix pure traumatic lesions and properly so called DMLs (which, by definition, do not involve a true initial trauma); the role of micro-traumas seems however probable. In reference to 87 type IV lesions, we remind of the difficulty of the radio-clinical diagnosis, insisting on the readily progressive nature of the troubles (49.4 p. cent of the cases), the lack of specificity of the symptoms, dominated by subjective pain (93 p. cent of the cases) and the pain induced by pressure on the medial joint space (70.1 p. cent of the cases). 87 patients underwent a partial meniscectomy. 72 were followed over a period of 32.4 months. In the entire group, the results are good or very good in 83.3 p. cent of the cases. In case of a considerable cartilaginous lesion visualized on arthroscopy (25 out of 87 patients), there are still 73.7 p. cent of good and very good results.

[Analysis of disorders of the principal pathways of calcium metabolism in Paget's disease. Effects of calcitonin administration. 26 cases]. / Analyse des perturbations des voies principales du métabolisme calcique dans la maladie de Paget. Effets de l'administration de calcitonine a propos de 26 observations

Analysis of the principal routes of calcium metabolism by means of calcium-45 in 26 patients suffering from Paget's diseases sometimes showed, in agreement with data from the literature, a considerable increase in the common stocks of calcium in 25 cases, and an elevation in the anabolism (Vo+) in bone and in the catabolism (Vo-) in bone in all cases. The calcium balance was sometimes equal, but often clearly positive (10 cases) or negative (10 cases) and the level intestinal absorption of calcium was usually within the normal limits. An elevation in the endogenous fecal calcium (Vf) noted in half of the cases, although no value was below normal, seemed to represent an metabolic anomaly of abnormally high frequency in patients with Paget's disease, even though this fact has never been emphasized before. Statistically significant correlations were shown between the values of different kinetic and metabolic parameters in the group of patients studied. A second kinetic study carried out after several weeks of treatment with porcine calcitonin showed a statistically significant diminution in the values of Vo +, Vo -, endogenous fecal calcium, calciuria, hydroxyprolinuria, and in alkaline phosphatasaemia, as well as significant variations in the calcium balance in a positive direction. The common calcium stocks did not show a significant diminution, contrary to the findings of other authors. The level of intestinal absorption of calcium increased more often than it decreased, but the magnitude of the variations was slightly less than the level of statistical significance.

[Thymoma and lupus disease (apropos of 2 cases]. / Thymome et maladie lupique ( â propos de deux observations)

Two new cases of association between a thymoma and a lupus illness are reported. The first was a women aged 42 years in whom were discovered simultaneously systemic lupus erythematosus (SLE) and a slowly invading thymoma, the histology of which was characterized by the predominance of epithelial cells; excision of this tumour did not appear to affect the evolution of the SLE. In the second case, a patient aged 60 years suffered from SLE ten months after the removal of a benign thymoma in which there was a predominance of lymphocytes. The SLE in this patient was easily controlled for more than a year by small doses of corticoids, but resulted in death after three years when anuria was associated with meningeal signs after the cessation of corticotherapy. The comparision of the data from these cases with those from eleven other cases in which there was association between a thymoma and SLE, brought to light several interesting facts. It is rare that SLE clearly precedes the discovery of the thymoma; it usually occurs afterwards or the two are discovered almost simultaneously. Collagenosis is of importance only when it coexists with a thymoma : starting later much more often than is usual in cases of SLE. The tumours were, in all but two cases, benign thymomas of different histological types, and their removal did not apparently influence the evolution of the SLE.