A bunion is a bony lump on the side of your foot at the big toe. It forms when your big toe starts to angle towards your second toe. The bunion eventually causes discomfort and pain. The skin over the lump can become red, blistered or infected. A fluid-filled space called a bursa may also develop under your skin in this area and this can be painful if it becomes inflamed. This is called bursitis.

Bilateral Hallux Valgus / Bunions

What Causes Bunions to Form?

A bunion occurs as a result of a problem with your big toe known as hallux valgus. Hallux means the big toe and valgus means that it’s pointing outwards towards the other toes.

In hallux valgus the bone in your foot at the base of your big toe, called the first metatarsal, moves out at the side of your foot. Your big toe angles towards your other toes.

There is evidence that people can inherit a tendency to develop bunions. However, it doesn’t always follow that if your parents or grandparents have bunions, you will have them too. Studies have shown that 63-68% of people who have bunions have a family history of bunions. So, heredity definitely plays a part. You do not inherit the bunions, but you inherit the foot type that may lead to bunions. Certain foot types cause the bones to change position and go out of alignment. This in turn allows the muscles and tendons to take advantage over other muscles and tendons and over time these changes may lead to bunions. Take a look at the feet of your grandparents, parents, aunts, uncles, sisters and brothers. There may be bunions in your family that you were not aware of.

Hallux valgus affects more women than men. This may be because the ligaments in the foot (the structures that connect bones together) are usually looser in women than men.

The type of shoes you wear may also affect the development of a bunion. If you wear narrow or high-heeled shoes, this puts extra strain on the bones and muscles in your foot, pushing your toes together and forcing your big toe to point towards your other toes. Footwear alone doesn’t cause bunions, but it can worsen them.

It has been said that in places where people seldom wear shoes, bunions hardly ever forms.

What Are the Symptoms?

The bunion can rub against the shoe when walking and this can lead to pain, redness and swelling.

The 2nd toe can be crowded out by the deviating big toe leading the an over-riding 2nd toe.

The main problems are difficulty with shoe wear!

What Are the Available Treatments?

Use a broader shoe.

Ice treatment.

Anti-inflammatory medications.

Special insoles.

Toe spacers.

Surgery.

What Surgery Do I Do for Bunions?

There was many different types of surgical procedures described for the treatment of the painful bunion. There is no best surgery or best technique for this problem. The choice of the surgery is dependent on the patient’s problem as well as the surgeon’s personal preference and experience.

Scarf Osteotomy

This is a lady with a painful bunion of her right foot and the 2nd toe has become over-riding.

Right Foot Hallux Valgus with Over-riding 2nd Toe

This is the x-ray finding:

X-rays of Hallux Valgus

X-rays of Right Hallux Valgus

A scarf osteotomy was performed. It involved cutting the 1st metatarsal bone using a Z-cut and displacing the toe laterally.

Post-op x-rays AP Standing

This is the big toe at about 6 weeks after the surgery:

Outcome of Hallux Valgus Correction

For more information on treatment of painful bunions, please contact Dr HC Chang at +65-683 666 36 or email hcchang@ortho.com.sg

It can be injured in accidents or during sports. When the articular surface of the tibia of the knee joint is injured, it is termed a tibial plateau fracture.  Such fractures need to be treated such that the articular cartilage surface of the tibial plateau heals properly. Otherwise the irregular cartilage surface can rapidly result in knee post-traumatic osteoarthritis.

This patient sustained a lateral tibial plateau fracture.

In order to obtain the best possible reduction of the articular surface, arthroscopic assisted open reduction and internal fixation of the fracture was performed.

The fracture was first assessed using arthroscopy.

The fracture was openly reduced and stabilized using special locking plates.

The intra-articular reduction was confirmed on arthroscopy.

The patient was asked to use the continuous passive motion machine for the next 3 weeks to encourage cartilage healing.

The patient used crutches to walk and the operated leg was only allowed toe-touch weight bearing for the initial 6 weeks.

The x-rays taken at 6th week after the surgery showed good fracture reduction and healing.

Lateral Tibial Plateau Fracture Treatment

Lateral Tibial Plateau Fracture Treatment

The patient was then allowed to walk full weight bearing without crutches.

Knee arthroscopy is a valuable method to assist the surgeon on obtaining the best articular surface reduction during surgery in order to avoid or minimize post-traumatic knee osteoarthritis.

For more information on tibial plateau fractures, please contact us at +65-683 666 36 or email hcchang@ortho.com.sg

Chronic expanding haematoma of soft tissue is a rare entity. It is characterized by its persistence and by its increasing size for more than a month after the initial haemorrhage. The diagnosis of this uncommon entity is often difficult, it being easily mistaken for one of the relatively more frequent malignant neoplasms (cancer).

Mr X presented to me with a large lump over his right shin. This lump has been with him for over 10 years but he noticed that it was gradually becoming bigger. It first started as a small lump after he was kicked in the shin during a game of football.

The lump did not cause him any pain or discomfort but it was obvious and appeared alarming to his friends and relatives.

Examination showed a large firm mass over the front of his right shin.

X-rays showed a soft tissue lump or tumour.

Fearing this could be a benign soft tissue lump that has turned cancerous, an MRI scan was promptly done.

The features were worrisome and suggestive of a cancer of the soft tissue or what we called a soft tissue sarcoma.

Fearing the worst, surgical excision of the tumour was advised.

The lump was treated as a cancerous lump and excised as such.

This is the tumour after it was removed from the leg.

The tumour was excised enbloc with a cuff of normal tissues.

The excised lump was sent for histology. It turned out to be a chronic organizing haematoma!

Most hematomas subside without causing any serious clinical problems. However, some persist for long periods and appear clinically as slowly expanding lesions in soft tissues simulating neoplastic growth; these are called chronic expanding hematomas.

The precise mechanism responsible for chronic expanding hematomas remains unclear. Bradshaw et al. speculated that the initial trauma results in displacement of skin and subcutaneous fatty tissue away from more deeply located, fixed fascia and underlying muscle, with the consequent formation of blood-filled cysts surrounded by dense fibrous tissue. The lesion’s self-perpetuating, expanding nature appears to be due to the irritant effects of blood and its breakdown products leading to repeated exudation or bleeding from capillaries in the granulation tissue of the cyst wall.

It seems that complete surgical excision, including the pseudocapsule, is the best treatment for chronic expanding hematoma, because aspiration of the fluid or incomplete excision could lead either to an unconfirmed diagnosis or recurrence.

This case report was brought to you by HC Chang Orthopaedic Surgery. Please contact us at 683-666-36 or hcchang@ortho.com.sg for an appointment for your Orthopaedic problems.

A ligament is a strong fibrous tissue that attaches one bone to another.

The anterior and posterior cruciate ligaments form an “X” in the centre of the knee joint. The posterior cruciate ligament (PCL) being the larger of the 2 and situated behind the anterior cruciate ligament (ACL).

PCL- Looking from the Back of the Knee

What is the Function of the PCL?

The PCL resists backwards motion of the lower leg. Unlike the ACL, which is mainly functional during certain high risk athletic activities, the PCL is important and is functioning almost all the time even during simple walking.

How Does One Injure the PCL?

A PCL tear occur when a direct blow to the front of the knee or leg just below the knee (tibia) creates a large sudden force directed backwards. This puts a significant amount of stress on the PCL. The stress in the ligament is even higher when the knee is flexed (bent) closed to 90°. The posterior cruciate ligament then stretches to the point of mechanical failure which is considered a tear.

This can happen when someone is tackled in football below the knee from the front or when someone in any sport lands forcefully directly onto their knee with their knee simultaneously bent.

The PCL can also tear in this manner when in a head-on motor vehicle collision the vehicle’s dashboard strikes directly against the knee.

Sometimes the PCL can be stretched and subsequently torn by forceful hyperextension (bending backwards beyond straight) occurring to the athlete’s knee. This may occur when, in football, a player is hit on the legs just below the knee from the front and their knee hyperextends because their foot is firmly planted in the playing surface. This mechanism, especially when the knee twists during the injury, can lead to tearing of other important knee structures beyond simply the PCL.

What are the Symptoms of PCL Tear?

Signs and symptoms of a posterior cruciate ligament injury may include:

•     Mild to moderate pain in the knee
•     Rapid onset of knee swelling and tenderness (within three hours of the injury)
•     Pain with kneeling or squatting
•     A slight limp or difficulty walking
•     Feeling of instability or looseness in the knee, or the knee gives way during activities
•     Pain with running, slowing down, or walking up or down stairs or ramps
•     Sometimes the patient may have little or no complaints until much later

When Does It Become More Serious?

It is more serious when the PCL tear is associated with other knee ligament tears.  It can be combined with an ACL tear, medial collateral ligament (MCL) or more commonly a lateral collateral ligament (LCL) or posterolateral corner of the knee injuries.

These knees tend to be more unstable and problematic compared to an isolated mild PCL tear.

How to Diagnose PCL Tear?

The best way to diagnose a PCL tear is to examine the knee for posterior sag at 90 degrees of knee flexion with the patient lying on the examination couch. The loss of the usual medial tibial plateau anterior step-off will imply the presence of a posterior tibial sag from a PCL tear.

A posterior drawer test can also be done.

This is the left knee of a patient.  Notice that there is no posterior laxity on posterior drawer  test.

This is the right knee of the same patient.  Notice the posterior sag of the tibia on posterior drawer test.

This implied a PCL tear in this patient’s right knee.

What are the Useful Investigations?

A knee x-ray should be done. This is to exclude a bony avulsion of the PCL off the tibial bone insertion. This can be treated with open reduction and internal fixation using screws.

I find the stress views of the knee in the lateral position with the knee at 90 degrees of flexion useful. I will request that each knee be subjected to an anterior and posterior drawer at the time of the x-rays. The knee with the PCL tear will show increased posterior translation of the tibial with respect to the femur.

Note the increased posterior sag in the left knee compared to the right knee during posterior drawer test:

PCL Stress Lateral Views

How to Classify the Severity of PCL Tears?

A PCL tear can be classifed as either an isolated PCL tear, where only the PCL is injured, or as a combined ligament injury. A combined ligament injury would involve a tear of the PCL and at least one other injured ligament. A common example would be a PCL and lateral-sided ligament injury.

Injuries to the PCL can also be graded as I, II or III.

Grade I and II injuries are partial PCL tears. Grade I refers to only a few mm of sag of the tibia backwards while Grade II injuries refer to sagging of the tibia to the level flush with the end of the thigh bone (femur). This roughly corresponds to 1 cm of backwards sag.

A grade III injury signifies a complete rupture and the tibia sags backwards even further. It is likely that when a grade III injury occurs, there are other ligaments torn along with the PCL. It is important to scrutinize the type of PCL injury an athlete sustains because there are significant treatment implications, especially for a Grade III or combined ligament injury.

How to Decide on Treatment?

A partial PCL tear, grade I and II, are typically treated non-operatively with a long course of intensive physical therapy to strengthen the surrounding muscles controlling the knee.

Complete PCL tears often require surgical treatment to regain knee stability.

When the PCL pulls off a small piece of bone from the back of the lower leg (tibial avulsion), the PCL may be surgically repaired. If the bone fragment is large enough a screw can be place to secure the piece of avulsed bone back to where it was originally.

However in the majority of PCL injuries, the ligament tears in the middle of the structure. In this case, the PCL must be reconstructed which refers to replacing the entire ligament with what is known as a graft.

PCL Reconstruction

I perform both single bundle and double bundle PCL reconstructions.

My graft of choice can be either autogenous hamstrings or allografts (usually tibialis anterior tendons).

Example of a PCL Single Bundle Reconstruction using Hamstring Grafts

The hamstring grafts are harvested from the patient through a small 3cm oblique incison along the medial aspect of his proximal shin bone.

The hamstring grafts are then prepared as shown.

Preparing the Hamstring grafts

Stitching the Hamstring grafts

Grafts looped over endobutton and pre-tensioned

This is a video of the surgical procedure.

For more information on PCL injuries and the treatments, please contact us at 683 666 36 or email hcchang@ortho.com.sg

Do visit us at www.ortho.com.sg

A bony growth that appears at the back of the heel bone can occur. This growth is called an exostosis (a benign cartilaginous growth) and is known as Haglund’s deformity.

This bony prominence can rub against the overlying Achilles tendon and causes pain in the tendon.  A small sac (called bursa) that lies between the bone and the Achilles tendon usually becomes inflamed and swollen.  This is called retrocalcaneal bursitis.

Haglund's Bony Protruberance Causing Bursitis and Achilles Tendon Pain

The syndrome is caused by repetitive impingement of the bursa between the ventral aspect of the Achilles tendon and the posterosuperior calcaneal prominence. Typically, patients have pain when they start to walk after a period of rest.

Haglund’s deformity can occur in one or both feet. The signs and symptoms include:

•     A noticeable bump on the back of heel
•     Pain in the area where the Achilles tendon attaches to the heel.
•     Swelling in the back of the heel.
•     Redness near the inflamed tissue.

Haglund’s disease is characterized by pain and tenderness at the posterolateral aspect of the calcaneus where a  calcaneal prominence can be palpated. This entity also is known as ‘‘pump-bump.’’ A distinction between Haglund’s disease and other pathologic conditions, such as a superficial Achilles bursitis, must be made.

Haglund’s syndrome involves a painful swelling of an inflamed retrocalcaneal bursa, sometimes combined with insertional tendinopathy of the Achilles tendon.

What Causes This?

High arches (pes cavus) can contribute to Haglund’s deformity. The Achilles tendon attaches to the back of the heel bone, and in a person with high arches, the heel bone is tilted backward into the Achilles tendon. This causes the uppermost portion of the back of the heel bone to rub against the tendon. Eventually, due to this constant irritation, a bony protrusion develops and the bursa becomes inflamed. It is the inflamed bursa that produces the redness and swelling associated with Haglund’s deformity.

A tight Achilles tendon can also play a role in Haglund’s deformity, causing pain by compressing the tender and inflamed bursa. In contrast, a tendon that is more flexible results in less pressure against the painful bursa.

Another possible contributor to Haglund’s deformity is a tendency to walk on the outside of the heel (varus heel). This tendency, which produces wear on the outer edge of the sole of the shoe, causes the heel to rotate inward, resulting in a grinding of the heel bone against the tendon. The tendon protects itself by forming a bursa, which eventually becomes inflamed and tender.

This is a person who is an avid runner.  He has pain in both heels from Haglund’s deformity.   The right heel was operated on with an open technique.  The Haglund’s exostosis was removed surgically with improvement of his right heel pain.   His left heel was now giving him pain when running.

Diagnosis

There is usually pain in the Achilles tendon insertion into the calcaneus (heel bone) posteriorly.

The Achilles tendon can be thickened (swollen) and tight.

There is pain in the retrocalcaneal bursa (see the 1st picture in this article).

I usually check for high arch of the foot as well as look at the heel from the back with the patient standing to make sure that there is no heel varus (the heel points inwards when standing).  These physical signs usually point to poorer results with treatment.

An X-ray of the heel can be done to look for any Haglund’s exostosis or deformity.

An MRI scan can be done.  This is useful to diagnose Achilles tendinosis (which is related to the Haglund’s bump), swelling of the sac between the Haglund’s bump and  Achilles tendon (retrocalcaneal bursitis).

MRI of Haglund's with Retrocalcaneal Bursitis | HC Chang

Non-Surgical Treatment

Non-surgical treatment of Haglund’s deformity is aimed at reducing the inflammation of the bursa. While these approaches can resolve the bursitis, they will not shrink the bony protrusion. Non-surgical treatment can include one or more of the following:

•     Medication. Anti-inflammatory medications may help reduce the pain and inflammation. Some patients also find that a topical pain reliever, which is applied directly to the inflamed area, is beneficial.

•     Ice. To reduce swelling, apply a bag of ice over a thin towel to the affected area for 20 minutes of each waking hour. Do not put ice directly against the skin.

•     Exercises. Stretching exercises help relieve tension from the Achilles tendon. These exercises are especially important for the patient who has a tight heel cord.

•     Heel lifts. Patients with high arches may find that heel lifts placed inside the shoe decrease the pressure on the heel.

•     Heel pads. Placing pads inside the shoe cushions the heel and may help reduce irritation when walking.

•     Shoe modification. Wearing shoes that are backless or have soft backs will avoid or minimize irritation.

•     Physical therapy. Inflammation is sometimes reduced with certain forms of physical therapy, such as ultrasound therapy.

•     Orthotic devices. These custom arch supports are helpful because they control the motion in the foot, which can aggravate symptoms.

•     Immobilization. In some cases, casting may be necessary to reduce symptoms.

Surgical Treatment

If non-surgical treatment fails to provide adequate pain relief, surgery may be needed.

Operative treatment consists of removal of the inflamed bursa and resection of the bony prominence. This can be done by the traditional open surgical technique with a 3 to 4cm scar or a minimally invasive endoscopic technique using 2 small stab incisions.

I perform a minimally invasive procedure to remove the Haglund’s bony prominence. This procedure is called Endoscopic Calcaneoplasty.

Endoscopic Calcaneoplasty

The operation is performed under general or regional anesthesia with the patient in a prone position.

The patient is in a prone position. The opposite leg is held away from the surgical field.

I use the fluoroscope (x-rays) to localise the position of the Haglund’s exostosis.

Fluroscopic Localisation of Haglund's

A small vertical incision is made through the skin at the level of the superior aspect of the calcaneus. The  retrocalcaneal space is penetrated by a blunt trocar. A 4.5-mm arthroscope is introduced into the retrocalcaneal space.

Dr HC Chang perforrming Endoscopic Calcaneoplasty

Under direct vision a spinal needle is introduced just medial to the Achilles tendon, again at the level of the superior aspect of the calcaneus, to locate the medial portal. After making a vertical stab incision, the 3.5-mm full radius
resector is placed and visualized by the arthroscope. The inflamed retrocalcaneal bursa is removed to provide a better view.

The superior surface of the calcaneus is visualized, and its fibrous layer and periosteum is stripped off using a radiofrequency wand.

Using radiofrequency wand to clear soft tissue

The Haglund’s exostosis is exposed.

Haglund's exostosis with foot in neutral position

When the foot is brought into full dorsiflexion, the impingement site is determined.

Haglund's exostosis impinging the Achilles tendon with foot in dorsiflexion

A 4.0mm hooded arthroscopic burr is used to remove the Haglund’s exostosis. All of the time the opening of the burr is facing the bone. The foot is placed in full plantarflexion and the posterior superior bone rim can be removed.

Burring away the Haglund's exostosis

Upon completion of the procedure, the exostosis should be flattened and the insertion of the Achilles tendon into the heel bone should be clearly seen.

Completion of Removal of Haglund's exostosis

View from lateral portal showing the Achilles tendon insertion

An intra-operative fluroscopy (x-rays) is taken to confirm complete removal of the Haglund’s protruberance.

Pre and Post Endoscopic Calcaneoplasty

This is the surgical scar after skin closure:

Surgical Wounds in Endoscopic Calcaneoplasty

Post-Surgical Recovery

The patient is allowed to walk with the help of crutches and avoid bearing weight in his operated foot for the next 3 weeks.

The operated foot should be elevated for at least 3 to 5 days.

The surgical wound should heal in 14 days after surgery and the stitches are removed.

The patient can start putting more weight on the operated foot from 3rd week onwards.

He can resume running in 3 months’ time.

The success rate of this procedure has been quoted to be 90%.

For more information on the treatment of heel pain, please contact us at +65-683 666 36 or email hcchang@ortho.com.sg

Do visit our website at www.ortho.com.sg

What Is Mucoid Degeneration of the ACL?

This is basically an MRI diagnosis of expansion and increased signal of an intact ACL in a person with knee pain which is worse on knee flexion/bending.

Presentation

Patients usually present with nonspecific posterior knee pain with restriction of flexion. There is usually no restriction of knee extension, no complaints of instability, no major trauma episode preceding the symptoms. It affects people of all age group but more commonly in the middle-aged patients, between 35 and 52 years old.

Mucoid Degeneration of ACL

What is the Cause?

The cause of mucoid degeneration of the ACL remains unknown. Two theories are generally accepted. One theory is that this lesion may simply represent a continuum of senescent degeneration (aging) of the ligament. I do not really subscribe to this theory as there have been reports of such cases in young people as well.  The second theory considers that congenitally displaced synovial tissue maybe the cause of cystic lesions within mucinous degeneration.  The truth is no one really knows why or how it occurs.

The lesion may look like an elongated cyst along the long axis of the ACL, or as an enlarged ACL. Discrete intraosseous ganglia are observed in 3/4 of the cases with mucoid degeneration of the ACL. These ganglia consist of myxoid material.

The MR-findings of mucoid degeneration of the ACL include:

• an ill-defined ACL
• an increased ligamentous girth
• a normal orientation of the ligament and an increased signal intensity on all sequences interspersed among visible intact ACL fibers (“celery stalk” appearance).

What is the Treatment?

Arthroscopic surgery is a great option to allow partial excision of the degenerate lesions of the ACL resulting in immediate pain relief and improvement of the range of motion without any symptoms of instability. The significant pain relief is being attributed to the decreased volume and tension in the ACL.

Mucoid degeneration of the ACL should be considered when an apparently thickened and ill-defined ACL with increased signal intensity on all sequences is identified in a patient with a clinically intact ACL.

Any Other Problems?

There has been reports of secondary instability of the knee after this surgery as the anterior cruciate ligament can be weakened to the state that it ruptures or is no longer functional.

There is also a risk of recurrence of the mucoid degeneration over time.

For more information, please contact us at +65-683 666 36 or email hcchang@ortho.com.sg

Do visit us at www.ortho.com.sg

The medial meniscus or inner shock absorber of the knee has attachment in the front (anterior horn) and the back (posterior horn).

The posterior horn or root can tear as a result of degeneration or trauma.

This typical presentation include:

1. Sudden onset of severe  knee pain.
2. Does not improve with pain killers.
3. May be associated with a sudden “pop” when walking followed by the onset of pain.
4. Typically in people older than 55.
5. Knee swelling within the next 1 day.
6. Pain is felt at the back of the knee.
7. Pain on bending the knee or squatting. Most patients cannot squat due to this pain.

The physical examination may show some swelling in the knee joint. Typically these knees already have some pre-existing degeneration or osteoarthritis.

There is usually pain on pressing of the inner and posterior aspect of the joint line of the knee.  The patient may not be able to squat down.

X-rays may show some osteoarthritis which was probably pre-existing.

MRI scan may sometimes show a root tear.  One need to actively look for a posterior horn root tear on MRI scan if this diagnosis is suspected.

This is a video showing a 59 year old woman who has pre-existing mild knee pain which suddenly worsened severely about 2 weeks ago.  She does not remember any trauma or injury.  She does Yoga as a form of exercise.

She was not able to walk properly due to pain in her right knee.

There was some fluid in her right knee on examination.  Tenderness (pain) was found along the posteromedial aspect of her right knee.

X-rays showed mild osteoarthritic changes.

MRI scan showed a possible posterior horn root tear.

Posterior Horn Medial Meniscus Root Tear

Arthroscopy of her right knee was done.  It showed an incomplete tear of the posterior root of the medial meniscus. The tear was cleaned up with an arthroscopic shaver and the posterior horn was the medial meniscus was secured to the capsule using a Fast-Fix meniscus repair device.

The patient’s right knee pain improved significantly after this surgery.  She was able to walk the very next day.

For more information on knee pain and meniscus tears, please contact us at 683 666 36 or email hcchang@ortho.com.sg

Do visit our website at www.ortho.com.sg

A SLAP tear is a cause of shoulder pain.

The the long head of your biceps tendon goes inside the shoulder joint and  joins with the glenoid labrum (shoulder cartilage) in the top of the shoulder.

A SLAP tear refers to a tear or avulsion of this attachment of the long head of biceps tendon’s anchorage into the upper portion of the glenoid labrum.

SLAP tear stands for Superior Labrum Anterior Posterior lesion.

Common reasons for a SLAP tear include:

1. Fall onto an outstretched hand
2. Repetitive overhead actions (throwing)
3. Lifting a heavy object

Symptoms of a SLAP tear may include:

1. Painful popping, clicking, or catching in the shoulder.
2. Pain when you move your arm over your head or reach back.
3. Pain when you throw a ball.
4. An ache often described as being deep inside the shoulder.

4 different types of SLAP tears have been described.  The commonest type that I see and treat is the Type 2 tear.

This is an arthroscopic picture of a Type 2 SLAP tear:

The symptoms of a SLAP tear include:

1. Painful popping, clicking, or catching in the shoulder.
2. Pain when you move your arm over your head or reach for the back.
3. Pain when you throw a ball.
4. An ache often described as being deep inside the shoulder (often difficult to pin-point).

Diagnosis of SLAP tear includes:

• Clinical examination.  I have found the O’Brien’s test to be useful in my clinical practice. This is a picture of how this test is done:

• MRI scan can usually show the tear.

SLAP tears rarely heal well without surgery in my experience.  The treatment is arthroscopic (keyhole) surgery to the shoulder to repair the tear back to the glenoid attachment.

This picture shows a type 2 SLAP tear being examined during arthroscopy of the right shoulder.

This is a picture of the SLAP tear after it has been surgically repaired through key-hole surgery.

For more information on SLAP tear of the shoulder or if you need advice on shoulder pain problems, please contact Dr HC Chang at 683-666-36 or email hcchang@ortho.com.sg

Do visit our website at www.ortho.com.sg

PVNS Knee

What is PVNS?

Pigmented villonodular synovitis (called PVNS for short) is a joint problem that usually affects the knee. It can also occur in the shoulder, ankle, elbow, hip, hand or foot.

When you have PVNS, the lining of a joint becomes swollen and grows. This growth harms the bone around the joint. The lining also makes extra fluid that can cause swelling and make the joint hurt.

Who Gets PVNS?

PVNS is not common. It usually affects people 20 to 45 years old, but it can also occur in children and people over 65 years old. Both men and women can suffer from this problem.

We do not know what causes PVNS. Some people with PVNS remember that they hurt their joint at some time in the past.

For unknown reasons, some or all of the synovial lining tissue of a joint occasionally undergoes a change and becomes diseased, wherein the joint lining tissue becomes thick and overgrown and accumulates a rust-colored, iron pigment known as hemosiderin. Strange, foamy cells and large (so-called “giant”) cells with many nuclei also appear. The overgrowth of the joint lining tissue can occur diffusely throughout a joint by way of a generalized thickening of the entire lining membrane, or a localised area of synovial membrane can overgrow and form a discrete nodule (tissue mass) that remains attached to the rest of the internal joint lining by way of a stalk. While this disease process does involve abnormal tissue growth, it is uniformly benign and has not been known to metastasize as do malignant growths. PVNS can be considered a benign, “neoplastic” (tumor growth) process, with some varieties being more aggressive in their growth and thus harder to treat, and other varieties being less aggressive in their growth and thus easier to treat.

What Are the Symptoms?

The common symptoms are swelling of the affected joint. As the knee joint is the most commonly affected joint in PVNS, the person may have swelling of the knee joint.

Swollen knee from PVNS

It can also cause pain due to erosion of the articular cartilage of the joint by the locally aggressive tumour.

pvns knee x-ray with erosion of patella

Sometimes the person with PVNS may present with acute swelling and pain in the knee. There may be a history of pain after getting up from a squatting position. The knee joint may become locked due to the tumour blocking knee extension.

How t0 Diagnose PVNS?

PVNS can look like arthritis and some other conditions.

After a physical exam, x-rays of the joint that hurts may be useful.

Soft tissue swelling seen on X-rays

Your doctor may also want to draw some fluid from the joint and test it.

pvns knee aspirate

Another test, magnetic resonance imaging (also called MRI), takes a “picture” of the joint.

Note the Nodular Tumours in front and behind the knee

What is the Treatment?

The best way to treat PVNS is to remove the lining of the joint. This can be done with regular surgery (sometimes called “open” surgery) or with arthroscopy. In arthroscopy, the doctor makes a tiny cut in the skin over your joint. Then a thin tube is put into the joint to remove the lining.

Even with treatment, PVNS comes back about half of the time. If the pain comes back again and again, radiation therapy may help. Sometimes, the joint may need to be replaced.

This is a video of a patient who presented with acute knee locking (inability to straighten the knee) after getting up from a squatting position. MRI showed nodular PVNS in the right knee.

Arthroscopic resection of the PVNS tumour together with thorough arthroscopic synovectomy was performed.

This is the picture of the tumours that were removed:

PVNS Tumours removed from the Knee

Summary

Treatment of PVNS is surgical excision.

For more information on PVNS, please contact us at 683 666 36 or email hcchang@ortho.com.sg

Visit us at www.ortho.com.sg

It can affect someone who does a lot of free-style swimming, tennis serves, badminton smashes etc.

The best x-rays to diagnose the bony spur include the AP and Supraspinatus outlet view.

This is an AP view of a right shoulder with shoulder impingement syndrome:

Anteroinferior Acromial Spur of the Shoulder

This is the Supraspinatus outlet view X-ray of a right shoulder showing a large bony spur. This is a typical Bigliani type 3 acromion with a hook.

Subacromial Impingement by Type 3 Spur

A high degree of suspicion for rotator cuff tendon tear should be borne in mind if the patient has a lot of rest pain, night pain or weakness of the affected shoulder.

This is the MRI scan of the right shoulder of this patient with shoulder impingement syndrome. 

The MRI shows a full thickness tear of the supraspinatus tendon. 

Full thickness Tear of Supraspinatus Cuff Tendon

In those with rotator cuff tendon tear of a longer duration, the muscle belly may undergo disuse atrophy (wasting).

This MRI shows the supraspinatus muscle atrophy.

Supraspinatus Muscle Atrophy

The treatment for this patient will include:

1. Arthroscopic removal of the bony spur i.e. arthroscopic subacromial decompression.
2. Arthroscopic repair of the shoulder tendon.

For more information on shoulder pain, please contact us at 683 666 36 or email us at hcchang@ortho.com.sg

Do visit our website at www.ortho.com.sg