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

There are concerns regarding complications and longevity of total elbow arthroplasty (TEA) in young patients, and the few previous publications are mainly limited to reports on linked elbow devices. We investigated the clinical outcome of unlinked TEA for patients aged less than 50 years with rheumatoid arthritis (RA).

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

Aims

The aim of this study was to assess orthopaedic oncologic patient morbidity resulting from COVID-19 related institutional delays and surgical shutdowns during the first wave of the pandemic in New York, USA.

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 evaluate health-related quality of life (HRQoL) and joint function in tenosynovial giant cell tumour (TGCT) patients before and after surgical treatment.

Aims

Intra-articular ⁹⁰Yttrium (⁹⁰Y) is an adjunct to surgical treatment by synovectomy for patients with diffuse-type tenosynovial giant-cell tumour (dtTGCT) of the knee, with variable success rates. Clinical information is, however, sparse and its value remains unclear. We investigated the long-term outcome of patients who underwent synovectomy with and without adjuvant treatment with ⁹⁰Yttrium.

Aims

Approved by the Food and Drug Administration in 2004, the Phase III Oxford Medial Partial Knee is used to treat anteromedial osteoarthritis (AMOA) in patients with an intact anterior cruciate ligament. This unicompartmental knee arthroplasty (UKA) is relatively new in the United States, and therefore long-term American results are lacking.

The August 2015 Oncology Roundup³⁶⁰ looks at: Glasgow prognostic score in soft-tissue sarcoma; Denosumab in giant cell tumour; Timing, complications and radiotherapy; Pigmented villonodular synovitis and arthroscopy; PATHFx: estimating survival in pathological cancer; Prosthetic lengthening of short stumps; Chondrosarcoma and pathological fracture

Pigmented villonodular synovitis (PVNS) is a rare proliferative process of the synovium which most commonly affects the knee and occurs in either a localised (LPVNS) or a diffuse form (DPVNS). The effect of different methods of surgical synovectomy and adjuvant radiotherapy on the rate of recurrence is unclear. We conducted a systematic review and identified 35 observational studies in English which reported the use of surgical synovectomy to treat PVNS of the knee. A meta-analysis included 630 patients, 137 (21.8%) of whom had a recurrence after synovectomy. For patients with DPVNS, low-quality evidence found that the rate of recurrence was reduced by both open synovectomy (odds ration (OR) = 0.47; 95% CI 0.25 to 0.90; p = 0.024) and combined open and arthroscopic synovectomy (OR = 0.19, 95% CI = 0.06 to 0.58; p = 0.003) compared with arthroscopic surgery. Very low-quality evidence found that the rate of recurrence of DPVNS was reduced by peri-operative radiotherapy (OR = 0.31, 95% CI 0.14 to 0.70; p = 0.01). Very low-quality evidence suggested that the rate of recurrence of LPVNS was not related to the surgical approach. . This meta-analysis suggests that open synovectomy or synovectomy combined with peri-operative radiotherapy for DPVNS is associated with a reduced rate of recurrence. Large long-term prospective multicentre observational studies, with a focus on both rate of recurrence and function, are required to confirm these findings. Cite this article: Bone Joint J 2015;97-B:550–7

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.

We retrospectively reviewed 30 patients with a diffuse-type giant-cell tumour (Dt-GCT) (previously known as pigmented villonodular synovitis) around the knee in order to assess the influence of the type of surgery on the functional outcome and quality of life (QOL). Between 1980 and 2001, 15 of these tumours had been treated primarily at our tertiary referral centre and 15 had been referred from elsewhere with recurrent lesions. The mean follow-up was 64 months (24 to 393). Functional outcome and QOL were assessed with range of movement and the Knee injury and Osteoarthritis Outcome Score (KOOS), the Musculoskeletal Tumour Society (MSTS) score, the Toronto Extremity Salvage Score (TESS) and the SF-36 questionnaire. There was recurrence in four of 14 patients treated initially by open synovectomy. Local control was achieved after a second operation in 13 of 14 (93%). Recurrence occurred in 15 of 16 patients treated initially by arthroscopic synovectomy. These patients underwent a mean of 1.8 arthroscopies (one to eight) before open synovectomy. This achieved local control in 8 of 15 (53%) after the first synovectomy and in 12 of 15 (80%) after two. The functional outcome and QOL of patients who had undergone primary arthroscopic synovectomy and its attendant subsequent surgical procedures were compared with those who had had a primary open synovectomy using the following measures: range of movement (114º versus 127º; p = 0.03); KOOS (48 versus 71; p = 0.003); MSTS (19 versus 24; p = 0.02); TESS (75 versus 86; p = 0.03); and SF-36 (62 versus 80; p = 0.01). Those who had undergone open synovectomy needed fewer subsequent operations. Most patients who had been referred with a recurrence had undergone an initial arthroscopic synovectomy followed by multiple further synovectomies. At the final follow-up of eight years (2 to 32), these patients had impaired function and QOL compared with those who had undergone open synovectomy initially. We conclude that the natural history of Dt-GCT in patients who are treated by arthroscopic synovectomy has an unfavourable outcome, and that primary open synovectomy should be undertaken to prevent recurrence or residual disease. Cite this article: Bone Joint J 2014; 96-B:1111–18

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.

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

We investigated the clinical response to arthroscopic synovectomy in patients with undifferentiated chronic monoarthritis (UCMA) of the wrist. Arthroscopic synovectomy was performed on 20 wrists in 20 patients with UCMA of the wrist who had not responded to non-steroidal anti-inflammatory drugs. The mean duration of symptoms at the time of surgery was 4.3 months (3 to 7) and the mean follow-up was 51.8 months (24 to 94). Inflamed synovium was completely removed from the radiocarpal, midcarpal and distal radioulnar joints using more portals than normal. After surgery, nine patients had early remission of synovitis and 11 with uncontrolled synovitis received antirheumatic medication. Overall, there was significant improvement in terms of pain relief, range of movement and Mayo score. Radiological deterioration was seen in five patients who were diagnosed as having rheumatoid arthritis during the follow-up period. Lymphoid follicles and severe lymphocyte infiltration were seen more often in synovial biopsies from patients with uncontrolled synovitis.

These results suggest that arthroscopic synovectomy provides pain relief and functional improvement, and allows rapid resolution of synovitis in about half of patients with UCMA of the wrist.

Purpose: Pigmented Villonodular Synovitis (PVNS) is an uncommon presentation characterised by hyperplastic synovium, bloody effusions and bone erosions. Incompletely resected localised and diffuse lesions have a high recurrence rate. The management of recurrent lesions depends on the expertise of the surgeon and severity of the lesion. The imaging characteristics of PVNS and experience of British knee surgeons in managing these lesions is presented in our study. Methods: A postal questionnaire was sent to 100 knee surgeons of the British Association of Surgeons of the Knee (BASK) with questions relating to their experience in managing localised and recurrent PVNS. The options included either arthroscopic or open synovectomy with or without radiotherapy, radical excision or referral. Results: 74 responses were included in the study. 73 out of the total cohort of 74 surgeons (98.7%) had seen less than 5 presentations in their career. Localised lesions were treated primarily by arthroscopic synovectomy [N=58(78.4%)] or open synovectomy [N=12(16.2%)] with radiotherapy being utilised in 4 lesions (5.4%). For local recurrence the management was arthroscopic [N=26(35.1%)] and open [N= 19(25.7%)] synovectomy. Radiotherapy was used in 18 (24.3%) of patients with localised recurrence and 8 (10.8%) of were referred to specialist units. Infiltrating lesions were treated with open synovectomy and radiotherapy [N=22(29.7%)] and 20 cases [27.02%] were referred to specialist units. Imaging of PVNS and Conclusions: The role of imaging is invaluable in early diagnosis and treatment due to limited experience in managing such presentations. Routine radiography and Computerised Axial Tomography (CT scan) often demonstrate non-marginal pressure erosions with sclerotic margins as well as nodular soft tissue masses. Sonography shows non-specific focal or nodular synovial thickening with increased flow on colour doppler. Magnetic Resonance imaging characteristics of PVNS are nodular, synovial masses which are low signal on T1-weighted and T2-weighted imaging

Introduction: PVNS is a benign proliferative disorder of the synovium presenting as local or diffuse variants. The condition commonly involves the knee with a slow and indolent progress. Case series:. Presented with anterior knee pain. Examination revealed supra-patellar fullness and tenderness. MRI scan showed a suspicious soft tissue tumour. Histology confirmed PVNS after excision biopsy. Presented with medial knee pain, most pronounced after exercise. McMurray test was positive for a meniscal tear. MRI confirmed meniscal tear and additional localised PVNS. The patient underwent repair of the meniscal injury but continued to complain of pain. Following excision of PVNS there was marked improvement in the patients’ symptoms. Presented as massive soft tissue swelling of the right knee. Past medical history included a diagnosis of tuberculosis and fibrosarcoma on the knee. She was referred to our centre following two diagnoses, three surgeries and a supracondylar femoral fracture. The patient was previously advised an above knee amputation which she refused. A repeat biopsy with immunohistochemistry studies at our unit confirmed the diagnosis of a PVNS. Patient is awaiting a total knee replacement with subtotal synovectomy. Presented with swollen right knee, pain and restriction of movement. MRI scan suggested a diagnosis of PVNS. The patient underwent subtotal synovectomy and histology confirmed this to be PVNS. Subsequently the patient had two recurrences, the first at 2 years and later at 4 years from initial surgery. Repeat MRI scan showed extensive third recurrence. The patient is awaiting a further open synovectomy, followed by low dose radiotherapy. Conclusion: This case series aims to highlight the complexities in diagnosing PVNS. It should be a differential diagnosis of any kind of soft tissue problem especially around the knee. Immunohistochemistry may be useful. Multiple recurrences is a problem; adjuvant therapy may be indicated in resistant cases

The management of patients with a painful total knee replacement requires careful assessment and a stepwise approach in order to diagnose the underlying pathology accurately. The management should include a multidisciplinary approach to the patient’s pain as well as addressing the underlying aetiology. Pain should be treated with appropriate analgesia, according to the analgesic ladder of the World Health Organisation. Special measures should be taken to identify and to treat any neuropathic pain. There are a number of intrinsic and extrinsic causes of a painful knee replacement which should be identified and treated early. Patients with unexplained pain and without any recognised pathology should be treated conservatively since they may improve over a period of time and rarely do so after a revision operation.

Purpose of the study: The purpose of this retrospective study was to analyze clinical datao n pigmented villon-odular synovitis (PVSN) of the knee as well as outcome after treatment in order to define the diagnostic stages, the surgical treatment, and follow-up modalities for this rare benign proliferative disease of the synovial which predominantly affects the knee joint. Material and methods: Between 1996 and 2004, 28 patients were managed in our department, 13 men and 15 women, diffuse PVNS in 20 and localized PVNS in 8. IN the localized forms, symptoms were similar to those observed in knees with intra-articular foreign bodies or a meniscal lesion (75%) was present for 14 months on average at the first consultation. Mean age at onset of therapeutic management was 40 years (range 20–62). Localized arthroscopic or open resection was performed. For the diffuse forms, symptoms had been present for 15 months on average at the first consultation. Patients sought medical care because of spontaneous hemarthrosis or diffuse knee pain with no specific signs. Mean age at onset of therapeutic management was 38 years (range 15–59). Bony lesions were observed in 20%. Synoviorthesis or surgical synovectomy were performed. Mean follow-up was 97 months (range 12–309). Outcome was analyzed separately for the localized and diffuse forms. Results: For the localized PVNS, there were no complications after surgical treatment but the relapse rate reached 12.5%. For diffuse PVNS, the cumulative rate of relapse was 50%, recurrence being noted on average 37 months after treatment. A stiff joint developed in 14% after open synovectomy. Surgical treatment was necessary in four cases (total arthroplasty in three) seen late after development of bony lesions; the clinical outcome was good with good gain in flexion. Discussion: MRI is essential for the topographic diagnosis and to guide surgery. For diffuse PVNS seen at an advanced stage or after several recurrences, adjuvant synoviorthesis can be useful 4 to 8 months after surgery. Conclusion: Appropriate treatment of PVNS of the knee depends on the presentation but usually involves a surgical procedure. The risk of recurrence for diffuse PVNS warrants annual MRI for four years