This case series highlights the use of the Ganz approach (trochanteric slide approach) and surgical dislocation for excision of fibrous dysplasia of the femoral neck, pigmented villonodular synovitis and synovial chondromatosis of the hip. The first patient was a 16-year-old girl, who presented with pain in her hip, having fallen whilst playing football. Investigations revealed a fibrous dysplasia, which was successfully excised returning her to an active lifestyle. The second patient was a 27-year-old lady, who presented having suffered left hip pain for four years. She was diagnosed with a pigmented villonodular synovitis, which was excised and the patient was able to return to the gym. The third patient was a 41-year-old lady, who presented after experiencing right hip pain both at night and at rest for a year, without any trauma. She was diagnosed with synovial chondromatosis and returned to all activities of daily living. The Ganz approach allows safe dislocation of the hip joint without the risk of osteonecrosis of the femoral head. We demonstrate that it is possible to obtain excellent exposure of the femoral neck, head and acetabulum to surgically treat these three tumours of the hip. The surgeon can thus be reassured that complete excision of the tumour has occurred. This series can recommend the Ganz approach with trochanteric slide and full surgical dislocation of the hip to excise pigmented villonodular synovitis, synovial chondromatosis and fibrous dysplasia of the hip

The transtrochanteric anterior rotational osteotomy (TRO) was developed by Sugioka as a joint-preserving procedure which prevents further deformity by transposing the necrotic area from a site of primary weight-bearing to a secondary area. We performed this procedure for children and young adults with various hip disorders. Between 1994 and 2015 we performed TROs on 12 joints in 12 patients with SCFE (4), pigmented villonodular synovitis (2), septic arthritis (1), FAI (1), hip dysplasia (1), femoral neck fracture (2) and postoperative RAO (1). The mean age at the time of surgery was 21 years (10–43) and the mean follow-up period was 8 years (1–22). The rotational directions of the femoral head were anterior (5) and posterior (7). Clinical assessment was undertaken using the system of Merle d'Aubigné and Postel, grading pain, mobility and walking ability with scores from 0 to 6. Radiographically bone regeneration and OA progression were estimated. The mean clinical score improved from 9.0 to 14.4 at final follow-up. Spur formation of femoral head was observed in 7 patients (58%). OA progression was in two patients (17%) and one patient was converted to THA 22 years after surgery. All cases with osteonecrosis in SCFE and femoral neck fracture showed remarkable bone regeneration. The TRO is a reliable joint-preserving procedure for various hip disorders in children and young adults

The June 2013 Foot & Ankle Roundup. 360 . looks at: soft-tissue pain following arthroplasty; pigmented villonodular synovitis of the foot and ankle; ankles, allograft and arthritis; open calcaneal fracture; osteochondral lesions in the longer term; severe infections in diabetic feet; absorbable first ray fixation; and showering after foot surgery

This case series highlights the use of the Ganz approach and surgical dislocation for excision of fibrous dysplasia of the femoral neck, pigmented villonodular synovitis and synovial chrondromatosis of the hip, which has never been described for use with all three tumours together. These are rare benign tumours, which were found incidentally and required excision. We demonstrate that it is possible to obtain excellent exposure of the femoral neck, head and acetabulum allowing easy inspection, exploration and debridement of these three tumours of the hip

Aim. Bumps and lumps of the hand are a common cause for consultation in general practice. However not all of these lesions are of true neoplastic nature and malignant tumours are a rarity in this location. Method. The records of all tumours of the hand and wrist treated surgically at our institution in the period 1994 to 2009 were reviewed. Because of their non-neoplastic nature typical lesions of the hand such as ganglion cysts or palmar fibromatosis and the like were not included in this study. Histological entity, location, radiographic and clinical findings were analysed; malignant tumours were followed up by X-ray and MRI. Results. Out of 142 cases which were further investigated, there were 86 bone tumours and 56 soft tissue lesions. The mean age was 41 years (range 8 to 85), there were 57 male and 85 female patients.122 cases (86%) were benign lesions, 71 cases located in the bone and 52 cases in the soft tissue respectively. There were twenty malignant lesions, sixteen of which were bone tumours; the most common being chondrosarcoma (11), followed by metastases (3) and osteosarcoma (2). The group of malignant soft tissue tumours (4) was comprised of synovial sarcoma (2), Ewing sarcoma (1) and extraosseus myxoid chondrosarcoma (1). Out of 52 benign soft tissue tumours, pigmented villonodular synovitis (32), haemangioma (6) and lipomatous tumours (6) have been the most frequent entities. Chondroma (48), osteoid-osteoma (4) and giant cell tumour (3) were the most common benign bone tumours. Conclusion. Knowledge of tumour prevalence under consideration of the patient's age and location of the tumour is an important prerequisite for identifying neoplastic lesions of the hand

This study presents an unusual recurrent case of pigmented villonodular synovitis (PVNS) around a ceramic-on-metal (COM) hip retrieved at 9-years. PVNS literature relates to metal-polyethylene and ceramic-ceramic bearings. Amstutz reported 2 cases with MOM resurfacing and Xiaomei reported PVNS recurring at 14 years with metal-on-polyethylene THA. Friedman reported on PVNS recurrence in a ceramic THA. Ours may be the first reported case of recurrent PVNS of a ceramic-on-metal articulation. This young female patient (now 38-years of age) had a total hip replacement in 2006 for PVNS in her left hip. In her initial work-up, this case was presumed to be a pseudotumor problem, typical of those related to CoCr debris with high metal-ion concentrations. She had an CoCr stem (AML), 36mm Biolox-delta head (Ceramtec), and a Pinnacle acetabular cup with CoCr liner (Ultramet, Depuy J&J). This patient had no concerns regarding subluxation, dislocation or squeaking. Three years ago she complained of mild to moderate groin and thigh pain in her left hip. This worsened in the past year. She noticed increased swelling now with an asymmetry to her right hip. She went to the emergency room in Dec-2014 and was referred to a plastic surgeon. In our consult we reviewed MARS-MRI and CT-scans that demonstrated multiple mass lesions surrounding the hip. Laboratory results presented Co=0.7, Cr=0.3 ESR=38 and Crp=0.3. At revision surgery, the joint fluid was hemorrhagic/bloody with hemosiderin staining the soft tissues. Multiple large 4–5×5cm nodules were present in anterior aspect of the hip as well as multiple nodules surrounding posterior capsule and sciatic nerve. Pathology demonstrated a very cellular matrix with hemosiderin-stained tissue and multiple giant cells, which was judged consistent with PVNS. The trunnion showed no fretting, no contamination and no discoloration. The superior neck showed impingement due to low-inclination cup. There was minimal evidence of metal-debris staining the tissues. There was a large metallic-like stripe across the ceramic head. This is a particularly interesting case and may be the first reported recurrent PVNS around a ceramic-on-metal bearing (COM). Data is scant regarding clinical results of COM bearings and here we have a nine-year result in a young and active female patient. She was believed to have a metalosis-related pseudotumor yet her metal-ion levels were not alarmingly high and there was no particular evidence of implant damage or gross wear products. In addition, the CoCr trunnion appeared pristine. Our work-up continues with analyses of wear and histopath-evidence. This case may demonstrate the need for a broadening of the differential diagnosis when dealing with hip failures

Introduction: Hoffa’s fat pad (HFP) of the knee is affected by a variety of tumours and tumour-like conditions. HFP can be affected by diffuse or solitary, focal disease. Solitary tumours are relatively uncommon but with widespread uptake of Magnetic Resonance Imaging Scans (MRI) an increasing number of Hoffa’s fat pad tumours (HFP) are being recognized. Methods: This paper reports a consecutive series of 20 cases of solitary symptomatic HFP tumours referred to Oxford bone and soft tissue tumour service between 1999 and 2008. The commonest presenting symptom was anterior knee pain. All patients underwent open excision after diagnostic magnetic resonance imaging (MRI). Results: Histology revealed varied diagnoses with the commonest being pigmented villonodular synovitis (PVNS) and ganglia. American Knee Society scores improved from 76 pre-operatively to 96 post-operatively with an improvement in functional scores from 92 to 100. In one patient, MRI identified the cause of hypo-phosphataemic osteomalacia as an HFP phosphaturic mesenchyma tumour despite the lack of local symptoms. Discussion In conclusion the majority of solitary HFP tumours are benign and may be either cystic or solid. MRI and plain radiographs are the imaging of choice. The definitive treatment of both cystic and solid tumours should be selective arthrotomy and excision biopsy. Arthroscopic resection is not advised, as complete excision is not always possible. None of the 20 patients in this series had a malignant tumour but this has been reported in the literature. Calcification on plain radiographs may indicate a malignant lesion. All patients in our series reported substantial improvement in symptoms following open tumour resection

Arthoscopic biopsy provides adequate tissue for most diagnostic requirements. Examination of endoarticular tissue can assist in the diagnosis of some joint infections; sometimes cultures of synovial tissue may be positive even when blood and synovial fluid cultures have been negative. In chronic infections such as tuberculosis and fungal disease, and characteristic synovial lesions, such as granuloma, it may be advised. Both gout and pseudo-gout can demonstrate tophus-like deposits in synovial tissue. Synovial biopsy can have a major role in the diagnosis of synthetic arthritis after ACL reconstruction with synthetic ligaments to identify a foreign body granulomatous reaction to particulate material implant or to verify the arthroplasty effect after loosening of a knee prosthesis. There is a lack of association between arthroscopic findings and clinical laboratory and radiological features of arthritis. The general diagnosis of rheumatoid arthritis (RA) is usually based on characteristic clinical, radiological and serological manifestations. Synovial biopsy in RA is not normally required for diagnosis because the appearance is not specific, but it may provide important prognostic information. Synovial chondromatosis and pigmented villonodular synovitis are tumours of the synovial membrane that require biopsy for diagnosis. The biopsy of articular cartilage is useful to evaluate the capacity of chondrocytes to proliferate and to test the regeneration of cartilage after resurfacing by autologous chondrocytes implantation or other techniques. Histological confirmation could improve the prognosis of the knee during arthrofibrosis (percentage of elastic fibres), fibrosis of Hoffa disease and cyclop lesion. Another application is study of ligamentisation phenomena after anterior cruciate reconstruction and the presence in osteoarthritic knees with degenerative changes in posterior cruciate ligament

Aim. To evaluate outcome and complications of knee arthrodesis with a modular prosthetic system (MUTARS(r) Implantcast), as primary and revision implants in musculoskeletal oncology. Method. Between 1975 and 2009, 24 prostheses were used for knee arthrodesis. Nineteen in oncologic cases: 6 osteosarcomas, chondrosarcoma, synovial sarcoma and metastatic carcinoma 3 each, 2 pigmented villonodular synovitis (PVNS), malignant fibrous hystiocitoma and giant cell tumour 1 each. Patients were grouped into: A) primary implants, B) revision implants. Group A included 9 patients: 8 arthrodeses after extra-articular resection with major soft tissue removal, 1 after primary resection following multiple excisions of locally recurrent PVNS. Group B included 15 patients: 12 arthrodeses for infection (5 infected TKAs, 7 infected megaprostheses), 2 for failures of temporary arthodesis with Kuntscher nail and cement, 1 for recurrent chondrosarcoma in previous arthrodesis. Results. Oncologic outcome ata mean follow-up of 6 years (ranging 1 to 26), showed 13 NED (68.4%), 2 NED after treatment of relapse (10.5%), 1 alive with metastases (5.3%), 2 dead with disease (10.5%) and one dead of other disease (5.3%). Complications causing failure were observed in 12 patients (50%): 11 infections at mean of 14 months (6 in arthrodeses as revision for previous infections, 5 in group A), 1 femoral stem breakage at 4.8 years (in group B). Treatment of infections was: amputation in 6, “one stage” in 1, “two stage” with new arthrodesis in 4 (1 subsequently amputated for recurrent infection). The breakage was revised, had further traumatic breakage at 2 years and a second revision. Conclusion. Arthrodesis with modular prosthetic system is indicated after major extra-articular resection or in revisions of severely failed previous reconstructions. High infection rate should be prevented with good soft tissue coverage, by flaps if needed

Introduction: Tumours of the foot are rare, representing only 4 to 8 per cent of all bone and soft tissue tumours: a negligible number compared to degenerative, posttraumatic, vascular and metabolic diseases of this exposed region. Hence neoplasms of the foot are often diagnosed late and treated inadequately. Methods: The records of all tumours of the foot and ankle treated surgically at our institution in the period 1993 to 2007 were reviewed. Because of their non-neoplastic nature typical lesions of the foot such as plantar fibromatosis or Morton neuroma as well as ganglion and the like were not included in this study. History, location, radiographic and clinical findings were analysed, malignant tumours were followed up by X-ray and MRI. Results: Of the eighty-eight cases which were further investigated, there were forty-four bone tumours and forty-four neoplastic soft tissue lesions. Sixty-nine cases (78%) were benign tumours, half of them (35 cases) located in the bone and in the soft tissue (34 cases) respectively. There were forty-four male and female patients each, the mean age being 40 years (range 4 to 85) for all cases, 39 years for benign and 45 years for malign tumours respectively. There were nineteen malignant lesions, nine of which were bone tumours; the most common being chondrosarcoma (3) and osteosarcoma (3). Malignant soft tissue tumours (10) were very heterogeneous, clear cell sarcoma being the only tumour appearing at least twice. Out of thirty-four benign soft tissue tumours, pigmented villonodular synovitis (11), fibrous (9) and lipomatous (5) tumours have been the most frequent. Thirty five benign bone tumours included chondroma (10), solitary bone cyst (10), aneurysmatic bone cyst (3), osteoid-osteoma (3) and giant cell tumour (3). Conclusion: Knowledge of tumour prevalence under consideration of the patient’s age and location of the tumour is an important prerequisite for identifying neoplastic lesions of the foot

Between 1974 and 1998, 34 patients with primary bone tumors and 28 with soft tissue tumors, all located in the foot, were surgically treated at our institutions. Of the 34 patients with a bone tumor, 27 (79%) had chondrogenic tumors: exostoses, 17; enchondromas, 7; benign chondroblastomas, 2 and chondrosarcoma, 1. This chondrosarcoma was misdiagnosed as a benign chondroblastoma at the initial biopsy. Five months after the initial curettage and bone grrafting, the tumor was recurred as a chondrosarcoma. This patient died with pulmonary metastasis another five months after the below the knee (BK) amputation. The differential diagnosis between benign chondrogenic tumors and low grade chondrosarcoma is very difficult as proposed by Mirra. Whereas the malignant tumor is very rare in the foot, the diagnosis of chondrogenic tumor should be made carefully. Of the 28 soft tissue tumors, diagnoses were giant cell tumor of tendon sheath or pigmented villonodular synovitis, 8; angioleiomyoma, 4; ganglion, 4; hemangioma, 2; miscellaneous benign tumors, 7 and soft tissue sarcomas (STS), 3. All patients with a STS were treated by a BK amputation, a partial foot amputation or a marginal resection, and died with pulmonary metastasis. However the function of the operated limb and the emotional acceptance were better in a patient with the less abrasion surgery. Conclusion: The majority of bone tumor in the foot was benign chondrogenic tumor. Even if the chondrosarcoma is very rare in the foot, it should be considered as a differential diagnosis to the benign chondrogenic tumors. Less abrasion surgeries for STS are recommended on the basis of functional evaluation and patient’s emotional acceptance, when the surgical margin is adequate wide

Fourteen cases of pigmented villonodular synovitis (PVNS) of the foot and ankle (between January 1957 and December 1999) accrued from Scottish bone tumor registry are presented with an average follow-up of 4.6 years aimed to analyse the clinical, radiological and histopathological features in order to investigate the clinical behaviour of PVNS in the foot and ankle, and to determine the factors influencing recurrence. The mean age was 26.4 years (range, 8 to 52 years). There were eight females and six males. The mean delay in presentation was 10.3 months. The anatomical sites were foot phalanges (n=2), tarso-metatarsal area (n=3) and hindfoot (n=9). Hindfoot cases comprised of 6 extra-articular soft tissue swelling around the ankle, two affecting the ankle joint and one involving the subtalar joint. There were eight (57.1%) cases presented with painless lump, five (35.7%) patients with painful lumps and one case with a lump associated with toe deformity. The clinical suspicion were ganglion, gout, soft tissue swelling (? tumour) and exostosis. Peri-articular tissue invasion and cortical infiltration was found in one third on plain films. CT scan showed multiple lytic lesions and MRI scan findings were consistent with extensive low signal soft tissue hypertrophy and bone erosion, two of which were suspected with synovial sarcoma. Excision of the lump was done in 4 cases with a complete recovery. Foot phalangeal PVNS were treated with toe amputation through metatarsophalangeal joint and no cases had recurrence of the lesion. There were two recurrences affecting the ankle and the subtalar joint. Recurrent ankle PVNS was treated with re-exploration, open synovectomy, curettage of talar cyst and autogenous bone grafting. The second recurrent case involving subtalar joint was treated with re-excision and curettage. Both recurred cases were primarily treated with intralesional excision for their diffuse variety. There were no recurrences in the nodular variety. Complete recovery was achieved in 85.7% case (12/14). A high index of suspicion for PVNS should be observed for cases presenting with a painless or painful mass in the foot and ankle region. Complete recovery can be achieved in the majority by complete excision. Toe amputation may be considered for foot phalangeal PVNS

Introduction: Diffused pigmented villonodular synovitis (PVNS) is a locally aggressive lesion for which surgery provides only marginal resection. An adjuvant treatment modality is therefore required to prevent local tumor recurrence. The authors describe their experience with intra-articular injection of Yttrium. 90. (Y. 90. ), a radioisotope, as an adjuvant for tumor resection. Materials and Methods: Between 1989 and 2002, 20 patients with diffuse PVNS were treated with post-operative, intraarticular injection of Y. 90. There were 15 male and 5 female patients who ranged in age from 13 to 67 years (mean, 35 years). Anatomic locations of the affected joints included: knee – 15, ankle – 4, hip – 1. Tumor resection was initially done in all patients: 13 patients required open arthrotomy, the remaining 7 underwent arthroscopic tumor resection. Ten patients were referred for treatment after having operation for a local tumor recurrence: 6 patients had one, 2 had two, 1 had three, and the remaining one had five local recurrences. Six to eight weeks after surgery, intraarticular injection of 15–25 mCi of Y. 90. was done. These procedures were conducted in the operating room under local anesthesia and fluoroscopic guidance. All patients were followed for a minimum of two years (range, 25–168 months; mean, 65 months). Results: Following Y. 90. injection, all patients reported mild pain around the affected joint. This pain was well controlled with the use of NSAID’s and typically resolved within a few days or weeks. Three patients had superficial skin inflammation and associated blisters around the site of injection, probably the result of Y. 90. effect on the soft-tissues. All were treated conservatively with complete resolution of their symptoms. All patients gained their pre-injection range-of-motion within 4–6 weeks. At the most recent follow-up, five patients had transient post-radiation skin changes (discoloration of the skin and dry and scaly skin) and local recurrence occurred in only one patient (5%) with PVNS around the knee; additional Y. 90. injections were unsuccessful and he eventually underwent knee arthrodesis. Conclusion: Y. 90. injection is a reliable adjuvant for surgery in the management of diffused PVNS. Local tumor control and good function, associated with only mild morbidity are achieved in the majority of the patients

Aims

Isolated acetabular liner exchange with a highly crosslinked polyethylene (HXLPE) component is an option to address polyethylene wear and osteolysis following total hip arthroplasty (THA) in the presence of a well-fixed acetabular shell. The liner can be fixed either with the original locking mechanism or by being cemented within the acetabular component. Whether the method used for fixation of the HXLPE liner has any bearing on the long-term outcomes is still unclear.

Aims

Tenosynovial giant cell tumour (TGCT) is a rare benign tumour of the musculoskeletal system. Surgical management is fraught with challenges due to high recurrence rates. The aim of this study was to describe surgical treatment and evaluate surgical outcomes of TGCT at an Australian tertiary referral centre for musculoskeletal tumours and to identify factors affecting recurrence rates.

Aims

To investigate the optimal thresholds and diagnostic efficacy of commonly used serological and synovial fluid detection indexes for diagnosing periprosthetic joint infection (PJI) in patients who have rheumatoid arthritis (RA).

The October 2014 Oncology Roundup³⁶⁰ looks at: how best to reconstruct humeral tumours; not everything is better via the arthroscope; obesity and sarcoma; frozen autograft; en-bloc resection and metastatic disease; positive margins in soft-tissue injuries; lipomatous tumours explored; and what happens with recurrence of osteosarcoma.

This article provides an overview of the role of genomics in sarcomas and describes how new methods of analysis and comparative screening have provided the potential to progress understanding and treatment of sarcoma. This article reviews genomic techniques, the evolution of the use of genomics in cancer, the current state of genomic analysis, and also provides an overview of the medical, social and economic implications of recent genomic advances.