Los tumores y seudotumores sinoviales son infrecuentes, esencialmente monoarticulares, a veces localizados en las vainas tendinosas o en las bolsas serosas. Su diagnóstico es difícil y se establece con retraso porque los signos clínicos son tardíos, inespecíficos y discretos, con radiografías que son normales durante mucho tiempo. Debe sospecharse su presencia ante una monoartropatía mecánica progresiva que aparece en una persona joven, sobre todo en la rodilla, y solicitar según los casos, una resonancia magnética (RM) o una artrotomografía computarizada (artro-TC), que se deberá completar con una biopsia. Pueden manifestarse de forma localizada o difusa; su presentación y pronóstico son muy diferentes. Los seudotumores, también denominados distrofias sinoviales, son los menos infrecuentes. La condromatosis sinovial es la afección más frecuente y consiste en una metaplasia de la sinovial que produce cuerpos extraños cartilaginosos causantes a menudo de bloqueos articulares; su diagnóstico radiológico es sencillo en el estadio de osificación de la osteocondromatosis, pero requiere una artro-TC en caso de crondromatosis pura. Un derrame serohemático crónico hace sospechar una sinovitis villonodular, que debe confirmarse por RM, en cuyas imágenes se suele observar un aspecto característico. Habitualmente, la artroscopia permite formular de entrada el diagnóstico de los seudotumores, que se confirmará con una biopsia sinovial dirigida; también permite la exéresis de las formas localizadas benignas, alcanzando así la curación. Dado el poder destructivo local de estos seudotumores articulares, tanto el diagnóstico como la sinovectomía deben ser precoces y si es posible por vía artroscópica, para evitar una artrosis secundaria y el deterioro funcional progresivo que conduce al remplazo protésico en una persona joven. En las formas difusas, suele ser necesaria una sinovectomía quirúrgica a cielo abierto, que se puede completar con sinoviortesis o radioterapia. El reciente uso de bioterapias (antitirosina-cinasa, antifactor de necrosis tumoral [anti-TNF]) por vía articular o sistémica representa una alternativa esperanzadora para las sinovitis villonodulares (SVN) difusas inextirpables. Como la tasa de recidivas es importante, es necesario realizar un estudio de extensión previo y detallado, así como un control por RM. Los tumores sinoviales benignos son el hemangioma sinovial, que hay que sospechar ante hemartrosis de repetición, y el lipoma arborescente, cuyo aspecto es característico en la RM. Los tumores sinoviales malignos son excepcionales; el más frecuente es el sarcoma sinovial, que habrá que sospechar ante la presencia de calcificaciones paraarticulares.

The purpose of this multicenter retrospective study of arthroscopic release of the glenohumeral joint was to evaluate the technical feasibility, the results, and the potential correlations between results and cause of the stiffness. Twenty-six shoulders in 25 patients (19 women and six men) were re-evaluated 3 to 72 months (mean, 21 months) after arthroscopic release of the glenohumeral joint. Diagnoses were primary frozen shoulder in 13 cases, bipolar stiffness (rotator cuff tear plus capsular contraction) in 3 cases, and postinjury or postsurgery stiffness in 10 cases. Results were evaluated on passive range of motion, Constant's score, and subjective assessment. Anterior or anterior inferior capsular release was done at the anterior rim of the glenoid fossa. Posterior capsule release was not performed in this series. There were no intraoperative complications. Mean range of motion gains were 86 degrees for forward elevation, 72 degrees for abduction, 34 degrees for external rotation, and 6 spinal processes for internal rotation. Constant's range of motion score increased from 12.9 out of 40 to 32 out of 40 points. Thirteen patients were very satisfied, 5 satisfied, 5 improved, and 3 unchanged. Range of motion gains were independent from the cause of shoulder stiffness, but global results were better in the primary frozen shoulder group in terms of pain and strength. Arthroscopic release of the glenohumeral joint is feasible and safe. For primary frozen shoulders, in case of failure of the functional treatment, arthroscopic release is a less traumatic alternative to manipulation under general anesthesia. For bipolar stiffness, arthroscopy provides the opportunity for treating concomitant lesions. For postsurgical stiffness, arthroscopic release improves range of motion, but the shoulder often remains painful.

UNLABELLED:Shoulder stiffness is a problem which covers many different conditions. In fact there is still a semantic and pathogenetic confusion. The words: capsulite retractile, frozen shoulder, adhesive capsulitis, stiff shoulder contracture have been successively used and this ambiguity renders the literature difficult to interpret. Moreover the cause of the stiffness which depends on the aetiology, is not always clearly known: capsular contraction, capsular adhesion, capsular scarring following trauma or surgery, extra capsular phenomenons in the subacromial bursa, muscles or tendons.MATERIALS AND METHODS:26 shoulders (25 patients) were reviewed with a follow up of 21 months using the Constant's scoring system. Patients had an average duration of symptoms for 13 months (1 to 27). Pre op passive motion was: abduction: 74 degrees, external rotation: 6 degrees, forward flexion: 84 degrees. The average motion core was 12.9/40. We distinguished three groups: primary frozen shoulder (13 cases) ; bipolar stiffness (3 cases) due to rotator cuff disease ; acquired "surgical" stiffness, (10 cases). The capsular release was performed, at the anterior rim of the glenoid fossa, purely anterior or anterior and inferior, followed by gentle manipulation. If external rotation was not improved the coraco-humeral ligament was detached from its coracoid attachment. Additional procedures were performed:acromioplasty (5 cases), bursectomy (3 cases), SLAP lesion debridement (1 case). Only 2 out 13 primary shoulders required an additional procedure.RESULTS:1-There were no intra-operative complications (vascular or neural). 2-Range of Motion: the average gain under anesthesia was: abduction: 72 degrees, external rotation: 34 degrees, forward flexion: 86 degrees. Final result was obtained with a mean duration of seven months. There was no difference according to the aetiology. Gain was more important in the primary group (9.69 to 34.9 vs 15.8 to 30.6). 3-Subjective results were better in the primary group. 4-Objective results demonstrated an absolute Constant's score of 70.3, that is to say 83.4 per cent of the contralateral supposed healthy shoulder. There were 3 excellent, 5 very good, 7 good, but 11 fair or poor results. The relative Constant's score was 91 per cent in the primary group and only 76 per cent in the acquired group. The difference was due to the pain and strength which were greatly improved in the primary group.DISCUSSION:Arthroscopic release of shoulder contracture is feasible, safe and effective. For primary frozen shoulder, there is usually spontaneous recovery. Indications for surgery are very few. There is no evidence that arthroscopic release shortens spontaneous evolution. Therefore, we propose it in very selected cases of dramatically limited motion. One year of evolution is an acceptable time. For bipolar stiffnesses, arthroscopy allows one to recognize the exact cause of the stiffness and to treat it, especially the subacromial pathology. In this occurrence, buroscopy must be performed and cuff pathology treated. For acquired surgical stiffnesses, gain of motion is significant. Subjective and objective results are less satisfactory than those of primary frozen shoulder, due to persistance of pain and lack of strength. The alternative is open release, but arthroscopic release has less morbidity. It can be proposed early as soon as capsular tissue has healed (for instance 6 months).

Shoulder stiffness is a problem which covers many different conditions. In fact there is still a semantic Ind pathogenetic confusion The words : capsule retractile: frozen shoulder. adhesive capsulitis. stiff shoulder contracture have been successively used and this ambiguity renders the literature difficult to interpret.Moreover the cause of the stiffness which depends on the aetiology, is not airways clearly known : capsular contraction. capsular adhesion, capsular scarring following trauma or suggery, sutra capsular phenomenons In the subacromial bursa, muscles or tendons.Materials and Methods26 shoulders (25 patients) were reviewed with a follow to of 21 months using the Constant's scoring system. Patients had an average duration of symptoms for 13 months (1 to 27).Pre op passive motion was : abduction : 74 degrees, external rotation : 6 degrees, forward flexion : 84 degrees. The average motion core was 12.9/40.We distinguished Three groups : primary frozen shoulder (13 cases) ; bipolar stiffness (3 cases) due to rotator cuff disease : acquired << surgical >> stiffness, (10 cases).The capsular release was performed, at the anterior rim of the glenoid fossa, purely anterior or anterior and inferior. followed by gentle manipulation, If external rotation was not improved the coraco-humeral ligament was detached from its coracoid attachment.Additional procedures were performed : acromioplasty (5 cases), bursectomy (3 cases), SLAP lesion debridement (1 case). Only 2 out 13 primary shoulders required an additional procedure.Results1 - There were no intra-operative complications (vascular or neural).2 - Range of Motion : the average gain under anesthesia was : abduction : 72 degrees. external rotation : 34 degrees, forward flexion : 86 degrees. Final result was obtained with a mean duration of seven months. There was no difference according to the aetiology. Gain was mole important in the primary group (9.69 to 34.9 vs 15.8 to 30.6).3 - Subjective results were better in the primary group.4 - Objective results demonstrated an absolute Constant's score of 70.3, that is to say 83,4 per cent of the contralateral supposed healthy shoulder. There were 3 excellent, 5 very good, 7 good, but 11 fair or poor results. The relative Constant's score was 91 per cent in the primary group and only 76 per cent in the acquired group. The difference was due to the pain and strength which were greatly improved in the primary group.DiscussionArthroscopic release of shoulder contracture is feasible, safe and effective.For primary frozen shoulder, there is usually spontaneous recovery. Indications for surgery are very few. There is no evidence that arthroscopic release shortens spontaneous evolution. Therefore, we propose it in very selected cases of dramatically limited motion. One year of evoluation is an acceptable time.For bipolar stiffnesses, arthroscopy allows one to recognize the exact cause of the stiffness and to treat it, especially the subacromial pathology. In this occurrence, buroscopy must be performed and cuff pathology treated.For acquired surgical stiffness, gain of motion is significant. Subjective and objective results are less satisfactory than those oi primary frozen shoulder, due to persistance of pain and lack of strength. The alternative is open release, but arthroscopic release has less morbidity. It can be proposed early as soon as capsular tissue has healed (for instance 6 months).

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.

The authors have studied the result of endoscopic treatment in 129 non ruptured and non calcified tendinitis of the rotator cuff as well as 33 partial thickness tears included in a multicentric study made by the french arthroscopic society.The files included a revision form using Constant's functional evaluation and filled by a physician different from the operator, and a radiological standardized evaluation allowing to appreciate, from A.P. and lateral views, the acromion shape and the importance of the resection.From the analysis of our results it appears that acromioplasty associated with a section of the coraco-acromial ligament (C.A.L.) under arthroscopic control is very efficient in tears of the superficial, bursal face of the rotator cuff.The same did not apply to the tears of the deep, articular face, as their origin is probably different.In non ruptured and non calcified tendinitis, 90 per cent of our patients were subjectively better. According to Constant's index, we noticed 75 per cent of satisfactory results. The importance of acromioplasty was not related to good results. We therefore think that one should relativise the notion of impingement between the coraco-acromial arch and the tendons of the rotator cuff. Acromioplasty is only effective on one of the factors of tendinous pain. The improvement of our indication by a better knowledge of this pathology should allow us to improve the results of an endoscopic procedure which is now well known and whose advantages do not need to be demonstrated any more.

The authors studied the results of the arthroscopic treatment of the chronic calcifying tendinitis within a multi-center study of the French Society of Arthroscopy.112 patients were available for the study. All shoulders had a preoperative radiographic clinical and radiographic evaluation. At follow up, functional results were assessed, using the Constant score, and X rays allowed to appreciate the acromial shape and the calcific deposit aspect. Several arthroscopic procedures were used on the calcification (respect or removal), and the coracoacromial arch (respect, ACL release or acromioplasty).This study found an objective success rate of 89 per cent and a patient subjective satisfaction rate of 82 per cent. Based on follow up radiographs, 88 per cent of the patients had a complete disappearance of the calcific deposit. There were no recurrence, no secondary rotator cuff tear.The results were not correlated with the age of the patients, or with the radiographic aspect (type, size, localization) of the calcification. The results were correlated with the arthroscopic procedure: they were better when the calcification had been removed (superior to deposit respect). Associated acromioplasty gave no better results: it was only considered as necessary when the calcification was not found (12 per cent).The greatest care must be taken in the surgical indication for this pathology because of a high rate of spontaneous resorption. The authors conclude that the arthroscopic surgery is a very effective method for chronic calcific tendinitis, compared to open procedure.

The authors report on their experience with 225 arthroscopies of the hip (performed in 241 patients from January 1983 through September, 1991). Only 15 arthroscopies were performed using traction. For 228 procedures they used their simplified method without traction which does not visualize the congruent cartilage surfaces or acetabular fossa. To determine whether this method ensures a satisfactory diagnostic and therapeutic approach to the hip, 100 patients belonging to three groups (normal arthroscopy, indeterminate diagnosis, and chondromatosis) were sent a questionnaire on one to three occasions. Follow-up at the time of the first questionnaire was at least six months. Mean follow-up was 3 years (range 8 to 83 months). Arthroscopic diagnosis was based on direct evidence for the peripheral part of the joint and indirect evidence for lesions of the congruent joint surfaces and acetabular fossa. Sixty four responses were obtained, rates of error were only 5% for patients with normal arthroscopies and 22% for those with indeterminate arthroscopies (i.e., the group with the highest potential for error). Therapeutic results with the simplified method were satisfactory in 40% (15/35) of patients with chondromatosis; however, 7 of 44 patients (16%) had a repeat arthroscopy which was unsuccessful in more than half the cases (4/7). No complications or technical failures occurred in this series. In conclusion, simplified arthroscopy without traction is advocated as the routine arthroscopy procedure for investigating and treating hip disorders. The conventional technique with traction remains necessary when imaging procedures (especially the CT scan or arthroscan) demonstrate lesions of the congruent articular surfaces or acetabular fossa.

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.

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.