Synovial Fistula Research Articles

External synovial fistula of the knee joint and its treatment with free radial artery fasciocutaneous flap

External synovial fistula of the knee joint is a rare entity. A case is reported in which the fistula presented 12 years after the original injury. The nature of injury and previous surgery precluded the use of a local flap. Treatment was successful using a free fasciocutaneous flap. Exposure of vital structures and metal work are the common indications for flap cover in the lower extremity. However synovial fistula is another instance where flap cover may be required. This case report emphasises the possibility of delayed presentation of a synovial fistula and the need for prompt closure, since it can be a path for retrograde infection

Soft Tissue Injuries of the Tarsus

Contrast radiography provides a clear survey of the size, shape, and location of extratendovaginal fluid-filled cavities, distended bursa, and tendon sheaths and demonstrates intersynovial communication. Ultrasonography effectively demonstrates Achilles tendon injury, slippage of the SDFT off the summit of the calcaneus, assorted ligamentous injuries, and cystic or solid extratendovaginal masses. It will also demonstrate distended bursae and tendon sheaths, but it is not as effective in demonstrating a synovial herniation, or a narrow synovial fistula. Contrast radiography may prove to be the imaging modality of choice for examination of fluctuating swellings, whereas ultrasonography is preferred for the assessment of firm swellings. Routine radiographic evaluation in the clinical assessment of soft tissue injuries in the hock region continues to play an invaluable diagnostic role.

Reconstruction of old anterior cruciate ligament tears with a Dacron prosthesis. A prospective study.

Seventy patients with chronic anterior instability underwent anterior cruciate ligament reconstruction with a Dacron prosthesis pretensioned to 60 N. Of these patients, 49% (34%) had combined medial instability, 32% (22) had failed previous anterior cruciate ligament surgery, and 37% (26) had previous meniscectomy. At reconstruction, 12 patients had their medial instability treated; 22 did not. Follow-up intervals were 3, 6, and 12 months and then each year to 5 years. The 5-year followup included 69 patients; the other 1 had the ligament removed because of a synovial fistula at 8 months. Results were 23% prosthesis ruptures, 3% poor, 17% fair, 16% good, and 39% excellent. The 2-year results showed the same distribution, but a lower rupture rate, which was affected by placement of the tibial tunnel within the anterior one-third of the tibia (9 times increase) and coexisting nonrepaired medial instability (5 times increase). Those patients with perfect placement of the ligament who also had good medial stability and no previous ligament surgery had no rupture at 5 years. The stability that was gained at surgery was gradually lost (-11.2% per year). At 5 years, the uninjured knee also had lost 41% of the preoperative stability; the mean laxity difference was within +/- 2 mm. The mean improvement in subjective knee function (Lysholm score 74.5 to 91.9) was maintained during the followup. The mean preoperative activity level improved significantly, but did not reach the preinjury level. These results show that the Dacron prosthesis will not give acceptable results in salvage cases where other instabilities are left untreated.

Treatment of chronic recurrent synovial fistulae with myofascial flaps

Chronic recurrent synovial fistulae of the knee are uncommon. They can occur as a surgical complication or as a consequence of traumatic injuries. Conservative treatment is usually adequate for initial management, but no consensus exists about the treatment for chronic or recurrent cases and the literature on the subject is scarce. Two cases are presented in which initial conservative and subsequent conventional surgical management failed and reconstruction with regional myofascial flaps was required.

Synovial fistula of the knee: A complication of arthroscopy

The occurrence of a synovial fistula after knee arthroscopy is uncommon. In a retrospective review of 976 arthroscopies of the knee over 3 years, six patients developed synovial fistulae (incidence 6.1/1,000). All patients were treated with short-term immobilization and oral prophylactic antibiotics. All fistulae closed after an average of 9 days of immobilization, and none required further treatment. Risk factors that may predispose a patient to fistula formation are posterior compartment portals and the presence of significant degenerative joint disease. A treatment protocol is presented.

Cryosurgery and Acrylic Cementation as Surgical Adjuncts in the Treatment of Aggressive (Benign) Bone Tumors

This article reviews the clinical experience with cryosurgery (use of liquid nitrogen) and acrylic cementation (polymethylmethacrylate; PMMA) in the treatment of aggressive, benign bone sarcomas and the biologic basis of this technique. The results of 25 patients below the age of 21 treated by cryosurgery, with an average follow-up period of 60.8 months, are reported. Three approaches to surgical reconstruction were used: Group 1 (four patients) had cryosurgery with no reconstruction, Group 2 (13 patients) had bone graft reconstruction alone, and Group 3 (eight patients) had composite osteosynthesis with internal fixation, bone graft, and/or PMMA. The overall control rate was 96% (one recurrence). The tumor types were giant-cell tumor, chondroblastoma, aneurysmal bone cyst, and malignant giant-cell tumor. Nineteen lesions involved the lower extremity, and six lesions were located in the upper extremity. There were two secondary fractures (8%), one local flap necrosis, and one synovial fistula. There were no infections. Two epiphyseodeses were performed. The functional results were excellent (83%), good (13%), and fair (4%). The technique of composite osteosynthesis is recommended for all large tumors of the lower extremity. Cryosurgical results compare favorably with those obtained by en bloc resection and demonstrate the ability of cryosurgery to eradicate tumors while avoiding the need for extensive resections and reconstructive procedures.

Failure of a bovine xenograft for reconstruction of the anterior cruciate ligament.

Fourteen patients with gross anterior instability had the anterior cruciate ligament reconstructed with a bovine xenograft. Major problems with swelling, pain, and synovitis were encountered in 13 patients, of whom 3 developed a synovial fistula. Histologic evidence for allergic reactions was found in 3 patients. Revisional surgery had to be performed in 10 patients because of substantial problems or rupture of the graft. At 3 years, there was only one possibly functioning graft. The 3 nonrevised patients were unstable at clinical examination. This type of reconstruction cannot be recommended for clinical use.

Surgical Management of Aggressive and Malignant Tumors of the Proximal Fibula

En bloc resection of tumors of the proximal fibula by a specified route allows safe exposure of the popliteal vessels and resection of the fibula, tibiofibular joint, and adjacent musculature. Type I (marginal excision) and Type II (wide intracompartmental resection) procedures performed in ten consecutive patients were evaluated. There were five male and five female patients; the average age was 18.9 years. The histologic diagnoses were osteosarcoma (2 patients), Ewing's sarcoma (3 patients), aggressive osteoblastoma (1 patient), giant cell tumor (3 patients), and "active" osteochondroma (1 patient). All resections achieved negative margins, with no local recurrences from 14 to 37 months after operation. Pathologic specimens showed a high incidence of direct muscle infiltration. Local complications included peroneal palsy (2 patients), flap necrosis (2 patients), and synovial fistula (1 patient). No secondary surgical procedures were required. At follow-up evaluation no knees showed ligamentous instability, and ankle function was good. Selected patients with aggressive (benign) and malignant tumors of the proximal fibula can be treated successfully by resection. A good functional outcome can be anticipated.

Therapeutischer Standpunkt bei dissezierender Bakerscher Zyste im Verlauf der chronischen Polyarthritis

In a group of 300 patients with definit or classical rheumatoid arthritis 26 patients (8.6%) with popliteal and 9 (3%) patients with true Baker's calf cysts were found. The diagnosis was proved by arthroscintigraphy and/or ultrasonography. In 6 patients the calf cysts disappeared after 1-3 lokal applications of 40-60 mg of triamcinolone acetonid in the homologous knee. A spontaneous infection was noted in Baker's cyst of one patient, a spontaneous synovial fistula in another, whereas in the third patient the operation was undertaken due to resistance to conservative treatment. In our view the direct punction of the Baker's cyst should be avoided because of raised liability to infection. When the operative treatment is performed the synovectomy of the ipsilateral knee should always be done at the same time. The early aspiration of the hydrops and proper treatment of the synovitis of the knee joint is the best prevention of the developement of Baker's cysts in rheumatoid arthritis.

Arthroscopic surgery of the knee.

In the first 1000 arthroscopic operations performed by one surgeon 136 patients had two or more procedures, making a total of 1168 during the 1000 operations. The indications for operation were internal mechanical derangements in 565 patients, anterior knee pain in 246, disorders of the synovium in 77, ligament injuries in 63, and degenerative joint disease in 49. Complications included fracture of instruments in the knee in five patients, haemarthrosis in 10, deep vein thrombosis in three, and synovial fistula in one. In no patient was the wound infected. A total of 26 different operations was performed.

Transformation of connective tissue cells by pathological altered synovial fluid as demonstrated by experimental studies (author's transl)

Joint cavities and tendon sheaths are fissurations in the mesenchyme. The coating synovial lining cell layer is caused through the environment of the synovial fluid. The pathologically altered synovial fluid initiates the transformation and proliferation of the marginal connective tissue cells. Evidence for this thesis are the synovial transformatory processes of the cutaneous connective tissue in the area of a synovial fistula and the formation of synovial like structures in the subcutaneous fatty tissues of the rat following the application of synovial fluid from patients with rheumatoid arthritis.