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Umetsu A, Eguchi K, Koga T, Araki T, Takatani A, Aramaki T, Terada K, Iwamoto N, Miyahara K, Yonemitsu N, Nakamura H, Kawakami A, Ueki Y. The Evaluation of Lipoma Arborescens with Intermittent Knee Joint Effusion Based on an Analysis of Serum Cytokine Levels and an Immunohistological Examination. Intern Med 2024; 63:1305-1309. [PMID: 37779066 DOI: 10.2169/internalmedicine.2393-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/03/2023] Open
Abstract
We herein report a 27-year-old woman who presented with recurrent knee pain. Laboratory findings revealed minimal inflammation. Arthrography revealed structures resembling adipose tissues. Magnetic resonance imaging showed a high signal intensity of these structures, leading to the diagnosis of lipoma arborescens (LA). Synovectomy was performed. Pathology revealed adipocyte proliferation and B-cell clusters but no T-cell infiltration. A serum cytokine analysis revealed low levels of interleukin-6 and tumor necrosis factor-α compared with patients with rheumatoid arthritis. The pathogenesis of LA remains unclear, but immunostaining and serum cytokine levels may provide valuable data for future investigations.
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Affiliation(s)
- Ayaka Umetsu
- Department of Rheumatology, Sasebo Chuo Hospital, Japan
| | | | - Tomohiro Koga
- Department of Immunology and Rheumatology, Division of Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, Japan
| | - Takeshi Araki
- Department of Rheumatology, Sasebo Chuo Hospital, Japan
| | | | | | - Kaoru Terada
- Department of Rheumatology, Sasebo Chuo Hospital, Japan
| | - Naoki Iwamoto
- Department of Immunology and Rheumatology, Division of Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, Japan
| | - Kenji Miyahara
- Department of Orthopedic Surgery, Sasebo Chuo Hospital, Japan
| | | | - Hideki Nakamura
- Division of Hematology and Rheumatology, Department of Medicine, Nihon University School of Medicine, Japan
| | - Atsushi Kawakami
- Department of Immunology and Rheumatology, Division of Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, Japan
| | - Yukitaka Ueki
- Department of Rheumatology, Sasebo Chuo Hospital, Japan
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Uğur MC, Aydoğdu S, Kaya Biçer E, Balkan C, Kavaklı K. Rifampicin-Induced Toxic Hepatitis in a Patient with Hemophilia After Chemical Synovectomy. Turk J Haematol 2024; 41:64-65. [PMID: 38323390 PMCID: PMC10918404 DOI: 10.4274/tjh.galenos.2024.2023.0420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 02/06/2024] [Indexed: 02/08/2024] Open
Affiliation(s)
- Mehmet Can Uğur
- İzmir Bakırçay University, Çiğli Training and Research Hospital, Clinic of Hematology, İzmir, Türkiye
| | - Semih Aydoğdu
- Ege University Faculty of Medicine, Department of Orthopedics and Traumatology, İzmir, Türkiye
| | - Elcil Kaya Biçer
- Ege University Faculty of Medicine, Department of Orthopedics and Traumatology, İzmir, Türkiye
| | - Can Balkan
- Ege University Faculty of Medicine, Department of Pediatric Hematology, İzmir, Türkiye
| | - Kaan Kavaklı
- Ege University Faculty of Medicine, Department of Pediatric Hematology, İzmir, Türkiye
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Janssen A, Odekerken G. [Synovial chondromatosis]. Rev Med Liege 2023; 78:533-534. [PMID: 37830315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 10/14/2023]
Abstract
Synovial chondromatosis is a rare pathology that involves most frequently the weight-bearing joints. It is due to the development of cartilaginous bodies from the synovial membrane that could migrate threw the joint. Primary and secondary forms exist. Clinical examination will be marked by swellings and loss of mobility. Cross-sectional imaging has the preference. The treatment of choice is the removal of cartilaginous loose bodies with or without a synovectomy.
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Higa K, Uehara F, Azuma C, Oshiro H, Tome Y, Nishida K. Oncological and functional outcomes of modified arthroscopic resection for intra-articular tenosynovial giant cell tumor of the knee using multiple portals. J Orthop Surg (Hong Kong) 2023; 31:10225536231220413. [PMID: 38051283 DOI: 10.1177/10225536231220413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/07/2023] Open
Abstract
BACKGROUND Arthroscopic resection of tenosynovial giant cell tumor (TS-GCT) presents favorable outcomes. However, there are reportedly higher recurrence rates in patients who had incomplete resection. To minimize incomplete resection, we established a multiple portal approach depending on the location of the disease. In this study, we aimed to retrospectively evaluate the clinical outcomes of arthroscopic resection for both localized and diffuse types of TS-GCT of the knee. METHODS From 2009 to 2019, 13 patients who underwent arthroscopic synovectomy of the knee and were histologically diagnosed with TS-GCT were included in this study. The pre- and postoperative range of motion (ROM) of the knee was measured. The Japanese Orthopaedic Association (JOA) score and the Knee Injury and Osteoarthritis Outcome Score (KOOS) were assessed at the final follow-up examination. Magnetic resonance imaging was performed to detect incomplete resection or local recurrence. RESULTS Among the 13 patients, seven and six had localized and diffuse type TS-GCT, respectively. Regarding the knee ROM, preoperative knee flexion in patients with the localized type was limited compared with that in those with the diffuse type. However, the ROM was significantly improved in patients with both types postoperatively. The JOA score and KOOS of patients with both types at the final follow-up were favorable, and there were no significant differences between both types. There was neither recurrence nor incomplete resection in any patient for both types. CONCLUSION All patients, regardless of the TS-GCT type, achieved favorable outcomes after arthroscopic surgery; especially, the failure rate was 0%.
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Affiliation(s)
- Kotaro Higa
- Department of Orthopedic Surgery, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan
| | - Fuminari Uehara
- Department of Orthopedic Surgery, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan
| | - Chinatsu Azuma
- Department of Orthopedic Surgery, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan
| | - Hiromichi Oshiro
- Department of Orthopedic Surgery, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan
| | - Yasunori Tome
- Department of Orthopedic Surgery, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan
| | - Kotaro Nishida
- Department of Orthopedic Surgery, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan
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Lavignac P, Herraudet P, Baudelle F, Commeil P, Legallois Y, Fabre T. Arthroscopic treatment of diffuse pigmented villonodular synovitis of the elbow. Orthop Traumatol Surg Res 2023; 109:103493. [PMID: 36455866 DOI: 10.1016/j.otsr.2022.103493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 10/07/2021] [Accepted: 10/11/2021] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- Pierre Lavignac
- Service de chirurgie orthopédique, CHU Bordeaux, place Amélie-Raba-Léon, 33000 Bordeaux, France.
| | - Paul Herraudet
- Service de chirurgie orthopédique, CHU Bordeaux, place Amélie-Raba-Léon, 33000 Bordeaux, France
| | - Fabien Baudelle
- Service de chirurgie orthopédique, CHU Bordeaux, place Amélie-Raba-Léon, 33000 Bordeaux, France
| | - Paul Commeil
- Service de chirurgie orthopédique, CHU Bordeaux, place Amélie-Raba-Léon, 33000 Bordeaux, France
| | - Yohan Legallois
- Service de chirurgie orthopédique, CHU Bordeaux, place Amélie-Raba-Léon, 33000 Bordeaux, France
| | - Thierry Fabre
- Service de chirurgie orthopédique, CHU Bordeaux, place Amélie-Raba-Léon, 33000 Bordeaux, France
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Synovectomy in juvenile idiopathic arthritis: A systematic review: Erratum. Medicine (Baltimore) 2023; 102:e32634. [PMID: 36607889 DOI: 10.1097/MD.0000000000032634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
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Hayashibara M, Hagino H, Hayashi I, Nagira K, Takasu Y, Mukunoki D, Nagashima H. A case of septic arthritis of the elbow joint in rheumatoid arthritis diagnosed by arthroscopic synovectomy. Mod Rheumatol Case Rep 2023; 7:24-27. [PMID: 35639881 DOI: 10.1093/mrcr/rxac048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 02/13/2022] [Accepted: 05/23/2022] [Indexed: 01/07/2023]
Abstract
We report a case of methicillin-resistant Staphylococcus aureus (MRSA) septic arthritis of the elbow detected by arthroscopic synovectomy in an 81-year-old woman with rheumatoid arthritis (RA) who was initially diagnosed with a rheumatoid arthritis flare-up. The patient was administered abatacept, an antirheumatic biological agent, as the synovial fluid culture was negative. Destruction of the joint progressed despite medication, and the patient underwent arthroscopic synovectomy. MRSA was detected in the culture of the synovium that was collected intraoperatively, and septic arthritis was diagnosed. The infection subsided with anti-MRSA antibiotics, but the patient continued to experience moderate pain and limited motion. In RA patients, it might be difficult to differentiate minor findings from infection. Arthroscopic synovectomy is one of the selectable procedures that should be actively considered when infection is suspected.
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Affiliation(s)
- Masako Hayashibara
- Department of Orthopedic Surgery, Faculty of Medicine, Tottori University, Tottori, Japan
| | - Hiroshi Hagino
- Department of Life Science, Faculty of Medicine, Tottori University, Tottori, Japan
| | - Ikuta Hayashi
- Department of Orthopedic Surgery, Faculty of Medicine, Tottori University, Tottori, Japan
| | - Keita Nagira
- Department of Orthopedic Surgery, Faculty of Medicine, Tottori University, Tottori, Japan
| | - Yuta Takasu
- Department of Orthopedic Surgery, Faculty of Medicine, Tottori University, Tottori, Japan
| | - Daichi Mukunoki
- Department of Orthopedic Surgery, Yowa Hospital, Tottori, Japan
| | - Hideki Nagashima
- Department of Orthopedic Surgery, Faculty of Medicine, Tottori University, Tottori, Japan
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Abstract
BACKGROUND Juvenile idiopathic arthritis (JIA) is an inflammatory arthropathy with onset in children younger than 16 years. Treatment is primarily medical; however, surgical interventions, such as arthroscopic or open synovectomy, can be beneficial. Many studies have investigated synovectomy in JIA, but the results of these studies have not been synthesized to our knowledge. Therefore, we performed a systematic review of the literature reporting synovectomy as a treatment for JIA to provide clinical recommendations regarding its risks and benefits. METHODS On March 8, 2022, we searched the Cochrane Library, Embase, PubMed, Scopus, and Web of Science for studies evaluating clinical outcomes of open or arthroscopic synovectomy to treat JIA in patients younger than 18 years. We included only studies published in English and excluded studies of synovectomy to treat other arthropathies, septic arthritis, hemophilia, or foreign body arthropathy. The level of evidence for included studies was determined by using the Oxford Centre for Evidence-Based Medicine criteria. We qualitatively analyzed clinical outcomes data, including patient-reported pain relief, rates of symptom recurrence, and postoperative complications. RESULTS Of 428 articles assessed, 14 were included in our analysis. One was a randomized trial, 1 was a case-control study, and all others were case-series. Studies consistently reported that synovectomy was associated with improved function and decreased pain postoperatively. However, comparisons with modern medical therapy were lacking. Rates of arthritis recurrence varied, with increasing symptom recurrence with longer follow-up and re-synovectomy rates up to 15%. Oligoarticular disease and early disease course were associated with better response to synovectomy, whereas systemic and polyarticular disease were associated with poor response. Stiffness requiring manipulation under anesthesia was the most common complication (4% of all included patients). CONCLUSION Although synovectomy is associated with positive functional outcomes and pain reduction postoperatively, there was inadequate comparison thus inadequate evidence to recommend it over modern medical therapy. The current literature suggests that synovectomy should be offered only to patients for whom medical management has failed, while noting the risks of decreased range of motion and symptom recurrence over time.
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Affiliation(s)
- Daniel Badin
- Department of Orthopaedic Surgery, Division of Pediatric Orthopaedics, The Johns Hopkins University, Baltimore, MD, USA
| | - Christopher R Leland
- Department of Orthopaedic Surgery, Division of Pediatric Orthopaedics, The Johns Hopkins University, Baltimore, MD, USA
| | - Rachel S Bronheim
- Department of Orthopaedic Surgery, Division of Pediatric Orthopaedics, The Johns Hopkins University, Baltimore, MD, USA
| | - Nayimisha Balmuri
- Department of Pediatrics, Division of Allergy, Immunology, and Rheumatology, The Johns Hopkins University, Baltimore, MD, USA
| | - R Jay Lee
- Department of Orthopaedic Surgery, Division of Pediatric Orthopaedics, The Johns Hopkins University, Baltimore, MD, USA
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Shim JW, Chae SH, Kim IS, Park MJ. Clinical course in patients with chronic undifferentiated arthritis of the elbow after arthroscopic synovectomy. J Shoulder Elbow Surg 2022; 31:2514-2520. [PMID: 36007866 DOI: 10.1016/j.jse.2022.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Revised: 06/26/2022] [Accepted: 07/07/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Surgical treatment can be considered for patients with undifferentiated arthritis (UA) limited to the elbow joint. The purpose of this study was to analyze the clinical outcomes of arthroscopic synovectomy. METHODS Nineteen patients who underwent arthroscopic synovectomy for chronic UA of the elbow between 2006 and 2019 were enrolled in this study. One patient was excluded because of evidence of tuberculosis in the biopsy. Chronic UA of the elbow was defined as (1) localized synovitis diagnosed by magnetic resonance imaging, (2) no specific cause, and (3) no response to conservative treatment for >3 months. We compared baseline characteristics and clinical outcomes between the remission and disease progression groups. RESULTS Postoperatively, synovitis was controlled in 13 patients. In 5 patients, the symptoms disappeared after surgery without any medical treatment. Four patients discontinued disease-modifying antirheumatic drugs. Nine patients were classified as in remission. The disease progression group had a longer symptom duration, elevated rheumatoid markers, and higher Larsen grading. However, the difference was not statistically significant. CONCLUSIONS Arthroscopic synovectomy achieved remission in approximately 47% of patients with chronic UA of the elbow. Although arthroscopic synovectomy did not prevent RA, it can be considered for rapid resolution of synovitis and diagnostic purposes.
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Affiliation(s)
- Jae Woo Shim
- Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Sang Hoon Chae
- Lee's Bon Spine & Joint Hospital, Busan, Republic of Korea
| | - Il Su Kim
- Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Min Jong Park
- Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
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Tang HC, Sadakah M, Wirries N, Dienst M. Outcomes of arthroscopic management for pigmented villonodular synovitis of the hip. Arch Orthop Trauma Surg 2022; 142:2811-2818. [PMID: 34807281 DOI: 10.1007/s00402-021-04242-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Accepted: 10/31/2021] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Early synovectomy is considered as the main treatment of pigmented villonodular synovitis (PVNS) of the hip in young patients with preserved cartilage. The purpose of the study is to evaluate outcomes of arthroscopic management for PVNS of the hip. METHODS Patients who underwent primary hip arthroscopy for the treatment of histology-confirmed PVNS by the senior author between January 2012 and December 2016 were retrospectively reviewed. We excluded patients who had less than 1-year follow-up or had undergone primary surgeries with other surgeons and then received revision hip arthroscopic procedures by the senior author. The recurrence of PVNS and postoperative condition of affected hip were assessed by follow-up magnetic resonance imaging (MRI). Patient-reported outcomes of modified Harris hip score (mHHS) and 12-item International Hip Outcome Tool (iHOT-12) were collected at latest follow-up. RESULTS Nine patients (2 males, 7 females) with a mean age of 24.3 ± 11.2 years (range 14-44 years) were included in this study. Localized PVNS was observed in four patients, and diffuse PVNS was observed in five patients. No patient presented with advanced osteochondral destruction. Five patients received single adjuvant radiosynoviorthesis. No patient had evidence of recurrence based on follow-up MRI. Patient-reported outcomes were obtained in eight patients at mean 55.8 ± 26.1 months (range 24-84 months) after the index surgery. The mean mHHS was 94.6 ± 4.9 (range 84.7-100) and the mean iHOT-12 was 93.3 ± 20.2 (range 50-120). No patient needed secondary surgery during the follow-up period. CONCLUSION Arthroscopic subtotal synovectomy can offer favorable short to mid-term outcomes in the treatment of hip PVNS in case of no advanced osteochondral damage at presentation.
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Affiliation(s)
- Hao-Che Tang
- Department of Orthopedic Surgery, Chang Gung Memorial Hospital, No.222, Maijin Rd., Anle Dist., Keelung City, 204, Taiwan
| | - Mohammed Sadakah
- Orthopedic department, Tanta University, El-Gaish, Tanta Qism 2, Tanta, Gharbia Governorate, Egypt
| | - Nils Wirries
- Orthopädische Chirurgie München, OCM Klinik GmbH, Steinerstraße 6, 81369, München, Germany
| | - Michael Dienst
- Orthopädische Chirurgie München, OCM Klinik GmbH, Steinerstraße 6, 81369, München, Germany.
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Samade R, Voskuil RT, Scharschmidt TJ. Two-stage TKA for tuberculosis septic arthritis of the knee masquerading as pigmented villonodular synovitis: A case report. Knee 2022; 38:30-35. [PMID: 35872480 DOI: 10.1016/j.knee.2022.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 05/31/2022] [Accepted: 07/07/2022] [Indexed: 02/02/2023]
Abstract
A 25-year-old female presented with left knee pain following arthroscopic synovectomy for presumed pigmented villonodular synovitis (PVNS). Radiographs and magnetic resonance imaging demonstrated tricompartmental arthritic changes. She underwent a two-stage procedure first involving antibiotic spacer implantation, followed 1 week later by spacer removal and definitive total knee arthroplasty (TKA) once initial intraoperative culture results were negative. Subsequent cultures confirmed tuberculosis septic arthritis. Repeat evaluation 1 year postoperatively showed no complications and patient satisfaction with left knee function. This is a unique case report in the United States describing 1-year outcomes following staged TKA for tuberculosis septic arthritis masquerading as PVNS.
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Affiliation(s)
- Richard Samade
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
| | - Ryan T Voskuil
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
| | - Thomas J Scharschmidt
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH 43210, United States.
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d'Ailly PN, Mulders MAM, Bisoendial RJ, Kuijper TM, Coert JH, Schep NWL. Arthroscopic Synovectomy of the Wrist in Patients With Rheumatoid Arthritis: A Systematic Review of the Current Literature. J Clin Rheumatol 2022; 28:77-83. [PMID: 34897196 DOI: 10.1097/rhu.0000000000001807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Rheumatoid arthritis (RA) of the wrist can lead to loss of wrist function and progressive joint destruction if inadequately treated. Arthroscopic synovectomy of the wrist may prove a valuable treatment for local inflammation. OBJECTIVE The aim of this study was to perform a systematic review evaluating functional outcomes and pain following arthroscopic synovectomy of the wrist in RA patients. METHODS A systematic review was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analysis) guidelines. MEDLINE, EMBASE, The Cochrane Library, Web of Science, and Google Scholar were searched for studies describing pain or functional outcomes following arthroscopic synovectomy of the wrist in RA patients (CRD42021270846). Risk of bias was assessed using the Methodological Index for Non-Randomized Studies. Data collection included patient characteristics, pain scores, wrist function questionnaires, secondary surgery, and complications. RESULTS Six noncomparative cohort studies were included, with a total of 153 arthroscopic synovectomies. Disease duration of RA ranged from 32 to 89 months, and radiographic progression was mild to moderate. The Methodological Index for Non-Randomized Studies scores ranged from 8 to 10 out of 16. Mean follow-up ranged from 21 to 95 months. Improvements were seen in pooled mean visual analog scale pain score (from 7.7 to 2.2, p < 0.05), pooled mean Modified Mayo Wrist Score (from 43.3 to 70.4, p < 0.05), and the Disability of the Arm, Shoulder, and Hand (from 67.5 to 36.5, p < 0.05). Two complications occurred, and 5 patients required secondary surgery. CONCLUSIONS There is limited evidence suggesting that arthroscopic synovectomy of the wrist improves wrist function and pain in patients with RA, with few complications. In centers with arthroscopic expertise, it can be considered as a treatment option.
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Affiliation(s)
| | | | - Radjesh J Bisoendial
- Department of Rheumatology and Clinical Immunology, Maasstad Hospital, Rotterdam
| | - T Martijn Kuijper
- Department of Rheumatology and Clinical Immunology, Maasstad Hospital, Rotterdam
| | - J Henk Coert
- Department of Plastic Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Niels W L Schep
- From the Department of Surgery, Maasstad Hospital, Rotterdam
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Ge L, Zhang L, Lu L. Stenosing tenosynovitis with rice bodies formation diagnosed by ultrasound: A case report. Medicine (Baltimore) 2022; 101:e28871. [PMID: 35363196 PMCID: PMC9282108 DOI: 10.1097/md.0000000000028871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Accepted: 02/01/2022] [Indexed: 01/04/2023] Open
Abstract
RATIONALE Rice bodies are usually found in several nonspecific chronic inflammatory diseases that are symptomatically dominated by primary disease and local compression symptoms. Rice bodies are usually detected by magnetic resonance imaging; however, some remote areas and areas with poor economic conditions do not have access to magnetic resonance imaging examination, which leads to delayed diagnosis of the disease. PATIENT CONCERNS We report the case of a 62-year-old man with pain in the metacarpophalangeal joint of his right middle finger and limited flexion activity of his middle finger. DIAGNOSES The mass was 1 cm, well-circumscribed, soft, and painless. Ultrasound showed stenosing tenosynovitis with rice body formation. INTERVENTIONS The patient underwent tenosynovectomy with synovectomy of the right middle finger tendon sheath under plexus block anesthesia. OUTCOMES No postoperative complications were noted. A 6-month follow-up showed no recurrence. The activity of the patient's middle finger improved significantly. LESSONS Stenosing tenosynovitis with rice body formation is a very rare condition, and we use ultrasound for diagnosis. Ultrasound is convenient, rapid, inexpensive, and can obtain blood flow information, facilitate disease follow-up, and even allow ultrasound localization in advance for guided needle biopsy.
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Affiliation(s)
- Lei Ge
- Department of Emergency, People's Hospital of Rizhao, Jining Medical University, Shandong, China
| | - Lei Zhang
- Department of Emergency, People's Hospital of Rizhao, Jining Medical University, Shandong, China
| | - Libin Lu
- Department of Emergency, People's Hospital of Rizhao, Jining Medical University, Shandong, China
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Pai SN, Kumar MM. Giant synovial chondromatosis of hip. BMJ Case Rep 2022; 15:e246039. [PMID: 35064037 PMCID: PMC8785164 DOI: 10.1136/bcr-2021-246039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/30/2021] [Indexed: 11/04/2022] Open
Abstract
Synovial chondromatosis is a rare, benign condition occurring due to metaplasia of synovium. A 65-year-old woman presented with pain in her right hip for 6 years. On examination, a swelling was palpable at the base of scarpa's triangle and her right hip movements were restricted. Imaging modalities showed ossified nodules in the antero-inferior aspect of the hip joint, joint effusion and arthritic changes. We diagnosed the patient to have synovial chondromatosis with secondary arthritis of the hip joint. We performed a total hip arthroplasty with simultaneous synovectomy and extraction of the osteochondral loose bodies, 5 of which were about 2×2 cm in size. We found that excessive acetabular reaming was required due to craters, the osteochondral masses formed on the acetabular surface. Histopathological analysis confirmed the diagnosis. The patient had an excellent functional outcome and no recurrence 5 years following the surgery.
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Affiliation(s)
- Satvik N Pai
- Department of Orthopaedic Surgery, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India
| | - Mohan M Kumar
- Department of Orthopaedic Surgery, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India
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15
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Abstract
Rice bodies are a rare finding in medicine and offer a therapeutic challenge. As their occurrence varies over multiple rheumatic as well as infectious diseases, multiple hypotheses have been made about their origin. While rice bodies are most frequently reported in the shoulder and knee joints, flexor tendon synovitis with accompanying rice bodies is rarer. We report a case of extensive flexor tenosynovitis with rice bodies in the wrist in a 90-year-old patient with seronegative rheumatoid arthritis. The patient reported a 5-month history of painful swelling of the right wrist. Ultrasound showed pronounced swelling of the synovial tissue of the flexor tendons. Laboratory test were negative for rheumatology tests with normal C-reactive protein and sedimentation rates. T2-weighted magnetic resonance imaging demonstrated an extensive synovitis reaching from the distal forearm into the hand with inclusions, better known as rice bodies. Synovectomy including carpal tunnel release was performed with dissection of the mass revealing an extensive synovitis with a multitude of rice bodies. Histopathology showed lymphohistiocytic infiltrates consistent with rheumatoid nodules. After surgery, the patient regained full function of the wrist within 2 weeks without any pain or remaining mass in the affected limb.
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Affiliation(s)
- Maurice Gillijns
- Department of Orthopaedic Surgery, AZ St-Dimpna Geel, Geel, Belgium
| | - Wim Vandesande
- Department of Orthopaedic Surgery, AZ St-Dimpna Geel, Geel, Belgium
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16
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McEneaney PA, Rundell JD, Nordquist T, Pacaccio D. Synovial chondromatosis of the ankle joint: 2 cases treated by open arthrotomy and synovectomy. Foot (Edinb) 2021; 49:101804. [PMID: 34016505 DOI: 10.1016/j.foot.2021.101804] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Revised: 02/27/2021] [Accepted: 04/11/2021] [Indexed: 02/05/2023]
Abstract
Synovial chondromatosis is a rare condition consisting of metaplasia of the synovial tissue that usually presents in large joints such as the knee and hip. The reported occurrence of synovial chondromatosis in the foot and ankle joints is rare in the literature. In this case report, the successful surgical management of two patients presenting with this condition using open ankle arthrotomy & synovectomy is described. These two cases are presented to provide added depth to the current literature, as well as presenting a review of published literature to further guide clinicians in the management of this rare condition. LEVEL OF EVIDENCE: 4 (case study).
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17
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Li M, Shi X, Yin S, Zhang L, Wu P, Liao T, Jie L, Wang P. Should synovectomy be performed during total knee arthroplasty for knee osteoarthritis: A protocol for systematic review and meta-analysis. Medicine (Baltimore) 2021; 100:e27820. [PMID: 34797309 PMCID: PMC8601306 DOI: 10.1097/md.0000000000027820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 10/29/2021] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND To evaluate the effect of synovectomy performed during primary total knee arthroplasty for knee osteoarthritis on patients' postoperative pain and knee function. METHODS We will search the following electronic databases from inception to June 2021, including PubMed, EMBASE, Web of Science, the Cochrane Library, the China National Knowledge Infrastructure, the Chinese Scientific Journals Database, the Wanfang database, and the Chinese Biomedicine Database. Eligible references will be all randomized controlled trials of initial total knee arthroplasty for primary knee osteoarthritis with or without synovectomy. Two reviewers will independently extract the data. Reviewer Manager 5.3 software will be used for statistical analysis. RESULT It will provide results on the short- and long-term efficacy and safety of synovectomy in total knee arthroplasty by various comprehensive assessments. CONCLUSION This study will provide solid evidence on whether and when synovectomy treatment should be performed during total knee arthroplasty.
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Affiliation(s)
- Mingchao Li
- Department of Orthopaedic Surgery, The Affiliated Hospital of Nanjing University of Chinese Medicine; 155 Hanzhong Road, Nanjing, Jiangsu, China
- Department of Orthopaedic Surgery, The Third People's Hospital of Kunshan, 615 Zizhu Road, Kunshan, Suzhou, Jiangsu, China
| | - Xiaoqing Shi
- Department of Orthopaedic Surgery, The Affiliated Hospital of Nanjing University of Chinese Medicine; 155 Hanzhong Road, Nanjing, Jiangsu, China
| | - Songjiang Yin
- Department of Orthopaedic Surgery, The Affiliated Hospital of Nanjing University of Chinese Medicine; 155 Hanzhong Road, Nanjing, Jiangsu, China
| | - Li Zhang
- Department of Orthopaedic Surgery, The Affiliated Hospital of Nanjing University of Chinese Medicine; 155 Hanzhong Road, Nanjing, Jiangsu, China
| | - Peng Wu
- Department of Orthopaedic Surgery, The Affiliated Hospital of Nanjing University of Chinese Medicine; 155 Hanzhong Road, Nanjing, Jiangsu, China
| | - Taiyang Liao
- Department of Orthopaedic Surgery, The Affiliated Hospital of Nanjing University of Chinese Medicine; 155 Hanzhong Road, Nanjing, Jiangsu, China
| | - Lishi Jie
- Department of Orthopaedic Surgery, The Affiliated Hospital of Nanjing University of Chinese Medicine; 155 Hanzhong Road, Nanjing, Jiangsu, China
| | - Peimin Wang
- Department of Orthopaedic Surgery, The Affiliated Hospital of Nanjing University of Chinese Medicine; 155 Hanzhong Road, Nanjing, Jiangsu, China
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18
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Subhashini R, Srinivasamurthy BC, Bhat RV, Kaliaperumal A, Sivagurunathan GM. Metastatic adenocarcinoma presenting as monoarticular arthritis of the knee: A case report with review of literature. J Cancer Res Ther 2021; 17:1562-1564. [PMID: 34916397 DOI: 10.4103/jcrt.jcrt-469-19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/11/2023]
Abstract
Patients who develop metastatic arthritis secondary to solid tumors are rare. It is even more uncommon to be a presenting symptom. We present a case where a known case of osteoarthritic patient presented with complaints of knee swelling secondary to primary colonic carcinoma with lung metastasis. It was initially diagnosed on histopathology examination as metastatic adenocarcinoma from excised synovial mass and further investigated for primary carcinoma. Later, computed tomography was done and found out the primary colonic carcinoma arising from transverse colon along with lung metastasis.
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Affiliation(s)
- R Subhashini
- Department of Pathology, Indira Gandhi Medical College and Research Institute, Puducherry, India
| | | | - Ramachandra V Bhat
- Department of Pathology, Indira Gandhi Medical College and Research Institute, Puducherry, India
| | - Arun Kaliaperumal
- Department of Orthopaedics, Indira Gandhi Medical College and Research Institute, Puducherry, India
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19
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Xiang X, Jiang W, Qiu C, Xiao N, Liang J. 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. Medicine (Baltimore) 2021; 100:e26659. [PMID: 34260572 PMCID: PMC8284748 DOI: 10.1097/md.0000000000026659] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 06/28/2021] [Indexed: 02/06/2023] Open
Abstract
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.
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20
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Abstract
Synovial chondromatosis of the finger is a rare metaplasia affecting either the finger joint or the tendon sheath. It is a benign extraosseus cartilage tumor that often occurs in numbers and is not solitary in nature. This accumulation of masses within the finger can lead the patient to seek medical care. Symptoms are often painful and functionally disabling. Although rare, synovial chondromatosis must be considered in the differential diagnosis for patients with multiple lesions or masses within the hand and finger. Patient workup involves advanced imaging, including magnetic resonance imaging, ultrasonography, and computerized tomography. However, the results of these studies may be inconclusive. Conservative management can be discussed with the patient but has proven to be ineffective. Surgical excision is the recommended first-line treatment. Whether the surgery is arthroscopic or open, with or without synovectomy, is at the surgeon's discretion. Mass recurrence after surgery is an unfortunate complication, and subsequent treatment strategies are undefined. Recurrence may not occur at the same anatomical site. This condition can be intra-articular (within the figure joint) or extra-articular (within the tendon sheath or bursa). Revision surgery in the form of open excision with synovectomy is the mainstay of treatment. There have been only a few case reports of synovial chondromatosis involving the finger. This case series and up-to-date review of the literature presents a discussion of current surgical care. [Orthopedics. 2021;44(3):e454-e457.].
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21
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Mizumachi K, Tsumura Y, Nakajima Y, Koh K, Nogami K. Clot waveform analysis for perioperative hemostatic monitoring of arthroscopic synovectomy in a pediatric patient with hemophilia A and inhibitor receiving emicizumab prophylaxis. Int J Hematol 2021; 113:930-935. [PMID: 33566316 DOI: 10.1007/s12185-021-03095-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 01/26/2021] [Accepted: 01/28/2021] [Indexed: 11/25/2022]
Abstract
Emicizumab reduces bleeding in patients with hemophilia A and inhibitors (PwHA-I). Coagulation potential during the perioperative period in emicizumab-treated PwHA-I undergoing surgery remains to be evaluated. We describe a 14-year-old boy with HA-I receiving emicizumab prophylaxis who experienced arthroscopic synovectomy. He was treated with a bolus infusion of recombinant factor VIIa (rFVIIa; 80 μg/kg) immediately before surgery, and treatment continued at the same dose every 3 h on day 1, every 4 h on day 2, and every 6 h on day 3. Treatment with rFVIIa was discontinued on day 4. No perioperative bleeding or thrombotic events were observed. Coagulation potential throughout the perioperative period was retrospectively assessed with an easy-to-use clot waveform analysis (CWA). Measurements from CWA returned to within or near the normal range, suggesting successful hemostatic management. Coagulation potentials assessed by CWA showed a significant correspondence with those from a thrombin generation assay (TGA) that is already in use. CWA and TGA could both provide useful data for assessing coagulation potential in the perioperative hemostatic management of emicizumab-treated PwHA-I.
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Affiliation(s)
- Kuniyoshi Mizumachi
- Department of Pediatrics, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Yusuke Tsumura
- Department of Hematology/Oncology, Saitama Children's Medical Center, Saitama, Japan
| | - Yuto Nakajima
- Department of Pediatrics, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan.
| | - Katsuyoshi Koh
- Department of Hematology/Oncology, Saitama Children's Medical Center, Saitama, Japan
| | - Keiji Nogami
- Department of Pediatrics, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
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22
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Abstract
INTRODUCTION After knee replacement, therapy resistant, persistent synovitis is a common issue, which causes effusion and pain, and leads to loosing. It has been hypothesized that radiosynovectomy (RSO) is useful in these patients. MATERIALS AND METHODS A cohort of 55 patients with 57 knee replacements and persistent synovitis underwent RSO using 4.9 ± 0.24 mCi (182 ± 9 MBq) of Y-citrate. The number of RSOs ranged from 1 to 4. Bone scans before and 3 months after every RSO were performed. Long-term follow-up ranged from 0.8 to 7.6 years with a mean of 23.2 months. For qualitative analysis, an established 4 steps scoring was used. For quantification, the uptake was determined within the Tc-MDP scintigraphy blood pool phase before and after therapy. RESULTS Long-term response was in 27% with excellent, 24% good, 30% weak, and 20% no response. The duration of response was 12.0 ± 12.0 months (maximum, 54 months). In patients with repeated treatment, the effect after the first therapy was lesser than in patients who received a single treatment in total. However, 3 months after the last RSO, patients with repeated treatment showed a similar effectiveness than single treated patients. At the end of long-term follow-up, patients with repeated RSOs had a higher effectiveness at similar duration response. In bone scan, 65% of patients showed a reduction of uptake. When comparing subjective and objective response, 78% of patients showed a concordance in both symptoms and scintigraphy. Pilot histological analysis revealed that the synovitis is triggered by small plastic particles. CONCLUSIONS We concluded that RSO is an effective therapy in patients with knee replacement and persistent synovitis with high long-term response. Repeated treatment leads to a stronger long-time response.
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Affiliation(s)
- Knut Liepe
- From the Department of Nuclear Medicine, GH Hospital Frankfurt (Oder), Frankfurt (Oder), Germany
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23
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Voss A, Pfeifer CG, Kerschbaum M, Rupp M, Angele P, Alt V. Post-operative septic arthritis after arthroscopy: modern diagnostic and therapeutic concepts. Knee Surg Sports Traumatol Arthrosc 2021; 29:3149-3158. [PMID: 33755737 PMCID: PMC8458194 DOI: 10.1007/s00167-021-06525-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 02/26/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE Septic arthritis is a significant complication following arthroscopic surgery, with an estimated overall incidence of less than 1%. Despite the low incidence, an appropriate diagnostic and therapeutic pathway is required to avoid serious long-term consequences, eradicate the infection, and ensure good treatment outcomes. The aim of this current review article is to summarize evidence-based literature regarding diagnostic and therapeutic options of post-operative septic arthritis after arthroscopy. METHODS Through a literature review, up-to-date treatment algorithms and therapies have been identified. Additionally, a supportive new algorithm is proposed for diagnosis and treatment of suspected septic arthritis following arthroscopic intervention. RESULTS A major challenge in diagnostics is the differentiation of the post-operative status between a non-infected hyperinflammatory joint versus septic arthritis, due to clinical symptoms, (e.g., rubor, calor, or tumor) can appear identical. Therefore, joint puncture for microbiological evaluation, especially for fast leukocyte cell-count diagnostics, is advocated. A cell count of more than 20.000 leukocyte/µl with more than 70% of polymorphonuclear cells is the generally accepted threshold for septic arthritis. CONCLUSION The therapy is based on arthroscopic or open surgical debridement for synovectomy and irrigation of the joint, in combination with an adequate antibiotic therapy for 6-12 weeks. Removal of indwelling hardware, such as interference screws for ACL repair or anchors for rotator cuff repair, is recommended in chronic cases. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Andreas Voss
- Department of Trauma Surgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany.
- Sporthopaedicum, Regensburg, Straubing, Germany.
| | - Christian G Pfeifer
- Department of Trauma Surgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
| | - Maximilian Kerschbaum
- Department of Trauma Surgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
| | - Markus Rupp
- Department of Trauma Surgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
| | - Peter Angele
- Department of Trauma Surgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
- Sporthopaedicum, Regensburg, Straubing, Germany
| | - Volker Alt
- Department of Trauma Surgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
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24
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Abstract
INTRODUCTION Lipoma Arborescens is a rare pathology that mainly affects the knee. Occurrences in the elbow are even more uncommon and mainly involve the bicipitoradial bursa. CASE'S DESCRIPTION We describe the case of a 54-year-old patient known for rheumatoid arthritis, who consulted for chronic elbow pain associated with swelling and limited extension. DIAGNOSIS The diagnosis of a lipoma arborescens of the elbow involving the whole joint was made using magnetic resonance imaging and confirmed during arthroscopy. INTERVENTIONS After a failed nonoperative treatment consisting in intra-articular cortisone injections and physiotherapy, the patient underwent arthroscopic synovectomy and arthrolysis. OUTCOME At 1-year follow-up, he reported no pain, satisfactory range of motion, and major improvements in clinical scores. CONCLUSION This is the first illustrated case report about lipoma arborescens involving the whole elbow joint. Even though it is a rare disease, awareness of its presentation, imaging patterns, and treatment options is therefore important for clinicians, radiologists, and surgeons. In this case, arthroscopic treatment resulted in satisfactory and long-lasting pain relief and functional results. It may be considered as a safe and effective option in case of failed nonoperative measures.
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Affiliation(s)
| | - Gregory Cunningham
- Department of Orthopaedics and Trauma Surgery, Geneva University Hospitals, Switzerland, Rue Gabrielle-Perret-Gentil 4
- Shoulder Center, Hirslanden Clinique la Colline, Geneva, Switzerland
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25
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Roulet S, Charruau B, Mazaleyrat M, Ferembach B, Marteau E, Laulan J, Bacle G. Modified Lateral Approach of the Elbow for Surgical Release and Synovectomy. Tech Hand Up Extrem Surg 2020; 25:84-88. [PMID: 32868694 DOI: 10.1097/bth.0000000000000312] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Elbow stiffness is a common reason for consultation. In recent years, arthroscopic techniques in elbow surgery have progressed, but there are still some contraindications to performance of arthroscopic synovectomy and release in this joint (elbows with anatomic deformity after multiple procedures, malunion, presence of osteosynthesis material, severe stiffness of >80 degrees, instability, or previous transposition of the ulnar nerve). Therefore, knowledge of a safe and reliable open approach to achieve elbow release and/or synovectomy is essential. We report the technical details of the modified lateral approach between extensor carpi radialis brevis and longus muscles, as well as the clinical results of 43 elbow release and/or synovectomy procedures, illustrating its feasibility. The modified lateral approach, providing visual control of the radial nerve and good anterior exposure of the elbow joint, is detailed. From 1994 to 2016, this approach was used in 43 release and/or synovectomy procedures of the elbow in 41 patients, 30 men and 11 women, with a mean age of 40.56 years (range, 17 to 84 y). Using this procedure, 38 elbows (93%) recovered full extension and 5 subtotal extension with an average deficit of 11 degrees (range, 5 to 20 degrees). All elbows were stable. No neurological complications were reported. The modified lateral approach preserves the insertion of the lateral epicondyle muscles that are major dynamic stabilizers and reduces the risk of instability. Initially described for the treatment of radial tunnel syndrome, it should also be recommended for elbow release and synovectomy.
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Affiliation(s)
- Steven Roulet
- Hand Surgery Unit, Department of Orthopedic Surgery, Trousseau University Hospital, Medical University François Rabelais of Tours, Tours
| | - Bertille Charruau
- Department of Upper Limb and Hand Surgery, Clinique de l'Essonne, Cedex, France
| | - Matthieu Mazaleyrat
- Hand Surgery Unit, Department of Orthopedic Surgery, Trousseau University Hospital, Medical University François Rabelais of Tours, Tours
| | - Benjamin Ferembach
- Hand Surgery Unit, Department of Orthopedic Surgery, Trousseau University Hospital, Medical University François Rabelais of Tours, Tours
| | - Emilie Marteau
- Hand Surgery Unit, Department of Orthopedic Surgery, Trousseau University Hospital, Medical University François Rabelais of Tours, Tours
| | - Jacky Laulan
- Hand Surgery Unit, Department of Orthopedic Surgery, Trousseau University Hospital, Medical University François Rabelais of Tours, Tours
| | - Guillaume Bacle
- Hand Surgery Unit, Department of Orthopedic Surgery, Trousseau University Hospital, Medical University François Rabelais of Tours, Tours
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Dwivedi S, Testa EJ, Modest JM, Ibrahim Z, Gil JA. Surgical Management of Rheumatoid Arthritis of the Hand. R I Med J (2013) 2020; 103:32-36. [PMID: 32357591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Affiliation(s)
- Shashank Dwivedi
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, RI
| | - Edward J Testa
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, RI
| | - Jacob M Modest
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, RI
| | - Zainab Ibrahim
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, RI
| | - Joseph A Gil
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, RI
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27
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Munger AM, Ibe IK, Rottmann D, Conway D, Costa J, Lindskog DM. Synovial Myxoma: Found in Canines, Rabbits, and Now Humans Too?: A Case Report. JBJS Case Connect 2020; 10:e0490. [PMID: 32224675 DOI: 10.2106/jbjs.cc.19.00490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
CASE A 63 year-old woman presented with a multiple-year history of right knee pain and effusions and pain refractory to numerous knee aspirations and an arthroscopic synovectomy. The patient underwent a 2-incision synovectomy and intralesional resection. A pathologic review of the specimens revealed an infiltrative tumor of basophilic, cluster of differentiation 68-positive synovial cells embedded within a myxoid stroma with low proliferative activity, most consistent with a synovial myxoma. CONCLUSIONS This case report of a synovial myxoma-a benign, slow growing but locally aggressive mass that is most commonly found in canines-indicates that the lesion may occasionally occur in humans.
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Affiliation(s)
- Alana M Munger
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut
| | - Izuchukwu K Ibe
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut
| | - Douglas Rottmann
- Department of Pathology, Yale School of Medicine, New Haven, Connecticut
| | - Devin Conway
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut
| | - José Costa
- Department of Pathology, Yale School of Medicine, New Haven, Connecticut
- Department of Pathology, University of Lausanne, Lausanne, Switzerland
| | - Dieter M Lindskog
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut
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28
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Do Cho S, Youm YS, Park SJ, Cho HI. Pigmented villonodular synovitis after anterior cruciate ligament reconstruction using active bioprosthetic composite artificial ligament. Rheumatol Int 2019; 40:657-661. [PMID: 31820085 DOI: 10.1007/s00296-019-04491-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Accepted: 12/03/2019] [Indexed: 11/26/2022]
Abstract
Pigmented villonodular synovitis (PVNS) is a proliferative disease that develops in the synovium of joints, especially the knee joints. A 52-year-old man visited our hospital with left knee pain, swelling and symptoms of collapse. Twenty-one years earlier, he had undergone anterior cruciate ligament (ACL) reconstruction using an active bioprosthetic composite (ABC) as an artificial ligament. T1 and T2 weighted magnetic resonance imaging of the knee joint showed rupture of the ABC ligament and low signal intensity of hyperplastic synovium. Arthroscopic total synovectomy without ACL reconstruction was performed and the lesion was histopathologically diagnosed as diffuse PVNS. Clinical outcomes included good pain relief and no recurrence of the disease after 5 years of follow-up.
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Affiliation(s)
- Sung Do Cho
- Department of Orthopedic Surgery, Dongcheondongkang Hospital, Ulsan, South Korea
| | - Yoon Seok Youm
- Department of Orthopedic Surgery, Myongji Hospital, Hanyang University College of Medicine, 55, Hwasu-ro 14beon-gil, Deogyang-gu, Goyang-si, Gyeonggi-do, 10475, South Korea.
| | - Sun Jae Park
- Department of Orthopedic Surgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, South Korea
| | - Hyung In Cho
- Department of Orthopedic Surgery, Myongji Hospital, Hanyang University College of Medicine, 55, Hwasu-ro 14beon-gil, Deogyang-gu, Goyang-si, Gyeonggi-do, 10475, South Korea
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29
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Kim B, Raphael B, Liu C, Golden BD. Non-Hodgkin Lymphoma with Synovial Involvement of the Knee. Bull Hosp Jt Dis (2013) 2019; 77:275-278. [PMID: 31785142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Musculoskeletal involvement occurs in approximately 25% of patients diagnosed with non-Hodgkin lymphoma (NHL). Skeletal involvement is typically secondary, with primary lymphoma of the bone being much rarer. We describe a case in which a 52-year-old man initially presented features suggestive of Lyme arthritis in his left knee. A synovial biopsy performed as part of a synovectomy procedure revealed a proliferative synovium with dense lymphoplasmacytic B cell infiltrate, suggestive of NHL. An inguinal lymph node biopsy was also performed but did not produce results pathologically similar to those of the left knee synovial biopsy.
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30
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Duarte ML, Santos LRD, Gastaldi TND. [Synovial Haemangioma of the Knee - Diagnosis by Magnetic Resonance Imaging]. Rev Port Cir Cardiotorac Vasc 2019; 26:235-238. [PMID: 31734979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Indexed: 06/10/2023]
Abstract
Synovial hemangioma is a rare nonneoplastic vascular malformation of the synovial membrane described by Bouchut in 1856. Fewer than 200 cases have been described in the literature, corresponding to 1% of all hemangiomas. The presenting symptoms are often non-specific, which often leads to a delay in diagnosis of many years and can result in arthropathy if left undetected. The early diagnosis of a synovial haemangioma is important as recurrent haemarthrosis may lead to irreversible joint damage and chronic inflammatory synovitis. In practice, there is no consensus on the best treatment of synovial hemangiomas in children. Total resection of the tumor can be performed by arthroscopy in localized forms and for small lesions. Open resection associated with synovectomy is necessary when the hemangioma occupies most of synovial membrane.
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Affiliation(s)
- Márcio Luís Duarte
- Radiologista da WEBIMAGEM, São Paulo, São Paulo, Brasil; Mestre em Saúde Baseada em Evidências pela UNIFESP, São Paulo, São Paulo, Brasil
| | - Lucas Ribeiro Dos Santos
- Professor de endocrinologia na Faculdade de Ciências Médicas de Santos, Santos, São Paulo, Brasil
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Pech J, Vlček M, Landor I. [Current Options of Rheumatosurgery of the Hand and Wrist]. Acta Chir Orthop Traumatol Cech 2019; 86:313-319. [PMID: 31748104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Rheumatosurgery is a discipline managing the symptoms of rheumatoid arthritis of the musculoskeletal system. In a vast number of patients this disease starts in the wrist and hand. The portfolio of surgical procedures performed on the skeleton and soft tissues in these regions can be divided into two groups that, however, often times overlap in practice. Commonly, a combination of these surgical interventions is used. The surgical management should commence with prophylactic interventions that aim to slow down the development of rheumatoid deformities. These are followed by reconstructive surgery which shall manage the already developed rheumatoid deformities and their complications. The prophylactic interventions include early and late synovectomy, peritenosynovectomy, tenodeses, tendon transpositions and limited arthrodeses. The reconstructive surgery procedures comprise osteotomy, resection procedures, alloplasties, total arthrodesis and tendon reconstructions. Key words: rheumatoid arthritis, rheumatosurgery, hand, wrist.
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Noback PC, Seetharaman M, Danoff JR, Birman M, Rosenwasser MP. Arthroscopic Wrist Debridement and Radial Styloidectomy for Advanced Scapholunate Advanced Collapse Wrist: Long-term Follow-up. Hand (N Y) 2018; 13:659-665. [PMID: 28825326 PMCID: PMC6300173 DOI: 10.1177/1558944717725383] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Symptomatic stage 2 or 3 scapholunate advanced collapse (SLAC) wrist is aggressively treated with salvage procedures, such as proximal row carpectomy or partial wrist fusion with resultant pain relief but limited motion. We hypothesize that arthroscopic synovectomy, radial styloidectomy, and neurectomy will preserve wrist motion, relieve pain, and delay or avoid salvage procedures. METHODS We evaluated outcomes in 13 wrists through questionnaires and 11 of these through additional physical examination at a mean follow-up of 5.0 years. Eight wrists were stage 2 and 5 were stage 3. Data at final follow-up included mobility/strength measurements, subjective outcome scores (Disabilities of the Arm, Shoulder, and Hand [DASH] and visual analog scale [VAS] pain), patient satisfaction, and return to work statistics. RESULTS Patients had an average flexion-extension arc of 88.0° in the treated wrist and an average grip strength that was 95.0% of the contralateral side. No patients required revision surgery at follow-up. The 13 wrists reported an average DASH score of 16.4 and mean VAS pain score at rest and with activity of 17.9 and 31.6, respectively. All patients working prior to the procedure (n = 8) were able to immediately return to work. In all, 84.6% of patients were satisfied. CONCLUSIONS The procedure studied may have advantages in relieving pain, while preserving wrist motion for SLAC stage 2 or 3 disease. This procedure does not preclude future salvage procedures in those patients with severe disease who prefer to maintain wrist motion for the short term. Patients experience good functional outcomes with the majority experiencing a reduction in pain with the ability to return to work.
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Abstract
RATIONALE Due to the low incidence and lack of effective diagnostic measures for the diagnosis of metal allergy in patients undergoing total joint arthroplasty (TJA), diagnosis relies mainly on the exclusion of other causes, in particular infection. It remains a relatively unpredictable and poorly understood cause of implant failure. At present, skin patch testing, leukocyte migration inhibition test (LMIT) and lymphocyte transformation tests (LTT) are being commonly used to assess metal hypersensitivity.This report presents both a case and literature review. PATIENT CONCERNS A 61-year-old female patient experienced continuous swelling and pain in the right knee joint for 9 months after a right-side total knee arthroplasty (TKA). DIAGNOSES We believe this is the case report of metal allergy in TKA. The following were the reasons for this. First, no definite symptoms of infection during revision arthroplasty were observed, but with obvious hyperplasia of synovium. Furthermore, a frozen biopsy revealed an extremely low neutrophil count, which was considered to be caused by chronic inflammation. Second, the results of repeated post-operation reexaminations indicate a clear increase in the number of eosinophils, while no bacteria were found in the tissue bacterial smear performed during the operation. Third, improvements were clearly observed in the patient following synovectomy, revision of the polyethylene insert and anti-anaphylactic treatment. INTERVENTIONS The patient underwent synovectomy, revision of the polyethylene insert and anti-anaphylactic treatment. OUTCOMES The patient's right knee remained mildly swollen; however, the pain has been relieved significantly. The range of motion could achieve 0 degrees of extension and 90 degrees of flexion. LESSONS No consensus has been reached about the best diagnostic criteria for this disease, and most physicians would consider it to be a possibility when other diseases including periprosthetic joint infection (PJI) have been excluded. Although this case followed the same course, the outcome following synovectomy and anti-anaphylactic treatment further confirmed our hypothesis.
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Gould D, Kulber D, Kuschner S, Dellamaggiorra R, Cohen M. Our Surgical Experience: Open Versus Endoscopic Carpal Tunnel Surgery. J Hand Surg Am 2018; 43:853-861. [PMID: 29759797 DOI: 10.1016/j.jhsa.2018.03.029] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Accepted: 03/18/2018] [Indexed: 02/02/2023]
Abstract
Carpal tunnel release is one of the most common hand operations in the United States and every year approximately 500,000 patients undergo surgical release. In this article, we examine the argument for endoscopic carpal tunnel release versus open carpal tunnel release, as well as some of the literature on anatomical variants in the median nerve at the wrist. We further describe the experience of several surgeons in a large academic practice. The goals of this article are to describe key anatomic findings and to present several cases that have persuaded us to favor offering patients open carpal tunnel release.
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Affiliation(s)
- Daniel Gould
- Division of Plastic and Reconstructive Surgery, University of Southern California, Los Angeles, CA.
| | - David Kulber
- Division of Plastic and Reconstructive Surgery, University of Southern California, Los Angeles, CA; Department of Orthopaedic Surgery, Cedars Sinai Medical Center, Los Angeles, CA; Division of Plastic Surgery, Cedars Sinai Medical Center, Los Angeles, CA
| | - Stuart Kuschner
- Division of Plastic and Reconstructive Surgery, University of Southern California, Los Angeles, CA; Department of Orthopaedic Surgery, Cedars Sinai Medical Center, Los Angeles, CA
| | - Ryan Dellamaggiorra
- Division of Plastic and Reconstructive Surgery, University of Southern California, Los Angeles, CA; Department of Orthopaedic Surgery, Cedars Sinai Medical Center, Los Angeles, CA
| | - Myles Cohen
- Division of Plastic and Reconstructive Surgery, University of Southern California, Los Angeles, CA; Department of Orthopaedic Surgery, Cedars Sinai Medical Center, Los Angeles, CA; Division of Plastic Surgery, Cedars Sinai Medical Center, Los Angeles, CA
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Kiyak G. In vivo confirmation of the reliability of the dorsal tangential view of the wrist. Hand Surg Rehabil 2017; 37:56-59. [PMID: 29229540 DOI: 10.1016/j.hansur.2017.11.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Revised: 10/10/2017] [Accepted: 11/15/2017] [Indexed: 01/09/2023]
Abstract
The purpose of the study was to evaluate the reliability of the dorsal tangential view (DTV) of the wrist using direct visualization of the extensor compartments in vivo. Twelve patients with extensor tendon complications [nine patients with extensor synovitis, two patients with isolated extensor pollicis longus (EPL) rupture, one patient with EPL and extensor indicis proprius rupture] after volar plating of a distal radius fracture were enrolled in the study. We obtained DTVs in the operating room before implant removal and explored the extensor compartments during synovectomy or tendon reconstruction to confirm suspected screw penetration. We confirmed screw penetration on 10 patients during exploration of the extensor compartments. DTV was able to detect seven of these dorsal cortex breaches. There were no false positive results, which we had defined as a screw penetrating an extensor compartment preoperatively, but not visible on the DTV. Of these seven breaches, one was in the second compartment, four were in the third compartment, and the remaining two were in the fourth compartment. The DTV is sufficiently reliable to be used routinely to reduce postoperative extensor tendon complications during volar plating of the distal radius. LEVEL OF EVIDENCE 4 (case series) diagnostic.
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Affiliation(s)
- G Kiyak
- Marmara Üniversitesi Vakfı Özel Academic Hospital, department of orthopaedics and traumatology, Yıldız Mh., İcadiye Bağlarbaşı Cd. No. 94, 34664 Üsküdar/İstanbul, Turkey.
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Bisgaard AK, Fagerberg SK, Hjort U. [Primary septic arthritis is a rare, atypical manifestation of invasive meningococcal disease]. Ugeskr Laeger 2017; 179:V09170693. [PMID: 29208200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
We present a case report of a 50-year-old man diagnosed with a primary septic arthritis with invasive Neisseria meningitidis serogroup W (MenW) clonal complex 11 identified with culture in blood and synovial fluid. The patient recovered from rapidly instituted relevant antibiotics and synovectomy, but there may be a risk of fatal delayed diagnosis and treatment by an atypical manifestation of invasive meningococcal disease. Invasive MenW disease has been increasing in recent years and has been described with atypical presentations.
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Abstract
CONTEXT Hip arthroscopy is gaining popularity within the field of orthopaedic surgery. The development and innovation of hip-specific arthroscopic instrumentation and improved techniques has resulted in improved access to the hip joint and ability to treat various hip pathologies. EVIDENCE ACQUISITION Electronic databases, including PubMed and MEDLINE, were queried for articles relating to hip arthroscopy indications (1930-2017). STUDY DESIGN Clinical review. LEVEL OF EVIDENCE Level 4. RESULTS Initially used as a technique for loose body removal, drainage/debridement of septic arthritis, and treatment of pediatric hip disorders, hip arthroscopy is currently used to treat various hip conditions. The recognition of femoroacetabular impingement (FAI) as a source of hip pain in young adults has rapidly expanded hip arthroscopy by applying the principles of osseous correction that were previously described and demonstrated via an open surgical dislocation approach. Hip pathologies can be divided into central compartment, peripheral compartment, peritrochanteric space, and subgluteal space disorders. CONCLUSION Although hip arthroscopy is a minimally invasive procedure that may offer decreased morbidity, diminished risk of neurovascular injury, and shorter recovery periods compared with traditional open exposures to the hip, it is important to understand the appropriate patient selection and indications.
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Affiliation(s)
- James R. Ross
- Boca Care Orthopedics, Deerfield Beach, Florida
- Florida Atlantic University College of Medicine, Boca Raton, Florida
| | - Christopher M. Larson
- Minnesota Orthopedic Sports Medicine Institute at Twin Cities Orthopedics, Edina, Minnesota
| | - Asheesh Bedi
- Sports Medicine and Shoulder Service, Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan
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Jain A, Ball C, Nanchahal J. Functional Outcome Following Extensor Synovectomy and Excision of the Distal Ulna in Patients With Rheumatoid Arthritis. ACTA ACUST UNITED AC 2017; 28:531-6. [PMID: 14599824 DOI: 10.1016/s0266-7681(03)00099-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
We prospectively measured hand and wrist function in rheumatoid patients undergoing excision of the distal ulna. Range of motion, visual analogue pain scores and grip strength were measured in 22 wrists, and the Jebsen hand function test was administered to seven patients, preoperatively and at 3 and 12 months. At 1 year there were improvements in forearm pronation ( P = 0.04), supination ( P = 0.03) and wrist extension ( P = 0.02), but a reduction in flexion ( P = 0.009). Active radial deviation was reduced and ulnar deviation increased. There was a significant improvement in grip strength ( P = 0.05) and reduction in wrist pain ( P = < 0.0001). At 1 year the Jebsen hand function test showed improvements in simulated feeding, stacking checkers, and lifting large empty cans. Excision of the distal ulna in rheumatoid patients results in an improvement in some aspects of hand function.
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Affiliation(s)
- A Jain
- Department of Musculoskeletal Surgery and the Kennedy Institute of Rheumatology, Imperial College School of Medicine, Charing Cross Hospital, Fulham Palace Road, London, UK.
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Martínez-Ruiz FJ, Salaverry-Walls A, Bautista-Morales M, Rivera-Reyes C, Montero-García JG. [Localized pigmented vellonodular sunovitis, cause of knee hemarthrosis]. Acta Ortop Mex 2017; 31:53-56. [PMID: 28741329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
The pigmented vellonodular sinovitis (PVNS) is benign neoplasm with synovial proliferation and hemosiderin deposit, characterized by large compromising joints, especially the knee. At present, two variants of clinics, the diffuse form (PVNSD) and the localized (PVNSL) are described. Arthroscopic synovectomy and radiosynoviorthesis (RSO) is the treatment that has shown the best functional results. Nuclear magnetic resonance is an appropriate method for conducting the diagnosis of PVNSL.
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Affiliation(s)
- F J Martínez-Ruiz
- Servicio de Ortopedia, Alta Especialidad en Cirugía Articular. Hospital Beneficencia Española de Puebla, Puebla, México
| | - A Salaverry-Walls
- Servicio de Anatomía Patológica. Hospital Beneficencia Española de Puebla, Puebla, México
| | - M Bautista-Morales
- Área de Resonancia Magnética, Neurorradiología. Hospital Beneficencia Española de Puebla, Puebla, México
| | - C Rivera-Reyes
- Servicio de Ortopedia, adjunto del Curso de Alta Especialidad en Cirugía Articular, Clínica de Cadera y Rodilla. Hospital Beneficencia Española de Puebla, Puebla, México
| | - J G Montero-García
- Servicio de Ortopedia, Titular del Curso de Alta Especialidad en Cirugía Articular, Clínica de Hombro. Hospital Beneficencia Española de Puebla, Puebla, México
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Affiliation(s)
- T Horino
- Department of Endocrinology, Metabolism and Nephrology, Kochi Medical School, Kohasu, Okoh-cho, Nankoku, Kochi 783-8505, Japan.
- Laboratory of Anatomy, Department of Biomedical Sciences, Graduate School of Veterinary Medicine, Hokkaido University, Sapporo, Japan.
| | - T Matsumoto
- Department of Endocrinology, Metabolism and Nephrology, Kochi Medical School, Kohasu, Okoh-cho, Nankoku, Kochi 783-8505, Japan
- Laboratory of Anatomy, Department of Biomedical Sciences, Graduate School of Veterinary Medicine, Hokkaido University, Sapporo, Japan
| | - Y Terada
- Department of Endocrinology, Metabolism and Nephrology, Kochi Medical School, Kohasu, Okoh-cho, Nankoku, Kochi 783-8505, Japan
- Laboratory of Anatomy, Department of Biomedical Sciences, Graduate School of Veterinary Medicine, Hokkaido University, Sapporo, Japan
| | - O Ichii
- Department of Endocrinology, Metabolism and Nephrology, Kochi Medical School, Kohasu, Okoh-cho, Nankoku, Kochi 783-8505, Japan
- Laboratory of Anatomy, Department of Biomedical Sciences, Graduate School of Veterinary Medicine, Hokkaido University, Sapporo, Japan
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Trivillin VA, Bruno LJ, Gatti DA, Stur M, Garabalino MA, Hughes AM, Castillo J, Pozzi ECC, Wentzeis L, Scolari H, Schwint AE, Feldman S. Boron neutron capture synovectomy (BNCS) as a potential therapy for rheumatoid arthritis: radiobiological studies at RA-1 Nuclear Reactor in a model of antigen-induced arthritis in rabbits. Radiat Environ Biophys 2016; 55:467-475. [PMID: 27568399 DOI: 10.1007/s00411-016-0664-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Accepted: 08/17/2016] [Indexed: 06/06/2023]
Abstract
Rheumatoid arthritis is a chronic autoimmune pathology characterized by the proliferation and inflammation of the synovium. Boron neutron capture synovectomy (BNCS), a binary treatment modality that combines the preferential incorporation of boron carriers to target tissue and neutron irradiation, was proposed to treat the pathological synovium in arthritis. In a previous biodistribution study, we showed the incorporation of therapeutically useful boron concentrations to the pathological synovium in a model of antigen-induced arthritis (AIA) in rabbits, employing two boron compounds approved for their use in humans, i.e., decahydrodecaborate (GB-10) and boronophenylalanine (BPA). The aim of the present study was to perform low-dose BNCS studies at the RA-1 Nuclear Reactor in the same model. Neutron irradiation was performed post intra-articular administration of BPA or GB-10 to deliver 2.4 or 3.9 Gy, respectively, to synovium (BNCS-AIA). AIA and healthy animals (no AIA) were used as controls. The animals were followed clinically for 2 months. At that time, biochemical, magnetic resonance imaging (MRI) and histological studies were performed. BNCS-AIA animals did not show any toxic effects, swelling or pain on palpation. In BNCS-AIA, the post-treatment levels of TNF-α decreased in four of six rabbits and IFN-γ levels decreased in five of six rabbits. In all cases, MRI images of the knee joint in BNCS-AIA resembled those of no AIA, with no necrosis or periarticular effusion. Synovial membranes of BNCS-AIA were histologically similar to no AIA. BPA-BNCS and GB-10-BNCS, even at low doses, would be therapeutically useful for the local treatment of rheumatoid arthritis.
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Affiliation(s)
- Verónica A Trivillin
- Department of Radiobiology, Comisión Nacional de Energía Atómica (CNEA), Avenida General Paz 1499, B1650KNA, San Martín, Provincia Buenos Aires, Argentina.
- Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Ciudad Autónoma de Buenos Aires, Argentina.
| | - Leandro J Bruno
- LABOATEM (Laboratorio de Biología Osteoarticular, Ingeniería Tisular y Terapias Emergentes), Facultad de Ciencias Médicas, Universidad Nacional de Rosario, Rosario, Argentina
| | - David A Gatti
- LABOATEM (Laboratorio de Biología Osteoarticular, Ingeniería Tisular y Terapias Emergentes), Facultad de Ciencias Médicas, Universidad Nacional de Rosario, Rosario, Argentina
| | - Mariela Stur
- Cátedra de Diagnóstico por Imágenes, Facultad de Ciencias Médicas, Universidad Nacional de Rosario, Rosario, Argentina
| | - Marcela A Garabalino
- Department of Radiobiology, Comisión Nacional de Energía Atómica (CNEA), Avenida General Paz 1499, B1650KNA, San Martín, Provincia Buenos Aires, Argentina
| | - Andrea Monti Hughes
- Department of Radiobiology, Comisión Nacional de Energía Atómica (CNEA), Avenida General Paz 1499, B1650KNA, San Martín, Provincia Buenos Aires, Argentina
| | - Jorge Castillo
- Department of Reactors, Comisión Nacional de Energía Atómica (CNEA), Avenida General Paz 1499, B1650KNA, San Martín, Provincia Buenos Aires, Argentina
| | - Emiliano C C Pozzi
- Department of Research and Production Reactors, Comisión Nacional de Energía Atómica (CNEA), Presbítero Juan González y Aragon 15, B1802AYA, Ezeiza, Province Buenos Aires, Argentina
| | - Luis Wentzeis
- Department of Reactors, Comisión Nacional de Energía Atómica (CNEA), Avenida General Paz 1499, B1650KNA, San Martín, Provincia Buenos Aires, Argentina
| | - Hugo Scolari
- Department of Reactors, Comisión Nacional de Energía Atómica (CNEA), Avenida General Paz 1499, B1650KNA, San Martín, Provincia Buenos Aires, Argentina
| | - Amanda E Schwint
- Department of Radiobiology, Comisión Nacional de Energía Atómica (CNEA), Avenida General Paz 1499, B1650KNA, San Martín, Provincia Buenos Aires, Argentina
- Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Ciudad Autónoma de Buenos Aires, Argentina
| | - Sara Feldman
- Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Ciudad Autónoma de Buenos Aires, Argentina
- LABOATEM (Laboratorio de Biología Osteoarticular, Ingeniería Tisular y Terapias Emergentes), Facultad de Ciencias Médicas, Universidad Nacional de Rosario, Rosario, Argentina
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Begly JP, Rapp TB, Shah MR. Synovial Hemangioma Presenting as a Painful Locked Knee A Case Report. Bull Hosp Jt Dis (2013) 2016; 74:309-313. [PMID: 27815956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
A 39-year-old man presented to orthopaedic care with a painful, fully locked knee. Workup revealed free intraarticular nodules, which were subsequently arthroscopically removed and identified to be synovial hemangioma. To the investigators' knowledge, this is the second reported case of synovial hemangioma presenting as a painful, definitively locked knee. Synovial hemangioma should be considered in the differential diagnosis of knee pain, particularly after more common diagnoses have been ruled out. Efficient and appropriate diagnosis and treatment may result in favorable patient outcomes and avoid long-term disability and dysfunction.
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Abstract
Wrist injuries in the gymnast are due to the transformation of the upper extremity into a weight bearing entity. Gymnast wrist pain presents a difficult diagnostic and therapeutic challenge. Here, we present a new case of extensor tendon impingement in an elite gymnast. To our knowledge, there is no similar report in the literature.
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Affiliation(s)
- S M Wilson
- Institut de la Main, Clinique Jouvenet Paris, France.
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44
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Luo HB, Feng XL, Wei CN, Wen JQ. [Long-term outcomes of arthroscopy and non-surgical therapy in patients with knee synovial plica syndrome]. Nan Fang Yi Ke Da Xue Xue Bao 2016; 36:1160-1162. [PMID: 27578592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
OBJECTIVE To compare the long-term outcomes of arthroscopy and non-surgical therapy in patients with knee synovial plica syndrome (SPS). METHODS Thirty-one patients with knee SPS undergoing arthroscopic surgery and 27 SPS patients undergoing conservative treatment with articular cavity injection of sodium hyaluronate (control group) were compared for visual pain score (VAS) and the Lysholm score before and after the operation. The patients were followed-up for more than 5 years, and the long-term outcomes were compared using Kaplan-Meier survival analysis. RESULTS s VAS and the Lysholm scores in both groups were significantly lowered after treatment (P<0.05). The postoperative VAS score was significantly lower while the Lysholm score significantly higher in arthroscopic surgery group than in the control group (P<0.05). Arithmetic mean and the median time of curative effect maintenance were 49 and 43 months in arthroscopic surgery group, as compared with 33 and 29 months in the control group, respectively; the cumulative effect maintenance rate in arthroscopic surgery group was significantly higher than that in the control group (Χ2=4.933, P=4.933). CONCLUSION Arthroscopic treatment produces better therapeutic effect on knee joint SPS and ensures longer long-term therapeutic effect maintenance than conservative treatment.
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Affiliation(s)
- Hong-Bin Luo
- Department of Orthopedics, Sanshui TCM Hospital Affiliated to Foshan TCM Hospital, Sanshui 528100, China. E-mail:
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Nishida K. [Recent advances in upper extremity surgery for rheumatoid arthritis]. Nihon Rinsho 2016; 74:981-985. [PMID: 27311189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
The number of cases with rheumatoid arthritis who requires arthroscopic synovectomy is declining, but it is still a useful procedure in combination with effective pharmacologic disease control. For the destruction of glenohumeral joint, total shoulder arthroplasty is effective for pain relief and functional outcome for patients without rotator cuff impairment. The reverse shoulder arthroplasty has been shown favorable short-term results, but need a careful indication for rheumatoid shoulder with poor bone stock and bone quality. Linked or unlinked total elbow arthroplasty are now reliable methods for the reconstruction of rheumatoid elbows with acceptable long-term survival. Joint replacement surgery for proximal interphalangeal joint is a challenging procedure in terms of relatively high complication rate and disappointing improvement in range of motion, whereas achieves good patients' satisfaction for pain relief and improved finger appearances.
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Mollon B, Griffin AM, Ferguson PC, Wunder JS, Theodoropoulos J. Combined arthroscopic and open synovectomy for diffuse pigmented villonodular synovitis of the knee. Knee Surg Sports Traumatol Arthrosc 2016; 24:260-6. [PMID: 25308157 DOI: 10.1007/s00167-014-3375-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2013] [Accepted: 10/01/2014] [Indexed: 11/27/2022]
Abstract
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.
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Affiliation(s)
- Brent Mollon
- Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada.
- Division of Orthopaedic Surgery, Mt. Sinai Hospital, Toronto, ON, Canada.
| | - Anthony M Griffin
- Division of Orthopaedic Surgery, Mt. Sinai Hospital, Toronto, ON, Canada.
| | - Peter C Ferguson
- Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada.
- Division of Orthopaedic Surgery, Mt. Sinai Hospital, Toronto, ON, Canada.
- University Musculoskeletal Oncology Unit, Department of Surgery, Mount Sinai Hospital, Toronto, ON, Canada.
| | - Jay S Wunder
- Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada.
- Division of Orthopaedic Surgery, Mt. Sinai Hospital, Toronto, ON, Canada.
- University Musculoskeletal Oncology Unit, Department of Surgery, Mount Sinai Hospital, Toronto, ON, Canada.
| | - John Theodoropoulos
- Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada.
- Division of Orthopaedic Surgery, Mt. Sinai Hospital, Toronto, ON, Canada.
- University of Toronto Orthopaedic Sports Medicine, Women's College Hospital, Toronto, ON, Canada.
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Levy DM, Haughom BD, Nho SJ, Gitelis S. Pigmented Villonodular Synovitis of the Hip: A Systematic Review. Am J Orthop (Belle Mead NJ) 2016; 45:23-28. [PMID: 26761914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Pigmented villonodular synovitis is a rare proliferative condition of the synovium that affects large joints. The primary treatment options are synovectomy and a combination of synovectomy and arthroplasty. We performed a systematic review of the literature, excluding all nonclinical and review articles with follow-up of less than 2 years. Primary outcomes reported were disease recurrence, symptom progression, and revision surgery. Student t tests were used to compare outcomes after synovectomy with outcomes after synovectomy combined with arthroplasty. Twenty-one studies (82 patients) were included. All represented level IV or V evidence. Fifty-one patients (59.3%) were female. Mean (SD) age was 33.2 (12.6) years. Synovectomy alone was performed in 45 patients (54.9%), and synovectomy with arthroplasty was performed in 37 patients (45.1%). Mean (SD) follow-up was 8.4 (5.9) years. The groups' revision rates were not significantly different (26.2% vs 24.3%; P = .17). Mean (SD) time to revision was significantly (P = .02) longer in the synovectomy-with-arthroplasty group, 11.8 (4.5) years, than in the synovectomy-only group, 6.5 (3.9) years. Study results showed revisions are common after surgery for hip pigmented villonodular synovitis, affecting 1 in 4 patients regardless of which surgery they have-either synovectomy alone or synovectomy combined with arthroplasty. Revision is required sooner in synovectomy-only patients than in patients who also undergo arthroplasty.
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Affiliation(s)
| | - Bryan D Haughom
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL.
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Abstract
Synovial osteochondromatosis is a benign metaplasia of the synovium resulting in the formation of osteocartilaginous nodules within the synovial lining. At presentation, radiographs typically reveal these nodules to have broken free from the synovial lining, becoming loose bodies residing in the free space of the affected joint. These fragments readily receive the necessary nutrients for continued growth from the synovial fluid in which they reside. Controversy exists over the management of the disease. Some physicians call for arthrotomy with a complete synovectomy, whereas others vouch for a minimally invasive arthroscopic approach. In the case described here, the surgeon decided on hip arthroscopy to treat synovial osteochondromatosis in a 61-year-old woman. All but one loose body that was adherent in the anterior hip capsule was successfully removed and the patient recovered promptly. This case highlights the importance of hip arthroscopy and its usefulness not only in treating conditions such as synovial osteochondromatosis, but also in accurately diagnosing them. Recognition and management of hip conditions such as synovial osteochondromatosis through arthroscopy result in minimally invasive treatment and decreased morbidity and may markedly accelerate patient rehabilitation. It is the authors' belief that this unique case further suggests the practicality of using hip arthroscopy to successfully treat synovial osteochondromatosis.
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de Almeida AM, de Rezende MU, Cordeiro FG, Villaça PR, D'Amico EA, Hernandez AJ, Camanho GL. Arthroscopic partial anterior synovectomy of the knee on patients with haemophilia. Knee Surg Sports Traumatol Arthrosc 2015; 23:785-91. [PMID: 25839071 DOI: 10.1007/s00167-013-2706-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
PURPOSE This study assessed the results of two-portal knee arthroscopic synovectomy in terms of bleeding recurrence, knee function, quality of life (QOL), and radiographic staging in a prospective case series of patients with haemophilia. METHODS Nine knees from eight patients (median age 16.1 years; range 9.6-25 years) with haemophilia and recurrent knee haemarthrosis were prospectively evaluated. Yearly recurrence of bleeding was evaluated once a year for 5 years postoperatively. Range of motion (ROM) and radiographic staging, as well as results of the short form (SF)-36 and subjective knee form of the International Knee Documentation Committee (IKDC) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) questionnaires, were evaluated before surgery and at the end of follow-up. RESULTS Mean bleeding recurrence was significantly reduced during the 5-year follow-up period. Questionnaire results showed significant improvements (IKDC P = 0.015, WOMAC P = 0.011, and SF-36 P = 0.023), whereas ROM was not significantly affected. Arthropathy progressed from Arnold-Hilgartner radiographic stage III to stage IV (P = 0.0082). CONCLUSIONS Two-portal knee arthroscopic synovectomy was effective at reducing bleeding recurrence and improving knee function and QOL in patients with haemophilia, but did not interrupt the progression of radiographic changes.
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Falborg B, Ebskov L. [Pigmented villonodular synovitis causing ankle pain]. Ugeskr Laeger 2014; 176:V01130057. [PMID: 25497623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
A rare case of diffuse pigmented villonodular synovitis is described. Because of unspecific symptoms as oedema and pain and uncertain relation with trauma the diagnosis was delayed for almost two years, until a MRI showed diffuse hypodense infiltrative lesions involving soft tissue structures around the ankle. Treatment was a radical open synovectomy of the ankle and subtalar joints and tenosynovectomy of the tendons around the ankle.
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Affiliation(s)
- Bettina Falborg
- Ortopædkirurgisk Afdeling 333, Hvidovre Hospital, 2650 Hvidovre.
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