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

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.

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.

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.

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.

Multifocal pigmented villonodular synovitis in a child: A case report

INTRODUCTION

Pigmented villonodular synovitis (PVNS) is a rare, benign proliferative disorder of the synovial membrane that typically presents in adults and affects a single joint. Multifocal PVNS is very rare, particularly in childhood. We reported a rare case of multifocal PVNS affecting over 20 joints in a child.

CLINICAL PROCEDURE

A 7-year-old female patient had a 6-month history of multifocal joints swelling with mild pain. She was diagnosed as polyarticular juvenile idiopathic arthritis at a local hospital. Naproxen, methotrexate, infliximab, and pavlin were used to treat the patient for 2 months. However, the treatment had no effect, the joints swelling remained. The patient was then transferred to our hospital. Physical examination revealed multiple joints swelling, especially in the shoulders joints. Puncture fluid from a shoulder joint was bloody. Magnetic resonance imaging (MRI) revealed synovial thickening and hemosiderin deposition. Biopsy of joint synovium found villous nodules, the invasion of foam cells, and hemosiderin deposition. By collecting all of the evidence, the diagnosis of PVNS was confirmed.

CONCLUSIONS

PVNS was easily misdiagnosed as rheumatoid arthritis and the formal treatment was usually delayed. This case described here is the first case of PVNS involving such a large numbers of joints that has been reported in the literature.