Midterm outcomes of 18 patients with primary intra-articular diffuse tenosynovial giant cell tumor (TGCT) of the knee treated with complete arthroscopic synovectomy and postoperative low-dose radiotherapy at a mean follow-up of 68 months

OBJECTIVE

To evaluate the long-term clinical outcome of the treatment of complete arthroscopic synovectomy combined with low-dose external radiotherapy in the knee affected by primary intra-articular diffuse tenosynovial giant cell tumor (TGCT).

METHODS

From May 2009 to January 2016, 18 patients with intra-articular diffuse TGCT underwent complete arthroscopic synovectomy and low-dose external-beam radiotherapy in Zhongnan Hospital were enrolled in this retrospective study. The preoperative symptoms of patients, the complications during or after the arthroscopic procedure and the recurrence were collected and recorded. Each patient was evaluated before treatment and at the follow-up visit. Efficacy evaluation criteria were based on Ogilvie-Harris score, and the evaluation of the functional ability of knee was based on the International Knee Documentation Committee (IKDC) Score.

RESULTS

The mean time from symptom onset to surgery was 9.1 ± 5.8 months (range from 3 to 29 months). The most frequent preoperative symptoms were joint effusion (100%), diffuse non-specific knee pain (66.7%), and a decreased range of motion (83.3%). Mean follow-up time was 68.0 ± 18.1 months (range from 35 to 120 months). The mean evaluation score according to the Ogilvie-Harris criteria before treatment was 3.19 ± 0.74, which corresponded to a rating of "poor". The mean score after treatment was 8.79 ± 1.57, rated as "good". The Ogilvie-Harris score was significantly increased after treatment (P = 0.003). The IKDC score of all patients increased significantly from 37.1 ± 3.8 before treatment to 83.9 ± 11.3 after treatment. The IKDC score was obviously increased after treatment (P = 0.001). No recurrence was noted at final follow-up. There were no complications during or after the arthroscopic procedure.

CONCLUSION

The outcome of this study proved that complete arthroscopic synovectomy combined with low-dose external radiotherapy was appropriate for treating primary intra-articular diffuse TGCT of the knee joint. It could be safely and reliably used with minimal complications, fast postoperative recovery and satisfactory control of recurrence rates.

Arthroscopic removal of loose bodies in synovial chondromatosis of shoulder joint, unusual location of rare disease: A case report and literature review

INTRODUCTION

Synovial chondromatosis is a benign mono-articular arthropathy affecting synovial joints. It mostly affects knee joint, followed by hip, elbow and wrist and is rarely reported for shoulder joint. The exact pathogenesis is not known. Usual symptoms are pain, difficulty in movement due to mechanical obstruction. The classic treatment is arthrotomy, removal of chondromatoid loose bodies and synovectomy. With recent advances arthroscopic removal of the chondromatoid loose bodies is a good option with relatively better post op rehabilitation and faster recovery.

CASE PRESENTATION

20 years old gentleman presented to clinic with history of pain in right shoulder for 2 years and decreased range of motion. There was no history of trauma or fever. Work up done and diagnosed with synovial chondromatosis. Arthroscopic removal of chondromatoid loose bodies and synovectomy was done. More than 120 loose bodies were removed. On two (2) years follow-up patient is pain free and having full range of motion at right shoulder joint.

DISCUSSION

Synovial chondromatosis is rare in shoulder joint. The Primary synovial chondromatosis of unknown etiology, and secondary synovial chondromatosis due to degenerative joint disease. Classic treatment is arthrotomy and synovectomy. With recent advances, arthroscopic removal of loose bodies and synovectomy is also a good option for its treatment. In literature only few cases have been reported treated with arthroscopic removal of loose bodies and synovectomy.

CONCLUSION

Arthroscopic treatment of synovial chondromatosis is a good option if expertise is available. It causes less surgical trauma, better visualization during surgery, early recovery.

[Hand surgery in the rheumatic hand-novel and established aspects]

BACKGROUND

Hand surgery of the rheumatoid hand has undergone significant changes mostly as a result of biologicals and biosimilars.

OBJECTIVE

The significance of established and innovative operative procedures in the modern treatment of the rheumatoid hand is elaborated and a subsumption of local interventional options in this context is carried out.

METHODS

The analysis, evaluation and discussion of the literature and expert recommendations are presented.

RESULTS

With the consistent use of modern antirheumatic drugs the destruction and deformation of the wrist and hand occur more slowly and less severely. The hand surgeon can therefore operate more selectively and focus on less pathologies at the same time. Up to the present many of the operative techniques described by the pioneers of modern hand surgery are still powerful tools. Most of the considerations about the correction of the disturbed biomechanics and about the reconstitution of stability and the range of motion are still valid. The combination of arthroscopic synovectomy and radiosynoviorthesis of the wrist seems to show promising results.

CONCLUSION

Modern treatment of the rheumatoid hand is a multidisciplinary challenge. Rheumatologists, nuclear medicine physicians and hand surgeons together can achieve excellent results. A consistent medication, an early operative intervention if necessary and systematic integration of nuclear medicine physicians into the therapeutic process enable preservation of the long-term function of the hand as the main tool in daily life.

Effectiveness of arthroscopic elbow synovectomy in rheumatoid arthritis patients: Long-term follow-up of clinical and functional outcomes

OBJECTIVE

To determine the long-term clinical and functional results of arthroscopic elbow synovectomy in rheumatoid arthritis patients with refractory elbow synovitis in terms of improvement in pain, function, and active range of motion (AROM) or arc of motion.

METHOD

Fifteen rheumatoid elbows in 13 patients, not responding to DMARD therapy and with radiological changes not more than Larsen grade 3 were taken, who underwent arthroscopic elbow synovectomy. The main outcome measured in forms of Mayo Elbow Performance Scale (MEPS) score, measurement of pain using a Visual Analogue Scale (VAS), radiological angles of elbow, disease activity score (DAS-28), arc of motions (AOM) and complications, which were assessed at follow-up periods of 6 months, 24 months, and 30 months. Statistical analysis was done both qualitatively and quantitatively. Mann-Whitney U test, chi-square test, and Student t test were used as the statistical test for determining significance.

RESULTS

In the study group, the improvement was sustained and significant as compared to baseline (VAS 1.28, MEPS 81.07 and mean flexion range 85°) (p value <0.001). No significant complications were encountered postoperatively after elbow synovectomy.

CONCLUSION

The study assesses the long-term results of arthroscopic synovectomy in elbow synovitis secondary to rheumatoid arthritis with significant results favoring arthroscopic synovectomy.

Combined arthroscopic and open synovectomy for diffuse pigmented villonodular synovitis of the knee

PURPOSE

There are few reports detailing recurrence rates or functional outcomes after combined arthroscopic and open synovectomy to treat diffuse pigmented villonodular synovitis (DPVNS) of the knee.

METHODS

Patients with DPVNS of the knee treated with combined synovectomy, followed for a minimum of 12 months at a tertiary orthopaedic oncology centre, were identified. We extracted data pertaining to demographics, complications, clinical outcomes and recurrence. Functional status was evaluated prospectively using the Toronto Extremity Salvage Score (TESS) and the Musculoskeletal Tumor Society (MSTS) 1987 and 1993 surveys. Data were reported descriptively as mean (SD) unless otherwise specified.

RESULTS

Fifteen patients [80% female; mean age 38.9 (SD 14.2) years] representing 15 knees were treated with combined synovectomies and followed for 81 (SD 55) months. Posterior arthroscopy was utilized in 73% of patients. External beam radiation was utilized post-operatively in 73% of patients. Two patients (13%) experienced symptomatic disease recurrence. The mean post-operative knee range of motion was 1° (range 0-10°) to 115° (range 90-135°). TESS and MSTS 1987/1993 scores all suggested excellent patient function. Post-operative complications included one posterior wound dehiscence, one case of femoral condyle avascular necrosis and one patient with lymphedema.

CONCLUSIONS

Combined synovectomy resulted in a low rate of symptomatic disease recurrence and good to excellent functional outcomes for diffuse PVNS of the knee. A literature review identified this as largest case series focusing on combined synovectomies for DPVNS of the knee and the only one describing functional outcomes or the use of external beam radiotherapy.

LEVEL OF EVIDENCE

Retrospective case series, Level IV.

Isolated proximal tibiofibular joint arthritis in a patient with juvenile idiopathic arthritis: A case report

We report the case of a 14-year-old girl of juvenile idiopathic arthritis (JIA) with isolated and chronic proximal tibiofibular (PTF) joint arthritis. The clinical history, magnetic resonance imaging, and pathological findings of the patient are presented. We should be careful to evaluate the patient for chronic lateral knee pain, and consider concomitant evaluation for JIA, including rheumatoid arthritis.

Primary arthroscopic synovectomy for pigmented villo-nodular synovitis of the knee: recurrence rate and functional outcomes after a mean follow-up of seven years

BACKGROUND

Pigmented villo-nodular synovitis (PVNS) is an uncommon proliferative condition of the synovial membrane that chiefly affects the knee. Arthroscopic synovectomy may carry lower morbidity rates but higher recurrence rates than open synovectomy. Here, our objective was to evaluate recurrence rates and functional outcomes after primary arthroscopic synovectomy for PVNS of the knee.

HYPOTHESIS

Primary arthroscopic synovectomy preserves knee function while producing low recurrence and complication rates.

MATERIALS AND METHODS

We retrospectively included consecutive patients with histologically documented PVNS managed with primary arthroscopic synovectomy at two centres between 1998 and 2011. Twenty-three patients, 13 men and 10 women with a mean age of 41 ± 12 years, were reviewed including 16 patients with nodular and 7 with diffuse form of this disease. Patients with localized disease underwent partial synovectomy and those with diffuse disease complete synovectomy followed by chemical synovectomy of any residual lesions. The primary outcome measure was recurrence. Secondary outcome measures were the Tegner-Lysholm and Ogilvie-Harris scores.

RESULTS

Follow-up data were obtained after a mean of 7 ± 4 years in 21 patients (14 with nodular and 7 with diffuse disease), of whom 2 had recurrences, after 2 and 5 years, respectively. At last follow-up, neither patient had any evidence of recurrence. The mean Tegner-Lysholm score was significantly improved (from 68 ± 10 to 90 ± 8, P=0.0004) and the mean Ogilvie-Harris score indicated excellent function (11 ± 1).

DISCUSSION

Primary arthroscopic synovectomy ensures satisfactory control of PVNS while preserving knee function. A full recovery remains possible even in patients with diffuse disease. In the event of a recurrence, open synovectomy can be performed.

Haemophilic synovitis of the elbow: radiosynovectomy, open synovectomy or arthroscopic synovectomy?

Arthroscopic synovectomy (AS) of the elbow, while providing similar pain relief to open synovectomy (OS), may place patients at higher risk for recurrence. The primary predictor of outcome is degree of pre-existing degenerative changes within the joint. Regarding haemophilia patients, radiosynovectomy (RS) is the best choice for patients with persistent synovitis of the elbow. In the elbow we recommend a dose of 30-40 megabecquerels (mBq) in children and a dose of 56-74 mBq in adults. If three consecutive RSs with 6 months intervals are ineffective, an AS or OS must be indicated. Synovectomy (by any method) significantly reduces bleeding episodes. Although the dose of radiation of RS is minimal, 0.32 millisieverts (mSv) in children, 0.54 mSv in adults, and neither articular nor systemic neoplastic changes related to RS have been reported so far, all patients must be given opportunity to consider risk/benefit ratios. Radiation dose due to natural sources is 2 mSv per year and the recommended limit for patients (apart from natural sources is 1 mSv per year). My current recommendation is to use RS in children older than 12 years of age. Therefore, in children younger than 12 years of age an AS should be indicated. OS should be reserved for adults requiring radial head excision (due to a severe limitation of pronation-supination) and synovectomy in the same surgical session.