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Hand Clinics Nov 2017This article describes the authors' experience with, and recent advancement in, the techniques that have allowed the development of many new arthroscopic procedures in... (Review)
Review
This article describes the authors' experience with, and recent advancement in, the techniques that have allowed the development of many new arthroscopic procedures in the finger joints. It also describes the role and techniques of arthroscopy in small finger joints. Because the intra-articular anatomy of the first to the fifth metacarpophalangeal (MCP) joints is similar, this article discusses the hand MCP joints without distinguishing thumb from fingers.
Topics: Arthralgia; Arthritis; Arthroscopy; Finger Joint; Fractures, Bone; Humans; Joint Instability; Ligaments, Articular; Patient Positioning; Postoperative Complications; Synovectomy
PubMed: 28991592
DOI: 10.1016/j.hcl.2017.07.018 -
Arthroscopy Techniques Apr 2021Primary synovial chondromatosis is characterized by newly formed chondral or osteochondral nodules in the synovial membrane, which may detach and form loose bodies. The...
Primary synovial chondromatosis is characterized by newly formed chondral or osteochondral nodules in the synovial membrane, which may detach and form loose bodies. The loose bodies can be calcified or ossified, and the condition is termed synovial osteochondromatosis. Three distinct stages can be identified in primary synovial chondromatosis : phase I is active synovitis without loose bodies, phase II shows nodular synovitis along with loose bodies, and phase III is characterized by the presence of loose bodies with the resolution of synovitis. Surgical treatment has been recommended as the first choice of therapy in phases II and III disease. Complete synovectomy and removal of all loose bodies is advisable for prevention of recurrence of the disease. In this technical note, the technical details of arthroscopic removal of loose bodies and synovectomy for the management of synovial osteochondromatosis of the elbow is described. Compared with open procedures, the arthroscopic approach has many advantages, including a shorter rehabilitation period and higher patient satisfaction.
PubMed: 33981557
DOI: 10.1016/j.eats.2020.12.009 -
Der Orthopade Nov 2018The introduction of biologics has led to a great improvement in the treatment options for inflammatory rheumatic diseases. Nevertheless, surgical interventions are... (Review)
Review
The introduction of biologics has led to a great improvement in the treatment options for inflammatory rheumatic diseases. Nevertheless, surgical interventions are still necessary in many patients but a change in surgical indications could be observed. The previously predominant synovectomy of inflamed rheumatic joints is now reduced to a few so-called rebellious joints with persistent inflammation. Joint-preservation and tenoplasty are standard surgical procedures requiring a specific approach including potential complications. The basic immunosuppressive medication has to be considered for all rheumatological interventions. Recommendations extensively evaluate the risk profile of immunosuppressants. The available clinical data are difficult to assess and incomplete. Advances in modern joint replacement procedures have increased the quality of life of patients. Compared to degenerative osteoarthritis, patients with rheumatism tend to present at a lower age, with poorer bone quality and have an increased risk for bacterial joint infections. In cases of a multilocular rheumatoid manifestation including all joints of the extremities, joint replacement specifics need to be taken into account. In patients with rheumatic diseases the mechanical stability of joint replacements, revision options, potential risk of joint infections and periprosthetic fractures vary sometimes considerably from patients with degenerative osteoarthritis. Missing clinical signs of joint infection despite a life-threatening, possibly multilocular dissemination of the disease due to immunosuppressants represents a particular challenge with respect to the diagnostics and treatment. The confusion of this with a rheumatic exacerbation might lead to general septicemia with a high mortality.
Topics: Arthroplasty, Replacement; Humans; Orthopedics; Quality of Life; Rheumatology; Synovectomy
PubMed: 30327820
DOI: 10.1007/s00132-018-3648-y -
Arthroscopy Techniques Nov 2022The current treatment of choice for diffuse-type pigmented villonodular synovitis (PVNS) is surgical excision. Complete synovectomy is necessary because of the local...
The current treatment of choice for diffuse-type pigmented villonodular synovitis (PVNS) is surgical excision. Complete synovectomy is necessary because of the local aggressiveness of the disease, with a significant recurrence rate and a minor chance of malignant transformation. The recurrence rate is even greater in those cases with extra-articular extension. Arthroscopic and endoscopic synovectomy have the advantage of avoidance of extensive soft-tissue dissection, which is associated with open synovectomy. The purpose of this Technical Note is to describe the details of combined arthroscopic and endoscopic synovectomy as treatment for diffuse PVNS of the ankle. By a combination of different arthroscopic and endoscopic approaches of the ankle region, a complete synovectomy of both intra-articular and extra-articular components of diffuse-type PVNS is feasible.
PubMed: 36457390
DOI: 10.1016/j.eats.2022.08.001 -
Clinical Orthopaedics and Related... Dec 2023Diffuse-type tenosynovial giant-cell tumor (D-TGCT), formerly known as pigmented villonodular synovitis, is a rare, locally aggressive, invasive soft tissue tumor that...
What Are the Recurrence Rates, Complications, and Functional Outcomes After Multiportal Arthroscopic Synovectomy for Patients With Knee Diffuse-type Tenosynovial Giant-cell Tumors?
BACKGROUND
Diffuse-type tenosynovial giant-cell tumor (D-TGCT), formerly known as pigmented villonodular synovitis, is a rare, locally aggressive, invasive soft tissue tumor that primarily occurs in the knee. Surgical excision is the main treatment option, but there is a high recurrence rate. Arthroscopic surgical techniques are emphasized because they are less traumatic and offer faster postoperative recovery, but detailed reports on arthroscopic techniques and outcomes of D-TGCT in large cohorts are still lacking.
QUESTIONS/PURPOSES
(1) What is the recurrence rate of knee D-TGCT after multiportal arthroscopic synovectomy? (2) What are the complications, knee ROM, pain score, and patient-reported outcomes for patients, and do they differ between patients with and without recurrence? (3) What factors are associated with recurrence after arthroscopic treatment in patients with D-TGCT?
METHODS
In this single-center, retrospective study conducted between January 2010 and April 2021, we treated 295 patients with knee D-TGCTs. We considered patients undergoing initial surgical treatment with multiportal arthroscopic synovectomy as potentially eligible. Based on that, 27% (81 of 295) of patients were excluded because of recurrence after synovectomy performed at another institution. Of the 214 patients who met the inclusion criteria, 17% (36 of 214) were lost to follow-up, leaving 83% (178 of 214) of patients in the analysis. Twenty-eight percent (50 of 178) of patients were men and 72% (128 of 178) were women, with a median (range) age of 36 years (7 to 69). The median follow-up duration was 80 months (26 to 149). All patients underwent multiportal (anterior and posterior approaches) arthroscopic synovectomy, and all surgical protocols were determined by discussion among four surgeons after preoperative MRI. A combined open posterior incision was used for patients with lesions that invaded or surrounded the blood vessels and nerves or invaded the muscle space extraarticularly. Standard postoperative adjuvant radiotherapy was recommended for all patients with D-TGCT who had extraarticular and posterior compartment invasion; for patients with only anterior compartment invasion, radiotherapy was recommended for severe cases as assessed by the surgeons and radiologists based on preoperative MRI and intraoperative descriptions. Postoperative recurrence at 5 years was calculated using a Kaplan-Meier survivorship estimator. The WOMAC score (0 to 96, with higher scores representing a worse outcome; minimum clinically important difference [MCID] 8.5), the Lysholm knee score (0 to 100, with higher scores being better knee function; MCID 25.4), the VAS for pain (0 to 10, with higher scores representing more pain; MCID 2.46), and knee ROM were used to evaluate functional outcomes. Because we did not have preoperative patient-reported outcomes scores, we present data on the proportion of patients who achieved the patient-acceptable symptom state (PASS) for each of those outcome metrics, which were 14.6 of 96 points on the WOMAC, 52.5 of 100 points on the Lysholm, and 2.32 of 10 points on the VAS.
RESULTS
The symptomatic or radiographically documented recurrence at 5 years was 12% (95% confidence interval [CI] 7% to 17%) using the Kaplan-Meier estimator, with a mean recurrence time of 33 ± 19 months. Of these, three were asymptomatic recurrences found during regular MRI reviews, and the remaining 19 underwent repeat surgery. There was one intraoperative complication (vascular injury) with no effect on postoperative limb function and eight patients with postoperative joint stiffness, seven of whom improved with prolonged rehabilitation and one with manipulation under anesthesia. No postradiotherapy complications were found. The proportion of patients who achieved the preestablished PASS was 99% (176 of 178) for the VAS pain score, 97% (173 of 178) for the WOMAC score, and 100% (178 of 178) for the Lysholm score. A lower percentage of patients with recurrence achieved the PASS for WOMAC score than patients without recurrence (86% [19] versus 99% [154], OR 0.08 [95% CI 0.01 to 0.52]; p = 0.01), whereas no difference was found in the percentage of VAS score (95% [21] versus 99% [155], OR 0.14 [95% CI 0.01 to 2.25]; p = 0.23) or Lysholm score (100% [22] versus 100% [156], OR 1 [95% CI 1 to 1]; p = 0.99). Moreover, patients in the recurrence group showed worse knee flexion (median 135° [100° to 135°] versus median 135° [80° to 135°]; difference of medians 0°; p = 0.03), worse WOMAC score (median 3.5 [0 to 19] versus median 1 [0 to 29]; difference of medians 2.5; p = 0.01), and higher VAS pain score (median 1 [0 to 4] versus median 0 [0 to 4]; difference of medians 1; p < 0.01) than those in the nonrecurrence group, although no differences reached the MCID. No factors were associated with D-TGCT recurrence, including the use of postoperative radiotherapy, surgical technique, and invasion extent.
CONCLUSION
This single-center, large-cohort retrospective study confirmed that multiportal arthroscopic surgery can be used to treat knee D-TGCTs with a low recurrence rate, few complications, and satisfactory postoperative outcomes. Surgeons should conduct a thorough preoperative evaluation, meticulous arthroscopic synovectomy, and regular postoperative follow-up when treating patients with D-TGCT to reduce postoperative recurrence. Because the available evidence does not appear to fully support the use of postoperative adjuvant radiotherapy in all patients with D-TGCTs and our study design is inadequate to resolve this controversial issue, future studies should look for more appropriate indications for radiotherapy, such as planning based on a more precise classification of lesion invasion.
LEVEL OF EVIDENCE
Level III, therapeutic study.
PubMed: 38153106
DOI: 10.1097/CORR.0000000000002934 -
Orthopaedics & Traumatology, Surgery &... Sep 2023Pigmented villonodular synovitis (PVNS) is a rare pathology of the elbow, but presents a risk of progression with cartilage destruction. Surgical treatment consists in...
INTRODUCTION
Pigmented villonodular synovitis (PVNS) is a rare pathology of the elbow, but presents a risk of progression with cartilage destruction. Surgical treatment consists in synovectomy, as complete as possible. Arthroscopy is an excellent tool for the exploration and treatment of intra-articular lesions in the elbow, but the results in PVNS of the elbow have never been evaluated. The aim of this study was to assess the recurrence rate of PVNS of the elbow after arthroscopic synovectomy, and secondarily to assess pain, joint range of motion, functional scores and complication rate.
MATERIAL AND METHODS
We performed a retrospective study of a continuous series of 8 patients operated on between February 2012 and February 2019, with a mean age of 43.7 years. The operated side was the dominant side in 75% of cases. Surgery consisted in the most complete synovectomy possible, performed arthroscopically. Recurrence, clinical evaluation, with pain at rest and on mpvement on visual analogue scale (VAS) and joint range of motion, functional MEPS and DASH scores, and any complications were collected.
RESULTS
At a mean 66.4 months' follow-up, 2 patients required revision surgery for recurrence. At the last follow-up, VAS for pain at rest was 0.9 and 1.9 for pain on movement. MEPS score was 85.6 and DASH score 82.2. No neurological, vascular or infectious complications of arthroscopic synovectomy were found in our series.
DISCUSSION
Arthroscopic synovectomy in the treatment of PVNS of the elbow was a reliable and safe therapeutic alternative, with a low complications rate and 2 cases of recurrence (25%) in our study. This was the first study to report the results of arthroscopic surgical treatment of elbow PVNS.
LEVEL OF EVIDENCE
IV Retrospective study without control group.
Topics: Humans; Adult; Synovitis, Pigmented Villonodular; Elbow; Treatment Outcome; Retrospective Studies; Knee Joint; Synovectomy; Pain; Arthroscopy
PubMed: 36455866
DOI: 10.1016/j.otsr.2022.103493 -
Arthroscopy Techniques Jul 2022Synovial disease is a common reason for hip joint dysfunction. Although traditionally treated with open synovectomy, with the popularization and development of...
Synovial disease is a common reason for hip joint dysfunction. Although traditionally treated with open synovectomy, with the popularization and development of arthroscopic techniques, arthroscopic synovectomy has become the main surgical treatment for synovial diseases. Given the long soft tissue channel and learning curve, arthroscopic synovectomy of the hip joint has high surgical requirements for surgeons. However, there is currently no standardized surgical protocol for arthroscopic synovectomy of the hip joint to guide the surgeon to perform hip synovectomy in an orderly manner. During the past 3 years, we have employed a novel technique, wherein we divided the synovium of the hip into seven regions based on the anatomical structure and the operating range of the arthroscopic portals. With the assistance of flexion, extension, and traction of the hip joint, synovectomy was sequentially performed under arthroscopic guidance. This regional surgical technique can be popularized and likely has the potential to become a standardized arthroscopic synovectomy protocol of the hip joint.
PubMed: 35936843
DOI: 10.1016/j.eats.2022.02.029 -
Arthroscopy Techniques Oct 2021Synovial chondromatosis is a benign metaplastic disease of the synovial joints, characterized by the development of cartilaginous nodules in the synovium. Treatment...
Synovial chondromatosis is a benign metaplastic disease of the synovial joints, characterized by the development of cartilaginous nodules in the synovium. Treatment generally includes open or arthroscopic loose body removal combined with a synovectomy. An all-arthroscopic approach has been described to minimize complications and reduce morbidity while providing adequate control of local disease. The purpose of this Technical Note is to describe our techniques and technical pearls that allow for adequate excision of disease while minimizing complications and disease recurrence. The combination of patient positioning, the establishment of multiple arthroscopic portals to ensure optimal visualization and freedom of instruments, the use of a leg holder, and the use of a variety of surgical instruments to facilitate loose body removal and synovectomy is critical to optimize clinical outcomes and minimize complications. Although technically demanding, our described technique can help facilitate extensive loose body removal and complete synovectomy.
PubMed: 34754733
DOI: 10.1016/j.eats.2021.07.001 -
Cureus Jun 2022Tenosynovial giant cell tumors (TGCT) are a rare group of generally non-malignant tumors that involves the synovium and tendon sheath. A young female patient presented...
Tenosynovial giant cell tumors (TGCT) are a rare group of generally non-malignant tumors that involves the synovium and tendon sheath. A young female patient presented to the outpatient department with a complaint of unilateral knee swelling and pain. She was evaluated as such and based on a provisional diagnosis of benign synovial proliferation, she was treated with an arthroscopic resection. We discuss our case and discuss the possible medical therapies to prevent recurrence.
PubMed: 35855244
DOI: 10.7759/cureus.25957 -
Der Unfallchirurg Mar 2022The arthroscopic treatment of arthritis of the ankle joint is very limited and is only indicated for early stages of arthritis with impingement, strictly localized forms... (Review)
Review
The arthroscopic treatment of arthritis of the ankle joint is very limited and is only indicated for early stages of arthritis with impingement, strictly localized forms and more for young patients. The most important aim of arthroscopy is to improve the range of motion (ROM) of the ankle by removal of bony projections (dorsal and ventral) and an extensive synovectomy with debridement. In cases of narrowing of the joint space to less than 2 mm and/or malalignment, the indications for arthroscopy should be considered very cautiously. This is independent of the localization of the narrowing, especially if the complete joint is affected. If necessary, arthroscopy can then be carried out as an additional intervention in cases of conversion osteotomy in order to improve the ROM.
Topics: Ankle Joint; Arthritis; Arthroscopy; Debridement; Humans; Synovectomy; Treatment Outcome
PubMed: 35043214
DOI: 10.1007/s00113-021-01133-0