Extra-articular Extension Research Articles

Synovial Lipomatosis With Extra-articular Extension in the Arthritic Wrist: An Unexpected Diagnosis.

Synovial lipomatosis is a rare condition characterized by adipocyte proliferation within joint synovial tissue. It most commonly affects the knee and is typically intra-articular. Only 5 published case reports describe extra-articular synovial lipomatosis of the wrist. We present a case of a sexagenarian patient seen for his wrist arthropathy. His x-ray revealed pan-wrist arthritis and inflammatory soft tissue swelling. The patient was slated for a wrist fusion and Darrach procedure. Following the dorsal skin incision in the operating room, an unusual adipose mass was identified infiltrating all extensor compartments: midcarpal, radiocarpal, and distal radioulnar joints. The mass was excised and sent to pathology prior to proceeding with the slated surgery. Synovial lipomatosis was diagnosed postoperatively based on histopathology. Six weeks postoperatively, the wrist fusion had healed clinically and radiographically, and his pain had improved. There was no evidence of recurrence. Synovial lipomatosis is a rare entity that may imitate multiple other pathologies. It is possible that synovial lipomatosis may represent a secondary occurrence following degenerative articular disease or trauma in older patients. This is the first case report to date describing synovial lipomatosis of the wrist with extra-articular extension in the setting of pan-carpal wrist arthritis.

The Role of Temporomandibular Joint Arthroscopy for Diagnosis and Surgical Management of Synovial Chondromatosis.

We report the experience of our maxillo-facial surgery unit into the diagnostic and the therapeutic role of arthroscopy of temporomandibular joint (TMJ) synovial chondromatosis (SC). A series of sixteen patients with an imaging, arthroscopical, and histological diagnosis of SC treated with arthroscopy was selected. The surgeries were conducted in the Department of Maxillo-facial surgery, Academic hospital of Udine, from January 2016 to December 2022. Medical history, clinical examination, imaging, arthroscopical, and histological characteristics were recorded and then reviewed and discussed. Clinical improvement, both in pain and in maximum incisal opening (MIO), were noticed in whole patients. Histologically, according to Milgram's classification, the sample was fairly homogeneous. Arthroscopic treatment was successful in 87.5% of the patients. Only two cases of SC relapse were registered and were then submitted to open surgery to perform a total sinovectomy. The data collected were used to develop an SC classification proposal based on clinical, radiological (magnetic resonance imaging), arthroscopical, and histopathological characteristics. TMJ arthroscopy must be considered the first line of treatment for SC, leaving open surgery to relapses cases and those cases with extraarticular extension. A univocal classification is essential to best stage and prognostically characterise this pathology.

Diagnosis and management of temporomandibular joint synovial chondromatosis: A systematic review

The aim of this study was to systematically review the diagnosis and management of temporomandibular joint synovial chondromatosis (TMJ-SC). Using a systematic study design based on the PRISMA guideline, the researchers implemented and analyzed a cohort of relevant publications indexed by PubMed, Embase, Medline, and LILACS between January 1990 and December 2022. The outcomes of interest were demographics of the primary studies, and Clinical, radiological, and therapeutic data associated with TMJ-SC. The study samples included 8 studies presenting 121 TMJ-SC cases (73.6% female; 100% unilateral; 53.7% left-sided; mean age, 43.3 ± SD 5,80 [range, 21–81]. Non-specific symptoms were mostly reported, including TMJ pain, noise and local inflammation, and/or malocclusion. Radiographically, loose bodies, masses with low-signal foci, and calcification were common charateristics. Until now, there has been no internationally accepted consensus on diagnosis and management of TMJ-SC. Arthroscopic surgery should be performed on masses confined to the superior TMJ space, while open arthroplasty is indicated in cases with the extra-articular extension. A combination of both treatment methods may be necessary, when the lesion locates extending beyond the medial groove of the condyle.

Combined Arthroscopic and Endoscopic Synovectomy for Diffuse Pigmented Villonodular Synovitis (PVNS) of the Ankle

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.

Endoscopic Resection of Recalcitrant Tuberculous Bursitis of the Popliteal Fossa

Tuberculosis of the musculoskeletal system is uncommon and constitutes 1% to 5% of all forms of tuberculosis. In total, 30% of skeletal tuberculosis involves the joints, the knee being the third most commonly affected after the spine and the hip. Knee tuberculosis commonly presents as synovitis or arthritis, and infected Baker’s cyst is a rather rare presentation. It is believed to result from the propagation of tuberculosis of the knee joint into the cyst, as approximately one half of the Baker’s cyst communicates with the knee joint and it appears as swelling in the medial aspect of the popliteal fossa. For tuberculous popliteal bursitis at the lateral aspect of the popliteal fossa, it may be an extra-articular extension of tuberculosis of the knee joint via the popliteal hiatus. Chemotherapy remains the cornerstone of treatment; surgery is indicated in recalcitrant cases. In this Technical Note, the technical details of endoscopic resection of recalcitrant tuberculous bursitis at the lateral aspect of the popliteal fossa are described. This minimally invasive technique has the advantage of better cosmetic results and fewer wound complications and reduces the extent of surgical dissection as compared with open surgery.

Open synovectomy treatment for intra- and extraarticular localized pigmented villonodular synovitis of the knee: a case report

BackgroundPigmented villonodular synovitis (PVNS) is a rare, benign, proliferative neoplastic process that commonly affects synovial-lined anatomic spaces. The diffuse type (DPVNS) is characterized by invasion of the entire joint synovium, while the localized type (LPVNS) is characterized by a relatively normal synovial appearance. This report describes a unique case of massive intraarticular LPVNS with an extraarticular extension through the lateral patellar retinaculum. No similar cases have been found in the literature.Case presentationA 58-year-old woman had a history of hyperuricemia and knee trauma and presented with unilateral knee acute swelling and pain symptoms with sudden onset. Recent expansion of the LPVNS caused the development of a tender palpable soft tissue mass in the anterolateral aspect of the knee and acute reduced mobility. Preoperative magnetic resonance imaging of the knee revealed the presence of only the soft tissue mass and mild degenerative changes. Open synovectomy was performed successfully to excise the mass. Intraoperatively, macroscopic features of the bright brown inflamed synovium suggested LPVNS, which was confirmed histopathologically. Postoperatively, the symptoms of limited mobility and pain were appreciably relieved. Recurrence was not observed during the clinical follow-up at 1, 6 or 18 months after surgery.ConclusionsHere, we report the unique case of localized pigmented villonodular synovitis of the knee in a misdiagnosed patient with intra- and extraarticular lesion, which might be attributed to the history of knee trauma and the focal defect of the lateral patellar retinaculum. Open synovectomy effectively relieved the symptoms of limited mobility and pain and no recurrence was observed prior to 18 months postoperatively. To reduce misdiagnosis, MRI examinations are recommended for all patients suspected of having PVNS, including those who have a history of hyperuricemia.

Assessment of Articular Cartilage Disorders After Distal Radius Fracture Using Biochemical and Morphological Nonenhanced Magnetic Resonance Imaging

To assess radiocarpal articular cartilage after distal radius fracture, with and without intra-articular extension, compared with healthy controls using multiparametric, nonenhanced magnetic resonance imaging (MRI). In this prospective study, multiparametric MRI of the radiocarpal articular cartilage was performed in 26 participants (16 males and 10 females; mean age, 39.5 ± 14.7 years; range, 20-70 years) using 3T MRI. The cohort consisted of 14 patients with a distal radius fracture and 12 healthy volunteers. The radiocarpal articular cartilage was assessed using morphological (Double Echo Steady-State [DESS] and True Fast Imaging With Steady-State Precession [TrueFISP]) and biochemical (T2∗) MRI sequences without an intravenous contrast agent. The modified Outerbridge classification system for morphological analyses and region-of-interest biochemical analysis were applied to assess the degree of articular cartilage damage in each patient. Morphological articular cartilage assessment showed no difference between the DESS sequence and the reference standard, TrueFISP. In the morphological (DESS and TrueFISP) and biochemical (T2∗) assessments, patients with intra-articular fractures did not show articular cartilage damage different from those with extra-articular fractures. Greater articular cartilage degradation was observed after distal radius fracture compared with controls. Posttraumatic radiocarpal articular cartilage damage did not differ between fractures with intra-articular and extra-articular extension, but patients with fractures had notably higher articular cartilage degradation compared with healthy controls. Magnetic resonance imaging using advanced multiparametric sequences may facilitate accurate, noninvasive assessment of articular cartilage changes after distal radius fracture without the need for a contrast agent. Diagnostic IV.

Total Hip Arthroplasty in Ankylosing Spondylitis With Extension Contracture of Hips

BackgroundDespite significant pain relief following total hip arthroplasty (THA) in patients with ankylosing spondylitis, a small subset of patients presenting with extra-articular extension contracture of hips remains unsatisfied. MethodsWe retrospectively evaluated the patients with ankylosing spondylitis who underwent simultaneous bilateral THA and had extensor tightness of both hips preoperatively. They were managed with modified Z-plasty of iliotibial band. Patients with windswept deformity, commonly seen in bilateral hip arthritis caused by ankylosing spondylitis, were excluded. ResultsBetween July 2011 and June 2015, out of 148 patients with bilateral hip involvement, 10 patients (20 hips) had extension contracture of both hips that was addressed during surgery. All patients were followed up for a minimum of 2 years. They could sit comfortably on a chair of height 18 inches with hips and knees flexed to at least 90°. The mean postoperative sum range of motion was 144.6° with an average hip flexion of 95° (range, 90°-105°). None of them had recurrence of extension contracture. There was significant improvement in range of motion and hence ambulation and function. No radiolucent lines exceeding 2 mm were seen in any of the zones around either of the components as evaluated in latest X-rays. ConclusionExtension contracture of hip although rare is a noticeable problem and needs to be addressed during THA. Modified Z-plasty technique of iliotibial band is a reliable method in managing these patients.

Arthroscopic Management of Synovial Chondromatosis of the Temporomandibular Joint. Case Series and Systematic Review.

Synovial chondromatosis (SC) is a benign condition that is characterized by the formation of cartilaginous nodules within the synovial tissue of a joint that may detach and form loose bodies inside the articular space. The purpose of this study is to evaluate the use of surgical arthroscopyfor the treatment of SC ofthe temporomandibular joint (TMJ). A series of six patients treated with arthroscopy (one patient requiring an open arthrotomy due to the size of the loose bodies) in our centre between 1997 and 2016 is presented and results are discussed. A systematic review of the literature of patients with SC treated with arthroscopy or arthroscopy-assisted open arthrotomy is also carried out. Pain, which was the main symptom in our patients, and maximum mouth opening both improved significantly after surgicaltreatment. Three of the patients were diagnosed with primary SC, and the other 3 had a previous diagnosis of internal derangement. None of the patients showed signs of relapse during the follow-up period. Surgical arthroscopy is a minimally invasive procedure that allows the extraction of loose bodies and even partial synovectomy of the affected membrane with good results and without recurrence of the disease. This technique can be useful in cases of SC with loose bodies measuring less than 3mm or without extra-articular extension.

Diffuse pigmented villonodular synovitis in knee joint: diagnosis and treatment

Pigmented villonodular synovitis is a rare proliferative condition of the synovium. Although the condition can present in any joint, the knee is the most commonly affected site. Despite being a benign condition, pigmented villonodular synovitis is often aggressive, with marked extra-articular extension in some cases. Monoarticular involvement occurs in two forms: localized and diffuse. The latter is more common, with a high recurrence rate. There is no standard method of management of this lesion. Open surgery is a classical and effective method for treatment. Arthroscopic synovectomy, however, has gained popularity, and has several advantages over the open technique particularly in exclusively articular cases. The combined approach is suggested in cases with extra-articular involvement. Synovectomy through any approach may prevent secondary osteoarthritis and subsequent joint arthroplasty. Internal irradiation or external beam radiation as an adjuvant treatment to surgical synovectomy appears to decrease the rate of local recurrence in diffuse cases. The authors observed a great heterogeneity in reporting of functional results, and specific conclusions should not be drawn. Each patient should be managed in accordance with his/her particular condition.

Results and recurrence of pigmented villonodular synovitis of the ankle: does diffuse PVNS with extra-articular extension tend to recur more often?

The aim of this study was to provide the outcomes and to analyze the recurrence of Pigmented Villonodular Synovitis (PVNS) of the ankle joint treated by surgical synovectomy. Thirty-one PVNS cases of the ankle, including 5 localized PVNS cases and 26 diffuse PVNS cases, were treated in our institute between 2004 and 2015. The median age was 35 (range 18-63) years. The 5 localized PVNS cases were treated with partial synovectomy (group I); 10 diffuse PVNS cases limited to intra-articular synovium received arthroscopic comprehensive synovectomy (group II); and 16 cases with diffuse PVNS spreading to extra-articular tendon sheaths underwent combined arthroscopic and open synovectomy (group III). Adjuvant radiotherapy was provided in groups II and III. The American Orthopaedic Foot and Ankle Society (AOFAS) score and subjective grading of procedure were used to evaluate the results. Twenty-seven patients were followed with a median of 54 (range 15-108) months. In the three groups, the average AOFAS score improved from 75 (in all three groups) points preoperatively to 100 (group I), 97 (group II), and 90 points (group III) postoperatively. The rate of good-to-excellent result was 100% in group I and II and 73.3% in group III. Only in group III, recurrence occurred in five cases. Diffuse PVNS of the ankle can be successfully managed with surgical synovectomy and adjuvant radiotherapy. Radiotherapy is not needed for localized PVNS. The recurrence rate in PVNS patients with extra-articular extension is higher. IV.

Hemiarthroplasty in a Patient With Pigmented Villonodular Synovitis of the Shoulder

We report the 2-year follow-up results of a hemiarthroplasty in a 29-year-old patient with pigmented villonodular synovitis (PVNS) with extra-articular extension and severe bony destruction. The patient presented with diffuse pain and swelling of the right shoulder for several years. Radiographs showed severe osteolytic lesions in the humeral head and neck, greater tuberosity, and a small osteolytic lesion in the glenoid neck area. Further examination with magnetic resonance imaging of the shoulder joint showed a large, lobulated soft tissue mass extending from the subdeltoid area to the chest wall invading the adjacent bony structures. The operative findings included a large, multilobulated, yellowish-brown mass extending from the subdeltoid area to the axillary pouch, subacromial space, and thoracic wall. The mass invaded the anatomical neck area of the humeral head and caused a fracture of the humeral head. We observed a complete rupture of the long head of the biceps tendon, supraspinatus tendon, and infraspinatus tendon, but the subscapularis tendon was partially ruptured. We performed the complete excision and cemented hemiarthroplasty. At 2-year follow-up, no signs of local recurrence were present. The patient had no significant pain and achieved a good functional result.To the best of our knowledge, 1 report with shoulder hemiarthroplasty in PVNS of the shoulder has been published in the English literature. For PVNS of the shoulder with a large extra-articular extension and bony destruction, shoulder arthroplasty with total synovectomy produces the lowest recurrence rates because of better access and excision to the posterior location of the PVNS lesion.

Arthroscopic Management for Synovial Chondromatosis of the Temporomandibular Joint: A Retrospective Review of 33 Cases

To present clinical, radiologic, and arthroscopic results of patients with synovial chondromatosis of the temporomandibular joint; to introduce a technique for removal of loose bodies in different areas; and to summarize the indications of therapeutic arthroscopy according to the magnetic resonance imaging (MRI) features. From April 2001 to April 2010, 33 consecutive patients underwent arthroscopy. Their demographics, clinical manifestations, imaging studies, arthroscopic findings, treatments, and outcomes were reviewed. The predominant symptoms were pain, limitation of mouth opening, and joint sounds. Obvious joint effusion was shown on MRI in 21 of 33 patients. Mass lesions were shown on MRI in 29 of 33 cases. The presence of loose bodies was shown in 31 cases under an arthroscope. Synovial hyperplasia was noted in 12 patients. Bony erosion of the articular surface was discovered in 11 patients. Thirty-two patients underwent therapeutic arthroscopy. Smaller loose bodies were commonly removed with joint lavage or biopsy forceps in 24 patients. Fragmentation with forceps or a wider additional incision was applied to remove larger loose bodies in 7 patients. Debridement was applied to remove intrasynovial lesions in 7 patients. Coblation was used to remove the hyperplastic synovium in 10 of 32 patients. Eight patients were lost to follow-up. The mean follow-up period was 38 months. No recurrence was suspected clinically and radiologically. Therapeutic arthroscopy was appropriate for patients with separate mass lesions and no extra-articular extension. Surgical treatment comprised thorough removal of loose bodies and affected synovial tissues.

Pigmented Villonodular Synovitis Responsive to Imatinib Therapy

Pigmented Villonodular Synovitis Responsive to Imatinib Therapy

Central Popliteal Mass Due to Communicating Posterior Cruciate Ligament Cyst: An Indication for a Combined Approach

An isolated symptomatic posterior cruciate ligament cyst is uncommon, and extra-articular communication of this cyst is extremely rare. We report a case of a symptomatic communicating posterior cruciate ligament cyst presenting as a central popliteal mass. In view of the large extra-articular extension of this cyst and its close proximity to the popliteal neurovascular structures, we successfully treated this cyst with a combined arthroscopic and open approach.

Pigmented Villonodular Synovitis

Pigmented villonodular synovitis is a proliferative condition of the synovium. Monoarticular involvement, the most common process, occurs in two forms: localized and diffuse. The localized form is characterized by focal involvement of the synovium, with either nodular or pedunculated masses; the diffuse form affects virtually the entire synovium. The localized form has an excellent prognosis and a low recurrence rate when managed surgically. The more common diffuse form has a reported recurrence rate of up to 46%. Although the condition can present in any joint, the knee is the most commonly affected site. Pigmented villonodular synovitis is often aggressive, with marked extra-articular extension. Open synovectomy is the standard method of management. Arthroscopic synovectomy, which has gained popularity, has several advantages over the open technique, but it is associated with higher recurrence rates in diffuse pigmented villonodular synovitis. Synovectomy by any approach, however, may prevent secondary osteoarthritis and subsequent joint arthroplasty. Radiation-induced synovectomy has shown mixed results. Combined surgical and nonsurgical approaches may be necessary, and in some patients, total joint arthroplasty may be the only effective treatment.

Synovial hemangioma: imaging features in eight histologically proven cases, review of the literature, and differential diagnosis.

This study was undertaken to describe the imaging characteristics of synovial hemangioma, with the goal of improving the disappointing rate (22%) of clinical diagnosis of this condition. A review of the literature and the differential diagnosis of intra-articular lesions, including synovial osteochondromatosis and pigmented villonodular synovitis, are also presented. The subjects of the study were 8 patients (4 males, 4 females; age range: 5-47 years; mean age: 19 years) with histologically confirmed synovial hemangioma involving the knee (n = 7) or wrist (n = 1). We retrospectively examined the imaging studies performed in these patients, including plain radiography (n = 8), magnetic resonance imaging (MRI; n = 4), angiography (n = 3), arthrography (n = 2), and contrast-enhanced computed tomography (CT; n = 2). Plain radiographs showed a soft tissue density suggesting either joint effusion or a mass in all patients. Phleboliths and bone erosions on plain films in four patients with extra-articular soft tissue involvement pointed to the correct diagnosis. Angiography, showing fine-caliber, smooth-walled vessels, contrast pooling in dilated vascular spaces, and early visualization of venous structures, was diagnostic in two patients. Neither arthrography nor CT yielded specific enough findings. MRI was consistently effective in allowing the correct diagnosis to be made preoperatively, showing an intra-articular or juxta-articular mass of intermediate signal intensity on T1-weighted images and of high signal intensity of T2- or T2*-weighted images with low-signal channels or septa within it. A fluid-fluid level was found in two patients with a cavernous-type lesion. Despite the limited nature of this study, it shows clearly that MRI is the procedure of choice whenever an intra-articular vascular lesion such as synovial hemangioma is suspected. Nonetheless, phleboliths and evidence of extra-articular extension of plain radiographs point to angiography as an effective procedure of first resort because it can be combined with embolotherapy.

Detection of infection in loosened hip prostheses: efficacy of sonography.

The purpose of this study was to determine the efficacy of sonography in the detection of infection in loosened hip prostheses. The normal capsular morphology in 15 asymptomatic patients with total hip replacements was studied sonographically. Sonograms were then obtained in 33 patients who had pain in the hip after arthroplasty and radiologic findings of loosening of the prosthesis. These patients subsequently underwent aspiration and arthrography of the hip. Six of the 33 symptomatic patients proved to have prosthetic joint infection. On sonograms, the normal pseudocapsule is adherent to the proximal part of the anterior femoral cortex, and the capsule-to-bone distance is less than 3.2 mm (average, 2.6 mm). No hips with a capsule-to-bone distance less than 3.2 mm were infected. Sonograms in the six patients with infection showed marked intraarticular effusion with a mean capsule-to-bone distance of 10.2 mm. Five of these six had extracapsular fluid collections. Two patients with hip dislocations and four with aseptic loosening of the prosthesis had capsular distension on sonograms and cultures of aspirated material that showed no growth. Sonography can be used to diagnose infection around loosened hip prostheses. All patients who had an intraarticular effusion with extraarticular extension seen on sonograms had infection.

Thymic Abscess with Bacteremia and Manubriosternal Pyarthrosis in a Geriatric Patient

We describe a geriatric patient with acute substernal chest pain thought to be due to coronary heart disease, who was subsequently found to have Staphylococcus aureus bacteremia associated with infection of the thymus and manubriosternal joint. To our knowledge, this is the first report of (1) a thymic abscess in a geriatric patient, (2) a thymic abscess associated with bacteremia, (3) extra-articular extension of manubriosternal pyarthrosis, and (4) manubriosternal pyarthrosis in the geriatric age group.

Temporomandibular Joint Chondrosarcoma

Chondrosarcoma of the temporomandibular joint is a rare lesion. A 49-year-old woman presented with painless left preauricular swelling. Computed tomography demonstrated a soft tissue mass in the left temporomandibular joint with extraarticular extension along the mandibular ramus. Calcification was present in the extraarticular component.