Download - Arthroscopic synovectomy of the knee joint: Indication, technique, and follow-up results

Arthroscopy: The Journal of Arthroscopic and Related Surgery 4(2):63-71 Published by Raven Press, Ltd. © 1988 Arthroscopy Association of North America

Arthroscopic Synovectomy Indication, Technique, and

of the Knee Joint: Follow-up Results

Wilhelm Klein, M.D. and Kai-Uwe Jensen, M.D.

Summary: Between 1981 and 1986, at the Orthopaedic Clinic of the University of DUsseldorf, arthroscopic synovectomy of the knee was performed on 59 joints in 56 patients. The follow-up examination covered 45 knee joints in 43 patients (18 female and 27 male patients). The follow-up results, taken at an average of 2.7 years after the arthroscopic synovectomy, have up to now been good and equal to those achieved using the conventional technique. In this experience, arthroscopic synovectomy is a surgical procedure that places less strain on the patient in the early postoperative healing period. An arthrotomy was no Longer required in the hypertrophic synovial diseases treated during this time. Fibroarthrosis, not uncommon after conventional arthrotomy, did not occur. Only a few stab incisions were necessary to reach all--in particular the posterior--knee-joint cavities. Postoperative pain was markedly reduced from a preoperative level of 16.6 points (47%) (35 maximum points possible, or 100%) to a level of 29.5 points (84%) at follow-up. Patients who experienced an open synovectomy previously in the other knee now favor the arthroscopic procedure. The majority of the patients had a range of motion between 0 and 120 degrees within the first 2 weeks after surgery. Swelling disappeared from a preoperative score of 2.9 points (19%) (15 maximal points possible, or 100%) to 12.2 points (81%). Subjectively, 78% of the patients were satisfied with the result of arthroscopic synovectomy, 7% considered the procedure a partial success, and 15% were dissatisfied. Key Words: Arthroscopic synovectomy-- Knee Joint--Indication--Technique--Follow-up results.

Editor's comments: This is one of the largest series of arthroscopic synovectomy of the knee yet reported. With experience and new instrumentation, it has become possible to do a complete synovee- tomy in most cases in a relatively short period of time. The authors' cases averaged slightly less than 1 h. As always, we should keep in mind that the ability to perform an operation is not an indication for doing it, and in this series, about half the cases were rheumatoid arthritis. The jury is still out on whether any form of synovectomy has a benefi-

From the Department of Orthopaedic Surgery, University of Dfisseldorf, Diisseldorf, ER.G.

Address correspondence and reprint requests to Prof. Dr. Wilhelm Klein, Department of Orthopaedic Surgery, An St. Swidbert 17, 4000 Diisseldorf 31, ER.G.

cial and lasting effect on rheumatoid arthritis. The authors of this article should do longer term follow- up studies on the rheumatoid arthritis cases and, if possible, perform second-look arthroscopies.

S y n o v e c t o m y of the knee jo in t p rev ious ly involved, in general, a r th ro tomy with a major medial Payr incision or two parapate t lar incisions. In order to reach the poster ior knee joint cavities, it was fre- quently necessary to make a fur ther incision in the popl i t ea l reg ion or in the p o s t e r o m e d i a l c o r n e r (1-3) . This caused the patient considerable pos top- e ra t ive pa in and a r e l a t ive ly long pe r i od o f re- covery, often linked with muscular a t rophy and re- stricted range of motion. F rom a cosmet ic point o f view, major incisions presented a problem. Intraar-

63

64 W. K L E I N A N D K.-U. J E N S E N

ticular fibroarthrosis was one of the complications that resulted from the arthrotomy. The subsequent development of cicatricial contractions disrupted the biomechanics of the knee joint, especially in the sensitive patella (4). Other, not infrequent, complications resulting from such a long skin incision were perception disorders caused by a lesion of the cutaneous branch of the saphenous nerve and damage to the proprioceptive receptors (5). The previous method of removing synovial membrane by conducting conventional arthrotomy meant too much surgery for the knee joint, especially in the case of localized forms of synovial disorders. For many patients, in particular those suffering from rheumatoid arthritis, the right moment for an operation was missed and the synovectomy performed as a so-called late synovectomy (6).

Arthroscopic synovectomies without arthrotomy offer a solution to this problem. In contrast to the conventional method, it is today possible to perform total arthroscopic synovectomy of all joint cavities (7-9). Improvements in motorized instruments with respect to their rotational speed, diam- eter, and shaving blade point have made total synovectomy of all joint sections possible while still protecting the cartilage surface and ligaments (10). Our own histological studies have shown that in this way all layers of the synovial membrane can be removed (Fig. 1) (6,11).

Arthroscopic synovectomies are today still rela-

tively unknown. The first published reports about technical implementation of the motorized removal of synovial membrane without arthrotomy began in 1984 (7,9,10,12,13). Reports on follow-up examina- tions after arthroscopic synovectomy are, as far as we are aware, even rarer in the pertinent literature (14). It was for this reason that we decided to report on our experience with arthroscopic synovectomies with respect to indication, technique, and the initial follow-up results attained after -2 .7 years.

INDICATIONS

In our experience, arthroscopic synovectomy can be best applied in all hypertrophic synovial disorders that partially or totally tampon the joint space. Such hypertrophic forms of synovitis in- clude aggressive rheumatoid arthritis, generalized or localized pigmented villonodular synovitis, and metaplastic disorders like chondromatosis, specific and nonspecific bacterial synovitis, and secondary arthrosynovitis (Figs. 2-4) (13,15,16). Basically, arthroscopic synovectomy was indicated when conservative treatment was unsuccessful and damage to the articular cartilage was expected. In the case of rheumatoid arthritis, patients were treated con- servatively for half a year before arthroscopic synovectomy was performed. We believed that in case of nonhypertrophic aggressive rheumatoid arthritis, arthroscopic synovectomy was technically not practicable, because the flat growing synovium was

FIG. 1. Arthroscopic photograph taken immediately after endoscopic shaving of the synovial membrane: view of subsynovial fibrotic joint capsule.

FIG. 2. Arthroscopic view of hypertrophic synovial villi in rheumatoid arthritis, in the medial compartment of the knee.

Arthroscopy, Vol. 4, No. 2, 1988

A R T H R O S C O P I C S Y N O V E C T O M Y O F T H E K N E E 65

firmly attached to the fibrous joint capsule and could not be completely eliminated by arthroscopic synovial resectors. Therefore, these cases should be saved for open synovectomy.

OUR TECHNIQUE

We performed our arthroscopic synovectomies under tourniquet control in a bloodless field and general or peridural anaesthesia. A leg holder was used in all cases. The cover used was a waterproof disposable limb sheet.

A 4-mm 30 Storz arthroscope was inserted anterolaterally into the suprapatellar pouch while the knee joint was being stretched. The joint was then filled with Ringer solution under hydrostatic pres- sure from two 5-L plastic bags suspended 1.5 m above the operating table. The inflow came through a 5-ram thick Dyonics cannula via a suprapatellar medial porta into the joint. The operating instruments were inserted anteromedially into the joint. While constant irrigation was maintained by control of the inflow and outflow, the joints were either partially or totally synovectomized. An average of 25-30-L irrigation solution was required for each knee joint. For the operation, only motor-driven instruments were used. In most cases we used the motor-driven Dyonics synovial resector (Figs. 5 and 6). The Aesculap motorized device developed

FIG. 4. Grapelike loose bodies in synovial chondromatosis, in the suprapatellar pouch of the knee.

by us, which has various window openings de- signed especially for arthroscopic synovectomies, was used from 1985 onwards. Without exception, the operations were conducted by the same operating team, so that we can speak of a standard procedure as far as the operating technique is con- cerned.

Overall, we distinguished between six sections, which, as a rule, can be reached from six ap-

tqG. 3. Generalized pigmented villonodular synovitis causing an impingement syndrome, in the medial compartment of the knee. FIG. 5. Arthroscopic aspect of motorized synovectomy

Dyonics Resector Type 1.


66 W. KLEIN AND K.-U. JENSEN

FIG. 6. Rosenberg "full radius blade synovial resector" during arthroscopic synovectomy in a patient with rheumatoid arthritis of the knee.

proaches. In 21% of the cases, it was necessary to synovectomize all sections, and in the remaining cases, five or fewer sections needed to be synovectomized. This was because synovitis was not equally pronounced in all s6ctions.

In 62% of the cases, the number of surgical ap- p roaches was res t r ic ted to the s tandard approaches: an anterolaterally inserted endoscope, a suprapatellar medial inflow, and anteromedially inserted operating instruments. Depending on the need and accessibility of the joint lumen, the line of sight of the arthroscope could be varied medially and laterally by replugging or changing to the motorized device. For this purpose, so-called switch sticks were used to make it easier to place the guide cannula. To ensure thorough synovectomy of the upper recess, the suction device was inserted in the original inflow portal and the inflow became antero- medial. By way of the modified semicentral access of the endoscope, it was possible in 90% of the cases to obtain a good view for assessment of the posteromedial and lateral sections through the intercondylar notch past the cruciate ligaments of the knee. If proliferative synovitis was established in the posterior sections, posteromedial and posterolateral accesses were made in addition to the standard approaches for the purpose of eliminating dis- eased synovial tissue in the posterior recess.

In 20% of the cases, posteromedial access was

indicated in addition to the usual standard access. In 2% of the cases, additional posterolateral access proved necessary. Additional posteromedial and posterolateral approaches were necessary for 4% of the knee joints. Because of excessive synovitis, suprapatellar medial and lateral approaches proved necessary in 9% of the cases (Fig. 7). The number of accesses required usually depended on the ex- tent to which the synovial disorder had spread, the elasticity of the articular capsule, and obstacles in the joint, such as broad plicae or cicatricial threads, or on the alar folds of the knee joint stretched like canvas, thereby causing problems when the endoscope was moved from the medial to the lateral section. As a rule, the semicentral access was suffi- cient in the virtually stretched knee to enable inser- tion of the endoscope cannulas with a blunt man- drin through the fossa into the posterior recess. However, this was not possible if the intercondylar fossa was contracted by osteophytes or a synovial tamponade blocked the fossa. For this reason, it proved impossible in 10% of the cases to view the posterior sections. Upon conclusion of the synovectomy, the joint then received a Redon drainage and a sterile compression bandage was applied. The stab incisions were left open.

Postoperative treatment All joints received a drainage for 48 h. A com-

pressive dressing was applied in the operating room. The knee joints were immobilized for 1 day. The second postoperative day, a constant passive motion machine allowing motion between 0 and 60 degrees was applied. Patients were kept n o n - weight-bearing for 4 weeks, after which the entire synovium was resected. An isometric exercise pro- gram was started the first postoperative day.

The average period of hospitalization was 13 days, the prolonged time being due to our inexperi- ence with the new technique and the healing pro- cess of the affected knee joint. Today, the hospitalization time has been reduced to 3-5 days.

MATERIALS AND METHODS

Between 1980 and 1986 at the Orthopaedic Clinic of the University of Dasseldorf, we performed arthroscopic synovectomy of the knee in 59 joints of 56 patients. We were able to conduct a follow-up examination of 43 patients, two of whom had undergone surgery of both knee joints. There were 18 female and 27 male patients. Degenerative arthritis


ARTHROSCOPIC SYNOVECTOMY OF THE KNEE 67

FIG. 7. Percentage of standard portals to the knee for arthroscopic synovectomy.

L o t e r o l S u p r o p o t e l l e r 9 ~

P o s t e r o l o t e r o l 2 % ( 4 ~ )

A n t e r o l a t e r a ! ( 6 2 %

( L S ) M e d l a l S u p r e p o t e l l e r 6 2 %

(MS)

- - P o s t e r o m e d l o l ( P M ) 2 0 % ( 4 % )

A n t e r o m e d l o l ( A M ) 6 2 %

( was not included in this study. The follow-up examination was conducted in our out-patient department, and the patients were at the same time asked to fill out a questionnaire based on the Lysholm point system (17) that we modified for specific questions on arthritis.

Twenty-five men and 18 women underwent this follow-up examination. The average age at the time of operation was 34 years, the oldest patient being 71 and the youngest 8 years old. The follow-up examination period lasted, on average, 2.7 years, the longest being 5.5 years and the shortest 8 weeks. In addition to the synovectomy, we performed partial meniscectomy in 11% of the cases and cartilage shaving in 16%. The average length of the operation was 55 min.

Of the 45 operated knee joints, 25 were in patients with rheumatoid arthritis (Fig. 2). Four patients suffered from pigmented villonodular synovitis (Fig. 3). In two cases, synovitis was attribut- able to a synovia l metaplas ia in the form of chondromatosis (Fig. 4). Four patients suffered from chronic hypertrophic synovitis in conjunction with hemophilic arthropathy, which caused repeated hemorrhaging into the knee joint. One case involved arthritis of the knee joint accompanied by ankylosing spondylitis. In five patients, chronic nonspecific synovitis had developed. Also included in the study were four patients who had developed so-called "foreign body synovitis" following im-

plantation of the Dacron cruciate ligament pros- thesis (Table 1). This "Abrasion synovit is" was caused by omitted notch plasty, the course of the ligament around corners and over edges, and the nonisometric fitting of the prostheses. Synovec- tomy was combined with notch revision in three cases. In one patient, the intraarticular portion of the ligament had to be removed.

FOLLOW-UP RESULTS

In the modified Lysholm system, the parameters pain (35 points), swelling, range of motion, and walking distance (15 points each) were weighted as the most critical factors. Further criteria such as limp, squatting, stair climbing, and support were

TABLE 1. Synovial disorders treated by arthroscopic synovectomy

Disorder No. %

Rheumatoid arthritis Pigmented villonodular synovitis Synovial chondromatosis Hemophilic synovitis Ankylosing spondytitis Unspecific synovitis Foreign body synovifis

25 56 4 9 2 4 4 9 1 2 5 11 4 9

45 100

No. of patients, 43; no. of knees, 45.


rated with only 5 points each. A patient with a healthy knee received 100 points. The point level in the scoring scale is expressed as a percentage of the corresponding maximum number of points. Prior to, immediately after, and 6 weeks after the operation as well as at the time of the follow-up examination (namely, an average of 2.7 years later), the patients were asked about their condition.

Results in all knees: main parameters

Pain Pain was markedly reduced from a preoperative

level of 16.6 points (47%) (35 maximum possible points = 100%) to 29.5 points (84%) (35 maximum possible points = 100%) at the time of the follow- up examination (Fig. 8).

Swelling With respect to knee joint swelling, we noted an

improvement from 2.9 points (19%) (15 maximal possible points = 100%) to I2.2 points (81%) (Fig. 8).

Range of motion Range of motion improved quite considerably as

a result of surgery from a preoperative level of 5.3 points (36%) to 13.0 points (87%) (15 points = 100%) at the time of the follow-up examination (Fig. 8). The majority of the patients had a range of

Results and synovial diseases

motion of 0-120 ° within the first 2 weeks after surgery (Fig. 8).

Walking distance The corresponding values for improvement in the

walking distance were 5.3 (36%) and 12.8 points (82%) (15 maximum points = 100%) (Fig. 8).

All parameters Taking all the parameters together, we found an

improvement from 39.2 to 83.8% (out of 100 maximum points) at the time of the follow-up examination. The development of the total number of points for each patient during the period of observation is shown in Figure 9.

Subjective opinion o f the patient Finally, we asked the patients for their subjective

assessment of the results of the operation; 78% were completely satisfied, and 7% considered the operation to be a partial success, but 15% were dissatisfied, which corresponds approximately with the results following an open synovectomy. The dissatisfied patients had all undergone a late synovectomy.

100

Rheumatoid arthritis--swelling The preoperative score was 20% and the postop-

erative score 79%.

8 0

6 0

4 0

Range of M0tion

Pain

WalKlng Distance

Swelling

2 0

0

68 W. KLEIN AND K.-U. JENSEN

"~" [ ;/J I J l I l l , , I

p r e p o s t 6 w e e k s 1 = o l l o w -

o p o p p o s t o p u p

FIG. 8. Development of the major parameters of pain, swelling, range of motion, and walking distance during the examination period, expressed as percentages of the corresponding maximum number of points.



Nonrheumatoid arthritis--swelling The preoperative score was 18% and the postop-

erative score 85%. Patients with rheumatoid arthritis had 8% more swollen knees at the time of the follow-up than the nonrheumatoid patients.

Rheumatoid arthritis--range o f motion The preoperative score was 36% and the postop-

erative score 77%.

Nonrheumatoid arthritis--range o f motion The preoperative score was 35% and the postop-

erative score 98%. Patients with rheumatoid arthritis had 22% less range of motion than nonrheumatoid patients.

Rheumatoid arthritis--walking distance The preoperative score was 36% and the postop-

erative 79%.

Nonrheumatoid arthritis--walking distance The preoperative score was 35% and the postop-

erative score 87%. Patients with rheumatoid arthritis had 9% less walking capacity compared with the other group.

Rheumatoid arthritis--pain The preoperative score was 46% and the postop-

erative score 82%.

Nonrheumatoid arthritismpain The preoperative score was 49% and the postoperative score 87%. Patients with rheumatoid arthritis had 2% more pain than the nonrheumatoid group.

From the percentages in the scoring scale after 2.7 years, it can be concluded that nonrheumatoid knees had in the main parameters a generally better prognosis. For range of motion, the difference in 22% was quite evident. For pain, there was no big difference. For swelling and walking distance, there was little difference in the score (8% and 9%).

In the nonrheumatoid group, the four knees with pigmented villonodular synovitis had the best results. The second best group were patients with hemophilic arthropathy (n = 4). In the third group were the patients with chronic unspecific synovitis (n = 5). Knees with synovial chondromatosis (n = 2) were in the fourth group. Improvement in foreign body synovitis after Dacron anterior cruciate ligament implantation was like that in rheumatoid arthritis. Improvement in the patient with ankylosing spondylitis was less than that in all other diseases.

DISCUSSION

As with the arthroscopic partial meniscectomy (18), in selected cases of synovial disorders that in- clude all forms of hypertrophic synovial diseases that resist conservative treatment, the previous form of conventional arthrotomy will be replaced by arthroscopic surgical removal of synovial membrane by use of motorized cutting devices. In 1987, Mohing drew attention to the limits of arthroscopy (3). In the meantime, however, further develop- ments of the arthroscopic surgical technique, using

FIG. 9. Development of the total number of points reached by each patient during the period of observation.

p r e o p p o s t o p 6 w e e k s f o l l o w - u p

p o s t o p

5o 50


70 W. K L E I N A N D K.-U. J E N S E N

so-called switch sticks, has made it possible to reach all sections of the inner area of the joint via fewer approaches and more easily than by conventional arthrotomy (7,9,10).

Following improvements to the motorized arthroscopic instruments with respect to rotational speed, suction capacity, and modification of specially developed synovectomy shaving blades, it is now possible to perform a total synovectomy of all joint sections while protecting the cartilage surfaces and ligaments. A retrospective comparison of our arthroscopic synovectomy follow-up results with results from earlier studies on conventional synovectomies gave the impression that-the results were approximately equally good (19). Marked differences emerge, however, in the early postoperative phase, as we learned from our own experience and the subjective assessment of patients suffering from rheumatoid arthritis who had undergone synovectomy of both knees but with two different techniques.

In 1986, Shibata was able, on the basis of his patients, to conduct a direct comparison between arthroscopic synovectomies and conventional synovectomies using arthrotomy (14). His results clearly favor the endoscopic procedure. The author also emphasized that this intervention can be repeated without difficulty in cases where the synovial disorder tends to recur. Possible complications resulting from arthroscopy have been reported (20). These reports distinguish between major complications such as infections, thrombosis, neurological irritations, and adhesions, and minor complications affecting wound healing, such as erythema and blisters. No severe complications developed in the patients we treated. In three cases, synovectomy had to be repeated arthroscopically because synovitis again developed.

CONCLUSIONS

Our experience leads us to believe that arthroscopic synovectomy poses less of a strain to the patient. An arthrotomy was not required in the hypertrophic synovial diseases we treated. The risk of damaging the cutaneous branch of the saphenous nerve is low; only one of our patients had a postoperative sensibility defect in the proximolateral aspect of the tibia. No severe fitiroarthrosis linked with decrease in range of motion developed. Gener- ally, range of motion returned within the first 2 weeks after surgery. In all joint sections, synovitis

could be visualized with the arthroscope and eliminated with a synovial resector without major incision or arthrotomy. Postoperative pain was min- imal. This is proved in three patients who had undergone synovectomy open on one side and closed on the other. In case of recurrence, the operation can be repeated without difficulty by use of the same stitch incisions. The low morbidity we ob- served with arthroscopic synovectomy encourages us to be more aggressive in performing early synovectomy to avoid cartilage damage induced through synovitis, when conservative treatment is ineffec- tive.

We believe that compared with conventional synovectomy, arthroscopic synovectomy is at least as good, if not even better. This leads us to the question whether this new operating technique will, in the long run, replace arthrotomy, as we have al- ready seen with meniscectomy. At the present stage of development, however, we have to limit this procedure to the hypertrophic forms of synovitis. The best results were obtained in patients with pigmented villonodular synovitis. Generally, the nonrheumatoid group had a better prognosis than the patients with rheumatoid arthritis. We view arthroscopic synovectomy more as an additional link in the chain of present prophylact ic rheumatoid-orthopaedic intervention techniques for removing synovial membrane, especially since long-term results and prospective studies are not available. Arthroscopic synovectomy is particu- larly suited for the treatment of synovial disorders accompanied by bulging hypertrophy that partially tampon the inner area of the joint. We believe that arthroscopic synovectomy in its present state of development still has some way to go before it can be used for the treatment of chronic forms in which the internal membrane of the joint is fibrotically ad- herent to the fibrous articular capsule. In such cases, we consider the present conventional technique using arthrotomy to be superior.

REFERENCES

1. Gschwend N. Die operative Behandlung der chronischen Polyarthritis. Stuttgart: Thieme, 1977:14-8,19-25,210-23.

2. Klein W. Nachuntersuchungen nach Synovektomie unter Berucksichtigung der klinischen und histopathologischen Diagnosen verschiedener Arthritiden. Z Orthop 1974;112: 299-305.

3. Mohing W, Franke M. Erworbene Krankheiten des Kniege- lenkes. In: Witt AN, Rettig H, Schlegel KF, eds. Ortho- paedie in Praxis und Klinik, 7 Band, Tell 1. Stuttgart, New York: Thieme, 1987:9.1-9.88.



4. Schleberger R, Klein W. Die Chondropathia patellae respek- tive Femoropatellararthrose in der Folge der Synovektomie des Kniegelenkes. Verh Dtsch Ges Rheumatol 1981;7: 592-3.

5. Fox IM, Del Pizzo W. Operative arthroscopy for treatment of fibroarthrosis of the knee. Presented at Am. Orthop. Soc. of Sports Medicine, Interim Meeting, Anaheim, California, 1983.

6. Klein W, Huth E Arthroskopie and Histologie yon Kniege- lenkserkrankungen. Stuttgart: Schattauer, 1980:66-7,71-3.

7. Highgenboten CL. Arthroscopic synovectomy. Arthroscopy 1985;1:190-3.

8. Inoue K, Morita H, Natsujama M, Namiki T, Mikanagi K. Selective synovialdesis using an argon-dye laser in arthritis. Am J Sports Med 1987;15:397.

9. Johnson LL. Arthroscopic surgery, principles and practice. St. Louis: Mosby, 1986:1269.

10. Rosenberg TD. An illustrated guide to arthroscopic synovectomy of the knee. Salt LakeCity: Dyonics, 1984:1-7.

11. Schulitz KP. Regeneration der Synoviatis. Z Orthop 1976; 114:161-76.

12. Ewing JW. Arthroscopic partial and total synovectomy In: Sprague NE Seminars on operative arthroscopy. Maui, Ha- waii: U.C.L.A. Extension, 1982:62-3.

t3. Strumper R, Hertel E. Moglichkeiten und Grenzen der arthroskopischen Synovektomie. In: Hettenkofer HJ, ed. Synoviorthese/Synovektomie: Ergebnisse und Differentia- lindikationen. Basel: Eular, 1986:61-7.

14. Shibata T, Shiraoka K, Takubo N. Comparison between arthroscopic and open synovectomy for the knee in rheumatoid arthritis. Arch Orthop Trauma Surg 1986;105:257-62.

15. Watanabe M, Takeda K, Ikeuchi H. Atlas of arthroscopy. Tokyo, New York: Springer, 1979:30-48,131-3.

16. Mohr W. Gelenkkrankheiten. Stuttgart, New York: Thieme, 1984:260-71.

17. Lysholm J, Gillquist J. Evaluation of knee ligament surgery results with special emphasis on use of a scoring scale. Am J Sports Med 1982;10:172-81.

18. Klein W. Nachuntersuchungen nach arthroskopischer par- tieller Meniskektomie. Orthop Praxis 1986;22:123-8.

t9. Klein W, Schlosser HW, Rosenbauer K, Huth E Beitrag zur Morphologie der Synovitis villosa pigmentosa. Z Orthop 1974;112:392-401.

20. Sherman OH. Arthroscopy: no-problem surgery? J Bone Joint Surg 1986;68A2:256-65.


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