LOOSE BODIES

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LOOSE BODIES

• DR MOHAMMED MAAZ AFZAL
• IInd YR PG,GMC.

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DEFINITION

• A loose body is a free-floating piece of bone,
  cartilage or foreign object in a joint.
• Loose bodies within the joint have the potential
  for continued growth.

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Sites of formation of loose bodies are1)Knee
joint,2)Shoulder jt.3)Elbow jt.4)Ankle
jt.KNEE JOINT IS THE MOST COMMON SITE.
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CLASSIFICATION

• Loose bodies are of following types
• 1)Osteocartilaginous
• Radio-opaque
• A) TRAUMATIC
• Osteochondral fractures.
• B)PATHOLOGICAL
• 1)Osteochondritis dessicans
• 2)Osteo Arthritis
• 3)Synovial osteochondromatosis
• 4)Charcots ds.
• 5)Sequestra in Tuberculosis.
  
• 2)Cartilaginous
• Radio-luscent
• TRAUMATIC
• Articular surface of patella/Tibial/Femoral
  condyle.
• .

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• 3)Fibrinous
• Radioluscent
• A)TRAUMATIC
• B)PATHOLOGICAL
• 1) Tuberculosis-Rice bodies
• 2)Rheumatoid arthritis
• 3)Osteo arthritis
• 4)Others
• 1)Intra-articular tumors(Lipoma)
• 2)localised nodular synovitis
• 3)secondary carcinoma
• 4)needles
• 5)Broken arthroscopic instruments

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• For practical purpose the common causes are
• 1)Osteo Arthritis(Adults)
• 2)Synovial chondromatosis
• 3)Osteochondritis dessicans(Adolescents)
• 4)Osteochondral fractures.

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CLINICAL FEATURES

• Pt. experiences sudden pain,which causes him to
  fall down.
• Then he finds his limb locked in semiflexion.
  can neither extend nor further flex the jt.
• This locking in mid movement must clearly be
  differentiated from locking of torn meniscus.
• Pt. is able to disengage L.B. free the jt
• Variable site of pain in successive attacks
  -unlike meniscal lesions.
• Most important diagnostic aid is pt. might have
  palpated the l.b.
• Knee jt. gets swollen with fluid.
• Commonly lodges in suprapatellar pouch.

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• O/E
• Minimal findings,
• Pt. presents with locked knee or effusion.
• Mild wasting of Quadriceps m.
• L.b. Sometimes can be palpated clinically.
• Slips away during palpation (Joint mouse).
• Features of underlying O.A.

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PATHOGENESIS

• 1)OSTEOARTHRITIS
• 3 forms of l.b. may occur
• 1)Synovial chondromata
• 2)Osteophytes
• 3)Detached fragments of articular cartilage
• They may increase in size while lying
  free in jt. due to nourishment
  from syn. Fluid.

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• 2)OSTEOCHONDRITIS DESSICANS
• A Small well demarcated fragment of avascular
  bone with overlying caritlge seperates from a
  femoral condyle. appears as l.b.
• Typically lesions involve convex surface in
  various joints
• Knee-Inner aspect of medial femoral condyle
• Elbow-Capitellum
• Ankle-outer Trochlear surface of Talus
• Hip-Superior aspect of Femoral head
• Joint M.C. to be affected is knee.
• M.C.cause is trauma
• 1.Medial Tibial spine
• 2.Edge of patella.
• gt80 lesions occur on lower lateral part of
  Medial femoral condyle.

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• 2 signs that are almost diagnostic of OCD
• 1)Tenderness localised to one Femoral condyle on
  90 degrees flexed knee.
• 2)WILSONS SIGN
• If knee flexed to 90 degree,rotated medially
  gradually straightened,pain is felt.
• Repeating the test with knee rotated latrally
  is painless.
• X Ray-A.p.,Lateral,Intercondylar(Tunnel)views
• Line of demarcation around a lesion in situ,in
• lat. Aspect of medial Femrl condyle.
• If frgmt is detached,empty hollow is
  seen,loose body seen elsewhere in jt.
• MRI-Reveals osteochondritic area on surface.
• ARTHROSCOPY- Appearance of L.b. varies with age.

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• JUVENILE OSTOCHONDRITIS DESSICANS
• In child below age of skeletal maturity-
• Treatment is Conservative with reduction
  of violent activities
• Cylinder cast for 3 weeks.
• ADULT OSTEOCHONDRITIS DESSICANS
• Any incongruity of articular surface tend to
  predispose jt. to Osteoarthritis later.
• In presence of persistent symptoms, jt. Should
  always be examined by arthroscopy.

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TREATMENT

• 1)In the earliest stage, when the cartilage is
  intact and the lesion is stable, no treatment
  is needed but activities are curtailed for 612
  months. Small lesions often heal spontaneously
• (or)
• Drill multiple fine 1 mm holes through articular
  surface into sub-chondral bone.
• Tiny holes will heal rapidly with fibrocartilage.

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• 2)If the fragment is unstable, i.e. surrounded
  by a clear boundary with radiographic sclerosis
  of the underlying bone, or showing MRI features
  of separation,
• treatment will depend on the size of the lesion.
• A small fragment should be removed by arthroscopy
  and the base drilled the bed will eventually be
  covered by fibrocartilage, leaving only a small
  defect.
• large fragment (say more than 1 cm in diameter)
  should be fixed in situ with 2 smillie pins or
  Herbert screws.
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• 3)If the fragment is completely detached but in
  one piece the crater is cleaned and the floor
  drilled before replacing the loose fragment and
  fixing it with Herbert screws.
• In recent years attempts have been made to fill
  the residual defects by articular cartilage
  transplantation
• 1)Either the insertion of
  osteochondral plugs harvested from another part
  of the knee or
• 2) the application of sheets of
  cultured chondrocytes.
• 4) If fragment is in pieces ill shaped,discard
  it, drill the crater allow it to fill with
  fibrocartilage.
• After any of these surgeries ,knee is held in a
  cast for 6 weeks,then movements are
  encouraged,wt.bearing is delayed till x ray shows
  signs of healing.

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• 3)SYNOVIAL CHONDROMATOSIS
• Rare disorder of synovial membrane.
• Joints contain multiple l.b.(upto 500 ),in pearly
  clumps ,
• Resemble sago(snowstorm knee)
• The presentation is monoarticular,sometimes b/l
  knee or Hip,Elbow,Wrist may involve.

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• 4)OSTEOCHONDRAL FRACTURES
• Always h/o trauma.
• Fractures may follow
• 1)Direct injury to knee-peripheral segment of
  cartilage with subchondral bone sheared off.
• 2)Indirect injury-Due to combined rotational
  compressive forces-central lesions.
• 3)Acute Dislocation of patella-Tangential
  osteochondral of patella (or) Lateral Femoral
  condyle (or) both.
• Rx
• 1)If small-lt1.5 cm- Fragment removed
  arthroscopically
• 2)If Larger- Joint is opened,detached fragment
  reduced with Smillie pins/Herbert screws.
• 3)Dislocated patella- Capsular tear should be
  repaired after reduction to prevent recurrence.

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CHARCOTS DISEASE

• Charcots disease (neuropathic arthritis) is
  a rare cause of joint destruction.
• Because of loss of pain sensibility and
  proprioception, the articular surface breaks down
  and the underlying bone crumbles.
• Fragments of bone and cartilage are deposited
  in the hypertrophic synovium and may grow into
  large masses.

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• Clinical features
• The patient chiefly complains of instability.
• Pain is unusual.
• The joint is swollen and often grossly deformed

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DIAGNOSIS

• X RAY
• Most L.b. are Radio-opaque,often seen in
  supra-patellar pouch.
• Should not be mistaken with Fabella.
• Underlying jt. Abnormality.
• CT-SCAN.
• MRI.
• ARTHROSCOPY

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DIFFERENTIAL DIAGNOSIS

• 1) FABELLA
• Seen in 15 normal individuals.
• A sesamoid bone in lateral head of
  Gastrocnemius ms.
• It is above the level of jt.line behind
• Femur,towrds lat. Side is always oval in
  shape with long axis vertical.
• 2)PELLEGRINI-STEIDAS DISEASE
• Calcification of the Femoral
  attachmnt of Medial collatral ligamt after
  trauma.

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MANAGEMENT

• 1)Removal of L.B. by arthroscopy.
• 2 techniques are used
• i)Small l.b. Removed by suctionlavage
• ii)Large l.b.-Removed by Triangulation
  technique.
• 2)Arthrotomy(for l.b. in posterior segment of
  knee).
• 3)In Synovial chondromatosis of knee- Anterior
  Synovectomy is performed

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ARTHROSCOPY

• Insert the 30 degree viewing arthroscope through
  Anterolateral portal.
• Perform complete systematic diagnostic
  arthroscopy.
• L.b. which was visibleon Pre-op X-rays is
  searched for.
• Search additional L.B.
• By applying Esmarch Torniquet,L.b. is usually
  found in supra-patellar pouch.
• L.b. in Supra patellar pouch may move away.
• Avoid this by turning off the outflow of
  irrigation fluid and inserting a small suction
  tip.
• . L.b is drawn to suction tip ,where it can be
  held removed by a 3rd instrument.

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• L.b. can also be trapped by Triangulating a
  spinal needle to it, removed by a grasper.
• If L.b. is large ,enlarge the portal to extract
  it.
• If multiple l.b. are present,smaller ones should
  be removed first.
• L.b. large enough to require a major incision can
  be removed in small fragments by morcellisation.
• Pedunculated l.b. in Nodular synovitis, are
  removed by Triangulation techniques after pedicle
  is cut with scissors.
• At last suction the jt.,in posterior compartment
  intercondylar notch to remove unseen l.b.
• Identify treat the pathological process
  accordingly(Biopsy,synovectomy,chondroplasty)

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• L.B. in Posterior compartment of knee
• May be removed by arthroscope.
• If symptoms are definite,may be removed with
  Arthrotomy.
• -S shaped incision
• Dissection carried out medial to Popliteal
  vessels
• Posterolateral compartment
• Incision parallel to anterior head of Biceps.
• Posteromedial compartment
• Incision is along anterior border of Sartorius.

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L.B. SHOULDER

• L.B. are encountered during shoulder arthroscopy.
• Are formed from
• Hill sachs lesion
• Glenoid rim
• Advanced arthritis
• Osteo necrosis
• Tend to gravitate into axillary pouch of
  shoulder,
• posterior
  recess of glenoid,
• 
  subscapular recess,
• synovial
  folds behind Biceps tendon.
• Small ones can be removed by applying suction to
  a large caliber outflow cannula.
• Large ones are removed by Grasping techniques or
  Triangulation techniques
• Determine the source of L.B. to correct
  underlying abnormality.

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L.B. OF ELBOW

• Most common indication for Elbow arthroscopy is
  removal of l.b.
• Site of origin must be identified.
• Osteocartilaginous l.b . Result from
  osteochondritic lesion of capitellum.
• L.b. may be embedded in fibrous tissue - Coronoid
  process,Radial head or olecranon fossa.
• Release of soft tissue with a shaver/Arthroscopic
  scissors is required.

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REFERENCE BOOKS

• Campbell operative orthopaedics
• Apleys systems of orthopaedics
• Adams outline of orthopaedics
• Mercers orthopaedic surgery
• Das clinical manual
• Internet sources.

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THANK YOU.