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

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

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

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

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

We describe a case of highly refractory synovial chondromatosis, which recurred despite four arthroscopic synovectomies, a chemical synovectomy, two open synovectomies and an arthrodesis. A review of the literature revealed one similar case. Both presented with marked joint stiffness suggesting a poor prognosis. Although arthrodesis may relieve short-term symptoms it does not prevent further recurrence of disease

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

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

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

The short-term assessment of 14 arthroscopic synovectomies of the elbow in 11 patients with rheumatoid arthritis showed that 93% achieved a short-term rating of excellent or good on the Mayo Elbow Performance Score. At the most recent assessment at an average of 42 months, however, only 57% maintained excellent or good results; four had required total elbow replacement. Although rehabilitation is facilitated by an arthroscopic procedure the results deteriorate more rapidly than after open synovectomy. This may be due to the limitations of the arthroscopic technique and is consistent with experience of the similar procedure in the knee. Recognition of the short-term gain and the potential for serious nerve injury should be considered when offering arthroscopic synovectomy

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.

A 12 year old girl presented with a history of intermittent pain in her left knee since she started walking. She was seen in the vascular clinic due to engorged veins in her left leg and was diagnosis of Klippel-Trenaunay syndrome was made. Her knee pain worsened and an orthopaedic opinion was obtained. A history of repeated knee effusion and swelling was noted. Examination revealed partial gigantism of the left leg and reduced range of motion of the knee. There was soft tissue swelling of the knee with no effusion. Blood investigations were normal. X-rays showed an arthritic joint. MRI scans revealed synovial thickening and a vascular malformation suggesting a synovial haemangioma. She underwent Radical Open Synovectomy and excision of the haemangioma. Blood loss was minimal. Extensive haemosiderin deposition was noted along with Grade IV arthritic changes. Postoperative recovery was uneventful. Surgeons have been reluctant to excise synovial hemangiomas due to the risk of haemorrhage. A recent paper from Switzerland suggested excision was possible with minimal blood loss. Haemosiderin deposition due to recurrent haemarthrosis may predispose to articular damage. We recommend early excision of synovial haemangiomas to minimise articular damage

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

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

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: 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

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

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

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).