Surgical Synovectomy Research Articles

Comparative analysis of synovectomy and total knee replacement in knee joint synovial chondromatosis: A case series

Synovial chondromatosis is a rare disorder characterized by cartilaginous growths within the joint lining, often confused with conditions like pigmented villonodular synovitis and rheumatoid arthritis. Primary treatment typically involves surgical synovectomy to remove the affected tissue and loose bodies. Documented cases are limited globally. The aim of this study was to present a case series of synovial chondromatosis and evaluate the functional outcomes by assessing the post-surgical Musculoskeletal Tumor Society (MSTS) score following different surgical interventions (synovectomy alone versus synovectomy with total knee replacement) in a resource-limited setting. Four cases of synovial chondromatosis were reported. A 61-year-old woman with a soft tissue tumor underwent synovectomy and total knee replacement on the right knee, then experienced a periprosthetic infection requiring revision arthroplasty, resulting in an MSTS score of 24. Another case was a 48-year-old woman who had a synovectomy for a lump on the right knee, also achieving an MSTS score of 24. Two additional cases involved women in their mid-to-late 60s who underwent synovectomy for knee lumps, with post-operative MSTS scores of 21 and 19, respectively. This case series underscores the diagnostic and management challenges of synovial chondromatosis in the knee joint, demonstrating various surgical interventions. This case series also suggested that the post-operative MSTS scores were slightly higher (indicating better outcomes) for synovectomy alone compared to synovectomy with total knee replacement, highlighting the need for further research to determine the most effective treatment approach.

The effect of radiation synovectomy with phosphorus-32 on the pain and swelling in 31 RA patients with resistant monoarthritis of the knee.

Rheumatoid arthritis (RA) is a chronic inflammatory disease characterized by symmetric polyarthritis. RA is routinely treated by various systemic drugs; on the other hand, administration of intra-articular corticosteroids or different types of synovectomies can be used in case of systemic medication's failure. Chemical, radio isotopic, and surgical synovectomies are being used as therapeutic options for chronic synovitis to improve joint function. Chemical synovectomy is not well tolerated, and the long-term response is relatively low. Surgical synovectomy has a better success rate, but it recommends higher expenses. In radiation synovectomy, radioactive labeled particles are applied directly in the articular cavity, followed by homogeneous distribution in joint. Next, the radioactive particles are transported in the depth of synovia and phagocytized by inflammatory cells. Finally, the radiation leads to fibrosis and sclerosis of formerly inflamed synovial membrane; thus, it stops the inflammation and reduces the symptoms. It has a success rate of 40-100% and its effect can be similar to surgical synovectomy. Thirty-one patients with resistant monoarthritis of the knee were enrolled in this study. One millicurie of phosphorus-32 was injected into patients' knee via US guide. Saline was injected afterwards to prevent leakage. Direct pressure was performed after removing the needle and the knee was flexed slowly to ensure homogenous distribution and fixed with a splint for 1 to 2weeks. Patients were followed up after 2weeks, 1month, 2months, and 6months. The following variables were assessed by the treating rheumatologist: patients' pain, joint tenderness, effusion, and ROM. At the time of injection and after the first week, patients were investigated for any complication including infection, necrosis, pain, and swelling. The effect of clinical characteristics and demographic data on existing complications and the changes of pain, joint tenderness, effusion, and ROM was assessed. Thirty-one patients with the mean age of 54.5 ± 12.2years and the mean disease duration of 12 ± 6.5years were enrolled in this study. Mean DAS-28 ESR score for our patients was 4 ± 0.7. The pain, effusion, and reduced ROM were decreased significantly after all follow-up intervals. Knee tenderness was not affected in the first 2weeks, but it was reduced significantly after 1, 2, and 6months. No serious complications like infection and necrosis were reported through our study. 51.6% and 54.8% of our patients reported pain and swelling in the administration site. Furthermore, 19.4% and 16.1% of patients reported deterioration of pain and effusion in the first week of injection. In our study, we demonstrated that pain, tenderness, effusion, and ROM are improved after radiation synovectomy with phosphorus-32. We also showed that there was no serious adverse effect like infection and necrosis. However, more than half of our patients experienced pain and swelling of injection site at the time of administration. Key points • We demonstrated the efficacy of radiation synovectomy as a medication for monoarthritis. • The results of our study can lead to a bigger clinical trial to assess the benefits and adverse effects of radiation synovectomy in comparison to treatment with local or systemic corticosteroids.

Haemophilic arthropathy: Diagnosis, management, and aging patient considerations.

Gene therapy and universal use of safer, more effective, and personalised prophylactic regimens (factor, and nonfactor) are expected to prevent joint bleeding and promote joint health in persons with haemophilia (PwH). Growing evidence suggests that subclinical bleeding, with active and inactive synovial proliferation, continues and haemophilic arthropathy remains a major morbidity in PwH despite early institution of joint prophylaxis. Joint health assessment is evolving with physical examination scores complementing imaging scores. Point-of-care ultrasound is emerging as a safe, cost-effective, and readily available tool for acute determination of musculoskeletal abnormalities, serial evaluation of joints for sonographic markers of haemophilic arthropathy, and in providing objective insight into the efficacy of new therapies. In acute haemarthrosis, arthrocentesis expedites recovery and prevent the vicious cycle of bleed-synovitis-rebleed. When synovial proliferation develops, a multidisciplinary team approach is critical with haematology, orthopaedics, and physiotherapy involvement. Synovectomy is considered for patients with chronic synovitis that fail conservative management. Non-surgical and minimally invasive procedures should always be offered and considered first. Careful patient selection, screening and early intervention increase the success of these interventions in reducing bleeding, pain, and improving joint function and quality of life. Chemical synovectomy is practical in developing countries, but radioactive synovectomy appears to be more effective. When surgical synovectomy is considered, arthroscopic/minimally invasive approach should be attempted first. In advanced haemophilic arthropathy, joint replacement and arthrodesis can be considered. While excited about the future of haemophilia management, navigating musculoskeletal challenges in the aging haemophilia population is equally important.

Debridement, Antibiotics, and Implant Retention in Unicompartmental Knee Arthroplasty Infection

BackgroundThis multicenter study sought to further investigate the method and outcome of debridement, antibiotics, and implant retention (DAIR) for the management of unicompartmental knee periprosthetic joint infection (PJI). MethodsThis retrospective study was performed on 52 patients who underwent DAIR for PJI of a unicompartmental knee arthroplasty (UKA) across 4 academic medical centers, all performed by fellowship-trained arthroplasty surgeons. Patient demographics, American Society of Anesthesiologists score, infecting organism, operative data, antibiotic data, and success in infection control at 1 year were collected. ResultsThe average time from index surgery to diagnosis of PJI was 11.1 weeks (range, 1.4 to 48). There was no correlation between time of diagnosis and success at 1 year (R = 0.09, P = .46). There was an association between surgical synovectomy and the eradication of infection (R = 0.28, P = .04). Overall, there was an 80.8% (42 of 52) infection-controlled success rate at 1 year from the DAIR procedure. All DAIR failures went on to require another procedure, either 1-stage (2 of 10) or 2-stage (8 of 10) revision to total knee arthroplasty (TKA). Of the DAIR successes, 6 (14.3%) went on to require conversion to TKA for progression of arthritis within 5 years. ConclusionsThis study demonstrates that DAIR is a safe and moderately effective procedure in the setting of acute PJI of UKA across institutions, with a success rate consistent with DAIR for TKA. The data suggest that a wide exposure and thorough synovectomy be incorporated during the DAIR UKA to improve the likelihood of successful eradication of PJI at the 1-year mark. Level of EvidenceLevel III.

Clonal Trafficking of Individual T Cells between Peripheral Blood and Inflamed Synovial Tissue in Patients with Immune-Mediated Refractory Arthritis

Background Rheumatoid arthritis (RA) is the most prevalent form of immune mediated arthritis, which is characterised by immune-mediated destruction of synovial joints, leading to synovitis, acute joint pain, reduced motility, and mortality. Enrichment of CD4+ memory T cell subsets with local clonal expansions in the RA synovial tissue (ST) has been extensively reported in the literature. In addition, emerging evidence suggests that CD8+ T cells with inflammatory phenotypes are also present in increased numbers in the ST. However, little is known about whether these populations represent autoantigen-experienced migratory T cells or locally proliferated populations. Here, with the help of paired single cell T cell receptor (scTCR) and RNA sequencing recognizing individual T cell clones, we aimed to gain insights into the trafficking of T cells between peripheral blood (PB) and inflamed target tissue. Methods We collected ST and PB samples from patients with immune mediated arthritis during surgical synovectomy. The patients had been diagnosed with seronegative juvenile arthritis (Pt1-JIA), seropositive RA (Pt2-SP) and seronegative RA (Pt3-SN), and at the time of sampling they were refractory to treatment. We flow sorted T cells and CD45+ leukocytes from ST and PB and profiled them with 10x Genomics 5´-scRNA+V(D)J-seq. Altogether, we captured 68,610 cells passing quality control thresholds. We integrated the data from all individual samples using scVI and visualised the subpopulation structure using UMAP dimensionality reduction as implemented in the Seurat package. Results Altogether we analysed 34134 CD4+ T cells and 23385 CD8+ T cells from PB and ST. In concordance with previous reports, we observed strong transcriptomic differences between the tissue of origin for both CD4+ and CD8+ T cells. We pooled all CD4+ and CD8+ T cells separately and further grouped all cells with identical CDR3b aa sequences into unique clones. In CD8+ T cells, a high number of clones (n=101, pertaining to 7409 cells) was shared between PB and ST. 8 of these clones were enriched to the ST as compared to PB. Interestingly, Pt2-SP harboured a large clone in the ST consisting of 27% of the CD8+ T cells (CDR3b sequence - CASRGGTSITDTQYF). This clone was also detected in PB with a much smaller frequency of only 2% and in a phenotypically different cluster, indicating local proliferation of specific T cell clones in the synovium. By performing a DE gene analysis between cells with the same TCR but between different tissues of origin, we found that the top upregulated genes in ST were CCL4 and CREM suggesting more activated and inflamed phenotype in ST. In the CD4+ compartment, we found only 12 intersecting TCR clones pertaining to 637 cells. Majority of these clones were coming from PB (458 cells from PB and 179 from ST) and were hyperexpanded in PB as compared to ST. No matches for common viral or bacterial epitopes in the existing VDJ database for any of the intersecting clones was found. We then pooled all T cell clones that were enriched in the ST and found 113 clones (p < 0.05, Fisher's exact test). DE gene analysis showed that ST enriched clones have a more activated profile. Pathway enrichment analysis with hypergeometric testing against the GO Biological Process database identified T cell activation and positive regulation of cell adhesion as the top hits. Using GLIPH2, we used publicly available data from a cohort of JIA patients to check TCR level similarity between the two cohorts. We found common motifs between these two cohorts in some of the hyperexpanded clones from PB and ST, and interestingly, TCRs which were predicted to target similar antigens, were enriched to both expanded and intersecting clones. By performing DE gene analysis, we found that predicted TCRs with similarity were more cytotoxic ( GZMH, GNLY, NKG7, GZMB, GZMA) and they overexpressed the TRBV7-6 gene. Conclusions Our results suggest that the cytokine signalling environment in the ST leads to a widespread activation and inflammatory signature within the T cell compartment. This shift in the phenotype occurs within clonal families and is not due to the selective recruitment of activated cells to inflamed tissue. Additional investigations may elucidate the cellular interactions that promote expansion of specific disease promoting clones in ST and provide a more detailed understanding of the spatiotemporal aspects of this process.

Post-traumatic Non-haemophilic Haemosiderotic Synovitis of the Elbow: A Case Report.

Haemosiderotic synovitis (HS) is a rare synovial proliferative disease secondary to haemarthrosis, often with articular cartilage destruction. It is most frequently reported in patients with haemophiliacs, and the knee joint is most frequently affected. However, there are no reports on the elbow joint without haemophiliacs. A 60-year-old woman who had undergone osteosynthesis for a left radial head fracture 8 years earlier came to our clinic with left elbow pain. X-rays and CT scans showed osteopenia and osteoarthritic changes throughout the elbow joint. MRI revealed joint effusion and synovial membrane hyperplasia. Surgical synovectomy and screw removal were performed. The pathological diagnosis of the synovial membrane was HS. Postoperatively, the pain was relieved, osteopenia improved and there was no recurrence of symptoms. This is the first report of non-haemophilic HS of the elbow; post-traumatic HS caused elbow arthropathy, which was improved by screw removal and synovectomy. Level of Evidence: Level V (Therapeutic).

Clinical Images: Cholesterol crystals bursitis.

The patient, a 45-year-old woman, was referred to the outpatient clinic with an effusion of her right olecranon bursa. She had a history of systemic sclerosis, liver cirrhosis, and autoimmune hepatitis that was treated with mycophenolate mofetil and prednisone. About 3 years ago, she started to develop an effusion of the right olecranon bursa. More recently she noticed white skin nodules, which turned out to be calcinosis cutis. There were no signs of arthritis on either clinical examination or imaging. An ultrasound of the right olecranon bursa was performed and revealed a tissue mass with hyperechogenic lesions within, which is compatible with crystal depositions (A). Analysis of the aspirate with the polarization microscope indicated the presence of cholesterol crystals (B; left: original magnification × 40; right: original magnification × 10). These crystals usually look like plates of glass, sometimes with a notch out of a corner. They are variably and mildly birefringent. Under polarized light, they may exhibit a stained-glass effect. Most cases of cholesterol crystals are associated with hyperlipidemia, yet our patient had normal lipoprotein levels and did not use cholesterol-lowering medication. Instead, increased local cell degeneration and/or increased lipid permeability in response to chronic inflammation might have contributed to the formation of cholesterol crystals in the olecranon bursa of our patient. Cholesterol crystals have been described previously just once in a patient with scleroderma, in the subcutis, mimicking calcinosis cutis (1). After failing local corticosteroid injections, the patient was finally referred to the orthopedic surgeon for surgical synovectomy. Cholesterol crystals in bursal fluid of a patient with scleroderma has not been previously reported, as most of the cases reported so far in patients with rheumatic diseases are concerning patients with rheumatoid arthritis (2). Disclosure Form Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Tratamiento de la sinovitis villonodular pigmentada difusa de rodilla: Sinovectomía artroscópica seguida de sinoviortesis radioisotópica.

Pigmented villonodular synovitis (SNVP) is a benign but locally aggressive disease of synovial proliferation that can occur in all joints, tendon sheaths and bursae, with a predilection for the knee. The etiology of PVNS remains unclear. Magnetic Resonance Imaging (MRI) is the best diagnostic method to establish suspected SNVP, although synovial biopsy is the gold standard for diagnosis. Initial treatment is based on synovectomy, open or arthroscopic. After surgery, there is a high rate of recurrence.1 Radioisotope synoviotrosis as an adjunct to surgical synovectomy appears to decrease the rate of local recurrence. Management of a case of knee SNVP by arthroscopic synovectomy and adjuvant radiosynoviordesis is presented.

Radiosynovectomy for the Treatment of Chronic Hemophilic Synovitis: An Old Technique, but Still Very Effective.

A radiosynovectomy (RS) should be indicated when recurrent articular bleeds related to chronic hemophilia synovitis (CHS) exist, established by clinical examination, and confirmed by imaging techniques that cannot be constrained with hematological prophylaxis. RS can be performed at any point in life, mainly in adolescents (>13−14 years) and adults. Intraarticular injection (IAI) of a radioactive material in children might be arduous since we need child collaboration which might include general anesthesia. RS is our initial option for management of CHS. For the knee joint we prescribe Yttrium-90, while for the elbow and ankle we prescribe Rhenium-186 (1 to 3 IAIs every 6 months). The procedure is greatly cost efficient when compared to surgical synovectomy. Chemical synovectomy with rifampicin has been reported to be efficacious, inexpensive, simple, and especially practical in developing countries where radioactive materials are not easily available. Rifampicin seems to be more efficacious when it is utilized in small joints (elbows and ankles), than when utilized in bigger ones (knees). When RS and/or chemical synovectomy fail, arthroscopic synovectomy (or open synovectomy in some cases) should be indicated. For us, surgery must be performed after the failure of 3 RSs with 6-month interims. RS is an effective and minimally invasive intervention for treatment of repeated articular bleeds due to CHS. Although it has been published that the risk of cancer does not increase, and that the amount of radioactive material used in RS is insignificant, the issue of chromosomal and/or deoxyribonucleic acid (DNA) changes remains a concern and continued surveillance is critical. As child and adulthood prophylaxis becomes more global, RS might become obsolete in the long-term.

Outcome of Arthroscopic Synovectomy for Diffuse Pigmented Villonodular Synovitis of the Knee in Sudanese Patients

Background: Diffuse pigmented villonodular synovitis (DPVNS) of the knee is a difficult tumor to eradicate, the gold standard treatment has traditionally been surgical excision with total synovectomy of the affected joint, either with an open or arthroscopic approach. In this study, we are focusing on arthroscopic surgical synovectomy. Objectives: Aimed to study the outcome of arthroscopic synovectomy for diffuse pigmented villonodular synovitis of the knee in Haj Alsafi Teaching Hospital. Methodology: Observational retrospective hospital-based study, performed in the Orthopedic Department, 12 patients (8 males and 4 females) with the diffuse form of PVNS of the knee were enrolled in the study after qualification. The clinical diagnosis was confirmed by magnetic resonance imaging and post-surgical histo-pathological examination. All patients underwent complete synovectomy through standard anterior, medial and lateral, then medial, lateral suprapatellar and posteromedial portals. Each patient was evaluated before and after treatment and followed up for a minimum of 18 months (range: 18 – 54 months) using the Lysholm score and International Knee Documentation Committee (IKDC) score. Results: The average age group of patients was (9–63years) with male predominance (66.7 %). Left knee more frequently affected (58.3%). None of the study participants had previous surgical history 100%. Both Lysholm and IKDCscores were significantly improved in all study participants. Regarding paired sample statistics, the mean for the score preoperatively and postoperatively was improved from 54.9 to77.9. Recurrence reported in one participant (8.3%). There was a statistical association between pre and post-operative LYSHOLM and IKDC scores and recurrence, hence p-value =0.000. Conclusion:Arthroscopic synovectomy is an appropriate treatment for knee DPVNS with a good clinical and functional outcome and with a low recurrence rate.

Outcome of Arthroscopic Synovectomy for Diffuse Pigmented Villonodular Synovitis of the Knee in Sudanese Patients

Background: Diffuse pigmented villonodular synovitis (DPVNS) of the knee is a difficult tumor to eradicate, the gold standard treatment has traditionally been surgical excision with total synovectomy of the affected joint, either with an open or arthroscopic approach. In this study, we are focusing on arthroscopic surgical synovectomy.
 Objectives: Aimed to study the outcome of arthroscopic synovectomy for diffuse pigmented villonodular synovitis of the knee in Haj Alsafi Teaching Hospital.
 Methodology: Observational retrospective hospital-based study, performed in the Orthopedic Department, 12 patients (8 males and 4 females) with the diffuse form of PVNS of the knee were enrolled in the study after qualification. The clinical diagnosis was confirmed by magnetic resonance imaging and post-surgical histo-pathological examination. All patients underwent complete synovectomy through standard anterior, medial and lateral, then medial, lateral suprapatellar and posteromedial portals. Each patient was evaluated before and after treatment and followed up for a minimum of 18 months (range: 18 – 54 months) using the Lysholm score and International Knee Documentation Committee (IKDC) score.
 Results: The average age group of patients was (9–63years) with male predominance (66.7 %). Left knee more frequently affected(58.3%). None of the study participants had previous surgical history 100%. Both Lysholm and IKDC scores were significantly improved in all study participants. Regarding paired sample statistics, the mean for the score preoperatively and postoperatively was improved from 54.9 to77.9.Recurrence reported in one participant (8.3%). There was a statistical association between pre and post-operative LYSHOLM and IKDC scores and recurrence, hence p-value =0.000.
 Conclusion: Arthroscopic synovectomy is an appropriate treatment for knee DPVNS with agood clinical and functional outcome and with a low recurrence rate.

Optimizing the anti-inflammatory strategies in (osteo)arthritis: local or systemic?

Arthritis is affecting millions of people globally, involvement and distribution depending on the type of arthritis. The most common arthritic conditions are osteoarthritis (OA) and rheumatoid arthritis (RA). Despite the pathogeneses being fundamentally different, both joint diseases share the same need for local treatment of synovitis. No current treatment can stop the progression of OA. Local articulate treatment including glucocorticoid (GC) injections, radiosynoviorthesis (RSO) and surgical synovectomy are the only options to relieve pain and temporally improve movability before surgical intervention. For RA, despite effective systemic treatments, similarly need for local articulate treatment is still present, especially early in the disease, but also in case of recurrent episodes of disease flare. Current evidence supports local GC injection as first line treatment for persistent synovitis in a single or a few joints. RSO provides an evident and effective alternative for GC refractory synovitis, especially in early RA. Surgical synovectomy is an invasive alternative, but with less documented efficacy. Whether one unsuccessful intraarticular GC injection is enough to change of mode of action for local treatment is still unclear and needs to be further investigated. In conclusion persistent single joint synovitis in OA and RA is well treated with local treatment. Intra-articular GC injection is considered as first line of treatment, but RSO provides an additional treatment alternative with less side effects and better evidence of efficacy than surgical synovectomy.

Silicone radial head prostheses: the clinical course and treatment of failure—a case series

Silicone radial head prostheses (SRHP) have a reputation of acceptable initial function but failure in the medium to long term as a result of the disintegration of the silicone material. Damaged SRHP can result in a silicone-induced synovitis and destruction of the joint. Early removal of damaged SRHP may prevent joint destruction. Literature is scarce; there are no studies describing early symptoms associated with clinical failure of SRHP and very few studies on appropriate treatment of destructed SRHP. The aim of this study was to describe the clinical course of failing SRHP and to provide practical guidance for treatment. Fifteen consecutive cases of failed SRHP, operated between 2005 and 2020, were retrospectively reviewed, using patient logs, radiographic results, and a questionnaire. Relevant data concerning pre- and postoperative complaints, function, and surgical details were gathered. Using the questionnaire, retrospective and current patient reported outcomes including Single Assessment Numeric Evaluation (SANE) scores, pain, instability, and range of motion were analyzed. The average time between implantation of the SRHP until outpatient presentation was 16 years. The average recalled SANE score before start of complaints was 8.6 out of 10 points. In 4 patients, the onset of complaints was preceded by a trauma. Five patients had symptoms for more than a year, and 9 patients for several months. Progressive pain in the elbow and/or wrist and mechanical symptoms were early and prominent symptoms of failure. Clinical signs of synovitis were frequently present. The majority of patients had a slow but progressive onset of complaints over several months before presentation. Twelve of 15 cases of failed SRHP were surgically treated. Fragmentation of the implant, osteoarthritis, and synovitis were found in all surgically treated cases. Both surgical removal and synovectomy alone, and revision to a new radial head prosthesis resulted in good medium-term outcomes with a mean SANE score of 7.3 points at 8.4 years of follow-up. Postoperative extension lags and mild instability were frequently mentioned as a reason for reimplantation of a metallic radial head implant and removal of the radial head alone, respectively. Both patients and physicians should be aware of early symptoms of a failing SRHP. Adequate recognition, radiographic evaluation, and early intervention may favor outcomes of failing SRHP. Surgical removal is easy to perform. In selected cases, revision of the radial head prosthesis may be considered. Both of these treatment strategies resulted in satisfying outcomes.

Localized Pigmented Villonodular Synovitis in a Child: About a Case

Pigmented Villonodular synovitis (PVNS) is a rare benign proliferative condition affecting synovial membranes of joints; it occurs in two forms, localized (LPVNS) and diffuse (DPVNS). We report a case of a 12 years old with LPVNS, confirmed on surgical biopsy. The patient underwent a surgical synovectomy, with good evolution after 1 year follow-up. PVNS is most common in early to middle age, It still exceptional in children. Clinically, its symptology remains aspecefic. This is often a cause of delay in diagnosis. Magnetic resonance imaging (MRI) is the exam of choice. Only a synovial biopsy with histological study confirms the diagnosis; the treatment typically involves surgery: synovectomy, with a risk of recurrence.

Pexidartinib in the Management of Advanced Tenosynovial Giant Cell Tumor: Focus on Patient Selection and Special Considerations.

Tenosynovial giant cell tumor (TGCT) is a neoplasm of the joint synovium that can have severe impacts on joint mobility, function, and quality of life. Traditionally, treatment modalities included partial or complete surgical synovectomy, radiotherapy (typically as an adjunct to surgery), and watchful monitoring (no medical or surgical intervention). However, these approaches have been met with varying degrees of success and high recurrence rates, as well as onerous complications and clinical sequelae. Pexidartinib, a colony-stimulating factor 1 receptor (CSF1R) inhibitor, presents a promising molecular approach that targets a neoplastic driver of TGCT. While the introduction of pexidartinib allows clinicians to avoid the significant morbidity associated with traditional treatment options, there are also defined risks associated with pexidartinib treatment. Therefore, patient selection is critical in optimizing treatment modalities in TGCT. The purpose of this literature review is to identify the TGCT patient population that would derive maximal benefit with minimal risk from pexidartinib, and to determine the specific indications and contraindications for selecting pexidartinib over other therapeutic approaches. Specifically, this paper compares the efficacy and safety profile of pexidartinib across clinical and preclinical studies to that of surgery, radiotherapy, and watchful monitoring. Rates of improvement in joint mobility, pain, and recurrence-free survival across studies of pexidartinib have been encouraging. The most common adverse events are mild (hypopigmentation of the hair) or reversible (transient aminotransferase elevation). Severe or permanent adverse events (notably cholestatic hepatotoxicity) are rare. While the optimal treatment strategy remains highly dependent on a patient’s clinical circumstances and treatment goals, pexidartinib has surfaced as a promising therapeutic in cases where the morbidity of surgery or radiotherapy outweighs the benefits.

MRI-Derived Radiomics of Hemophilic Arthropathy Is Associated with Severity of Joint Disease

IntroductionJoint bleeding resulting in synovial hypertrophy and articular cartilage damage are the hallmarks of hemophilic arthropathy. Early prophylaxis with extended half-life factor products and non-factor replacement therapies reduce joint bleeds but do not provide complete protection from development of arthropathy. MRI is the gold standard imaging technique to diagnose and monitor arthropathy in hemophilia. MRI changes that are associated with joint bleeding and development of arthropathy, however, are not sensitive enough to detect early changes in the synovial membranes after sub-clinical bleeding. Radiomics, the computerized extraction of sub-visual attributes from imaging scans can detect early changes of hemophilic arthropathy and help in more accurate characterizations of severe joint disease. The goal of this project was to develop and compare MRI radiomics with the International Prophylaxis Study Group (IPSG) score, an established MRI joint disease scale, in assessing the severity of joint disease.MethodsAfter IRB approval, knee MRI scans of 17 hemophilia patients with a history of joint bleeding and 12 age-matched healthy controls were included in this study. Manual annotations were performed in consensus by a board-certified musculoskeletal radiologist to include the prefemoral fat, suprapatellar fat pad and bursa . To ensure that the signal intensities from different cases were in tissue-specific correspondence, a landmark-based histogram transformation was used to align MRI signal intensity distributions across all cases. 560 radiomic features capturing MRI pixels texture heterogeneity (Gabor wavelets, Laws texture, Haralick and GoLIAGe co-occurrence patterns) were subsequently extracted on all MRI slices with ROI for all the cases. Top 2 radiomic features (F 2) for differentiating between abnormal joint changes and control were selected by Minimum Redundancy Maximum Relevance (mRMR) algorithm with 100 iterations of 3-fold cross-validation. Consensus hierarchical clustering was then applied on F 2, from which two patient clusters were generated. A disease severity score was calculated based on historical lifetime bleed events in the joint, designation of target joint status, and history of surgical synovectomy. A previously described 17-point MRI IPSG score was also calculated by 2 independent reviewers. Both the IPSG score and the F 2 were then fit into a linear regression model separately as predictors whereas the disease severity score was set to be the response variable. The Akaike's Information Criteria (AIC) and the root mean square error (RMSE) were used to evaluate the model fitness and the likelihood ratio (LR) test was applied for model comparison.ResultsThe dataset consisted of 17 males with moderate and severe hemophilia ranging in age from 10-55 years. The median disease severity score was 2 (0-11) and the median IPSG MRI Score was 2 (0-11). The top 2 radiomic features F 2, a Gabor wavelet feature and a Lawshc texture feature, yielded an AUC of 0.94 and an accuracy of 0.9 for differentiating between hemophilic joint changes and healthy control patients. Unsupervised clustering demonstrated good separation between the two classes (Fig panel A and B). The radiomic-based linear regression model (AIC: 86.67; RMSE: 2.86) was significantly better than the IPSG score-based model (AIC: 94.24; RMSE: 3.66) in joint disease severity characterizations (LR, p = 0.0083, Fig panel C).ConclusionsRadiomic analysis of knee MRI in hemophilia patients with history of joint bleeding is correlated with the severity of joint disease. Our study demonstrates the feasibility of developing and utilizing a radiomics based tool to detect the severity of joint damage in a small population of knee joint hemophilic arthropathy. We plan to perform an Independent validation of the radiomics signature in a larger dataset of hemophilia joint MRI scans [Display omitted] DisclosuresMadabhushi: Astrazeneca: Membership on an entity's Board of Directors or advisory committees; Bristol Meyers-Squibb: Membership on an entity's Board of Directors or advisory committees; Merck: Membership on an entity's Board of Directors or advisory committees; Roche: Consultancy; Caris: Consultancy; Aiforia: Consultancy; Philips: Research Funding; AstraZeneca: Research Funding; Boehringer-Ingelheim: Research Funding; Bristol Meyers-Squibb: Research Funding. Ahuja: Sanofi: Membership on an entity's Board of Directors or advisory committees; XaTek, Inc: Patents & Royalties; Genentech: Membership on an entity's Board of Directors or advisory committees; Takeda: Other: DSMB member .

Modified Lateral Approach of the Elbow for Surgical Release and Synovectomy.

Elbow stiffness is a common reason for consultation. In recent years, arthroscopic techniques in elbow surgery have progressed, but there are still some contraindications to performance of arthroscopic synovectomy and release in this joint (elbows with anatomic deformity after multiple procedures, malunion, presence of osteosynthesis material, severe stiffness of >80 degrees, instability, or previous transposition of the ulnar nerve). Therefore, knowledge of a safe and reliable open approach to achieve elbow release and/or synovectomy is essential. We report the technical details of the modified lateral approach between extensor carpi radialis brevis and longus muscles, as well as the clinical results of 43 elbow release and/or synovectomy procedures, illustrating its feasibility. The modified lateral approach, providing visual control of the radial nerve and good anterior exposure of the elbow joint, is detailed. From 1994 to 2016, this approach was used in 43 release and/or synovectomy procedures of the elbow in 41 patients, 30 men and 11 women, with a mean age of 40.56 years (range, 17 to 84 y). Using this procedure, 38 elbows (93%) recovered full extension and 5 subtotal extension with an average deficit of 11 degrees (range, 5 to 20 degrees). All elbows were stable. No neurological complications were reported. The modified lateral approach preserves the insertion of the lateral epicondyle muscles that are major dynamic stabilizers and reduces the risk of instability. Initially described for the treatment of radial tunnel syndrome, it should also be recommended for elbow release and synovectomy.

Functional improvement and low recurrence rate after combined staged synovectomy and external radiotherapy for diffuse pigmented villonodular synovitis of the knee: a minimum 2 years' follow-up case series

ObjectiveTreatment of diffuse pigmented villonodular synovitis (DPVNS) of the knee is problematic and controversial with a high rate of morbidities and local recurrence. The purpose of this study is functional evaluation of patients with diffuse knee PVNS treated with combined surgical and external radiosynovectomy.MethodsBetween June 2011 and May 2015, twelve patients (four males and eight females) with DPVNS of the knee were treated by staged surgical synovectomy (arthroscopic anterior and open posterior) followed by low-dose external radiation. SF-36, Musculoskeletal Tumor Society (MSTS), Lysholm, International Knee Documentation Committee (IKDC) scores and range of motion (ROM) were assessed preoperatively and at the final follow-up.ResultsAfter a mean follow-up period of 46.7±15 (25–72) months, there were statistically significant improvement of ROM from 72.5±17.6 to 94.2±7.01, Lysholm score from 42.8±5.2 to 78.1±5.1, IKDC from 39.6±8.3 to 75.3±6, MSTS from 5.6±2.7 to 19.7±6.06 and SF-36 score from 29.4±7.5 to 72.3±17.5. Apart from limited range of motion, three mild complications were encountered (superficial wound infection, repeated effusion and transient neuropraxia).ConclusionCombined staged synovectomy and external radiotherapy provide functional improvement of the knee and quality of patients’ lives with low rate of recurrence for knee DPVNS cases.Level of evidenceProspective case series; level IV.

Pigmented Villo-Nodular Synovitis of Shoulder Joint Leading to Humeral Head Erosion

Pigmented villo-nodular synovitis (PVNS), also known as giant cell tumor of the tendon sheath or benign synovial histiocytoma, is a benign yet locally aggressive tumor of the synovium that affects both the large joints and the tendon sheaths. The most common site for the tumor includes knees, hip, ankle, and wrist joints; shoulder joint being a very unusual site for the occurrence of this tumor. We present here an unusual case of diffuse PVNS of shoulder joint with eroded humerus head treated with surgical synovectomy and adjuvant radiosynovectomy to prevent recurrence. This case report highlights the natural history of this rare disease due to late presentation, difficulty in the diagnosis, and management of recurrence.

Clinical Improvement after Surgical Debridement and Synovectomy on 4 Year Old Girl with Chronic Septic Arthritis of the Hip

Background: Incidence of septic arthritis in children less than 5 years old about 5 from 100,000 cases every year and adult above 64 years old about 8.4 cases every 100,000 people every year. The diagnosis of the chronic septic arthritis, especially in hip joint is still challenging, even for skilled doctor in musculo­skeletal. Delayed diagnosis and inadequate treatment can lead to permanent joint damage and impairment. Case presentation : In this case we discuss about clinical improvement of chronic septic arthritis in a 4 year old girl with hip pain that had been felt since 2 months before admission. Physical examination, laboratory examination, and ultrasonography examination was done and the diagnosis had been made. Results: A surgical debridement and syno­vec­tomy was done with addition antibiotic therapy. The patient not only felt the pain was relieved but also can return into good function of hip joint. Conclusion: Diagnosis with proper early treatment is expected to reduce permanent joint loss and improve the clinical outcome for the patient. Keyword s : septic arthritis, hip, synovectomy, surgical debridement Correspondence: Pamudji Utomo. Prof DR R Soeharso Ortho­paedic Hospital, Pabelan, Kartasura, Surakarta, Central Java. Email: scapoid@yahoo.com. Indonesian Journal of Medicine (2020), 05(03): 253-258 https://doi.org/10.26911/theijmed.2020.05.03.11