Diffuse pigmented villonodular synovitis (diffuse-type giant cell tumour) of the foot and ankle

MRI Prediction Model for Tenosynovial Giant Cell Tumor with Risk of Diffuse-type

RATIONALE AND OBJECTIVES

To propose a magnetic resonance imaging (MRI) prediction model for diffuse-type tenosynovial giant cell tumors (D-TSGCTs).

MATERIALS AND METHODS

Anatomic locations were classified and then nodularity, margin, peripheral and internal hypointensity, and bone and cartilage involvement were evaluated on MRI. Student's t-test, chi-square test, diagnostic performance, logistic regression analysis, and decision tree were performed.

RESULTS

Nineteen intra-articular (11 localized; eight diffuse) and 55 extra-articular (44 localized; 11 diffuse) TSGCTs were included. Extra-articular D-TSGCTs showed significantly more frequent multinodular (72.7% vs. 25.0%, p = 0.009), and infiltrative lesions (90.9% vs. 34.1%, p = 0.002), without peripheral hypointensity (90.9% vs. 18.2%, p < 0.001), and contained granular internal hypointensity (72.7% vs. 31.8%; p = 0.003) with more frequent bone (81.8% vs. 27.3%; p = 0.003) and cartilage (50.0% vs. 0.0%; p = 0.038) involvement than localized-type. Intra-articular D-TSGCT also showed significance in all MRI features (100.0% vs. 9.1%, p = 0.001; 100.0% vs. 27.3%, p = 0.007; 100.0% vs. 36.4%, p = 0.018; 100.0% vs. 27.3%, p = 0.007; 50.0% vs. 0.0%, p = 0.038), except bone involvement (37.5% vs. 9.1%, p = 0.352) than localized-type. Cartilage involvement revealed the highest specificity (88.6-100.0%), regardless of location. Nodularity (100.0%; odds-ratio [OR]: 70.000) and peripheral hypointensity (90.9%; OR: 62.250) demonstrated the highest sensitivities ORs for D-TSGCT in intra-articular and extra-articular cases, respectively. MRI models for D-TSGCG beginning with the cartilage involvement in both anatomic locations and next on nodularity and peripheral hypointensity in intra-articular and extra-articular locations, respectively, exhibited sensitivity and specificity of 100% and 90.9% for intra-articular and 100% and 77.2% for extra-articular TSGCTs, respectively.

CONCLUSION

MRI can suggest the risk of D-TSGCT by combining imaging features with anatomic locations.

Distraction Arthroplasty Combined with Autologous Bone Grafting for Diffuse-type Tenosynovial Giant Cell Tumour with Articular Cartilage Defect and Subchondral Bone Cysts: A Case Report

Tenosynovial giant cell tumour encompasses a group of lesions that present with synovial differentiation and most commonly occur in the joint synovium, bursae, and tendon sheaths. Diffuse-type tenosynovial giant cell tumour, previously known as pigmented villonodular synovitis, is one of the most common benign soft tissue tumours of the foot and ankle and usually affects young adults. The differential diagnosis of diffuse-type tenosynovial giant cell tumours remains a clinical problem because its clinical symptoms are similar to those of inflammatory arthritis, including rheumatoid arthritis. Moreover, persistent diffuse-type tenosynovial giant cell tumours can lead to articular deterioration, including osseous erosions and subchondral bone cysts. Joint-preserving procedures are considered optimal for treating younger patients with ankle osteoarthritis because the indication of ankle arthrodesis and total ankle arthroplasty is limited. Thus, ankle distraction arthroplasty could be an alternative for treating diffuse-type tenosynovial giant cell tumour with articular deterioration in young patients. Here, we report about a woman in her early 30s who presented with ankle pain owing to a diffuse-type tenosynovial giant cell tumour with an articular cartilage defect and subchondral bone cysts. We performed ankle distraction arthroplasty combined with an autologous bone graft. A follow-up examination at 2 years revealed preservation of physical function and pain alleviation. These findings suggest that distraction arthroplasty is a viable treatment option for remedying the destruction of the articular cartilage and subchondral bone owing to diffuse-type tenosynovial giant cell tumours in young adults.

Treatment, recurrence rates and follow-up of Tenosynovial Giant Cell Tumor (TGCT) of the foot and ankle-A systematic review and meta-analysis

Background

The tenosynovial giant cell tumor (TGCT) is a usually benign lesion which arises from the synovium. It affects joints, tendon sheaths and bursae. The clinical course is often unpredictable, and local recurrences frequently occur. The aim of this study was to describe different treatment options, surgical complications, and to develop a follow-up regime based on a systematic literature review and meta-analysis of foot and ankle lesions.

Methods and results

1284 studies published between 01/1966 and 06/2021 were identified. 25 met the inclusion criteria, with a total of 382 patients. Of these, 212 patients had a diffuse (dTGCT) and 170 a localized (lTGCT) TGCT. Patients with a dTGCT had a mean age of 36.6±8.2 years, and 55% were female. The overall complication rate was 24% in dTGCT, irrespective of the therapeutic procedure; the mean follow-up was 37.9±27.4 months with a recurrence rate of 21%, and recurrences occurred between 3 and 144 months, the vast majority (86%) within the first 5 years following intervention. Patients with a lTGCT had a mean age of 31.2±5.7 years, and 53% were female. Complications occurred in 12%. The mean follow-up was 51.1±24.6 months, the recurrence rate was 7%, and recurrence occurred between 1 and 244 months after intervention.

Conclusion

Diffuse TGCTs of the foot and ankle region have a remarkable recurrence rate irrespective of therapeutic procedures, and most lesions reoccurred within 5, with more than half of these in the first 2 years. The lTGCTs are well treatable lesions, with a low recurrence and a moderate complication rate. Based on these findings, we propose a follow-up regime for the dTGCT including a clinical survey and MR imaging 3 months after surgical intervention (baseline), followed by twice-yearly intervals for the first 2 years, yearly intervals up to the fifth year, and further individual follow-up due to the fact that recurrences can even occur for years later. For the lTGCT a clinical survey and MRT is proposed after 3–6 months after intervention (baseline), followed by annual clinical examination for 3 years, and in case of symptoms MR-imaging. Larger prospective multi-center studies are necessary to confirm these results and recommendations.

[Imminent fracture of the tibia due to an osteolytic lesion caused by an intraosseous tenosynovial giant cell tumor : An unusual clinico-histopathological constellation]

Der tenosynoviale Riesenzelltumor (TSGCT) ist eine seltene gutartige Erkrankung von Gelenkschleimhäuten, Sehnenscheiden und Schleimbeuteln. Wir berichten über die ungewöhnliche Konstellation einer intraossären Manifestation der proximalen Tibia eines Unterschenkelstumpfes nach Burgess-Amputation infolge eines lokal nicht beherrschbaren tenosynovialen Riesenzelltumors des oberen Sprunggelenkes. Die Kürettage des Lokalbefundes und die operative Stabilisierung durch eine intramedulläre Verbundosteosynthese führten zu einer frühzeitigen Rehabilitation der Exoprothesenversorgung mit Wiedererlangung der Patientenautonomie.

Tenosynovial giant cell tumor of the upper cervical spine arising from the posterior atlanto-occipital membrane: a case report

A tenosynovial giant cell tumor is a benign proliferative disease, mostly arising from the synovial membrane of tendon sheaths, bursae, and joints. Axial skeleton involvement is very rare, but it is often found in the cervical spine. Spinal tenosynovial giant cell tumors often arise at the facet joints; a completely extra-articular spinal tenosynovial giant cell tumor is rare. We report an extremely rare case of tenosynovial giant cell tumor in the upper cervical spine that extended from the posterior atlanto-occipital membrane rather than the facet joint. Herein, the clinical and radiological findings will be reviewed to better our understanding of the characteristics of spinal tenosynovial giant cell tumors, and to help improve their diagnosis despite their non-typical locations of origin.

Incomplete resection increases the risk of local recurrence and negatively affects functional outcome in patients with tenosynovial giant cell tumor of the hindfoot

BACKGROUND

Diffuse tenosynovial giant cell tumors (TGCT) are more likely to occur in the hindfoot and tend to recur after surgical excision. We performed a pooled analysis of hindfoot TGCT cases to identify factors associated with local recurrence and functional outcomes.

METHODS

We retrospectively reviewed medical records of 33 patients diagnosed with TGCT (15, localized cases; 18 diffused cases) of the hindfoot between 1998 and 2017. Median follow-up was 32 months. Multivariable Cox proportional hazards regression analysis was conducted to estimate the hazard ratios for risk factors for local failure. Generalized linear regression models were used to assess whether resection status, tumor size, tumor type or bone involvement correlated with the Musculoskeletal Tumor Society (MSTS) score.

RESULTS

Local failure was reported in 30% (10/33) patients. Multivariable analysis showed that macroscopically incomplete resection was the only independent prognostic factor for poor local failure-free survival (P=.001). Incomplete resection significantly decreased MSTS score and negatively affected functional outcome (P=.047).

CONCLUSIONS

Incomplete resection increases the risk of local recurrence and negatively affects functional outcome in patients with TGCT of the hindfoot.

Tenosynovial giant cell tumor in the foot and ankle

BACKGROUND

Tenosynovial giant cell tumor (TSGCT) originates from the synovial cells of the tendon sheath and is the most common soft tissue tumor of the foot and ankle. Due to the lack of clinical data about TSGCT in the foot and ankle, this study was performed with the aim of investigating the clinical characteristics, and surgical outcomes that might predict the likelihood of recurrence.

METHODS

Clinical data, obtained from the pathology records and the clinic files, along with the tumor subtype, local recurrence, and patient functional status among 26 cases of TSGCT were evaluated with the mean 73 months follow-up period.

RESULTS

There were 26 patients including 16 males and 10 females with a mean age of 40 years, who underwent surgery. There were 15 localised TSGCT and 11 diffuse TSGCT. The diffuse TSGCT was more likely to be in the hindfoot dorsum (54,5%, 6/11). The localised TSGCT was mostly located in the forefoot (80%, 12/15). The recurrence rate in the diffuse TSGCT was 27,3% (3/11). In the localised TSGCT, recurrence was seen in 6,6% of patients (1/15). The mean AOFAS score was 79.

CONCLUSION

Diffuse TSGCT is more likely to occur in the hindfoot and localised TSGCT is more common in the forefoot. Excision with clear margins is an effective treatment for TSGCT, with good oncological and clinical outcomes. But the orthopaedic surgeons should consider the equilibrium between surgical margins and the functional status of the patient.

Unusual manifestations of diffuse-type tenosynovial giant cell tumor in two patients: importance of radiologic-pathologic correlation

Diffuse-type tenosynovial giant cell tumor (TSGCT) is a rare, locally aggressive neoplasm. It most commonly occurs in the knee, followed by the hip, and has distinctive imaging features, including mass-like foci of low T2 signal intensity, "blooming" on gradient-echo MRI, and pronounced uptake on FDG PET/CT. Histologically, TSGCT demonstrates a neoplastic population of mononuclear cells admixed with hemosiderin-laden macrophages, foamy histiocytes, inflammatory cells, and osteoclast-like giant cells. In cases where diffuse-type TSGCT presents in an uncommon location or with atypical features, the imaging diagnosis may be challenging. Furthermore, because of its polymorphous appearance, it may be mistaken microscopically for other neoplastic and non-neoplastic histiocytic lesions. Herein, we present two cases of diffuse-type TSGCT presenting as large masses, and underscore the importance of radiologic-pathologic correlation for accurate diagnosis.

Patient-Reported Outcome Measures in Sports Medicine: A Concise Resource for Clinicians and Researchers

BACKGROUND

Despite the importance of assessing patient outcomes during patient care, current evidence suggests relatively limited use of patient-reported outcome measures (PROMs) by athletic trainers (ATs). Major barriers to PROM use include lack of knowledge, navigating the intricate process of assessing a wide variety of PROMs, and selecting the most appropriate PROM to use for care. A concise resource for ATs to consult when selecting and implementing PROMs may help facilitate the use of PROMs in athletic health care.

OBJECTIVE

To review the instrument essentials and clinical utility of PROMs used by ATs.

METHODS

We studied 11 lower extremity region-specific, 10 upper extremity region-specific, 6 generic, and 3 single-item PROMs based on the endorsement of at least 10% of ATs who use PROMs, as reported in a recent investigation of PROM use in athletic training. A literature search was conducted for each included PROM that focused on identifying and extracting components of the instrument essentials (ie, instrument development, reliability, validity, responsiveness and interpretability, and precision) and clinical utility (ie, acceptability, feasibility, and appropriateness). Through independent review and group consensus, we also classified each PROM question by International Classification of Functioning, Disability and Health domain and health-related quality-of-life dimensions.

KEY FINDINGS

The PROMs contained in this report generally possessed appropriate instrument essentials and clinical utility. Moreover, the PROMs generally emphasized body structure and function as well as the physical functioning of the patient. Athletic trainers aiming to assess patients via a whole-person approach may benefit from combining different PROMs for use in patient care to ensure broader attention to disablement health domains and health-related quality-of-life dimensions.

Risk factors for early osteoarthritis in tenosynovial giant cell tumour

OBJECTIVE

Tenosynovial giant cell tumour (TGCT) is locally aggressive entity affecting young people (around 4^th decade of life) and can cause joint destruction. It could be nodular or diffuse. These two varieties are histological and genetically similar, but present a different prognosis. The aim of this study is to identify risk factors for local recurrence and predisposing factors for the development of early osteoarthritis in patients with TGCT.

MATERIAL AND METHODS

We conducted a retrospective study of 35 patients with an anatomopathological diagnosis of TGCT in our Institution from 1991 to 2017. The mean follow-up was 8.2 years. Demographic variables, characteristics of the primary tumor and its evolution were collected to assess the risk factors for local recurrence and early osteoarthritis.

RESULTS

The diffuse type was identified as a risk factor for the development of osteoarthritis (p=0.01) and for local recurrence (p=0.015). Osteoarthritis was more frequent in the hip and ankle than in the knee (p=0.03). A difference of 16 months in the duration of symptoms prior to diagnosis between those who developed osteoarthritis and those who did not was observed (p=0.05).

CONCLUSIONS

The diffuse type is more aggressive than the nodular type; it is associated with a higher risk of osteoarthritis and local recurrence. The hip and ankle present a higher risk of osteoarthritis than other joints. The time of evolution of the symptoms before diagnosis and adequate treatment, negatively influences the development of osteoarthritis.

A Rare Incidence of Pigmented Villonodular Synovitis of the Ankle in an Adolescent

Pigmented villonodular synovitis mostly affects the knee and other large joints such as the hip. Although the disease is most commonly found in adult patients aged 30 to 40 years, rare cases in children and the elderly have been reported. We present the case of an 11-year-old female who was found to have biopsy-proven pigmented villonodular synovitis in her subtalar joint in 2012. Five years after surgical excision, the patient has continued to be involved in competitive dancing and cheerleading without any pain in her ankle. Moreover, follow-up magnetic resonance imaging studies showed no evidence of recurrence. Our case report emphasizes that the disease should not be solely considered in the middle-age population but should be included in the differential diagnosis of the pediatric patient.

Results and recurrence of pigmented villonodular synovitis of the ankle: does diffuse PVNS with extra-articular extension tend to recur more often?

PURPOSE

The aim of this study was to provide the outcomes and to analyze the recurrence of Pigmented Villonodular Synovitis (PVNS) of the ankle joint treated by surgical synovectomy.

METHODS

Thirty-one PVNS cases of the ankle, including 5 localized PVNS cases and 26 diffuse PVNS cases, were treated in our institute between 2004 and 2015. The median age was 35 (range 18-63) years. The 5 localized PVNS cases were treated with partial synovectomy (group I); 10 diffuse PVNS cases limited to intra-articular synovium received arthroscopic comprehensive synovectomy (group II); and 16 cases with diffuse PVNS spreading to extra-articular tendon sheaths underwent combined arthroscopic and open synovectomy (group III). Adjuvant radiotherapy was provided in groups II and III. The American Orthopaedic Foot and Ankle Society (AOFAS) score and subjective grading of procedure were used to evaluate the results.

RESULTS

Twenty-seven patients were followed with a median of 54 (range 15-108) months. In the three groups, the average AOFAS score improved from 75 (in all three groups) points preoperatively to 100 (group I), 97 (group II), and 90 points (group III) postoperatively. The rate of good-to-excellent result was 100% in group I and II and 73.3% in group III. Only in group III, recurrence occurred in five cases.

CONCLUSIONS

Diffuse PVNS of the ankle can be successfully managed with surgical synovectomy and adjuvant radiotherapy. Radiotherapy is not needed for localized PVNS. The recurrence rate in PVNS patients with extra-articular extension is higher.

LEVEL OF EVIDENCE

IV.

Tenosynovial Giant Cell Tumor in the Midfoot Treated With Femoral Head Allograft Reconstruction

Tenosynovial giant cell tumor (also known as giant cell tumor of tendon sheath or pigmented villonodular synovitis) is a rare soft tissue tumor that arises from the tenosynovium of a tendon sheath or the synovium of a diarthrodial joint. This disease process occurs infrequently in the foot and ankle but can result in significant bone erosion and destructive changes of affected joints. These cases are challenging to treat, because the tumor most commonly presents in young, active patients and can be associated with extensive bone loss. We review a case of tenosynovial giant cell tumor of tendon sheath of the midfoot, which was treated with mass resection, structural femoral head allograft bone grafting, and internal fixation with dorsal plating. The patient had achieved successful bony fusion and acceptable functional outcomes at the final follow-up visit 40 months postoperatively.

Cystic bone tumors of the foot and ankle

Bone tumors are relatively rare in the foot and ankle region. Many of them present as cystic lesions on plain films. Due to the relative rarity of these lesions and the complex anatomy of the foot and ankle region, identification of such lesions is often delayed or they get misdiagnosed and mismanaged. This review discusses the most common cystic tumors of the foot and ankle including their radiographic features and principles of management.

Diffuse Pigmented Villonodular Synovitis Around the Ankle

BACKGROUND

Pigmented villonodular synovitis (PVNS) is a rare disorder around the ankle joint. The optimal treatment for diffuse-type PVNS is still controversial because of the high incidence of recurrence. We present the clinical features of our patients and review the current diagnostic and treatment modalities.

METHODS

Five patients with PVNS located around the ankle were surgically treated. In three patients, diffuse PVNS arose from the ankle joint, and in the other two it arose from the calcaneocuboid and intercuneiform joints. The average follow-up time after surgery was 2.9 years (range, 2-4.6 years).

RESULTS

The average time between onset of pain and diagnosis of PVNS was 6.4 years (range, 4-10 years). Arthrotomic tumor resection was performed in all of the patients. In the three patients with ankle joint PVNS, both medial and lateral approaches were used. One patient experienced mild infection at the surgical site, but this healed conservatively. No tumor recurrences had occurred after minimum follow-up of 2 years, although mild pain persisted in the three patients with ankle PVNS.

CONCLUSIONS

Diagnosis of diffuse PVNS is frequently delayed due to vague symptoms and variable growth patterns. Orthopedic clinicians should be aware of the existence of this lesion, and it should be suspected in patients with persistent ankle swelling. To prevent tumor recurrence, accurate evaluation of tumor location and careful operative planning are mandatory. A combined surgical approach involving medial and lateral incision is necessary to expose the entire joint cavity.

Arthroscopic treatment of intra-artricularly localised pigmented villonodular synovitis of the ankle: 4 cases with long-term follow-up

BACKGROUND CONTEXT

Pigmented villonodular synovitis (PVNS) is a rare, locally aggressive benign proliferative pathology of synovial tissue. Lesions are classified regarding location as diffuse or localised which are same as histologically. Intra-articularly localised type is relatively rare, especially in the ankle joint. Because of the high recurrence rate and aggressive nature, localised lesions should be excised totally.

PURPOSE

We performed a retrospective study of 4 patients with intra-articularly localised PVNS in the ankle joint who were treated by total arthroscopic excision and evaluated for functional results and recurrence rate.

STUDY DESIGN

Case series.

PATIENT SAMPLE

The mean age of the patients was 27 (17-46) years at the time of arthroscopic surgery. The mean follow-up time was 33 (24-48) months.

METHODS

Functional evaluation according to the Musculoskeletal Tumour Society Score was performed, and patients were evaluated for recurrence by MR imaging.

RESULTS

In all patients, functional results were excellent and there was no recurrence.

CONCLUSIONS

This study demonstrates that the intra-articularly localised PVNS can be successfully treated with arthroscopic procedures without recurrence.

Surgical treatment for diffused-type giant cell tumor (pigmented villonodular synovitis) about the ankle joint

Background

Diffused-type giant cell tumor(Dt-GCT) is a rare, aggressive disorder of the joint synovium, bursa and tendon sheaths. Osseous erosions and subchondral cysts may develop as the result of synovium infiltration in Dt-GCT. We present a retrospective study of a series of patients who are diagnosed with Dt-GCT about the ankle joint, there clinical outcome is evaluated in this study.

Material and method

Fifteen patients with radiologically and histologically confirmed Dt-GCT about the ankle joint were identified in our foot and ankle department. Patients were managed with open synovectomy for the tumor tissue and bone grafting for bony erosions. X-rays and MRI scans were used for evaluation of the tumor and bony erosions pre- and post-operatively. Pre- and post-operative ankle function was assessed using the American Orthopedic Foot and Ankle Society –Ankle and Hindfoot (AOFAS-AH) score and the Muscularskeletal Tumor Society (MSTS) score.

Results

The mean follow-up duration was 37.4 months (range 25 to 50 months). There were 6 males and 9 females, with a mean age of 35 years old (range 18 to 65 years). All patients had talar erosion with the average size of 10.1*9.1*8.2 mm, distal tibia was affected in 5 patients with the average size of 6.2*5.6*5.8 mm. 7 patients had tendon involvement, 2 patients had recurrence and progression of ankle osteoarthritis. Both of them underwent ankle fusion. At the time of last follow-up, the mean AOFAS-AH score increased from 49 to 80 points (p < 0.05), the MSTS score increased from 12 to 22 points (p < 0.05).

Conclusion

For Dt-GCT with bony erosions, open synovectomy combined with bone grafting seems to be a safe and effective operation for the salvage of ankle joint. Fusion is recommended for failed and severe cartilage destruction of the ankle joint.

Giant cell tumor of tendon sheath: Open surgery or arthroscopic synovectomy? A systematic review of the literature

PURPOSE

Giant cell tumor of tendon sheath (GCTTS), formerly known as pigmented villonodular synovitis (PVNS), is a benign, locally aggressive, proliferative disorder of the synovium involving a joint, bursa, or tendon sheath. Treatment of GCTTS involves early surgical resection to limit articular destruction and the risk of recurrence. Synovectomy remains the treatment of choice for GCTTS, but without clear consensus to make an open or arthroscopic synovectomy and no certainty on the responsibility of surgery in the evolution towards the degenerative osteoarthritis. The aim of this study was to evaluate the long-term clinical outcomes and the rate of recurrence of open or arthroscopic excision of GCTTS of the four most frequently involved joints: the shoulder, hip, knee and ankle.

METHODS

We performed a systematic review of literature in September 2015. The keywords were "villonodular synovitis" AND "surgical treatment". The two authors analyzed 413 articles, according to title and abstract. Forty articles were selected, read entirely and references were analyzed.

RESULTS

Thirty-three articles were selected.

CONCLUSION

Our review of literature showed that arthroscopic excision is effective for localized type of GCTTS for all four joints. In diffuse type GCTTS, the efficacy of arthroscopic synovectomy has only been shown for the knee joint. In the other joints, early diagnosis can improve clinical outcomes, but we cannot certify that surgical treatment avoids osteoarthritis degradation.

STUDY DESIGN

Review of literature, level of evidence IV.

Localized pigmented villonodular synovitis of the ankle: Expect the unexpected

BACKGROUND

We present the technique, results and discuss arthroscopic treatment of the localized form of pigmented villonodular synovitis (LPVNS) of the ankle.

METHODS

Medical records of five patients diagnosed and treated for ankle LPVNS with a minimum five-year followup were retrospectively reviewed. All patients were treated arthroscopically, altered synovial tissue was resected and a sample of tissue was sent for pathohistological examination for the definitive diagnosis.

RESULTS

No recurrence was noted at a mean followup of 6.5 years, both clinically and by MRI at one year postoperatively. Patients were evaluated using the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot score, and an improvement was noted from an average score of 65.6 prior to treatment to 94.6 at final followup.

CONCLUSION

Considering the results of this case series, and the absence of complications, arthroscopy is a viable option for treating LPVNS of the ankle.

Localized and diffuse forms of tenosynovial giant cell tumor (formerly giant cell tumor of the tendon sheath and pigmented villonodular synovitis)

Tenosynovial giant cell tumor (TSGCT) is a rare benign tumor arising from joint synovia, bursae and tendon sheaths. Their variable clinical presentation is related to variations in site and progression. Localized forms are most frequent in the hands, and diffuse forms in the knee. MRI is necessary and sometimes sufficient for diagnosis. Treatment strategy is guided by progression, symptomatology, location and diathesis. Optimally complete resection is the principle of first-line treatment. Radiation therapy is effective and targeted therapies are promising; both should especially be considered in case of relapse.

Villonodular synovitis of the ankle. Analysis of the risk of recurrence

INTRODUCTION

Villonodular synovitis (VNS) is a rare disease with an incidence of 1.8 per 1,000,000 inhabitants. VNS of the ankle has seldom been described and evaluated given its extreme rarity (2.5% of VNS cases). It presents an 11% recurrence rate. We report a continuous retrospective series with the main objective of clinically and radiologically evaluating these ankles searching for any risk factors of recurrence. At revision the study's main endpoint was the existence of local recurrence (radiological and clinical) and the secondary endpoint was the existence of tibiotalar osteoarthritis. The working hypothesis was that recurrence could be subclinical, warranting systematic imaging studies during follow-up.

MATERIAL AND METHODS

The study was retrospective, conducted on seven patients (six males) whose mean age was 42 years treated over a period of 9 years (two diffuse forms and five localized forms). The initial treatment consisted in synovectomy via the conventional approach. Four patients also received adjuvant isotopic synoviorthesis treatment. The revision was clinical (MMTS, AOFAS, and OMAS scores) and radiological (standard and MRI) to evaluate the joint after-effects and search for recurrence.

RESULTS

Six patients were seen at a mean 6.5 years of follow-up. One case of early recurrence (4 years) was noted, with a major clinical manifestation because it was associated with joint destruction requiring arthrodesis, and one case of late asymptomatic recurrence (9 years), diagnosed radiologically on the follow-up MRI. The functional results remained good at follow-up (MMTS 77%, AOFAS 71, OMAS 71). Five of the six patients returned to their daily activities. At revision, no sign of osteoarthritis was observed. No risk factor for recurrence was demonstrated.

DISCUSSION/CONCLUSION

The hypothesis was confirmed with the existence of asymptomatic recurrence at revision, underscoring the value of systematic MRI at follow-up. Other than major joint destruction, the prognosis remains good even in case of recurrence. The literature emphasizes the existence of an initial diffuse form and partial surgical resection as risk factors of recurrence. None of the reports in the literature has proven that adjuvant treatment, whose modalities do not meet with consensus, reduces this risk.

LEVEL OF EVIDENCE

Retrospective series, level IV.

Tumours of the foot and ankle

Sarcomas are rare tumours and particularly rarer in the foot and ankle region. The complex anatomy of the foot and ankle makes it unique and hence poses a challenge to the surgeon for limb salvage surgery. Other lesions found in the foot and ankle region are benign bone and soft tissue tumours, metastasis and infection. The purpose of this article is to discuss the relevance of the complex anatomy of the foot and ankle in relation to tumours, clinical features, their general management principles and further discussion about some of the more common bone and soft tissue lesions. Discussion of every single bone and soft tissue lesion in the foot and ankle region is beyond the scope of this article.

Diffuse-type giant cell tumor of the tendon sheath in the temporal region incidentally diagnosed due to a temporal tumor: A report of two cases and review of the literature

Diffuse-type tenosynovial giant cell tumor (D-GCTS) is a rare benign lesion that not only frequently occurs in the fingers, but also along the tendon sheaths of the foot and ankle. The present study reports the cases of two middle-aged patients that were diagnosed with D-GCTS. The presentation of the D-GCTS lesions was extremely rare, as the tumors were located in the temporal fossa and threatened the skull base and external auditory canal. There were similarities and differences between the two patients in their clinical symptoms, disease progressions and invading sites. The patients' disease course occurred unnoticed with the absence of pain, was protracted and became infiltrative. However, the female patient was admitted to the hospital due to the occurrence of pain in the left temporal region, and the male patient presented at the doctor due to a painless left temporal mass and external auditory canal bleeding. Therefore, the operation area of the two patients was not the same. This type of illness should be considered in the differential diagnosis for masses occurring in the temporal region. Total tumor removal is the best treatment for D-GCTS, and the careful monitoring of recurrence can achieve a good clinical outcome subsequent to the surgical resection.

Refractory knee giant cell tumor of the synovial membrane treated with intra-articular injection of Infliximab: a case series and review of the literature

Giant cell tumor (GCT) of the synovial membrane, also known as pigmented villonodular synovitis, causes a progressive, relapsing and destructive arthropathy affecting one or more synovial joints. Systemic therapy can be combined to intra-articular treatments, including surgical synoviectomy, especially when monoarticular. Despite that, the synovial membrane commonly grows again with clinical relapse. Here, we report three case of patients diagnosed with GCT of the knee who had an early relapse of the disease even after surgical synoviectomy. All of them underwent intra-articular therapy with infliximab and subsequent synoviectomy to eradicate residual tissue. A complete remission of CGT was achieved without relapse occurring during the follow-up. These preliminary data need to be confirmed by further clinical trials; however, intra-articular therapy with infliximab might be deemed a potential option to treat CGT of a single joint.

Arthroscopic T-capsulotomy for excision of pigmented villonodular synovitis in the hip

Pigmented villonodular synovitis (PVNS) is a benign synovial tumor of unknown etiology with a predilection for the large joints of the appendicular skeleton. The poor prognosis for patients with hip disease is partially imparted by current surgical techniques. Recent advances in hip arthroscopy technique and instrumentation may enable arthroscopic treatment for PVNS in the hip. The authors report the first case where hip arthroscopy was used to surgically excise a biopsy-confirmed local PVNS lesion in the hip. Using selected capsular releases and accessory portals, the authors achieved adequate visualization and instrument mobilization to successfully excise the entire PVNS tumor with no identifiable complications.

Surgical outcomes after excision of pigmented villonodular synovitis localized to the ankle and hindfoot without adjuvant therapy

Although a benign disorder, pigmented villonodular synovitis (PVNS) has a high rate of recurrence. Because of the high incidence of recurrence and concern about destruction of the affected joint, several adjuvant therapies have been promoted without a clear standard treatment strategy. We reviewed cases of PVNS affecting the ankle and hindfoot joints (ankle and/or subtalar joints) treated with surgical resection without adjuvant therapy in an effort to identify the incidence of PVNS recurrence after excision without adjuvant therapy. Of the 10 cases with a mean follow-up duration of 33.2 ± 19.8 months, 4 (40%) developed a recurrence, with a mean interval of 6 (range 3 to 14) months. At the final follow-up visit, the mean American Orthopaedic Foot and Ankle Society ankle-hindfoot score was 86.6 ± 12. The clinical outcomes of PVNS affecting the ankle and hindfoot joints are associated with a relatively high incidence of recurrence, and additional clinical investigation comparing the incidence of recurrence in patients undergoing excision versus excision with adjuvant therapy is needed for us to better understand this condition and provide more informed recommendations to our patients.

Pigmented villonodular synovitis on lumbar spine : a case report and literature review

Pigmented villonodular synovitis (PVNS) is a benign proliferative joint disease with an uncertain etiology that uncommonly involves the spine. We present a case of PVNS involving the lumbar spine. A 38-year-old male developed back pain and pain in both legs caused by a mass in the L4 region of the right lamina. After gross total tumor removal, the symptoms improved. The pathological finding was synovial hyperplasia with accumulation of hemosiderin-laden macrophages. He was diagnosed with PVNS and experienced no recurrence for up to 2 years after surgery. In this report, we review the previous literature and discuss etiology, clinical manifestations, diagnosis, and treatment.

Clinical and oncological outcomes after surgical excision of pigmented villonodular synovitis at the foot and ankle

BACKGROUND

Pigmented villonodular synovitis (PVNS) is a rare benign neoplastic disease of the synovium of joints and tendon sheaths, which may be locally aggressive. It can be broadly classified into localised disease or more diffuse forms, with the latter more prone to recurrence after surgical excision. We describe our experience in the management of foot and ankle PVNS, focusing on the diffuse type.

METHODS

Patients with PVNS were identified from a histology database from 2000 to 2010 at the University Hospitals of Leicester. The primary aim was to determine oncological outcomes and evaluate clinical outcomes with the Toronto Extremity Salvage Score (TESS) and the American Academy of Foot and Ankle Surgeons (AOFAS) scores.

RESULTS

30 patients, 16 males and 14 females with a mean age of 37±15 years, who underwent surgery, were identified. There were 22 nodular PVNS and 8 diffuse PVNS. The diffuse PVNS was more likely to be in the hindfoot (75%, 6/8), of which 50% (3/6) had osteoarthritis at presentation. The localised PVNS was mostly located in the forefoot (91%, 20/22). None of the localised PVNS had a recurrence. The surgical recurrence rate in this series was similar to the pooled recurrence rate from the literature [12.5% (1/8) compared to 12.2% (6/49)]. The mean TESS and AOFAS scores were 86 and 78, respectively.

CONCLUSIONS

Diffuse PVNS is more likely to occur in the hindfoot and nodular PVNS is more common in the forefoot. Aggressive synovectomy alone is an effective treatment for diffuse PVNS, with good oncological and clinical outcomes.