A total of 187 patients with primary osteoarthritis (OA) of the knee undergoing total knee replacement (TKR) were randomly divided into two groups, one of which underwent synovectomy. The patients and assessors were blinded to the randomisation both before and after surgery. The duration of surgery, hospitalisation period, concealed bleeding, drainage volume, blood transfusion rate and range of movement of the knee at three days after the operation were analysed. Patients were followed up at four weeks and 12 months after their operation, and a visual analogue score (VAS) for pain, Knee Society score (KSS) and a patellar ballottement test were compared between the groups. The mean amount of concealed bleeding was higher in the synovectomy group compared with the control group (1.24 l (0.08 to 3.28) vs 1.03 l (0.16 to 2.94); p = 0.042), as was the mean drainage volume (0.90 l (0.35 to 1.81) vs 0.81 (0.25 to 1.65); p = 0.030). The mean operating time was also higher in the synovectomy group compared with the controls (1.50 hours (1.34 to 1.75) vs 1.41 hours (1.21 to 1.79); p = 0.006). There were no significant differences in blood transfusion rate (p = 0.882), hospital stay (p = 0.805) or range of movement of the knee (p = 0.413) between the two groups. At four weeks and 12 months post-operatively there were no statistically significant differences in any of the measured parameters. We concluded that synovectomy confers no clinical advantages in TKR for primary OA while subjecting patients to higher levels of bleeding and longer operating times. Cite this article: Bone Joint J 2013;95-B:1197–200

We examined the effects of previous resection of the radial head and synovectomy on the outcome of subsequent total elbow arthroplasty in patients with rheumatoid arthritis. Fifteen elbows with a history of resection and synovectomy were compared with a control group of patients who had elbow arthroplasty with an implant of the same design. The mean age in both groups was 63 years. In the study group, resection of the radial head and synovectomy had been undertaken at a mean of 8.9 years before arthroplasty. The mean radiological follow-up for the 13 available patients in the study group was 5.89 years (0.3 to 11.0) and in the control group was 6.6 years (2.2 to 12.6). There were no revisions in either group. The mean Mayo elbow performance score improved from 29 to 96 in the study group, with similar improvement in the control group (28 to 87). The study group had excellent results in 13 elbows and good results in two. The control group had excellent results in seven and good results in six. Our experience indicates that previous resection of the radial head and synovectomy are not associated with an increased rate of revision following subsequent arthroplasty of the elbow. However, there was a higher rate of complication in the study group compared with the control group

We compared inflammation in the knee after total knee replacement (TKR) for primary osteoarthritis between two groups of patients undergoing joint replacement with and without synovectomy. A total of 67 patients who underwent unilateral TKR were randomly divided into group I, TKR without synovectomy, and group II, TKR with synovectomy. Clinical outcomes, serial serum inflammatory markers (including interleukin-6 (IL-6), CRP and ESR) and the difference in temperature of the skin of the knee, compared with the contralateral side, were sequentially evaluated until 26 weeks after surgery. Pre-operatively, there were no statistically different clinical parameters between groups I and II. At the 26-week follow-up, both groups had a similarly significantly improved American Knee Society clinical score (p < 0.001) and functional score (p < 0.001) with no differences between the groups. Similar changes in serial inflammatory markers were found in both groups, including mean peak levels of IL-6 (189 pg/ml (. sd. 53.4) versus 201 pg/ml (. sd. 49.4) for groups I and II, respectively) and CRP (91 mg/L (. sd. 24.1) versus 88 mg/L (. sd. 23.4), respectively) on the first post-operative day, returning to pre-operative values at two and six weeks, respectively. The mean peak level of ESR for the respective two groups was 46 mm/hr versus 48 mm/hr at two weeks, which had still not returned to its pre-operative mean value at 26 weeks. The elevation in the skin temperature appeared to mirror the peak elevation of the ESR, with a range of 2.5° C to 4.5° C with some reduction at 26 weeks but still exceeding the pre-operative value. We concluded that synovectomy at the time of TKR does not provide any benefit to the clinical outcome or shorten the duration of the inflammatory response after surgery

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

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

1. Synovectomy was carried out in thirty-four knees, of which thirty-one were certainly or probably afflicted by rheumatoid arthritis. 2. Synovectomy was considered only when adequate medical and physical treatment had failed to afford relief. Its purpose is to preserve useful function, and one of the principal factors influencing the decision to operate was the retention of a normal or good radiographic joint space in a persistently painful, warm and swollen knee. 3. Radiographic appearances constituted a useful but not infallible guide to the true state of the articular surfaces. 4. The method of operation, findings and subsequent care are described. 5. Up to two years after operation it appeared that improvement might be related to the state of the articular surfaces, but after two years this relationship was not evident and an attempt to explain this difference has been made. 6. It seems clear that the longer-term results are determined mainly by the course taken by the rheumatoid process. An unfavourable course was associated with considerably less satisfactory results than was a favourable course. 7. It is concluded that in rheumatoid arthritis which has resisted rest and medical treatment synovectomy of the knee is most likely to be successful when the radiographic joint space is good or normal, and when the rheumatoid process follows a favourable course. To undertake the operation at an early stage in the disease is to leave in doubt the outcome, as this is dependent upon the as yet undeclared general course of the disease. Even so, early synovectomy is worth considering when nothing else has given relief. The fact that arthrodesis has only once been necessary after synovectomy appears to justify the policy of salvage described

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

1. Opinion is divided as to the value of synovectomy of the knee in juvenile rheumatoid arthritis. 2. Between 1964 and 1970 thirty synovectomies of the knee were performed in twenty-seven children, who have now been kept under review for one to eight years. Three have required a second operation. 3. The operative findings at various stages are presented and discussed, with special reference to the effect on growth of the limb. 4. Synovectomy is a useful procedure which should be reserved for cases where effusion persists despite nine months of conservative treatment and performed before signs of bone erosion appear

1. The follow-up reports of ninety-one joints affected by rheumatoid arthritis and treated by synovectomy showed that seventy-three joints remained free of pain. Forty-nine out of ninety-one joints retained useful function after a period averaging three and a half years. 2. The average duration of the disease before admission was eight and a half years. 3. The joints causing most distress were selected for operation. Better results might have been obtained if these patients had received constitutional treatment, splintage and synovectomy earlier. Many of these patients had advanced disease which was continuing to advance at the time of their admission, in spite of previous treatment. Many accepted a trial of treatment in a long stay hospital as a last hope. 4. The return of forty-eight out of sixty-two patients to unassisted or nearly unassisted activity and the maintenance of this state in thirty-nine out of fifty-four shows that the success of the pilot scheme conducted in cooperation with Dr W. S. Tegner and Dr R. M. Mason of the London Hospital has been confirmed by further experience

Our experience of five children with chronic thorn synovitis indicates that removal of free thorn fragments and all the macroscopically abnormal synovium is required in order to achieve a complete cure. Four children required total synovectomy for diffuse proliferative synovitis and one needed partial synovectomy of the area immediately around the embedded thorn. Joint washouts and partial synovectomy were unsuccessful in children with diffuse synovitis. Careful review is required following removal of a thorn as fragments may be retained within the joint

The results of thirty synovectomies of the elbow for rheumatoid arthritis are reported. Satisfactory relief of pain was obtained in twenty-seven elbows and the range of movement was improved in twenty-one. The classical operation includes excision of the radial head but in this series approximately half the radial heads were conserved with comparable results. The results of synovectomy do not significantly deteriorate with time up to ten years and the operation can be done with good results, especially in respect of relief of pain, even in elbows with relatively advanced rheumatoid disease. Radiographic assessment is not of much help in evaluating the results of the operation, but is essential in selection of elbows for synovectomy

We analysed the results of arthroscopic synovectomy of the wrist in 18 patients (19 wrists) with rheumatoid arthritis who had not responded to conservative treatment. The patients’ symptoms were assessed using visual analogue scales for pain and satisfaction. Standard posteroanterior radiographs which were taken pre-operatively and at final follow-up were analysed using a modified Larsen scoring system (normal, 0; total destruction, 40). The mean follow-up period was 29.2 months (24 to 45). The mean pre-operative pain score was 8.58 which decreased to 3.58 one year after surgery and increased again to 4.42 at final follow-up. This suggested a gradual increase in pain with time. The mean satisfaction score was 6.26. The mean modified Larsen’s score was 9.8 pre-operatively and 13.9 at final follow-up, which demonstrated the slow progression of degenerative changes. Arthroscopic synovectomy for rheumatoid arthritis of the wrist allows effective pain relief and high patient satisfaction, although any prolonged benefits will require long-term follow-up

1. One hundred and twenty-three patients with rheumatoid arthritis who had synovectomy and excision of the head of the radius performed on 154 elbows have been reviewed one to six years after operation. 2. The severity of the disease process at the time of operation was graded radiologically and an attempt made to relate this to the results. 3. Overall, the clinical results were most satisfactory; more than 70 per cent of the patients were pleased with the outcome. When radiographic deterioration of the joint was taken into account, however, only 54 per cent achieved a "satisfactory" result. 4. Clearance of the synovium through combined medial and lateral incisions gave better results than a lateral approach alone. 5. When the disease was far advanced by the time of operation any good results were likely to be short-lived. 6. The indications for synovectomy of the rheumatoid elbow are discussed in the light of these findings

Little is known of the effects of synovectomy on articular cartilage. In order to investigate this matter, anterior synovectomy of the knee was performed in thirty-five normal adult rabbits and in thirty-five which were given 25 milligrams of hydrocortisone intramuscularly each week afterwards. The animals were killed at intervals from four to 110 days after synovectomy. Histological examination of the regenerating synovium in both groups showed complete structural and functional regeneration by eighty days in the first group and a delay in regeneration in the steroid group. . 35. Sulphur autoradiographs of the articular cartilage of femoral and tibial condyles revealed surface fibrillation and chondrocyte death in 23 per cent of normal knees after eighty days but only 1·8 per cent of knees of animals receiving hydrocortisone. Thus synovectomy in a healthy joint may have an unfavourable effect on the physiology of cartilage by alteration of synovial composition and hyaluronate content in normal joints. Systemically-administered hydrocortisone may reduce this harmful effect in normal cartilage

We reviewed 61 elbow synovectomies in 50 patients with rheumatoid arthritis, with follow-up varying from 4 to 10 years (mean 6.5 years). The results were graded as satisfactory in 70%, with no significant difference in the results between joints which were radiologically good before operation and those which had been destroyed. Longer term results were analysed of 27 elbow synovectomies in 22 patients followed up for over six years. The results were satisfactory in 67% of the patients in both 1981 and in 1987, with no deterioration over this period

We have compared the concentrations of stromal-cell-derived factor-1 (SDF-1), matrix metalloproteinase-1 (MMP-1), MMP-9 and MMP-13 in serum before and after synovectomy or total knee replacement (TKR). We confirmed the presence of SDF-1 and its receptor CXCR4 in the synovium and articular cartilage by immunohistochemistry. We established chondrocytes by using mutant CXCR4 to block the release of MMPs. The level of SDF-1 was decreased 5.1- and 6.7-fold in the serum of patients with OA and RA respectively, after synovectomy compared with that before surgery. MMP-9 and MMP-13 were decreased in patients with OA and RA after synovectomy. We detected SDF-1 in the synovium and the bone marrow but not in cartilage. CXCR4 was detected in articular cartilage. SDF-1 increased the release of MMP-9 and MMP-13 from chondrocytes in a dose-dependent manner. The mutant CXCR4 blocked the release of MMP-9 and MMP-13 from chondrocytes by retrovirus vector. Synovectomy is effective in patients with OA or RA because SDF-1, which can regulate the release of MMP-9 and MMP-13 from articular chondrocytes for breakdown of cartilage, is removed by the operation

Subtotal synovectomy was performed in the knee joints of New Zealand white rabbits. The changes noted in the articular cartilage as manifest by decreased metachromatic staining of the matrix were considered to indicate matrix degradation caused by the altered joint environment. The documentation of the enzyme changes suggests that the histological alteration in the articular cartilage noted after synovectomy may be mediated through the activation of endogenous chondrocyte lysozomal enzymes, particularly cathepsin and acid hydrolases

1. . 133. Xe clearance rates as a measure of blood flow were determined in the knees oftwo groups of patients. 2. In the first group eight patients with rheumatoid arthritis were studied before, three months after and one year after synovectomy. Blood flow values were significantly lower three months after operation but the values recorded one year after operation did not differ significantly from those before operation. 3. In the second group (twenty-one patients with rheumatoid arthritis) blood flow values were determined two to three years after synovectomy. The values obtained differed from those obtained in normal joints and fell within the range of values obtained in forty-three patients with rheumatoid arthritis who did not have synovectomy

1. Synovectomy of the elbow affected by rheumatoid arthritis is a worthwhile procedure even in the presence of advanced radiological changes. 2. Relief of pain is good (93 per cent) and movement is retained (87 per cent). 3. Although the follow-up in this series was short, averaging nineteen months, the results seem to be maintained. 4. Good access to the joint may be had through medial and lateral incisions, and division of the olecranon is unnecessary. A lateral incision alone is not recommended. 5. The ulnar nerve should be preserved during dissection. Anterior transposition is needed only if there are neurological symptoms before operation

1. The results of synovectomy of the knee in eighty-five patients with rheumatoid arthritis are presented. 2. When reviewed between five and nine years after operation 55 per cent of 122 knees still had improvement in pain. 3. Only 31 per cent of knees lost movement. 4. Recurrence of symptoms in nearly all cases was related to the recurrence of active rheumatoid synovitis. 5. Recurrence of symptoms was a little less likely when the generalised disease improved, when the Rose-Waaler test was negative, when only one knee was involved and when the operation had been carried out within three years of the onset of disease in that knee

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

We carried out a survival analysis of elbow synovectomy (ES) and excision of the radial head (RHE) performed on 171 rheumatoid elbows. The failure criteria were revision surgery (performed or desired) and/or the presence of significant or severe pain. The cumulative survival was 81% at one year which thereafter decreased by an average of 2.6% per year. The strongest predictor for success was a low preoperative range of supination-pronation when corresponding survival curves were compared. A low range of flexion-extension also predicted failure. Combining both factors gave better prediction (failure: 6.3% v 67%), but a long duration of elbow symptoms before surgery predicted failure (72%, p = 0.04). At review, there was a mean gain of 50° in supination-pronation and 11° in flexion-extension; both correlated with success. Failure correlated with recurrence of synovitis, elbow instability, ulnar neuropathy, poor general mobility and poor upper-limb function. The last was independently affected by the severity of RA in the ipsilateral shoulder. Our findings show that although the short-term result of ES and RHE in rheumatoid arthritis is good, the long-term outcome is poor except in a subgroup with more than 50% limitation of forearm rotation

The infrequency of serious cartilage destruction in the joints of children makes it probable that the majority will recover with antibiotic and constitutional treatment alone, especially if a joint biopsy is performed. Synovectomy for children should therefore be reserved for those whose knees remain swollen and warm, even after antibiotic therapy, or whose range of movement does not show signs of returning. Exploration of such joints may show that pannus is wholly or partly covering the cartilage and that it is soft and pitted. Removal of the pannus allows better nutrition of the cartilage. The number of children who require arthrodesis in the future should be very small. Adults who respond well to antibiotic and constitutional treatment may also recover without surgery, except biopsy, but for patients with more severe disease the need for an alternative to arthrodesis exists. The choice between synovectomy–better called joint clearance –can often only be made after the joint has been opened. The choice between the two operations has always been fully discussed with the patient before the operation. The results enumerated in this paper suggest that arthrodesis may only need to be performed for patients with severe disease, often involving the bony articular surfaces, and that joints may recover function even when there has been partial destruction of cartilage

1. In twenty-five patients with rheumatoid arthritis of the knee examined by contrast arthrography certain typical features were encountered. These consisted of enlargement of the suprapatellar pouch and loss of the normally smooth outline of the joint cavity because of nodular filling defects. In some cases less definite filling defects were seen, due to loose fibrinous deposits, particularly in popliteal cysts. 2. This method of assessment of the results of synovectomy of the knee correlated well with the clinical findings. The more satisfactory the clinical result the more normal the arthrograph. Patients who had recurrence of pain, swelling and tenderness in the knee showed arthrographic findings similar to those before operation

We report 60 synovectomies of the knee in 51 children with juvenile chronic arthritis. Synovitis had been present for an average of 5 years and the average age at operation was 13 years. Results were evaluated in terms of pain, knee movement, relapse of synovitis and radiological change during a follow-up averaging 7.5 years. The relief of pain was rewarding and there was a slight postoperative gain in range of knee movement in most cases. The older the patient at onset of disease, the greater the risk of pain during follow-up. Progressive joint destruction was more common in younger patients, those with systemic or polyarticular disease, and those with highly active disease at the time of operation. Recurrence of synovitis was more frequent in patients who had their operation in a phase of high disease activity; this occurred most often in patients with polyarticular disease

We retrospectively identified 18 consecutive patients with synovial chrondromatosis of the shoulder who had arthroscopic treatment between 1989 and 2004. Of these, 15 were available for review at a mean follow-up of 5.3 years (2.3 to 16.5). There were seven patients with primary synovial chondromatosis, but for the remainder, the condition was a result of secondary causes. The mean Constant score showed that pain and activities of daily living were the most affected categories, being only 57% and 65% of the values of the normal side. Surgery resulted in a significant improvement in the mean Constant score in these domains from 8.9 (4 to 15) to 11.3 (2 to 15) and from 12.9 (5 to 20) to 18.7 (11 to 20), respectively (unpaired t-test, p = 0.04 and p < 0.0001, respectively). Movement and strength were not significantly affected. Osteoarthritis was present in eight patients at presentation and in 11 at the final review. Recurrence of the disease with new loose bodies occurred in two patients from the primary group at an interval of three and 12 years post-operatively. In nine patients, loose bodies were also present in the bicipital groove; seven of these underwent an open bicipital debridement and tenodesis.

We found that arthroscopic debridement of the glenohumeral joint and open debridement and tenodesis of the long head of biceps, when indicated, are safe and effective in relieving symptoms at medium-term review.

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.

1. Experience in the treatment of tuberculous disease of the spine, hip and knee by combined constitutional, antibiotic and operative measures is described.

2. In patients with tuberculosis of the spine, especially in the thoracic region and when perispinal abscess formation is a prominent feature, the treatment helps to ensure stable ankylosis in the type of case in which it otherwise might not occur.

3. In children with tuberculosis of the hip and in adults and children with tuberculosis of the knee it is usually possible to save the joint and to restore function, provided the joint has not been destroyed before treatment is begun.

The records of these patients show that restitution of joint function is quite possible even after severe disease. These results have been obtained by a combination of three methods, constitutional, antibiotic and operative. The duration of treatment averaged ten months and the patients were discharged to full activities in a short time without splints. There was one immediate failure in a child who received full, early and adequate treatment. There were two late relapses in patients treated early in the series whose operation was inadequate. The results were more variable in adults. If it is conceded that the triple treatment is valuable for patients with bone necrosis or severe synovial disease with pus in the joint, eight patients in this series remain who might have got better without operation. Two of these had had a synovial biopsy before admission. Whether the remaining six would have done as well without operation is a matter for speculation. It is difficult to assess the condition inside the joint solely by radiographic examination. Cauchoix (1955) allows me to say that, at the Institut Calot, Berck Plage, he has used similar methods to those reported in this paper, and that he endorses my belief that good results can be obtained by them. He does not, however, open the joint when operating upon an iliac focus, and for patients with purely synovial disease he prefers repeated intra-articular injections of streptomycin to operation. For my part, I consider that a simple arthrotomy at the beginning of treatment is less disturbing, and that, even if it is only done for diagnosis, it may be of therapeutic benefit. To me it seems unjustifiable to delay intra-articular operation for a patient whose hip disease is not manifestly resolving: operation is especially indicated for patients who have necrotic bone lesions.

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

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

Aims. Intra-articular . 90. Yttrium (. 90. Y) 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 . 90. Yttrium. Patients and Methods. All patients with dtTGCT of the knee who underwent synovectomy between 1991 and 2014 were included in the study. Group A patients underwent synovectomy and an intra-articular injection of . 90. Yttrium between six and eight weeks after surgery. Group B patients underwent surgery alone. Results. There were 34 patients in group A and 22 in group B. Recurrence of dtTGCT was identified by MRI, which was undertaken in patients with further symptoms. At a mean follow-up of 7.3 years (2.5 to 25.4), there was residual disease in 15 patients in group A and 11 in group B (p < 0.363). The mean Musculoskeletal Tumor Society (MSTS) score at final follow-up was 85% and 83%, respectively (p < 0.91). Conclusion. There were no significant differences in outcome between patients treated surgically for dtTGCT of the knee with or without an adjuvant intra-articular injection of . 90. Yttrium. We were unable to provide conclusive evidence of any benefits derived from the adjuvant treatment. Cite this article: Bone Joint J 2018;100-B:984–8

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

A key to the success of revision total knee arthroplasty (TKA) is a safe surgical approach using an exposure that minimises complications. In most patients, a medial parapatellar arthrotomy with complete synovectomy is sufficient. If additional exposure is needed, a quadriceps snip performed through the quadriceps tendon often provides the additional exposure required. It is simple to perform and does not alter the post-operative rehabilitative protocol. In rare cases, in which additional exposure is needed, or when removal of a cemented long-stemmed tibial component is required, a tibial tubercle osteotomy (TTO) may be used. Given the risk of post-operative extensor lag, a V-Y quadricepsplasty is rarely indicated and usually considered only if TTO is not possible. . Cite this article: Bone Joint J 2016;98-B(1 Suppl A):113–15

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.

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A conventional arthroscopic capsuloligamentous repair is a reliable surgical solution in most patients with scapholunate instability. However, this repair does not seem to be sufficient for more advanced injuries. The aim of this study was to evaluate the functional results of a wide arthroscopic dorsal capsuloligamentous repair (WADCLR) in the management of severe scapholunate instability.

Two-stage exchange remains the gold standard for treatment of peri-prosthetic joint infection after total hip replacement (THR). In the first stage, all components and associated cement if present are removed, an aggressive debridement is undertaken including a complete synovectomy, and an antibiotic-loaded cement spacer is put in place. Patients are then treated with six weeks of parenteral antibiotics, followed by an ‘antibiotic free period’ to help ensure the infection has been eradicated. If the clinical evaluation and serum inflammatory markers suggest the infection has resolved, then the second stage can be completed, which involves removal of the cement spacer, repeat debridement, and placement of a new THR. Cite this article: Bone Joint J 2013;95-B, Supple A:84–7

1. Anterior synovectomy was undertaken in sixteen knees of fourteen patients with rheumatoid arthritis associated with popliteal or calf cysts. Subsequent changes in the knees and cysts were observed clinically and by arthrography. 2. In all instances there was alleviation of symptoms and in fourteen cases the cysts disappeared. 3. It is suggested that anterior synovectomy is the logical treatment of a posterior cyst associated with rheumatoid arthritis of the knee

The morphological changes in bone and articular cartilage destruction have been described in sixteen consecutive cases of rheumatoid arthritis in which biopsy material was obtained during synovectomy of the knee. The following observations were made. 1. Bone and cartilage is replaced by fibrous granulation tissue which proliferates from periosteal and perichondrial fibroblasts. 2. These proliferative changes are distinct from the chronic synovitis of rheumatoid disease, but a chronic synovitis is necessary for them to appear. 3. Synovectomy does not remove the cells replacing bone and cartilage but its performance in some ways leads to their regression

1. Osmium tetroxide and nitrogen mustard were injected into normal adult rabbit joints. Within one week widespread chondrocyte necrosis had occurred as evidenced by electron microscopic examination and radioactive proline uptake autoradiography. 2. Initially, the cartilage matrix was intact but three to seven months later the cartilage surface began to disintegrate. 3. These studies indicate that osmium tetroxide and nitrogen mustard are unsuitable agents for chemical synovectomy. 4. They also indicate that there may be a long latent period between cartilage cell death and cartilage destruction, and that the evaluation of any agent for chemical synovectomy must take this into consideration

The June 2024 Oncology Roundup³⁶⁰ looks at: Chondrosarcoma of the femur: is local recurrence influenced by the presence of an extraosseous component?; Diagnostic challenges in low-grade central osteosarcoma; Single osteotomy technique for frozen autograft (pedicled freezing) in patients with malignant bone tumours; Unplanned resection for small superficial soft-tissue sarcomas: disastrous or simply bad?; Inactivation and replantation of the knee joint: an infeasible surgical method; Active surveillance of diffuse-type tenosynovial giant cell tumours: a retrospective, multicentre cohort study.

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The aim of this study was to evaluate medium- to long-term outcomes and complications of the Stanmore Modular Individualised Lower Extremity System (SMILES) rotating hinge implant in revision total knee arthroplasty (rTKA) at a tertiary unit. It is hypothesized that this fully cemented construct leads to satisfactory clinical outcomes.

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The use of cementless total knee arthroplasty (TKA) components has increased during the past decade. The initial design of cementless metal-backed patellar components had shown high failure rates due to many factors. The aim of this study was to evaluate the clinical results of a second-generation cementless, metal-backed patellar component of a modern design.

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Wrist arthroscopy is a standard procedure in hand surgery for diagnosis and treatment of wrist injuries. Even though not generally recommended for similar procedures, general administration of perioperative antibiotic prophylaxis (PAP) is still widely used in wrist arthroscopy.

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Pelvic discontinuity is a challenging acetabular defect without a consensus on surgical management. Cup-cage reconstruction is an increasingly used treatment strategy. The present study evaluated implant survival, clinical and radiological outcomes, and complications associated with the cup-cage construct.

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As an alternative to external fixators, intramedullary lengthening nails (ILNs) can be employed for distraction osteogenesis. While previous studies have demonstrated that typical complications of external devices, such as soft-tissue tethering, and pin site infection can be avoided with ILNs, there is a lack of studies that exclusively investigated tibial distraction osteogenesis with motorized ILNs inserted via an antegrade approach.

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The optimal bearing surface design for medial unicompartmental knee arthroplasty (UKA) remains controversial. The aim of this study was to compare outcomes of fixed-bearing (FB) and mobile-bearing (MB) UKAs from a single high-volume institution.

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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).

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Metal and ceramic humeral head bearing surfaces are available choices in anatomical shoulder arthroplasties. Wear studies have shown superior performance of ceramic heads, however comparison of clinical outcomes according to bearing surface in total shoulder arthroplasty (TSA) and hemiarthroplasty (HA) is limited. This study aimed to compare the rates of revision and reoperation following metal and ceramic humeral head TSA and HA using data from the National Joint Registry (NJR), which collects data from England, Wales, Northern Ireland, Isle of Man and the States of Guernsey.