Result of arthroscopic treatment of pigmented villonodular synovitis of the knee

Bilateral knee pigmented villonodular synovitis in a young adult: Radiologic diagnosis and surgical approach

Pigmented villonodular synovitis is a rare proliferative disorder of the synovial joints, characterized by synovial thickening and hemosiderin deposition. It predominantly affects the knee joint, with bilateral involvement being exceedingly rare. We present a case of diffuse bilateral pigmented villonodular synovitis in a 20-year-old female, initially presenting with left knee pain and swelling, diagnosed via MRI. Following an open total synovectomy, the patient developed postoperative stiffness, requiring arthroscopic arthrolysis. Subsequently, similar symptoms emerged in the right knee, leading to a second synovectomy and subsequent arthrolysis. Despite the challenges associated with managing this condition, including a high recurrence rate and postoperative stiffness, the patient showed significant improvement 1 year postoperatively. This case underscores the importance of thorough synovectomy and highlights the potential need for further surgical intervention to address complications such as stiffness.

Patient Outcomes After Resection of Pigmented Villonodular Synovitis in Patients in King Abdulaziz Medical City

Introduction  Pigmented villonodular synovitis (PVNS) is a proliferative disorder that affects synovial joints. PVNS, also known as tenosynovial giant cell tumor (TGCT), is a broad term that refers to a variety of diseases, both localized and diffuse. The current study aims to describe the outcomes of PVNS in patients in King Abdulaziz Medical City (KAMC) Riyadh, Saudi Arabia especially after surgical resection, highlighting radiological and pathological evidence of disease recurrence and symptom progression. The study is also concerned with comparison between patients who had adjuvant radiotherapy versus patients who underwent surgery only in addition to comparison between patients who underwent arthroscopic surgery versus those who underwent open surgery. Objective Pigmented villonodular synovitis is a disorder that occurs in the synovial joints with the highest incidence rates in the third and fourth decades. PVNS is categorized into localized and diffuse. The current study aims at defining the recurrence rate and outcomes of PVNS in patients in KAMC between 2008 and 2019. Design A retrospective study that comprises patients with proven PVNS of the knee, hip, and elbow for a minimum follow-up duration of two years. Data was collected from the KAMC database, National Guard Health Affairs, Riyadh, Saudi Arabia. Results Nearly a third of patients reported a prior history of trauma. The knee joint was most frequently involved followed by the ankle followed by the hip. Diffuse PVNS was more common than localized disease with more affection on the right side. The most common presenting symptoms were pain and swelling followed by decreased range of motion (ROM). About one-fifth of patients had undergone prior surgery. 30.8% received adjuvant radiotherapy. Post-operative stiffness or decreased ROM were noted in 23.1% of cases. Half of the patients received follow-up for more than 24 months. Overall recurrence rate was 19.2%. Recurrence rates were significantly higher in patients with left-sided lesions and those with prior surgery but it did not reach statistical significance. Non-statistically significant trends for increased recurrences were also seen with older age, diffuse type PVNS, and knee involvement. Conclusions In summary, this study reports the outcomes of PVNS after surgical resection in patients in King Abdulaziz Medical City. The study showed recurrence rates being significantly higher in patients with left-sided lesions than those with prior surgery. Also, non-statistically significant trends for increased recurrences were also seen with older age, diffuse type PVNS, and knee involvement.

Pigmented villonodular synovitis/giant cell tumor in the knee

PURPOSE OF REVIEW

Pigmented villonodular synovitis (PVNS) is a rare diagnosis in pediatric patients and commonly presents with symptoms of swelling and pain. Early diagnosis is important to prevent secondary degeneration into the subchondral bone. This review will analyze the etiology, clinical signs/symptoms, diagnosis, treatment, and recent literature on PVNS in the pediatric population.

RECENT FINDINGS

Many theories of PVNS etiology have been described in the literature; however, an inflammatory response has been most widely accepted. PVNS can occur in any joint, but most commonly in the knee. The most common treatment for PVNS is synovectomy, and long-term follow-up is necessary to detect disease persistence or recurrence.

SUMMARY

Although uncommon, PVNS does occur in the pediatric population and this diagnosis should be included in the differential of atraumatic joint swelling and pain.

Diffuse-Type Tenosynovial Giant Cell Tumor: What Are the Important Findings on the Initial and Follow-Up MRI?

Tenosynovial giant cell tumor (TSGCT) is a rare soft tissue tumor that involves the synovial lining of joints, bursae, and tendon sheaths, primarily affecting young patients (usually in the fourth decade of life). The tumor comprises two subtypes: the localized type (L-TSGCT) and the diffuse type (D-TSGCT). Although these subtypes share histological and genetic similarities, they present a different prognosis. D-TSGCT tends to exhibit local aggressiveness and a higher recurrence rate compared to L-TSGCT. Magnetic resonance imaging (MRI) is the preferred diagnostic tool for both the initial diagnosis and for treatment planning. When interpreting the initial MRI of a suspected TSGCT, it is essential to consider: (i) the characteristic findings of TSGCT-evident as low to intermediate signal intensity on both T1- and T2-weighted images, with a blooming artifact on gradient-echo sequences due to hemosiderin deposition; (ii) the possibility of D-TSGCT-extensive involvement of the synovial membrane with infiltrative margin; and (iii) the resectability and extent-if resectable, synovectomy is performed; if not, a novel systemic therapy involving colony-stimulating factor 1 receptor inhibitors is administered. In the interpretation of follow-up MRIs of D-TSGCTs after treatment, it is crucial to consider both tumor recurrence and potential complications such as osteoarthritis after surgery as well as the treatment response after systemic treatment. Given its prevalence in young adult patents and significant impact on patients' quality of life, clinical trials exploring new agents targeting D-TSGCT are currently underway. Consequently, understanding the characteristic MRI findings of D-TSGCT before and after treatment is imperative.

Arthroscopic treatment of diffuse pigmented villonodular synovitis of the elbow

INTRODUCTION

Pigmented villonodular synovitis (PVNS) is a rare pathology of the elbow, but presents a risk of progression with cartilage destruction. Surgical treatment consists in synovectomy, as complete as possible. Arthroscopy is an excellent tool for the exploration and treatment of intra-articular lesions in the elbow, but the results in PVNS of the elbow have never been evaluated. The aim of this study was to assess the recurrence rate of PVNS of the elbow after arthroscopic synovectomy, and secondarily to assess pain, joint range of motion, functional scores and complication rate.

MATERIAL AND METHODS

We performed a retrospective study of a continuous series of 8 patients operated on between February 2012 and February 2019, with a mean age of 43.7 years. The operated side was the dominant side in 75% of cases. Surgery consisted in the most complete synovectomy possible, performed arthroscopically. Recurrence, clinical evaluation, with pain at rest and on mpvement on visual analogue scale (VAS) and joint range of motion, functional MEPS and DASH scores, and any complications were collected.

RESULTS

At a mean 66.4 months' follow-up, 2 patients required revision surgery for recurrence. At the last follow-up, VAS for pain at rest was 0.9 and 1.9 for pain on movement. MEPS score was 85.6 and DASH score 82.2. No neurological, vascular or infectious complications of arthroscopic synovectomy were found in our series.

DISCUSSION

Arthroscopic synovectomy in the treatment of PVNS of the elbow was a reliable and safe therapeutic alternative, with a low complications rate and 2 cases of recurrence (25%) in our study. This was the first study to report the results of arthroscopic surgical treatment of elbow PVNS.

LEVEL OF EVIDENCE

IV Retrospective study without control group.

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.

Effectiveness of arthroscopic excision based on the distribution of the tenosynovial giant cell tumor around knee joint

BACKGROUND

The mainstay treatment for tenosynovial giant cell tumor (TGCT) is open excision. However, open excision is associated with the risk of stiffness, infection, neurovascular injury, and prolonged hospital stay and rehabilitation. The purpose of this study was to evaluate the efficacy of arthroscopic excision of tenosynovial giant cell tumor (TGCT) of the knee joint, including the diffuse type of TGCT.

METHODS

Patients who underwent arthroscopic excision of TGCT between April 2014 and November 2020 were retrospectively analyzed. TGCT lesions were divided into 12 distributions (nine intra- and three extra-articular lesions). The distribution of TGCT lesions, portals used, degree of excision, recurrence, and magnetic resonance imaging (MRI) scans were evaluated. The prevalence of intra-articular lesions in diffuse TGCT was also analyzed to validate the existence of a connection between intra- and extra-articular lesions.

RESULTS

Twenty-nine patients were included in the study. Fifteen patients (52%) had localized TGCT, and 14 patients (48%) had diffuse TGCT. The recurrence rates for localized, and diffuse TGCT were 0%, and 7%, respectively. Intra-articular posteromedial (i-PM), intra-articular posterolateral (i-PL), and extra-articular posterolateral (e-PL) lesions were found in all patients with diffuse TGCT. The prevalence rates of i-PM and i-PL lesions among e-PL lesions were both 100% (p = 0.026 and p < 0.001, respectively). Diffuse TGCT lesions were managed with posterolateral capsulotomy and viewed from the trans-septal portal.

CONCLUSIONS

Arthroscopic excision of TGCT was effective in both localized and diffuse TGCT. However, diffuse TGCT was associated with posterior and extra-articular lesions. Therefore, technical modification such as posterior, trans-septal portal, and capsulotomy were required.

STUDY DESIGN

Retrospective case series; level Ⅳ.

The Clinical Effect of Topical Application of Tranexamic Acid in Arthroscopic Synovectomy of Pigmented Villonodular Synovitis of the Knee

This study investigated the clinical effect of topical application of tranexamic acid (TXA) in arthroscopic synovectomy of pigmented villonodular synovitis (PVNS) of the knee. Eighty patients who were diagnosed with unilateral knee PVNS underwent arthroscopic synovectomies from January 2017 to January 2021 and were retrospectively investigated in this study. Patients were divided into two groups: group A was the control group, whereas patients in group B received an intra-articular injection of 50 mL of TXA (1 g:100 mL) immediately after the synovectomies. The primary outcome measurement was the drainage volume of the affected knee in each postoperative stage, as well as the hematological parameters. Secondary outcomes included visual analog scale score, knee range of motion, and Lysholm score. Postoperative complications were also recorded. A lower volume of drainage was found in group B than in group A on postoperative day (POD) 1, on POD 2, and in total (POD 1, P=.000; POD 2, P=.000; total, P=.000). A lower visual analog scale pain score in group B was noticed on POD 1 (P=.000) and POD 2 (P=.005). Range of motion (P=.019) and Lysholm score (P=.001) were significantly superior in group B compared with group A on POD 14. Regarding complications, 3 patients in group A and 1 patient in group B developed deep venous thrombosis after surgery. Hematomas were found intra-articularly in 5 patients in group A during follow-up. Intraarticular topical application of TXA was effective in reducing postoperative bleeding and early postoperative pain for patients who underwent arthroscopic synovectomy of PVNS. [Orthopedics. 20XX;XX(X):xx-xx.].

Diffuse pigmented villonodular synovitis treated with arthroscopic total synovial peel

BACKGROUND

Diffuse pigmented villonodular synovitis (PVNS) is prone to recurrence after surgery, and it is difficult to achieve a long-term complete cure.

OBJECTIVE

To reduce the recurrence rate of PVNS, the author pioneered the arthroscopic total synovial peel (ATSP).

METHODS

From March 2014 to July 2020, a total of 19 patients (6 males and 13 females) with diffuse PVNS of the knee were treated in our department and underwent ATSP. It's 'peel' rather than simple excision. This method is similar to peeling bark. Relapse rates and functional scores were determined, with follow-ups ranging from 12 to 72 months, on average 36 months.

RESULTS

Treatment efficacy was assessed by imaging and functional scores. Imaging results indicated a recurrence rate of 10.5%. In patients without recurrence, the visual analog score (VAS) decreased from 4.76 ± 2.02 preoperatively to 1.56 ± 1.15 postoperatively. The Tegner-Lysholm knee function score (TLS) score increased from 67.76 ± 15.64 preoperatively to 90.32 ± 8.32 postoperatively. Compared with the literature, ATSP significantly reduces the postoperative recurrence rate of diffuse PVNS. The preliminarily findings suggest that this approach could greatly reduce the recurrence rate of postoperative PVNS in follow-up studies.

CONCLUSION

This approach may be a viable option for treating diffuse PVNS via arthroscopy and is worthy of clinical consideration.

Surgical management of villonodular-pigmented synovitis of knee: decisional algorithm

Pigmented villonodular synovitis (PVNS) of knee is an uncommon disease defined as benign despite presenting local aggressiveness and high propensity to recurrence. Etiology is still not completely understood. It seems to be a chronic inflammation process involving synovial membranes characterized by hemosiderin deposition which leads to pain, limitation of range of motion and, if not treated, bone erosion and osteoarthritis of knee. The gold standard for treatment is surgical excision; other adjuvant or alternative therapies are described, too. We present a case series of PVNS of the knee treated with surgical excision at our institution. Functionality was assessed using the Muscoloskeletal Tumor Society (MSTS) Score for lower limbs and Oxford Knee Score (OKS). Statistical analysis were performed.

At the latest follow-up, our patients’ mean MSTS score was 26.4 (30-18): 27.4 for those treated with posterior approach and 26.1 for the anterior ones. Only 5% of patients suffered local complications and 15% had a local recurrence of the disease.

Adequate pre-operative study and careful surgical excision, that should be tailored to each patient are the key to obtain a low recurrence rate.

Hip Tenosynovial Giant Cell Tumor without Recurrence in a 9-Year Follow-Up

Background. Tenosynovial giant cell tumors are a benign but rare condition with potentially aggressive tumor-like traits which should be considered in young patients with monoarticular joint involvement. Case Presentation. This report presents a 31-year-old otherwise healthy woman with a right hip pain. Clinical and histopathological investigations revealed the diagnosis of diffuse-type tenosynovial giant cell tumor of the hip (the diffuse intra-articular form of PVNS). Open synovectomy and tumor resection and surgical dislocation of the hip were performed. She was free of symptoms and recurrence within a 9-year-follow-up period. Conclusion. Open synovectomy and tumor resection through surgical dislocation of the hip without adjutant radiotherapy could be a reliable choice for the localization of the hip.

Arthroscopic Versus Open Management of Diffuse-Type Tenosynovial Giant Cell Tumor of the Knee: A Meta-analysis of Retrospective Cohort Studies

Whether arthroscopic or open surgical management for diffuse-type tenosynovial giant cell tumor (D-TGCT) of the knee is associated with a lower rate of recurrence is unknown.

Clinical outcomes of diffuse PVNS of the knee following arthroscopic complete synovectomy±posterior open resection

Introduction

This study compares recurrence rates and functional outcomes of patients who underwent anterior arthroscopic synovectomy versus combined anterior arthroscopic/posterior open synovectomy for diffuse pigmented villonodular synovitis (DPVNS).

Methods

41 patients were grouped by initial procedure and tracked for disease recurrence and functional outcomes (Lysholm Scale).

Results

24 patients (58.5%) had disease recurrence [16 (57.1%) arthroscopic, 8 (61.5%) combined, chi-square test p = 0.81]. The combined procedure mean Lysholm Score (75.4) exceeded the arthroscopic (68.1) (two-sample t-test p = 0.25).

Conclusions

There is no statistical evidence that the combined procedure harms functionality more than arthroscopic only or that recurrence rates differ between treatment methods.

A case series of intra-articular diffuse pigmented villonodular synovitis of the knee: Prognosis of complete synovectomy under arthroscopic surgery

PURPOSE

The purpose of this study is to evaluate the outcome and prognosis of complete synovectomy performed under arthroscopic surgery in the treatment of diffuse pigmented villonodular synovitis (DPVNS) of the knee.

METHODS

We retrospectively reviewed 7 cases (6 female and 1 male) diagnosed with diffuse pigmented villonodular synovitis (DPVNS) of knee from 2013 to 2017. All of these cases were treated with knee arthroscopy-assisted complete synovectomy. The follow-up period ranged from 36 months to 60 months (average: 48.0 months). The pain score, range of motion and functional outcome of the knee joint were evaluated after surgery. Symptoms and signs were monitored and magnetic resonance imaging (MRI) were routinely requested to note for possible recurrence during clinical follow up.

RESULTS

During and after the surgeries of complete synovectomy under arthroscope by the same surgeon, no complications were noted in the ward or the clinic. Significant improvements were achieved in terms of the range of motion and Lysholm knee function score. There was no recurrence of DPVNS observed in our patients during a follow-up of 4 years.

CONCLUSIONS

Intra-articular DPVNS of the knee can successfully be treated by complete synovectomy under arthroscope. This case series emphasized the technique of multiple portals and cycling different shavers to achieve satisfactory outcomes.

Image-guided, intensity-modulated radiotherapy for the treatment of diffuse-type tenosynovial giant cell tumor of the knee: Case report and review of the literature

RATIONALE

Tenosynovial giant cell tumor (TGCT) is a neoplastic, inflammatory disease with a benign but aggressive course that often presents as localized (TGCT-L) and diffuse (TGCT-D) forms based on the growth pattern and clinical behavior. For TGCT-L, simple excision of the diseased synovial tissue is the preferred treatment option, while for TGCT-D, adequate synovectomy is usually tricky but is essential. However, approximately 44% of TGCT-D cases will relapse after surgery alone. Thus, the optimal treatment strategy in patients with TGCT-D is evolving, and standalone surgical resection can no longer be regarded as the only treatment. The previous studies have shown that postoperative adjuvant radiotherapy can reduce recurrence in TGCT, especially in patients with incomplete synovectomy.

PATIENT CONCERNS

In the first case, a 54-year-old male presented with recurrent pain and swelling of the right knee with a protracted disease course (≥10 years). The other patient is a 64-year-old male who developed swelling, pain, abnormal bending, and limited movement of the left knee without obvious inducement.

DIAGNOSES

Clinical and imaging examinations can provide a definitive diagnosis, and pathology is the gold standard. TGCT-D was confirmed by postoperative pathology. After the operation, the patients underwent an MRI re-examination and showed that the lesions of the knee were not completely resected.

INTERVENTIONS

Arthroscopic synovectomy was performed on the patients, and postoperative pathology was confirmed as TGCT-D. Because of incomplete synovectomy, the 2 cases received image-guided, intensity-modulated radiotherapy (IG-IMRT) after the operation.

OUTCOMES

The follow-up time was 1 year, no evidence of disease progression was found in MRI. No obvious adverse effects associated with radiotherapy were detected during the follow-up period.

LESSONS

These cases and reviews illustrate the necessity of radiotherapy for TGCT-D and that IG-IMRT is a safe and effective method for treating TGCT-D of the knee.

Postoperative radiotherapy for pigmented villonodular synovitis (PVNS): case series and literature review

Purpose:

Pigmented villonodular synovitis (PVNS) is a rare benign proliferative disease of the synovium with locally aggressive behaviour. We reviewed our experience using external beam radiotherapy (RT) in the treatment of PVNS.

Method:

We report five cases of PVNS who underwent Arthroscopic Synovectomy followed by postoperative RT in National Oncology centre in Oman. The total dose RT ranges between 30 and 36 Gray (Gy) Three-dimensional radiotherapy technique.

Conclusion:

Postoperative RT is effective in preventing disease recurrence and should be offered following maximal cytoreduction to enhance local control in PVNS.

Tenosynovial Giant-Cell Tumor Presenting as Septic Arthritis of the Knee

Tenosynovial giant-cell tumor (TGCT) is an intraarticular giant-cell tumor of the synovial tissue and tendon sheaths which often mimics multiple conditions on presentation. This case report describes a previously asymptomatic 67-year-old man with preliminary clinical and laboratory evaluation suggestive of septic arthritis; however, arthroscopy revealed diffuse synovitis, and biopsy confirmed TGCT. To our knowledge, this is the first report of TGCT presenting as septic arthritis in an adult patient. This diagnosis should be considered in evaluation of acute, atraumatic knee pain with associated inflammatory marker elevation.

[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.

Monoarticular, Multifocal, Localized Tenosynovial Giant Cell Tumor of the Knee: A Case Report

CASE

We present a 37-year-old man with uniarticular, multifocal, localized tenosynovial giant cell tumor (TSGCT) of the knee. He was treated with arthroscopic partial synovectomy of each tumor foci alone without the use of any adjuvants. At a 2-year follow-up, he had painless, full function of the knee with no signs of disease recurrence.

CONCLUSION

There have been several reports of multiple joints or multiple compartments in and around a joint involved with TSGCT in the same patient, but this is the first case reported to our knowledge of multiple discrete foci within the same joint.

Open synovectomy treatment for intra- and extraarticular localized pigmented villonodular synovitis of the knee: a case report

Background

Pigmented villonodular synovitis (PVNS) is a rare, benign, proliferative neoplastic process that commonly affects synovial-lined anatomic spaces. The diffuse type (DPVNS) is characterized by invasion of the entire joint synovium, while the localized type (LPVNS) is characterized by a relatively normal synovial appearance. This report describes a unique case of massive intraarticular LPVNS with an extraarticular extension through the lateral patellar retinaculum. No similar cases have been found in the literature.

Case presentation

A 58-year-old woman had a history of hyperuricemia and knee trauma and presented with unilateral knee acute swelling and pain symptoms with sudden onset. Recent expansion of the LPVNS caused the development of a tender palpable soft tissue mass in the anterolateral aspect of the knee and acute reduced mobility. Preoperative magnetic resonance imaging of the knee revealed the presence of only the soft tissue mass and mild degenerative changes. Open synovectomy was performed successfully to excise the mass. Intraoperatively, macroscopic features of the bright brown inflamed synovium suggested LPVNS, which was confirmed histopathologically. Postoperatively, the symptoms of limited mobility and pain were appreciably relieved. Recurrence was not observed during the clinical follow-up at 1, 6 or 18 months after surgery.

Conclusions

Here, we report the unique case of localized pigmented villonodular synovitis of the knee in a misdiagnosed patient with intra- and extraarticular lesion, which might be attributed to the history of knee trauma and the focal defect of the lateral patellar retinaculum. Open synovectomy effectively relieved the symptoms of limited mobility and pain and no recurrence was observed prior to 18 months postoperatively. To reduce misdiagnosis, MRI examinations are recommended for all patients suspected of having PVNS, including those who have a history of hyperuricemia.

Pigmented Villonodular Synovitis of the Knee Joint in a 10-Year-Old Patient Treated With an All-Arthroscopic Synovectomy: A Case Report

Pigmented villonodular synovitis (PVNS) is a relatively rare, benign lesion characterized by exuberant proliferation of the synovial tissue that most commonly affects the knee and hip joint. Magnetic resonance imaging (MRI) is the imaging modality of choice for the diagnosis of PVNS. The disease is confirmed histologically by examination of the synovial tissue removed. The mainstay of treatment is synovectomy, performed in an open, arthroscopic, or combined fashion. Although postoperative adjuvant external beam radiotherapy can improve the local recurrence rate, the course of the disease is not always uneventful. We present a rare case of a 10-year-old boy presented to our orthopaedic department with a four-month history of intermittent right knee pain and swelling. MRI revealed joint effusion and extensive nodular synovial proliferation suggestive of PVNS. An arthroscopic synovectomy was performed and histological examination confirmed the diagnosis. The postoperative course was uneventful. Clinical suspicion of PVNS is essential in children with chronic knee pain and swelling. Arthroscopic synovectomy is an effective and reliable treatment option.

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.

Arthroscopic Technique for the Treatment of Localized Pigmented Villonodular Synovitis of the Knee

Pigmented villonodular synovitis (PVNS) is caused by a proliferation of the synovial membrane and can be a rare cause of pain and locking of the knee. In its localized form, it can be removed arthroscopically. We describe in detail a step-by-step arthroscopic technique applied to treat a 27-year-old patient who had been suffering from pain and episodes of locking for a year and whose left knee MRI revealed an intra-articular mass. The formation was completely enucleated arthroscopically and histological analyses confirmed the diagnosis of localized PVNS. There were no complications, and the patient was symptom-free at the six-month follow-up with no clinical or radiological evidence of recurrence.

Recurrence of pigmented villonodular synovitis of the knee: A case report with review of literature on the risk factors causing recurrence

RATIONALE

Pigmented villonodular synovitis is a rare disease which may involve any joints. It has localized and diffuse forms, and the latter is more aggressive with a higher recurrence rate. Different treatments are applied to each form of the disease, but there is no standard surgical procedure or any consensus on whether adjuvant therapy should be used. Many factors may lead to recurrence of the disease; however, there is no reliable way to predict the recurrence.

PATIENT CONCERNS

A 21-year-old female patient presented with a one-year history of progressive pain of the right knee.

DIAGNOSES

Pigmented villonodular synovitis.

INTERVENTIONS

We performed an anterior approach arthroscopic synovectomy and a posterior approach open synovectomy in the popliteal fossa, but the patient declined to take radiotherapy as a post-surgical adjuvant therapy. Then, she received a repeat arthroscopic synovectomy 20 months later because of the recurrent lesions, and a radiotherapy was performed 6 weeks after the second surgery.

OUTCOMES

There were no abnormal signs in the right knee on magnetic resonance imaging scanning 6 months after the second surgery. The range of motion of her right knee was normal.

LESSONS

Pigmented villonodular synovitis is a rare disease which may involve any joints. Surgical resection plus adjuvant therapy is recommended for patients with risk factors of recurrence.

Surgical Treatment of Localized-Type Tenosynovial Giant Cell Tumors of Large Joints: A Study Based on a Multicenter-Pooled Database of 31 International Sarcoma Centers

BACKGROUND

Localized-type tenosynovial giant cell tumor (TGCT) is a rare, neoplastic disease with only limited data supporting treatment protocols. We describe treatment protocols and evaluate their oncological outcome, complications, and functional results in a large multicenter cohort of patients. A secondary study aim was to identify factors associated with local recurrence after surgical treatment.

METHODS

Patients with histologically proven localized TGCT of a large joint were included if they had been treated between 1990 and 2017 in 1 of 31 tertiary sarcoma centers. Of 941 patients with localized TGCT, 62% were female. The median age at initial treatment was 39 years, and the median duration of follow-up was 34 months. Sixty-seven percent of the tumors affected the knee, and the primary treatment at the tertiary center was 1-stage open resection in 73% of the patients. Proposed factors for predicting a first local recurrence after treatment in the tertiary center were tested in a univariate analysis, and those that demonstrated significance were subsequently included in a multivariate analysis.

RESULTS

The localized TGCT recurred in 12% of all cases, with local-recurrence-free rates at 3, 5, and 10 years of 88%, 83%, and 79%, respectively. The strongest factor for predicting recurrent disease was a prior recurrence (p < 0.001). Surgical treatment decreased pain and swelling in 71% and 85% of the patients, respectively, and such treatment was associated with complications in 4% of the patients. Univariate and multivariate analyses of the patients who had not undergone therapy previously yielded positive associations between local recurrence and a tumor size of ≥5 cm versus <5 cm (hazard ratio [HR] = 2.50; 95% confidence interval [CI] = 1.32 to 4.74; p = 0.005). Arthroscopy (versus open surgery) was significantly associated with tumor recurrence in the univariate analysis (p = 0.04) but not in the multivariate analysis (p = 0.056).

CONCLUSIONS

Factors associated with recurrence after resection of localized-type TGCT were larger tumor size and initial treatment with arthroscopy. Relatively low complication rates and good functional outcomes warrant an open approach with complete resection when possible to reduce recurrence rates in high-risk patients.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

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.

Complications After Total Knee Arthroplasty in Patients With Pigmented Villonodular Synovitis

BACKGROUND

Pigmented villonodular synovitis (PVNS) is a locally destructive histiocytic proliferation most commonly occurring in the knee. Extensive local joint destruction can indicate the need for a total knee arthroplasty (TKA). The objective of this study is to evaluate PVNS of the knee as a risk factor for complication after TKA.

METHODS

Patients who underwent TKA with a diagnosis of PVNS of the knee from 2007 to 2016 were identified in a national private payer insurance database. Complication rates for emergency room visits, readmission, revision, stiffness, infection, and death were calculated and compared to a control population of patients who received TKA for osteoarthritis (OA).

RESULTS

Four hundred fifty-three patients were diagnosed with PVNS of the knee and underwent TKA during the time period and compared with a matched control cohort of 1812 patients who underwent TKA for OA. The rate of revision TKA at 2 years, emergency room visits, readmission, and death did not differ between the PVNS group and the control cohort. The PVNS group had stiffness at 1 year compared to the OA group (6.84% vs 4.69%, odds ratio 1.48, P = .023). The infection rate at 2 years was 3.31% in the PVNS group and 1.55% in the OA group (odds ratio 1.73, P = .011).

CONCLUSION

The complication rates for TKA in patients with a diagnosis of PVNS of the knee have not been previously demonstrated. These patients have a higher rate of stiffness and infection when compared to a control cohort, so they may have a more complicated postoperative course.

Distinct extra-articular invasion patterns of diffuse pigmented villonodular synovitis/tenosynovial giant cell tumor in the knee joints

PURPOSE

Pigmented villonodular synovitis (PVNS)/tenosynovial giant cell tumor (TGCT) is a benign, proliferative lesion of the synovium, the bursa, and the tendon sheath. Little is known about the anatomical distribution pattern of diffuse extra-articular PVNS/TGCT around the knee joint. In this retrospective study, anatomical distribution of PVNS/TGCT using magnetic resonance imaging (MRI) and arthroscopy was analyzed.

METHODS

This study was designed as a retrospective, observational cross-sectional study based on MRI and arthroscopy. Twenty-four PVNS/TGCT patients (24 knees) who underwent arthroscopic or posterior open surgery between 2009 and 2016 were enrolled. Of these, eight intra-articular and 16 diffuse extra-articular PVNS/TGCT of the knee were classified. The anatomical locations of the PVNS/TGCT masses were determined with a newly devised mapping scheme. Analysis was performed on the prevalence of each compartment and agreement rates between each compartment.

RESULTS

The point prevalence of intra-articular posterior compartment was higher in diffuse extra-articular PVNS/TGCT group compared with intra-articular PVNS/TGCT group. The point prevalence of diffuse PVNS/TGCT was most prevalent in the extra-articular posterolateral compartment (12 out of 16 diffuse extra-articular PVNS/TGCT patients, 75%) and second most common in the below to joint capsule compartment (11 out of 16, 68.8%). The agreement rate was the highest between intra-articular posterolateral and extra-articular posterolateral compartments (75%).

CONCLUSION

Extra-articular invasion of diffuse PVNS/TGCT occurred in specific patterns in the knee joint. Extra-articular lesions were always accompanied by lesions in intra-articular compartments. In particular, lesions in the intra-articular posterior compartments were observed in all of the diffuse extra-articular PVNS/TGCT patients. The point prevalence of diffuse extra-articular PVNS/TGCT for each compartment was the highest [12 out of 16 (75%)] in extra-articular posterolateral compartment. In contrast, invasion to the extra-articular posteromedial side was less frequent [5 out of 16 (31.3%)] than to the extra-articular posterolateral side. Knowing where the lesions frequently occur may provide important information for deciding the timing, method, and extent of surgery.

LEVEL OF EVIDENCE

Level IV.

Simultaneous pigmented villonodular synovitis and synovial chondromatosis of the hip: case report

This report presents a case of a 37-year-old female with a history of hip pain. Magnetic resonance arthrography revealed loose bodies within the joint and synovial hypertrophy indicative of synovial chondromatosis (SC). Hip arthroscopy revealed free chondral bodies and focal villonodular synovial proliferation. The focal synovial proliferation was excised, a total synovectomy performed, and all cartilaginous free bodies removed. A post-operative histological examination of the removed nodular mass and synovium yielded evidence of both SC and pigmented villonodular synovitis (PVNS). A 1-year post-operative clinical examination showed marked clinical improvement and no signs of recurrence on MR images. Despite the clinical similarities, PVNS and SC are two distinct conditions that, to our knowledge, have never been reported as simultaneously occurring in a hip joint. The simultaneous presence of both pathologies may suggest a common origin of synovial metaplasia.

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.

Localized pigmented villonodular synovitis of posterior compartment of the knee

Pigmented villonodular synovitis (PVNS) is an uncommon entity involving articular or extra-articular tissues and maybe localized or diffuse in extent. The knee is by far the commonest joint to get involved. Localized PVNS of the knee can occur in any location but its confinement to the posterior compartment is infrequent. We present our experience of managing localized posterior compartment PVNS of the knee. There were 10 patients (7 males and 3 females) with average age of 33 years. These patients had symptoms of pain, locking, or swelling for a mean of 13.9 years before diagnosis. All the patients underwent arthroscopic synovectomy without adjuvant therapy, and PVNS was proven on histopathology. At an average follow-up of 23 months, no patient had recurrence of symptoms. The average International Knee Documentation Committee (IKDC) score at last follow-up was 85.21. Magnetic resonance imaging evaluation at final follow-up did not reveal any residual disease or recurrence in any patient.

Long-term outcome of pigmented villonodular synovitis of the hip after joint preserving therapy

INTRODUCTION

Pigmented villonodular synovitis (PVNS) is a rare, destructive synovial disease that affects the hip joint the second most common after the knee. However, in contrast, joint preserving surgery in the hip joint is considered to be significantly more difficult or even impossible due to earlier occurrence of osteochondral dissemination and surgical difficulties. Today, earlier diagnosis due to the generous use of MRI and modern surgical strategies raise hope for improved outcomes.

METHODS

Since 2005, six patients with PVNS of the hip and a minimal follow-up of 2 years underwent joint preserving surgery in our institution (mean age 20.5 years, range 14-27). After PVNS was suspected in the MRI and confirmed by arthroscopic biopsy (four diffuse, two focal forms), synovectomy was carried out in 5 patients via surgical hip dislocation and in one focal case via arthroscopy. In diffuse forms, adjuvant radiosynoviorthesis (RSO) was conducted 6-8 week postoperatively. MRI and clinical examinations were performed during follow-up.

RESULTS

After a mean follow-up of 8 years (range 35-141 months), five of six patients did not show recurrence or secondary osteoarthritis. Clinical outcome evaluation resulted in a mean modified Harris Hip Score of 91 points (range 67-100 points). A 21-year-old patient with a diffuse form and advanced osteochondral involvement at the time of diagnosis was eventually treated by total hip arthroplasty.

CONCLUSION

In cases without osteochondral involvement, recurrence-free long-term results without progression of joint degeneration can be achieved by joint preserving therapy.

Necessity of adjuvant postoperative radiotherapy for diffuse pigmented villonodular synovitis of the knee: A case report and literature review

RATIONALE

Pigmented villonodular synovitis (PVNS) is an idiopathic, proliferative disorder lesion of synovial tissue, which is regarded as a benign disease, but has a local invasion. Up to now, these are no consensus about the etiology and pathogenesis of PVNS. Because of the lack of typical clinical features, misdiagnosis and delayed diagnosis are not uncommon, magnetic resonance imaging (MRI) can assist diagnosis and histopathological examination is recognized as the gold standard for the final diagnosis. Because this disease is so rare, there is no standard treatment. Surgical resection of the lesion is considered the preferred treatment, but postoperative recurrence is a problem that cannot be ignored. Postoperative radiotherapy is necessary, especially for patients with diffuse PVNS of the knee.

PATIENT CONCERNS

A 27-year-old female teacher presented with 3 years chronic pain of the right knee, and progressive swelling aggravated for 1 week. The range of motion of the knee was limited.

DIAGNOSES

Clinical and laboratory examination failed to provide definitive diagnosis. Imaging can assist in diagnosis, and pathology is the gold standard. Erythrocyte sedimentation rate (ESR), antihemolytic streptococcus O (ASO), and rheumatoid factors (RF) were all negative. Joint puncture revealed giant cell tumor of the synovial membrane. PVNS was confirmed by postoperative pathology. The characteristic T2 weighted low signal of MRI suggests the recurrence of PVNS.

INTERVENTIONS

The patient underwent 2 stages of treatment: open synovectomy was performed in the first place and postoperative external radiotherapy was not considered. After 2 years of disease-free remission, she was diagnosed with a recurrence of the disease by MRI. Further, arthroscopic total synovectomy of the right knee was performed and external beam radiotherapy was carried out after the operation.

OUTCOMES

Up to now, the patient was followed up for 3 years without any sign of recurrence.

LESSONS

Adjuvant postoperative radiotherapy can improve the local control rate, it is a reliable treatment method for diffused PVNS.

Diffuse Pigmented Villonodular Synovitis as a Rare Cause of Graft Failure Following Anterior Cruciate Ligament Reconstruction

This case report describes a 42-year-old woman who was diagnosed with pigmented villonodular synovitis (PVNS) in the knee. The patient had received a bone-patella tendon-bone autograft reconstruction of her anterior cruciate ligament (ACL) 22 years prior to her diagnosis of PVNS. After a traumatic event that tore her ACL graft, she underwent a second surgery to repair the initial reconstruction. However, her pain and joint instability remained unresolved. When radiolucent lesions in her tibia and femur were identified through a radiographic image, the patient was referred to the authors' orthopedic oncology clinic. Additional imaging, including magnetic resonance imaging, revealed PVNS, and she was scheduled for debridement and a complete synovectomy of the knee. After surgery, the patient's pain decreased dramatically. She continues to maintain an active lifestyle despite a relatively minor decrease in range of motion. In this case, PVNS proved to be an unlikely complication after ACL reconstruction. The patient remains at risk for the development of degenerative arthritis. [Orthopedics. 2018; 41(1):e142-e144.].

All-Arthroscopic Treatment of Intra- and Extra-Articular Localized Villonodular Synovitis of Knee

Pigmented villonodular synovitis (PVNS) is a rare, benign, proliferative neoplastic condition affecting synovial-lined anatomic spaces. PVNS is characterized by hypertrophy of a synovial membrane by villous, nodular, and villonodular proliferation, with pigmentation secondary to hemosiderin deposition. The two forms of PVNS that have been described are diffuse (DPVNS) and localized (LPVNS). The knee is the most commonly involved anatomic location, followed by hip, ankle, shoulder, and elbow. Diagnosis of PVNS is not always obvious clinically. Various imaging modalities are often necessary to exclude other conditions and narrow the diagnosis. Magnetic resonance imaging has become the modality of choice for diagnosing PVNS. We present a case of intra-articular LPVNS with an extra-articular extension through the posterior capsule that has been successfully removed in an all-arthroscopic fashion.

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.

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 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.

Acute Knee Pain in a Child Due to Pigmented Villonodular Synovitis

Introduction:

Pigmented villonodular synovitis (PVNS) is a proliferative condition of the synovium, which is composed of nodules and/or villi and has an abundant number of hemosiderin-laden macrophages.

Case Report:

A 10-year-old boy presented with an acute irritable knee. Emergency arthroscopy showed a nodular PVNS in the intercondylar notch. The symptoms resolved after resection of the lesion.

Conclusion:

PVNS of the knee in children is a rare entity. It can be one of the causes of acute irritable knee. Complete resection of the nodular PVNS can cure the disease.

Pigmented villonodular synovitis: a crowdsourcing study of two hundred and seventy two patients

PURPOSE

We aimed to ascertain the feasibility of crowdsourcing via Facebook for medical research purposes; by investigating surgical, oncological and functional outcome and quality-of-life (QOL) in patients with pigmented villonodular synovitis (PVNS) enrolled in a Facebook community (1112 members).

METHODS

Patients completed online open surveys on demographics, surgery and clinical outcomes (group 1); and patient-reported outcome measures (PROMs) including knee-injury osteoarthritis outcome score (KOOS), hip-disability osteoarthritis outcome score (HOOS), Toronto extremity salvage score (TESS) and SF-36 (group 2). Mean follow-up was 70 months (12-374). Consistency checks were performed with Cohen's kappa statistic for intra-rater agreement.

RESULTS

The first survey was completed by 272 patients (group 1) and 72 patients completed the second (group 2). In group 1, recurrence-rate was 58 % (69/118) after arthroscopic, 36 % (35/97) after open and 50 % (5/10) after combined synovectomy (p = 0.003). In group 2, recurrence-rate was 67 % (26/39) after arthroscopic and 51 % (17/33) after open synovectomy (p = 0.19). Recurrence-risk was increased for diffuse disease (OR = 16; 95%CI = 3.2-85; p < 0.001). Mean function and QOL did not differ after arthroscopic or open synovectomy: KOOS 49 vs. 58 (p = 0.24), HOOS 62 vs. 53 (p = 0.56), TESS 78 vs. 82 (p = 0.86), SF-36 61 vs. 66 (p = 0.41). Cohen's kappa statistic for intra-rater agreement was good to outstanding (κ = 0.68-0.95; p < 0.001).

CONCLUSION

Local recurrence-risk was higher for diffuse-type disease and arthroscopic synovectomy. Functional outcome and QOL were comparable for both types of surgery. Gathering data via crowdsourcing seems a promising and innovative way of evaluating rare diseases including PVNS.

Unusual Presentation of Anterior Knee Pain in Elite Female Athletes: Report of Two Cases

Two elite female athletes presented with anterior knee pain with range of motion and reproducible tenderness to palpation. Diagnostic arthroscopy was performed in both cases resulting in excision of a nodular pigmented villonodular synovitis (PVNS) in the first patient and scar tissue in the second patient. Correct diagnosis of anterior knee pain in the elite female athlete can present a challenge to clinicians. Although patellofe-moral pain is the most common diagnosis, other uncommon causes include PVNS and residual scar formation in patients with a history of surgery or trauma. Magnetic resonance imaging (MRI) images are helpful in confirming the diagnosis, however, in a subset of patients, the physician must rely on clinical suspicion and physical exam to make the proper diagnosis. Given the possibility of a false negative MRI images, patients with persistent anterior knee pain with a history of knee surgeries and focal tenderness reproducible on physical exam may benefit from a diagnostic arthroscopy.

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.

Arthroscopic resection of benign tumors of the knee posterior compartment: a report of 15 cases

INTRODUCTION

The management of tumors located in the posterior compartment of the knee, whatever the nature of the tumor, remains surgical excision and can be done by open surgery or under arthroscopic control. The objective of this study was to evaluate the arthroscopic management of intra-articular tumors of the posterior compartment of the knee. The hypothesis is that tumors or tumor-like lesions confined to the posterior compartment are accessible by arthroscopy with low iatrogenic risk.

MATERIALS AND METHODS

All patients with an intra-articular tumor of the posterior compartment of the knee were enrolled between 2009 and 2013. The surgical management consisted of arthroscopic resection. Patients underwent postoperative MRI, repeated at last follow-up. The outcomes were the occurrence of complications, functional evaluation using the Lysholm Knee Scoring Scale, and the recurrence rate.

RESULTS

Fifteen patients were included. All patients had a complete resection. One case of delayed healing of the arthroscopic entry point was observed. At a mean 22months, the mean Lysholm Knee Score increased from 74 (±8.5) preoperatively to 92 (±7.7) postoperatively, a significant increase of 18 points (P=0.001). One patient had a recurrence of osteochondromatosis, requiring removal of a foreign body.

DISCUSSION

Resection of posterior intra-articular tumors of the knee using arthroscopy is possible, subject to a learning curve.

Giant Cell Tumor of the Patella Tendon Sheath Presenting as a Painful Locked Knee

Patient: Male, 26

Final Diagnosis: Giant cell tumor of the patella tendon seath

Symptoms: Efusion • locking knee • pain

Medication: None

Clinical Procedure: Arthroscopy and open resection of the tumor

Specialty: Orthopedics and Traumatology