Diffuse-type Tenosynovial Giant-Cell Tumour (d-TGCT) of large joints is a rare, locally aggressive, soft tissue tumour affecting predominantly the knee. Previously classified as Pigmented Villonodular Synovitis (PVNS), this monoarticular disease arises from the synovial lining and is more common in younger adults. Given the diffuse and aggressive nature of this tumour, local control is often difficult and recurrence rates are high. Current literature is comprised primarily of small, and a few larger but heterogeneous, observational studies. Both arthroscopic and open synovectomy techniques, or combinations thereof, have been described for the treatment of d-TGCT of the knee. There is, however, no consensus on the best approach to minimize recurrence of d-TGCT of the knee. Some limited evidence would suggest that a staged, open anterior and posterior synovectomy might be of benefit in reducing recurrence. To our knowledge, no case series has specifically looked at the recurrence rate of d-TGCT of the knee following a staged, open, posterior and anterior approach. We hypothesized that this approach may provide better recurrence rates as suggested by larger more heterogeneous series. A retrospective review of the local pathology database was performed to identify all cases of d-TGCT or PVNS of the knee treated surgically at our institution over the past 15 years. All cases were treated by a single fellowship-trained orthopaedic oncology surgeon, using a consistent, staged, open, posterior and anterior approach for synovectomy. All cases were confirmed by histopathology and followed-up with regular repeat MRI to monitor for recurrence. Medical records of these patients were reviewed to extract demographic information, as well as outcomes data, specifically recurrence rate and complications. Any adjuvant treatments or subsequent surgical interventions were noted. Twenty-three patients with a minimum follow-up of two years were identified. Mean age was 36.3 at the time of treatment. There were 10 females and 13 males. Mean follow-up was seven and a half years. Fourteen of 23 (60.9%) had no previous treatment. Five of 23 had a previous arthroscopic synovectomy, one of 23 had a previous combined anterior arthroscopic and posterior open synovectomy, and three of 23 had a previous open synovectomy. Mean time between stages was 87 days (2.9 months). Seven of 23 (30.4%) patients had a recurrence. Of these, three of seven (42.9%) were treated with Imatinib, and four of seven (57.1%) were treated with repeat surgery (three of four arthroscopic and one of four open). Recurrence rates of d-TGCT in the literature vary widely but tend to be high. In our retrospective study, a staged, open, anterior and posterior synovectomy provides recurrence rates that are lower than rates previously reported in the literature. These findings support prior data suggesting this approach may result in better rates of recurrence for this highly recurrent difficult to treat tumour

Diffuse-type Tenosynovial Giant-Cell Tumour (d-TGCT) of large joints is a rare, locally aggressive, soft tissue tumour affecting predominantly the knee. Previously classified as Pigmented Villonodular Synovitis (PVNS), this monoarticular disease arises from the synovial lining and is more common in younger adults. Given the diffuse and aggressive nature of this tumour, local control is often difficult and recurrence rates are high. Current literature is comprised primarily of small, and a few larger but heterogeneous, observational studies. Both arthroscopic and open synovectomy techniques, or combinations thereof, have been described for the treatment of d-TGCT of the knee. There is, however, no consensus on the best approach to minimize recurrence of d-TGCT of the knee. Some limited evidence would suggest that a staged, open anterior and posterior synovectomy might be of benefit in reducing recurrence. To our knowledge, no case series has specifically looked at the recurrence rate of d-TGCT of the knee following a staged, open, posterior and anterior approach. We hypothesized that this approach may provide better recurrence rates as suggested by larger more heterogeneous series. A retrospective review of the local pathology database was performed to identify all cases of d-TGCT or PVNS of the knee treated surgically at our institution over the past 15 years. All cases were treated by a single fellowship-trained orthopaedic oncology surgeon, using a consistent, staged, open, posterior and anterior approach for synovectomy. All cases were confirmed by histopathology and followed-up with regular repeat MRI to monitor for recurrence. Medical records of these patients were reviewed to extract demographic information, as well as outcomes data, specifically recurrence rate and complications. Any adjuvant treatments or subsequent surgical interventions were noted. Twenty-three patients with a minimum follow-up of two years were identified. Mean age was 36.3 at the time of treatment. There were 10 females and 13 males. Mean follow-up was seven and a half years. Fourteen of 23 (60.9%) had no previous treatment. Five of 23 had a previous arthroscopic synovectomy, one of 23 had a previous combined anterior arthroscopic and posterior open synovectomy, and three of 23 had a previous open synovectomy. Mean time between stages was 87 days (2.9 months). Seven of 23 (30.4%) patients had a recurrence. Of these, three of seven (42.9%) were treated with Imatinib, and four of seven (57.1%) were treated with repeat surgery (three of four arthroscopic and one of four open). Recurrence rates of d-TGCT in the literature vary widely but tend to be high. In our retrospective study, a staged, open, anterior and posterior synovectomy provides recurrence rates that are lower than rates previously reported in the literature. These findings support prior data suggesting this approach may result in better rates of recurrence for this highly recurrent difficult to treat tumour

Ultrasound screening has shown that the shoulder joint is almost always involved in rheumatoid arthritis. But only few of rheumatoid patients suffering from omarthritis are in considerable pain. Loss of strength and mobility is often compensated by the adjacent joints. Low patients demands, as pain and swelling can be treated often temporarely successfully by corticoid injections and the need of a wide exposure of the shoulder joint when performing an open synovectomy are the reasons of the low rate of synovectomies performed in rheumatoid shoulder joints. The clinical outcome after synovectomies in rheumatoid omarthritis is generally superior to those of knee synovectomies and shows a reliable reduction of pain, swelling and an increase of ROM. The surgical trauma in open synovectomy of the shoulder results in an impairment of the complex muscle co-ordination of the shoulder and a painful long-lasting aftertreatment. This disadvantages can be prevented when using arthroscopic techniques. The advantages of the arthroscopic technique are mostly obvious in the shoulder joint. The reduced surgical trauma of the periarticular tissue leaving the proprioreception intact results in reduced postoperative pain, allowing early mobilisation and shorter rehabilitation. Arthroscopic surgery of the shoulder is performed with the patient in beach- chair position under general anesthesia. We use a standard 5mm arthroscope and a motorised synovial resector. To prevent bleeding it is advantageous to utilise cooled non-ionic irrigation solution with epinephrin in addition pressurised by a roller pump. Synovectomy of the glenohumeral joint and of the subacromial bursa is performed via four portals. Potential hazards like injury to the periarticular vessels and nerves or damage of the joint cartilage especially in stiff shoulders can only be prevented with careful proceeding. Active and passive physiotherapy starts on the first postoperative day. Our first series of 12 shoulder arthroscopies done 1989–1991 was followed 3. 8 years postoperatively. Swelling and pain at rest disappeared rapidly after surgery. Pain during motion took longer to subside. At the end of follow-up patients reported slight pain on motion in five shoulders. Postoperatively all patients reported improvement of pain. There was one recurrence of swelling due to bursitis. In this patient no bursectomy was done during shoulder arthroscopy, which is now done as a routine. There was subjectively and objectively an increase of strength postoperatively. ROM showed immediate postoperative improvement, although a slight reduction was noticed during the follow-up period. In 1990–1999 we performed 52 arthroscopical synovectomies of rheumatoid shoulders. 31 shoulders could be followed by questionnaire at a mean of 6. 5years postoperatively. Pain at rest and pain on motion was improved in about 80% and 74% respectively. Recurrence of swelling was reported by 26% of the patients. Five patients has to be operated again. The clinical outcome compare favourably with the results published about open shoulder synovectomy. Five patients with large humeral cysts were treated with arthroscopic synovectomy, arthroscopically assisted curettage and bone grafting of the cyst via a small incision at the major tuberculum. Until now none of the patients suffered from humeral collaps, no shoulder has to be replaced. In painful rheumatoid omarthritis swelling and pain can be improved reliably with arthroscopic synovectomy. The reduced surgical trauma of minimal invasive synovectomy should raise the rate of early preventive surgery

Aim: To test the hypothesis that open surgical synovectomy of the knee results in better long-term control of chronic inflammatory synovitis of the knee than arthroscopic synovectomy. Method: To test this hypothesis a prospective clinical trial was carried out involving three groups of patients:- In Group I (22 cases in 18 patients) arthroscopic synovectomy was performed by a surgeon experienced in arthroscopy (Bartlett). In Group II (15 cases in 11 patients) open surgical synovectomy / debridement was performed (Rush). In Group III (10 cases in seven patients) arthroscopic lavage was carried without synovectomy (Rush) and this acted as a “control” group. The patients were followed up for some 10 years. At the final review the clinical and functional scores were recorded using the H.S.S. knee score system. There are obvious problems in comparing two or three groups of patients from two separate units and these are discussed. Results: The results showed that in both groups (i.e. Groups I & II) there was a significant shift to the right in the clinical and functional scores. This did not occur in the “control” group. In Group I, two cases out of 22 came to total knee replacement. In Group II, four cases out of 15 and in Group III, five cases out of 10 came to knee replacement. Conclusions: It was concluded that knee synovectomy was a worthwhile procedure and that arthroscopic synovectomy was just as good and probably better than open surgical synovectomy but it needs to be done early and by a surgeon with experience in carrying out this difficult procedure

Purpose. There is controversial whether synovectomy must be done in primary total knee arthroplasty (TKA). The objectivity of the study was to compare the effect of synovectomy on inflammation and clinical outcomes after surgical treatment of knee osteoarthritis. Methods. A total of 240 patients who underwent primary unilateral TKR were randomly divided into a group without (Group A) and with synovectomy (Group B). All operations were performed by the same surgeon and follow-up was for 4 year. Clinical outcomes (including American Knee Society score (AKS), SF-36, and HSS scores) serum inflammatory markers (including interleukin-6 (IL-6), CRP and ESR) and the difference in temperature of the affected knee skin, swelling, ROM, patients VAS satisfaction score and VAS pain score were sequentially evaluated until 4 years after surgery. Result. There were no statistically different clinical parameters between the two groups preoperatively. At the 4 years follow-up, both groups had a similarly significantly improved AKS clinical and functional score. Similar changes in serial inflammatory markers were identified in both groups. In addition, no difference was seen regarding drainage-fluid inflammatory markers at any follow-up time. There was no difference in respect to patients satisfaction score from surgery to 1 year, but Group B showed greater patients satisfaction score from 2 year to four year, with less number of patients suffering from anterior pain. There was no difference with regard to other parameters at any follow-up time. Conclusions. Synovectomy in primary TKA does not seem to have any clinical advantage and shorten the duration of the inflammatory response, but it might increase patient satisfaction score and reduce anterior knee pain

Synovitis of the smaller hand joints leads to soft-tissue and bony affections. Radiologically Larsen/Dale/Eek (LDE) distinguish 6 stages of increasing destruction. Tendon ruptures, swan-neck and buttonhole deformities may occur. In early stages, when the ligament- and capsule structures require no balancing therapy, arthroscopic synovectomy may be indicated in order to prevent fast deteriorating of the joints and disability. We perform the endoscopic procedure in the MCP- and PIP-joints, when an oligoarticular situation is present or single digits are affected, provided that the surrounding soft tissues are intact, in LDE-stages 0 to 2/3. We use the laser additionally for completion of the synovectomy and for shrinking of the capsule. Technically it is necessary to have an short optical device of 1. 0 diameter, miniaturised instruments, shaver and the laser at one’s disposal. The radial and the ulnar incision proximal to the joint are used. A pilot study of 12 patients with an arthroscopic, laser-assisted synovectomy in 20 joints of various digits (LDE 0 – 2) are opposed to 10 patients with an open synovectomy of 24 joints. The follow-up-period amounts to 9 months (6 – 9). We have looked after the reccurrence rate, the time-lag until the patients are pain-free, the necessary rehabilitation measures, the progression of the LDE-stages, and the subjective judment of the patients. Both groups had no recurrence of the synovitis in the joints cared for surgically. The period until the patients were free of complaints in the arthroscopic group amounts to 4 days, opposed to 10 days in the open surgery group. Radiologically both groups revealed no further bony destruction according to LDE. 12 physiotherapy treatments after open synovectomy are twice the amount needed for the endoscopic group. This is true also for the time away from work: 14 days against 7 days. The arthroscopically treated patients remark favorably the discrete scars, the relatively pain-free perioperative period, low tissue trauma, quick rehabilitation. In open surgery the patients complain about large scars and long postoperative swelling of the joints. We can not guarantee the completeness of the synovectomy in both procedures. The effect of the intraoperative lavage and the assistance of the laser are not entirely clear either. The arthroscopic synovectomy itself is technically easy to perform. Although in this pilot study we have small numbers only, the results suggest that arthroscopic synovectomy is low in tissue trauma, quick in rehabilitation, perfect in patient acceptance and followed by a very short time away from work compared to open surgery

To determine the long term outcome and complications associated with arthroscopic synovectomy in 22 knees with rheumatoid arthritis. A consecutive series of 22 knees in 18 patients with seropositive RA underwent arthroscopic synovectomy for painful and swollen knees unresponsive to medical treatment. All operations were performed by the senior author. The mean age at operation was 44 years (22–64). All pre-operative Xrays showed Larsen grade 2 or less and no knees demonstrated marked joint laxity. Knee Society scores were recorded pre-operatively and at review, with a mean follow-up of 8 years(6–16). Two out of 22 knees (9%) have undergone TKR at 1 and 2 years post synovectomy. Two patients underwent further synovectomy for persistent symptoms but have since remained well. No per-operative complications were recorded but one large haemarthrosis and one stiff knee requiring manipulation were seen. The mean clinical and function scores increased by 22 and 15 points respectively at follow-up. The mean length of stay was 3 days and radiographs of the 20 knees not undergoing prosthetic replacement have all shown a small progression of degenerative radiological change. This long-term study shows that arthroscopic synovectomy in appropriately selected patients with RA is a safe and reliable procedure with a low complication rate. The surgery is technically demanding but involves a shorter in-patient stay than with open synovectomy. The development of radiological degenerative changes were seen with all patients at review

Purpose: In order to investigate if arthroscopic synovectomy is effective for non-responder by infliximab, anti-TNF-α antibody, for rheumatoid arthritis (RA), we assessed 7 patients including 10 arthroscopic synovectomy including in knee joint, in shoulder joint and in ankle joints respectively. Materials and Methods: We performed arthroscopic synovectomy in 10 joints of 7 patients to compare CRP and DAS28 before and after surgery at 6 and 50 weeks. Those patients include 1 male and 6 female from 49 to 68 years old with average of 62 years old. 3 patients was underwent arthroscopic synovectomy after 4 times of infliximab, 2 patients were after 5 times and 2 patient was 6 times. All patients were initially responder to infliximab and MTX but gradually the effect decreased, the average of CRP was 3.45±0.4 (2.7–5.6) mg/dl at the surgery. The indication of operation was that after treatment infliximab CRP was more than 2.5 mg/dl and the numbers of arthritis joints were limited to within five joints of relatively large joints such as knee, shoulder including ankles and wrists. After arthroscopic synovectomy we continued infliximab treatment with MTX in routine manner. Results: We detected synovium proliferation with vascular increase in patella femoral (PF) joint and around the meniscus and femoral and tibial side of the anterior cruciate ligament (ACL) in the knee joints. We also found synovial proliferation in rotator interval (RI) in the glenohumeral joint and fatty changing in subacromial bursa (SAB) in shoulder. In ankle joint we found synovial proliferation with white meniscoid between tibiofibular joint to develop impingement. Serum CRP was improved from 3.45±0.4 to 1.12±0.2 at 6 weeks, 1.22±0.4 at 50 weeks after arthroscopic synovectomy. There is no severe side effects by arthroscopic synovectomy during infliximab treatment, however 1 patient had slight rash that was improved. DAS28 was improved from 5.58±0.23, to 3.87±0.47 at 6 weeks, improved to 2.58±1.49 at 50 weeks after arthroscopic synovectomy. Conclusion: It is possible that arthroscopic synovectomy can be one of the effective method to continue infliximab treatment when its efficacy decreased or in non-respond of infliximab for RA patients

Purpose: Synovium proliferation of rheumatoid arthritis (RA) is a key role in development of destruction in articular joints. Arthroscopic synovectomy is quite useful for resection synovium less invasively for RA patients. However there are few papers about shoulder joint synovectomy of rheumatoid arthritis. Ho-YAG laser is also effective to decrease synovium proliferation. The advantage of using Ho-YAG laser is effective to pannus even in deep zone of bone erosion. In this paper, we treated 13 shoulders of 11 patients of RA by using Ho-YAG laser to assess whether Ho-YAGH laser is effective in shoulder arthroscopic synovectomy of RA. Materials and Methods: We treated 13 shoulders in 11 patients of RA, including 8 in stage II, 4 in stage III, 1 in stage IV. The duration of RA is an average of 4, 6 years. The follow-up period is an average of 14 months. We compared CRP, DAS28 and MRI findings before and after surgery. Those patients were taking DMARDs such as MTX in 8 patients, steroid in 3 patients infliximab in 1 patient and etanercept in 1 patient. We used 4.0 mm arthroscope, VAPR and shaver for synovectomy. Ho-YAG laser set to 10W to bone erosion area to reach deep zone of pannus and to resect synovium. Results: We found villous synovium proliferation with vascularity in rotator interval and supraspinatus tendon in shoulder joint. In subacromial bursa, yellow fat tissue and white fibrous soft tissue was detected almost all shoulders. After synovectomy by using Ho-YAG laser, CRP was decreased from an average of 3.6 to 0.8 and DAS28 was also decreased an average of 5.4 to 3.7 at 14 month after surgery. MRI showed decreased pannus with synovium and joint destruction was not preceding after 14 month. Discussion: Ho-YAG laser is effective for using shoulder arthroscopic synovectomy especially to treat pannus in bone erosion. The amount of energy of Ho-YAG laser for synovectomy is not clear so far. We used 10W for 5 second in each area that could be effective to decrease pannus formation. We would further investigate in the basic experimental levels to confirm Ho-YAG laser efficacy

Purpose: Rheumatoid arthritis (RA) frequently affects the finger joints. Persistent synovitis is believed to cause not only bone destruction but also various deformities of the hands. For this reason, synovectomy of the finger joints is attempted when chronic swelling of the synovium of finger joints does not respond to any conservative treatment. The purpose of this study is to evaluate the effectiveness of surgical synovectomy of finger joints in RA patients. Method: Forty-six finger joints (MP 24; Steinbrocker Stage II: 8, Stage III: 16) (PIP 22; Stage I: 5, Stage II: 9, Stage III: 8) of 20 patients with rheumatoid arthritis who had synovectomy were examined at an average of 20 months follow-up (range 14–43 months). The active motion exercises of the operated fingers started as early as 2 or 3 days after surgery. The results of synovectomy in these patients were evaluated by pain, range of motion, and radiograph. Results: Pain was relieved (Visual analogue scale MP: 6.5→1.4, PIP: 6.2→0.7), swelling was diminished in all and only a little loss of motion was observed (arc of motion MP: 59.8→53.4, PIP: 75.5→69.6) after surgery. Radiological bone changes progressed in 4 (17%) MP and 3 (14%) PIP joints. Deformities (ulnar drift or subluxation) after surgery developed in 3 (12%) MP-joints. Conclusion: Synovectomy performed on finger joints of RA patients were evaluated. From the results of this clinical study we recommend synovectomy of finger joints in RA patients before bone changes, when chronic synovitis of finger joints does not respond to any conservative treatment

Aim of study: To determine the long term outcome and complications associated with arthroscopic synovectomy in 22 knees with rheumatoid arthritis. Methods: A consecutive series of 22 knees in 18 patients with seropositive RA underwent arthroscopic synovectomy for painful and swollen knees unresponsive to medical treatment. All operations were performed by the senior author. The mean age at operation was 44 years(22–64). All pre-operative Xrays showed Larsen grade 2 or less and no knees demonstrated marked joint laxity. Knee Society scores were recorded pre-operatively and at review, with a mean follow-up of 8 years (6–16). Results: Two out of 22 knees(9%) have undergone TKR at 1 and 2 years post synovectomy. One patient underwent a further synovectomy for persistent swelling at 2 years and has since remained well. No per-operative complications were recorded but one large haemarthrosis and one stiff knee requiring manipulation were seen. The mean clinical and function scores increased by 22 and 15 points respectively at follow-up. The mean length of stay was 3 days and Xrays of the 20 knees not undergoing prosthetic replacement have all shown a small progression of degenerative radiological change. Conclusion: This long-term study shows that arthroscopic synovectomy in appropriately selected patients with RA is a safe and reliable procedure with a low complication rate. The surgery is technically demanding but involves a shorter in-patient stay than with open synovectomy. The development of radiological degenerative changes were seen with all patients at review

Introduction. Synovectomy in children with juvenile rheumatoid arthritis (JRA) and psoriatic arthritis (PSA) is still subject of controversial discussion. Our results of arthroscopic synovectomy of the knee in children with chronic inflammatory joint disease are presented. Material. From 1989–1997 27 synovectomies were performed in 27 children with inflammatory arthritis (15 JRA, 12 PSA). Average age at surgery was 12. 5 y (2. 9–17. 8 y). Mean follow-up was 4. 9 years. Methods. Onset of disease and conservative therapy was documented. Each patient was physically and radiologically examined preoperatively and 24 children postoperatively (mean follow-up 4. 9 years). For arthroscopic shaver-assisted synovectomy of the knee we used minimum 4 portals and normally 6 portals (2 anterior, 2 suprapatellar and 2 posterior portals). In addition to the physical examination we used a special clinical score (Laurin 1974). We compared the pre- and postoperative limits of active and passive knee movement. We performed sonographs and radiographs of the infected joint. Radiography was classified following the Larsen-Scale. Patient and parents gave their opinion whether the operation was successful. Before surgery all children had intensive drug and physical therapy for 8–62 months (42 month). In the course of conservative treatment, knees had local joint treatment with triamcinolonhex-acetomid (THA), normally for three times before surgery. Preoperative X-rays showed Larsen stage I in 3 knee joints and Larsen stage 0 in the other knees. Results. In 85% of the children, we found good or excellent surgical outcome. 2 joints achieved fair and 2 joints poor outcome. Concerning subjective outcome 22 (82%) children had been very satisfied (56%) or satisfied (26%). 25 of the children’s parents would agree in the same surgical procedure again. In 6 knee joints we found recurrent synovitis. 2 of these knee joints were reoperated (30 and 22 month postoperatively with satisfying result), the other 4 joints were treated with THA i. a.. The 2 reoperations were regarded as poor result. We had no postoperative complications and the normal hospitalisation was 15 days. Prior to surgery, 12 knee joints had an average deficit of active knee extension of 10° (5–20°). Postoperatively, no extension deficit was found anymore in 25 of the knees. Compared to the contralateral knees, a flexion deficit of 10° (5–15°) was obtained postoperatively. At sonography, no joint effusion could be revealed. Postoperative X-rays showed no progression in Larsen stage. Outcome in children with oligoarthritis was better than in those with polyarthritic disease. Discussion. Early arthroscopic synovectomy of the knee in children with chronic inflammatory joint disease is, in case of failure of conservative treatment, a useful method of treatment. We propose early synovectomy of the knee joint as an essential part of the treatment scheme for children with inflammatory joint disease

Purpose: The synovectomy-reaxation-stabilisation (SRS) procedure classically involves tenosynovectomy of the extensors, articulr synovectomy, partial deinnervation of the wrist, and tendon transfer. The purpose of this study was to: 1) evaluate functional and radiographic results, 2) search for possible correlations between results and the extent of articular synovectomy or type of tendon transfer. Material and methods: Between 1984 and 1998, an SRS procedure was performed in 75 patients, 14 were excluded: seven had died, five were lost to folow-u and two had had wrist arthrodesis. A total of 73 wrists were analysed in 61 patients. Mean follow-up was 70 months and mean patient age was 53 years. Functional assessment was based on the Gschwend pain scale. Results: Before surgery, 94% of the patients had grade III or IV pain. At last follow-up, 93% of them grade 0 or I. The gain in pain was greatest for patients with severe carpitis. At last follow-up, the wrist was stiff; stiffness basically involved flexion with 43° pre and 27° postoperatively, radial inclination 13° pre and 9° postoperatively, and pronation in patients with advanced Larsen grade preoperatively. Extension, ulnar inclination, and supination were improved 5° to 10°. Extension of the synovectomy to carpal joints had a stiffening effect. Before the operation, 25 wrists were in Larsen grades 0, 1 and 2 and 48 wrists were in Larsen grades 3 or 4. At last follow-up, there were nine wrists in Larsen grades 0, 1, or 2 and 64 in Larsen grades 3 or 4. Carpitis thus continued to evolve and the height of the carpus declined. Ulnar translation of the carpus progressed a mean 2 mm. Spontaneous radial inclination of the wrist was aggravated by a mean 3°. The frontal position of the wrist was better after transfer of the long radial extensor of the carpus on the short radial extensor of the carpus than for transfer on the ulnar extensor of the carpus or without transfer. Discussion: Our pain results are in agreement with data in the literature but we did not observe preserved or improved mobility. Extended synovectomy appeared to have a stiffening effect. Progression of the ulnar translation of the carpus was less pronounced with simple resection of the head of the ulna. It was better to transfer the long radial extensor of the carpus on the short radial extensor of the carpus to correct for frontal deviation of the carpus

Introduction: Diffuse pigmented villo-nodular synovitis (DPVNS) of the knee remains a difficult tumor to eradicate. We report our experience with a combined posterior and open synovectomy technique. Method: A single surgeon operated on 40 patients averaging 35 years old (14 to 68 years). The patients were placed into one of three groups: group I received surgery alone (five patients), group II had surgery and intra-articular radiation synovectomy using Dysprosium-165 (165Dy) (30 patients), and group III had surgery and external beam radiation (5 patients). The adjuvant radiation was performed three months postoperatively. MRI evaluation was used preoperatively and post-operatively. Results: The average combined Knee Society Scores and range of motion improved. Thirty-seven patients (92.5%) had a good or excellent results; two (5%) had a fair result; and one (2.5%) had a poor result. There were seven recurrences (17.5%). None occurred in group I; five occurred in group II (12.5%); and two occurred in group III (5%). Discussion & Conclusions: This technique allowed excellent visualisation and removal of intra- and extra-articular DPVNS tissue with excellent functional results and few recurrences documented by MRI. Adjuvant intra-articular radiotherapy may be beneficial for small foci of residual disease but complete resection of all DPVNS tissue was the key to prevent recurrence. External beam radiation did not prevent recurrence and possibly predisposed patients to pain and less improvement in knee flexion. Extensive pre-operative degenerative joint disease predisposes patients to continued pain

Since 1976 we have performed 60 radioactive synoviorthesis in 53 haemophilic patients with age from 6 to 40 years with a mean of 10 years of age, 45 of these patients were under 12 years of age. The knees were injected in 38 cases, elbow in 16 cases, ankles in 5 and shoulders in 1 case. The procedure was performed in 6 sittings of 10 patients each. The synoviorthesis is done by an intrarticular injection of the radioactive material preceded by a local anesthetic. The clinical results of this procedure gives an 80 % of excellent results with no further bleeding. One of the criticisms against this method is the possible chromosomal damage induced by the radioactive material. In our center, two previous studied have been done in order to see whether these possible changes are everlasting and both have demonstrated that chromosomal changes are reversible. The radioactive material used in these synoviorthesis was 189 Au In 1978, 354 metaphases were studied with 61 ruptures, 17.23 %, (non premalign) and 6 structural changes -considered premalignant, 1.69 %. Any number below 2 % is considered non dangerous. A further study was done in 1982, in the same group of patients with a result of 21 ruptures, 3.34% and no structural changes. This demonstrated that the possible premalignant changes disappeared with time. A third study was performed in a series of 13 patients that unstained radioactive synoviorthesis with Re 186 in November 1991. We performed for comparison a chromosomal study just before and 6 months after the radioactive material injection. The results confirmed that changes that could be attributed to the radiation, appears equally in non irradiated patients and those due to the radiation disappear with time, never reaching the dangerous zone of 2 %. In these group treated with 186 Re we studied an additional number of 130 metaphases with identical results and NO structural changes. Conclusions: In view of these results, it seems that radioactive synovectomy is safe procedure and gives great benefits to the haemophilic patients, and no long standing structural chromosomal damage

Purpose: Recurrent hemarthrosis is a common clinical entity in hemophiliacs. They not only interfere with daily life but also trigger hemophilic arthropathy. Synovial hypertrophy has a pivot role in hemarthrosis related joint damage and ablation of the synovium prevents further deterioration. Current treatment strategy is to ablate synovium in the early stages in order to prevent progression of the arthropathy. We report a series of hemophilia patients with advanced arthropathy who had been treated with radionuclide synoviorthesis.

Materials and Methods: The patients who had been treated with radionuclide synoviorthesis for either knee or elbow disease between 2002 and 2004 were included in this study. The inclusion criteria were having > 1 hemarthrosis episode per month in the index joint, chronic synovial hypertrophy, advanced degenerative changes of grade III and IV as defined by Arnold-Hilgartner Classification, F8 inhibitor level < 3. The frequency of hemarthrosis, range of motion of the affected joint, pain level that was evaluated by visual analog scale, was recorded during each follow-up. 90Y was used for the synoviorthesis of the knee, whereas 186Re was used for the elbow cases. Patients were screened for radionuclide leak by using a gamma camera following the injection.

Results: Twenty radionuclide synoviorthesis were performed in 14 knees. The average age was 20 (range, 10–31) with an average follow-up of 17 months (range, 3–29). There were 12 severe hemophilia A and 2 severe hemophilia B patients. The frequency of intaarticular bleeding episodes was significantly reduced at the final follow-up (p< 0,05). Although the range of motion and the pain scores were improved, the change was not statistically significant (p> 0,05). Six patients required repeated treatment because of inadequate response. No radioactive material leakage were detected at the draining lymph nodes.

Conclusions: Our results demonstrate that radionuclide synoviorthesis significantly reduces the number of the bleeding episodes even in the knees presenting with advanced arthritis, and increases the quality of life. Although most patients respond to single injection, some patients may require more than one injection, to achieve a satisfactory clinical outcome.

Aims. This study aimed to define the histopathology of degenerated humeral head cartilage and synovial inflammation of the glenohumeral joint in patients with omarthrosis (OmA) and cuff tear arthropathy (CTA). Additionally, the potential of immunohistochemical tissue biomarkers in reflecting the degeneration status of humeral head cartilage was evaluated. Methods. Specimens of the humeral head and synovial tissue from 12 patients with OmA, seven patients with CTA, and four body donors were processed histologically for examination using different histopathological scores. Osteochondral sections were immunohistochemically stained for collagen type I, collagen type II, collagen neoepitope C1,2C, collagen type X, and osteocalcin, prior to semiquantitative analysis. Matrix metalloproteinase (MMP)-1, MMP-3, and MMP-13 levels were analyzed in synovial fluid using enzyme-linked immunosorbent assay (ELISA). Results. Cartilage degeneration of the humeral head was associated with the histological presentation of: 1) pannus overgrowing the cartilage surface; 2) pores in the subchondral bone plate; and 3) chondrocyte clusters in OmA patients. In contrast, hyperplasia of the synovial lining layer was revealed as a significant indicator of inflammatory processes predominantly in CTA. The abundancy of collagen I, collagen II, and the C1,2C neoepitope correlated significantly with the histopathological degeneration of humeral head cartilage. No evidence for differences in MMP levels between OmA and CTA patients was found. Conclusion. This study provides a comprehensive histological characterization of humeral cartilage and synovial tissue within the glenohumeral joint, both in normal and diseased states. It highlights synovitis and pannus formation as histopathological hallmarks of OmA and CTA, indicating their roles as drivers of joint inflammation and cartilage degradation, and as targets for therapeutic strategies such as rotator cuff reconstruction and synovectomy. Cite this article: Bone Joint Res 2024;13(10):596–610

Aim. The aim of this systematic review was to assess the existing published data on tuberculous arthritis involving native joints in adults aged 18 years and older. The specific research questions focused on the diagnosis and management of the disease. Method. This study was performed in accordance with the guidelines provided in the Preferred Reporting Items for Systematic reviews and Meta-Analysis extension for Scoping Reviews (PRISMA-ScR). A systematic literature search was undertaken of Pubmed, Web of Science, Scopus and the Cochrane library. Only studies published in English since 1970 were considered. Case series involving less than 10 patients, systematic and narrative reviews, and laboratory or animal studies were excluded. We also excluded reports of TB infections not involving a “native joint” and tuberculosis of the spine. The level of evidence and strength of recommendations was performed in accordance with the GRADE system. Results. The systematic review of the literature yielded 2023 potential sources. Following deduplication, screening and full-text review, 20 data sources involving 573 patients from nine countries, were included. There was considerable variation amongst the studies in terms of the approach to diagnosis and management. The most common method used to confirm the diagnosis was microbiological culture of tissue obtained by biopsy, with positive findings in 93% of cases. Medical management involved a median 12 months of antitubercular treatment (IQR 8–16; range 4–18 months). Duration of pre-operative treatment ranged from two to 12 weeks in duration. Surgery was performed in approximately 87% of patients and varied from arthroscopic debridement to complete synovectomy combined with total joint arthroplasty. When arthroplasty and arthrodesis cases are excluded, 80% of patients received an open or arthroscopic debridement. The mean follow-up time of all studies was 26 months, with most studies demonstrating a minimum follow-up of at least six-months (range 3–112 months). Recurrence rates were reported in most studies, with an overall average recurrence rate of 7,4% (35 of 475). Conclusions. The current literature on TB arthritis highlights the need for the establishment of standardised diagnostic criteria. Further research is needed to define the optimal approach to medical and surgical treatment. The role of early debridement in active tuberculous arthritis needs to be explored further. Specifically, comparative studies are required to address the questions around use of medical treatment alone versus in combination with surgical intervention

Pigmented villonodular synovitis is a monoarticular proliferative process most commonly involving the synovium of the knee joint. There is considerable debate with regards to diagnosis and effective treatment. We present our experience of managing PVNS of the knee joint over a 12 year period. Twenty-eight patients were reviewed. MRI was used to establish recurrence in symptomatic patients rather than routine screening and to identify posterior disease prior to surgery. Eight patients had localised disease and were all treated with open synovectomy and excision of the lesion, with no evidence of recurrence. Twenty patients had diffuse disease, eight treated arthroscopically and twelve with open total synovectomy. Nineteen patients (95%) had recurrence on MRI, however, only five (25%) had evidence of clinical recurrence. There were no significant complications following arthroscopic synovectomy. Open synovectomy, in contrast, was associated with three wound infections and two thrombo-embolisms. Three patients had Complex regional pain syndrome. We believe diffuse disease should be treated with arthroscopic synovectomy which is associated with minimal morbidity and can be repeated to maintain disease control. Radiotherapy is helpful in very aggressive cases. TKR was used when there was associated articular erosion

Improvements in ceramic materials, component design, and surgical technique have made ceramic bearing complications increasingly rare. However, when it happens, a fractured ceramic component can cause significant pain and morbidity following total hip arthroplasty (THA). The hard and sharp particulate debris from fractured ceramic components can cause damage to the existing hip prosthesis and jeopardise subsequent revision THA results due to third body wear. Patients with ceramic fractures can present with sudden onset of pain and dysfunction. Often, the patient will report a noisy hip articulation. Radiographs can range from subtle densities surrounding the hip implant to complete disintegration and loss of sphericity of the femoral head or acetabular liner. Ceramic component fractures should be treated expeditiously. Revision options for failed ceramic components depend on existing component fixation, position, and locking mechanism and femoral trunnion integrity. In order to retain the implants, the components must be well-fixed, in good position, and have tapers and locking mechanisms that can accept new modular components. Additionally, an extensile exposure and complete synovectomy are necessary to remove as much of the sharp particulate debris. Finally, a new ceramic ball head with a titanium inner sleeve should be used in revisions for fractured ceramics due to their hardness and scratch resistance. Early results for revision surgery for fractured ceramic components were inconsistent. Allain et al. reported on a series of 105 revisions performed for ceramic head fractures and found that the survivorship at 5 years was only 63%. The authors reported a high reoperation rate and also worse survivorship when the acetabular component was retained, a metal head was used for revisions, age younger than 50 years, and when a complete synovectomy was not performed at the time of revision. More recently, Sharma and colleagues reported on a series of 8 ceramic fractures revised to a metal-on-polyethylene articulation performed with a complete synovectomy. At 10-year follow-up, the authors reported on failures; increased wear; or lesser function compared to 6 matched patients undergoing revision using similar implants for other diagnoses. Others have also reported catastrophic failures when revising fractured ceramic components using metal ball heads. In summary, ceramic bearing complications in THA are rare but catastrophic events. A systematic approach to evaluation and management is necessary to ensure a safe return