Aims

Tenosynovial giant cell tumour (TGCT) is one of the most common soft-tissue tumours of the foot and ankle and can behave in a locally aggressive manner. Tumour control can be difficult, despite the various methods of treatment available. Since treatment guidelines are lacking, the aim of this study was to review the multidisciplinary management by presenting the largest series of TGCT of the foot and ankle to date from two specialized sarcoma centres.

Aims

The aim of this study was to explore the prognostic factors for postoperative neurological recovery and survival in patients with complete paralysis due to neoplastic epidural spinal cord compression.

Patients who have limb amputation for musculoskeletal tumours are a rare group of cancer survivors. This was a prospective cross-sectional survey of patients from five specialist centres for sarcoma surgery in England. Physical function, pain and quality of life (QOL) outcomes were collected after lower extremity amputation for bone or soft-tissue tumours to evaluate the survivorship experience and inform service provision.

Of 250 patients, 105 (42%) responded between September 2012 and June 2013. From these, completed questionnaires were received from 100 patients with a mean age of 53.6 years (19 to 91). In total 60 (62%) were male and 37 (38%) were female (three not specified). The diagnosis was primary bone sarcoma in 63 and soft-tissue tumour in 37. A total of 20 tumours were located in the hip or pelvis, 31 above the knee, 32 between the knee and ankle and 17 in the ankle or foot. In total 22 had hemipelvectomy, nine hip disarticulation, 35 transfemoral amputation, one knee disarticulation, 30 transtibial amputation, two toe amputations and one rotationplasty. The Toronto Extremity Salvage Score (TESS) differed by amputation level, with poorer scores at higher levels (p < 0.001). Many reported significant pain. In addition, TESS was negatively associated with increasing age, and pain interference scores. QOL for Cancer Survivors was significantly correlated with TESS (p < 0.001). This relationship appeared driven by pain interference scores.

This unprecedented national survey confirms amputation level is linked to physical function, but not QOL or pain measures. Pain and physical function significantly impact on QOL. These results are helpful in managing the expectations of patients about treatment and addressing their complex needs.

Cite this article: Bone Joint J 2015;97-B:1284–90.

Purpose of study:. “Ganglia are a benign condition taking up the time of competent surgeons who might be more usefully engaged.” – McEvedy. Our aim was to perform a retrospective review comparing preoperative clinical presentation, intraoperative findings and histological diagnosis of all hand and wrist ganglia presenting to the Hand Unit at Chris Hani Baragwanath Hospital. Methods:. A retrospective review of hand and wrist ganglia treated at the Hand Unit at Chris Hani Baragwanath Hospital. Clinical and surgical notes and histology reports were reviewed. All ganglia were removed surgically as directed by clinical findings. Results:. A total of 75 hand and wrist masses were operated over a period of 6 months between January and June 2012. Of these 42 were clinically diagnosed as ganglia. All 42 “ganglia” were removed surgically and sent for histological evaluation. Of these, 40 were diagnosed intra-operatively as ganglia. In 2 cases the diagnoses were changed intra-operatively to synovitis and Giant Cell Tumor of tendon sheath. Histologically 5 out of 42 cases were found not to be ganglia; their diagnoses were as follows:. 1. Granulomatous synovitis. 2. Chronic inflammation (possible tuberculous). 3. Giant Cell Tumour of Tendon Sheath. (Correlates with intra-op diagnosis). 4. Nerve sheath tumour (Schwannoma). 5. Chronic bursitis. Conclusion:. Be wary of “the simple ganglion”. Other conditions may mimic a ganglion with potentially disastrous consequence if misdiagnosed. In our setting histological evaluation is compulsory. Always follow the patient up and confirm histological diagnosis

Pigmented villonodular synovitis (PVNS) is a rare benign disease of the synovium of joints and tendon sheaths, which may be locally aggressive. We present 18 patients with diffuse-type PVNS of the foot and ankle followed for a mean of 5.1 years (2 to 11.8). There were seven men and 11 women, with a mean age of 42 years (18 to 73). A total of 13 patients underwent open or arthroscopic synovectomy, without post-operative radiotherapy. One had surgery at the referring unit before presentation with residual tibiotalar PVNS. The four patients who were managed non-operatively remain symptomatically controlled and under clinical and radiological surveillance. At final follow-up the mean Musculoskeletal Tumour Society score was 93.8% (95% confidence interval (CI) 85 to 100), the mean Toronto Extremity Salvage Score was 92 (95% CI 82 to 100) and the mean American Academy of Orthopaedic Surgeons foot and ankle score was 89 (95% CI 79 to 100). The lesion in the patient with residual PVNS resolved radiologically without further intervention six years after surgery. Targeted synovectomy without adjuvant radiotherapy can result in excellent outcomes, without recurrence. Asymptomatic patients can be successfully managed non-operatively. This is the first series to report clinical outcome scores for patients with diffuse-type PVNS of the foot and ankle.

Cite this article: Bone Joint J 2013;95-B:384–90.

Giant cell tumours (GCT) of the synovium and tendon sheath can be classified into two forms: localised (giant cell tumour of the tendon sheath, or nodular tenosynovitis) and diffuse (diffuse-type giant cell tumour or pigmented villonodular synovitis). The former principally affects the small joints. It presents as a solitary slow-growing tumour with a characteristic appearance on MRI and is treated by surgical excision. There is a significant risk of multiple recurrences with aggressive diffuse disease. A multidisciplinary approach with dedicated MRI, histological assessment and planned surgery with either adjuvant radiotherapy or systemic targeted therapy is required to improve outcomes in recurrent and refractory diffuse-type GCT.

Although arthroscopic synovectomy through several portals has been advocated as an alternative to arthrotomy, there is a significant risk of inadequate excision and recurrence, particularly in the posterior compartment of the knee. For local disease partial arthroscopic synovectomy may be sufficient, at the risk of recurrence. For both local and diffuse intra-articular disease open surgery is advised for recurrent disease. Marginal excision with focal disease will suffice, not dissimilar to the treatment of GCT of tendon sheath. For recurrent and extra-articular soft-tissue disease adjuvant therapy, including intra-articular radioactive colloid or moderate-dose external beam radiotherapy, should be considered.

Giant cell tumours of tendon sheaths have been given multiple denominations due to the uncertain pathologic nature of this lesion. Various contributory factors have been accounted for a wide variation in their recurrence rates. Owing to their high recurrence rates ranging from 9% to 44%, these tumours continue to present with treatment dilemma. There is a lack of consensus regarding how to best manage the balance between extensive dissection and preservation of normal tissues for normal function and recovery versus the risk of recurrence. The authors studied 46 patients with histopathologically confirmed Giant cell tumours over a period of 9 years between 1997 and 2006. The average follow-up in this case series was 35 months. This study aims to analyse the distribution of giant cell tumours of tendon sheaths in hand and our experience with their resection in a District General Hospital with possible predictors associated with recurrence. The referral letters, radiographs, operative and histology records were reviewed. The data was carefully analysed including patients' age and sex at the time of presentation and surgery, presenting symptoms, any associated trauma and the anatomical location of the tumour. A telephonic questionnaire was conducted and the patients with any complications or recurrence were reviewed. Our recurrence rate of 8.6% (4 patients) is lower than previously reported in the literature when the patients did not receive post-operative radiotherapy. Recurrence was seen to be statistically higher in cases where the tumours were excised piecemeal as opposed to removed in one piece and in patients with osseous erosions which were confirmed radiologically and intra-operatively. No atypical mitosis was reported on histology. None of our patients received radiotherapy post-operatively. Other factors including age, size, degenerative joint disease and location within the digit were not confirmed as risk factors in our study. We recommend meticulous surgical technique by an experienced hand surgeon and warning patients of the risk of recurrence if any risk factors were identified

Introduction: Giant cell tumor of the tendon sheath is a solitary benign soft tissue tumor of the limb. We present our prospective experience of 106 cases, over a period of 22 years to assess the effectiveness of prophylactic radiotherapy in postoperative period. We also present a classification system to help in selecting patients for postoperative radiotherapy. Material & Methods: Between 1986 and 2008, we treated 106 patients with giant cell tumor of the tendon sheath of the hand. There were 77 females and 29 males with a mean age of 31.2 years. All patients presented with gradually progressive swelling. Pain was present in 3 cases. All patients were investigated preoperatively with plain X-rays. MRI was done in 36 cases. A preoperative diagnosis of giant cell tumour of the tendon sheath was made in 98 patients preoperatively. Rest 8 patients were diagnoses on histo- pathological examination. We developed a classification system to identify the patients for risk of recurrence and consequently selection of patients for postoperative radiotherapy. Group 1(a) and 2(a) were identifies as low risk groups and comprised of 56 patients. Results: None of the patient in this group received postoperative radiotherapy and no patient had recurrence among them. All other patients (50 patients) were considered to be high risk and given postoperative radiotherapy. Among them 4 had recurrence. A total recurrence rate of 3.7% was found in our study, which is favourably comparable to reported incidences of between 25% to 45%. Conclusion: In our series, we gave radiotherapy to only high risk patients and had a recurrence rate of only 3.7%. Even in high risk group alone, to whom postoperative radiotherapy was given, recurrence rate was 8%. This indicate the role of radiotherapy as well as importance of our classification system to identify the patients for high risk of recurrence

Giant cell tumor of the tendon sheath (nodular synovitis) is a benign soft tissue tumor, usually affecting older women, that most often occurs in the interphalangeal joints of the fingers, wrist or knee. Malign giant cell tumor of the tendon sheath is rare. We present a case of a 56-year-old woman presented with a slow-growing, painless mass on the anteromedial aspect of the ankle 5 year duration. Apparent rapid enlargement of the mass was observed and went under surgery. The resected tumor, measuring 50x21x28 mm.cm, was encapsulated and located on the tibialis anterior tendon sheath of the ankle. The tumor was intracapsular and its margins was clear. We performed radioterapy. The patient was quite well at the last follow-up 12 months after wide excision. It seems likely that may expect the good outcome, superficial location and the minority of the tumor composed of malignant component. However, long-term follow-up is mandatory, due to the poor prognosis

Introduction: Anterior knee pain is a very common presenting symptom. Fat pad syndrome is an uncommon and a difficult condition to manage. The diagnosis is usually reached after a period of physiotherapy and investigation to rule out the more common aetiologies of anterior knee pain. Patients & Methods: All patients who underwent excision of the infrapatellar fat pad following a diagnosis of Fat pad syndrome are included. Each patient was evaluated to exclude patellofemoral problems and intraarticular pathologies as the cause of anterior knee pain. Each patient underwent MR imaging and all the excised specimens were sent for histological analysis. Results: The MR imaging provided with the provisional diagnosis in all patients. All the specimens were examined by a single senior histopathologist to correlate with the provisional diagnosis. The histology confirmed Hoffa’s syndrome in 5 patients and in the remaining 15 patients a spectrum of rare diagnoses as suspected by Magnetic Resonance imaging. The more notable conditions were two synovial sarcomas, three haemangiomas and a Giant cell tumour of the tendon sheath. All patients were treated successfully with complete excision. No recurrences were recorded at the end of 3 year follow-up and all patients were symptom free. Conclusion: The work up of a patient with suspected infrapatellar fat pad syndrome must include MR imaging and the exact underlying pathology should be confirmed with histological analysis of the excised fat pad as the rare causes include soft tissue malignancy

We evaluated 56 patients for neurological deficit after enucleation of a histopathologically confirmed schwannoma of the upper limb. Immediately after the operation, 41 patients (73.2%) had developed a new neurological deficit: ten of these had a major deficit such as severe motor or sensory loss, or intolerable neuropathic pain. The mean tumour size had been significantly larger in patients with a major neurological deficit than in those with a minor or no deficit. After a mean 25.4 months (12 to 85), 39 patients (70%) had no residual neurological deficit, and the other 17 (30%) had only hypoaesthesia, paraesthesiae or mild motor weakness.

This study suggests that a schwannoma in the upper limb can be removed with an acceptable risk of injury to the nerve, although a transient neurological deficit occurs regularly after the operation. Biopsy is not advised. Patients should be informed pre-operatively about the possibility of damage to the nerve: meticulous dissection is required to minimise this.

Giant cell tumour of tendon sheath is usually benign in nature but their tendency to recur is well known, this cause problems for surgeons and there is always a puzzle in determining the appropriate therapy. This study was done to highlight characteristics, differential diagnosis and current options of treatment for giant cell tumour of tendon sheath. We report two cases treated at our hospital. Both are females, one of 24 years while other was 65 years at the time of diagnosis. First patient had incidental associated benign teratoma of ovary as well. One tumour was of thumb in non dominant hand while in older patient it was at distal interphalangeal joint of ring finger in dominant hand. Both presented with history of slowly growing painful swelling, they were treated with local excision but in both patients there was an aggressive local recurrence. Revision surgery was performed with wider local excision. There was no recurrence this time. Giant cell tumour of tendon sheath is mostly benign condition but need to be differentiated from serious conditions like clear cell sarcoma. Therapy of choice is local excision. Wider excision after surgery should be reconsidered where microscopic examination reveals a lesion with characteristics suggestive of potential aggressive behaviour. A literature review and discussion of salient diagnostic and treatment issues is included

Purpose: We report a locally invasive tenosynovial haemangioma infiltrating the flexor digitorum sublimis of the non dominant little finger in a sixteen year old student which was excised with part of the sublimis tendon and the A2 pulley. Patients and Methods: Haemangiomata developing in the hand in relation to tendon and the tenosynovium (tendon sheath) are very rare. To our knowledge only three cases have been described arising in relation to the tenosynovium of the tendons of the hand only one of which showed infiltration of the underlying tendon. We report the case of a sixteen year old right hand dominant student who presented to her family doctor with a swelling on her left little finger. A magnetic resonance scan was arranged which confirmed a soft tissue lesion between the flexor tendons and the proximal phalanx of the left little finger with appearance similar to giant cell tumour of the tendon sheath. Surgical exploration demonstrated a dark red fleshy tumour that appeared to infiltrate the flexor digitorum ublimes tendon, and extend around either side of the proximal phalanx. For complete excision of the lesion the infiltrated sublimis tendon and a part of the A2 pulley were sacrificed. There was no resultant bowstringing of the profundus tendon. Histologically the tenosynovium was expanded by a vascular lesion consisting of dilated, thin-walled vascular channels within fibrous tissue The appearances were those of a synovial haemangioma of the tenosynovium of the flexor tendons. Conclusion: Our case illustrates the pitfalls in diagnosis and the invasive potential of a synovial haemangioma which in our case had infiltrated the flexor sublimis tendon and the area around the A2 pulley. A complete surgical excision is critical to prevent recurrence

This study describes the clinical features and treatment of the 53 patients with primary tumors of the hand. A review of primary tumors of the small bones of the hand during a 9 year period (1991–2001) was done. There were 14 enchondromas, 1 malignant fibrous histiocytoma, 15 ganglions, 5 haemangiomas, 1 haemangioma of median nerve, 4 giant cell tumors of tendon sheath, 4 osteoid osteomas, 1 lymphangioma, 1 exostosis, 1 dermatofibrosarcoma, 1 neurilemoma, 2 neurinomas, 1 glomus tumor, 1 benign fibrous histiocytomas and 1 papillary endothelial hyperplasia. There were 34 males and 19 females with an average age 37.7 years. The mean follow-up was 6y (1–8y). There were 33 lesions in the fingers, 3 in the metacarpals, 13 in the carpus and 4 in the palm. Swelling and localized tenderness were the most common presenting complaints. One patient died of metastatic disease. 3 patients were seen initially with locally reccurent lesion. All the patients were treated surgically. The material was analyzed in terms of diagnosis, localization, surgical management and post-operative complications. Primary tumors of the hand are rare. The cases in these series are similar to that of other reports. As in other musculoskeletal neoplasms, a treatment plan must be formulated based on the location, size and biologic behaviour of the lesion

Giant Cell Tumour of the Tendon Sheath is a benign tumour of synovial origin most frequently affecting the upper limb. Up to 11% exhibit radiographic evidence of cortical erosion and intra-osseous expansion. In the upper limb recurrence rates of between 10–50% following excision have been reported. However, GCT-TS is rarely described in the foot and ankle and its behaviour is ill understood. 17 cases of this rarely described tumour in the foot and ankle are presented, describing their clinical presentation, histopathology, treatment and outcome. Analysis of all cases of histopathologically proven GCT-TS of the foot and ankle from the Oxford Tumour Registry, was conducted between the periods of January 1984 to December 1999. 22 cases were identified of which 17 cases had adequate records to allow analysis of patient demographics, duration of symptoms, preoperative investigations, presumed diagnosis, precise site of origin, post operative complications and recurrence rates. The mean age of presentation was 28 (8–53). 10 cases were female and 7 male. 76% cases occurred in the foot, all of which arose adjacent to the phalanges or heads of the metatarsals. 14% occurred in relation to the ankle or sub-talar joint. 82% presented with a painless swelling. The duration of symptoms ranged from 6 months to 8 years. Only one patient complained of sensory symptoms. Pre-operative investigations included radiographs in 64% with 3 cases having an additional MRI scan. The MRI scans of GCT-TS have characteristic changes on T1 and T2 images. The presumed preoperative diagnosis was incorrect in 82%. 36% of radiographs taken showed changes including cortical erosion and speckled calcification. A local excision was performed in 15 cases, an amputation in one and a wide local excision in one case only. There have been no recurrences during the follow up period of between 1–12 years. GCT-TS of foot and ankle is rare and is commonly misdiagnosed. Despite only a local excision being performed in more than 80% of this series there were no recurrences. Plain radiographs may show cortical erosion or speckled calcification in up to 36% and MRI is helpful in further defining the anatomy of the lesion, allowing planned excision and reducing the risk of recurrence

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