Total Synovectomy Research Articles

A Successful Arthroscopic Management of a Benign but Locally Aggressive Tenosynovial Giant Cell Tumour in the Shoulder.

Introduction Pigmented villonodular synovitis (PVNS) is a relatively rare disorder affecting the synovial membrane and tendon sheath of a joint. It rarely affects the shoulder joint. This prospective study aims to document the challenges encountered in achieving total synovectomy and assesses the clinical outcomes of arthroscopic synovectomy for PVNS in shoulder patients. Methods This is a prospective study conducted from April 2017 to September 2023. This monoarticular disease was observed among six patients (four females and two males). All patients underwent arthroscopic extensile synovectomy with biopsy and culture. The outcomes were measured using Constant score,American Shoulder and Elbow Surgeons (ASES), and University of California Los Angeles (UCLA) scores. All patients were followed up for a minimum of 36 months after arthroscopic synovectomy. Results All intraoperative findings were consistent with PVNS and confirmed with histopathological examination. All patients achieved a satisfactory, painless range of movements following surgery. The individual Constant score improved from a mean value of 64.83 to 94.50, the ASES score improved from a mean value of 81.15 to 99.73, and the UCLA score improved from a mean value of 23.16 to 34.83 post-arthroscopic intervention, proving its effectiveness. No recurrences were reported after 36 months of follow-up. Conclusion PVNS can be easily missed, and one must have a high index of suspicion to diagnose early.Delayed presentation of the disease had led to severe destruction of the joint. Early diagnosis and arthroscopic intervention prior to joint destruction are crucial for achieving a good functional outcome. Incomplete excision may lead to recurrence of the disease. Therefore, we propose extensile arthroscopic synovectomy of the shoulder, wherein by expecting and addressing the intraoperative challenges, complete excision can be achieved, thus preventing recurrence.

The Impact of Total Synovectomy on Blood Loss and Knee Function. A Prospective Randomized Study

"Synovial proliferation is a common intraoperative finding during total knee arthroplasty (TKA) and many studies have proposed synovectomy for the reduction of postoperative pain. We included 180 patients that were split into two groups, one which received a total synovectomy (TS) and the other with partial synovectomy (PS). We measured the amount of intra- and post-operative bleeding as well as perceived pain (using the Visual Analogue Scale) and knee function (using the Knee Society Knee Score) at 4 and 12 weeks. The blood loss during the surgical procedure was 367.77 ± 115.71 mL for TS, while the other group recorded 295.55 ± 106.17 mL (p < 0.05). Regarding postoperative bleeding, the TS group aspirated 533.77 ± 281.65 mL, which was significantly higher than the PS group (404.44 ± 211.55 mL, p < 0.05). No significant differences were recorded between the TS and PS groups regarding pain and knee function at 12 weeks. Total synovectomy demonstrated significantly higher blood loss and lower postoperative hemoglobin levels, even though knee function and pain level did not show improvements. We consider that the decision of performing synovectomy should rely on the clinical indication and, if conditions allow for it, a limited resection should be attempted."

Total Knee Arthroplasty in Unrecognized Septic Arthritis-A Descriptive Case Series Study.

Synovitis, like that associated with chronic bacterial arthritis, is a very rare finding during the implantation of knee endoprostheses. In such cases, we fix the knee prostheses with cement containing two antibiotics and carry out a course of systemic antibiotic administration. The aim was to analyze these cases for incidence, detection of bacteria, risk factors, and outcome. Out of 7534 knee replacements between January 2013 and December 2020, 25 cases were suspected during the surgical procedure to have suffered from bacterial arthritis and were treated accordingly. Total synovectomy was carried out, whereby five intraoperative synovial samples were examined bacteriologically, and the complete synovitis was analyzed histologically. The mean follow-up was 65.3 ± 27.1 (24-85) months. In nine cases (0.12%), the diagnosis of bacterial arthritis was made histologically and by clinical chemistry (elevated CRP), and in two of these cases, pathogen verification was performed. Eight of these nine patients had previously had injections or surgery associated with the corresponding knee joint or had an underlying immunomodulatory disease. None of the patients developed a periprosthetic infection at a later stage. With an incidence of 0.12%, it is rare to unexpectedly detect bacterial synovitis during surgery. Total synovectomy, use of bone cement with two antibiotics, and immediate systemic antibiotic therapy seem to keep the risk of periprosthetic infection low.

Tenosynovitis of the Flexor Digitorum and Flexor Carpi Caused by <i>Mycobacterium Tuberculosis</i>: Case Report and Review

Background. Mycobacterial tenosynovitis of the hand and forearm is an extremely rare form of extrapulmonary tuberculosis, which can lead to permanent disability of patients.
 Case presentation. We present a rare clinical case of generalized tenosynovitis of the tendons of all hand and finger flexors of the right upper extremity caused by Mycobacterium tuberculosis (MBT). Patient complained of a lump on the palmar surface of the right hand with periodic spontaneous discharge in the form of rice grains. MRI revealed a peritendinal synovial cystic mass on the volar surface of the hand and wrist joint with the presence of multiple chondromal bodies, tendinitis and tenosynovitis of the flexor of IV and V fingers. Removal of the neoplasm, pathological tissues, and total synovectomy were performed. Intraoperative material was tested using PCR. DNA of Mycobacterium tuberculosis complex was detected.
 Conclusion. Presented case report demonstrates the importance of preoperative MRI examination in tenosynovitis of unknown etiology and the necessity of histological and bacteriological examination of intraoperative material. Transportation of obtained tissues for examination should be performed without the use of formalin in order to exclude false negative results. One should be vigilant against nonspecific infections, including Mycobacterium tuberculosis, when treating patients with immunocompromising diseases. The presence of limb neuropathy, instrumental signs of the second or the third stage of tuberculous tenosynovitis according to Kanavel classification are indications for surgical treatment.

Total Synovectomy and Bone Grafting/Cementation after Curettage of the Bone Lesion in Diffuse‏ Type ‏of Tenosynovial‏ Giant Cell Tumor‎: A Retrospective Cohort Study.

Although the diffuse type of tenosynovial giant cell tumor (D-TGCT) is rare, bone involvement is common in such lesions. However, the optimal management of bone lesions in D-TGCT is not well-described. In this study, we reported the outcomes of total synovectomy, curettage, and bone grafting/cementation in the treatment of D-TGCT with subchondral bone involvement. We also described the prevalence, demographic, and characteristic features of the lesions. In a retrospective study, we included 13 patients with D-TGCT of large joints and associated subchondral cyst/cyst-like bone lesions of ≥ 5 mm that were managed with total synovectomy and curettage. Cavities with a bone defect of ≤ 30 mm (n=12) were filled with bone grafts. Cavities of > 30 mm (n=1) were augmented with bone cement. The limb function was evaluated by the Musculoskeletal Tumor Society (MSTS) score. The study population consisted of 6 (46.1%) males and 7 (53.9%) females with a mean age of 30 ± 7.9 years. The most frequent sites of involvement were the knees and ankle joints (n=5 each, 38.5%). The mean follow-up of the patients was 69.2 ± 32.9 months. The mean MSTS score of the patients was obtained at 98.2 ± 3.2 (range 90-100). The D-TGCT recurred in two patients, both of which were in the synovium. Postoperative complications were three cases of transient pain and one case of knee joint stiffness. While no patient had an osteoarthritic change in preoperative radiographs, two patients had osteoarthritic change (grade II) in the last follow-up, one in the knee and one in the hip. Curettage and filling the defect with bone graft or cement are adequate treatments for managing bone lesions in D-TGCT.

Ceramic Liner Fracture in Total Hip Arthroplasty: A Case Report

Background. Ceramic component fracture is a severe complication of primary and revision total hip arthroplasty, leading to multiple revision surgeries.
 Case report. This report of rare clinical case of ceramic liner fracture. Fifteen months after a planned left hip replacement, the patient experienced anterior surface pain in the area of the operated joint accompanied by creaking, so the patient went for a consultation. Based on the results of the consultation, the patient was urgently hospitalized and underwent a delayed surgery for revision arthroplasty. Radiologically, there was varus position of the femoral component, dislocation of the bearings. MSCT showed ceramic liner fracture and fragment dislocation. Intraoperatively, the multifragmentary fracture of the liner, significant damage to the head, and retroversion of the acetabular component (retroversion was detected on the preoperative CT scan) were identified. All components of the endoprosthesis and tribologic bearings were replaced with identical ones, total synovectomy was performed, and the wound was cleaned and sanitized.
 Conclusion. The presented case report demonstrates the danger of incorrect positioning of the components when using a ceramic bearings. In this case, retroversion of the acetabular component and varus position of the femoral component resulted in a reduced contact area between the head and the liner, which caused the ceramic to fracture. The described observation confirms the need for further in-depth study of the ceramic bearings in order to prevent ceramic component fracture, as it leads to severe complications and significant economic costs.

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.

Clinical results of a 10-year follow-up of surgical treatment for elbow stiffness in rheumatoid arthritis: A case series

BackgroundRheumatoid arthritis commonly causes transient limitation of joint motion, but the treatment of persistent stiffness in the rheumatoid elbow has rarely been reported. The purpose of this study was to evaluate the long-term clinical results of surgical treatment of rheumatoid elbow stiffness. MethodsSurgical treatment, including open arthrolysis with hinged external fixation, total synovectomy, and ulnar nerve release and anteriorization, was performed in 48 elbows in 43 patients with rheumatoid arthritis and early joint destruction. Mobility (flexion-extension and pronation-supination), Mayo Elbow Performance Score (MEPS), visual analog scale (VAS) score, muscle strength, nerve symptoms, postoperative complications, and recurrent synovitis were evaluated 9–11 years (average, 9.88 years) postoperatively. ResultsThe mobility of the elbow was significantly improved over the preoperative period either in extension, flexion, protonation, supination (P < .001, P < .001, P < .001, P = .002). The mean MEPS was significantly improved from 56.25 points (range, 30–90) to 87.40 points (range, 40–100) (P < .001). The pain was relieved, and the mean VAS score was reduced from 3.56 (range, 0–8) to 1.08 (range, 0–5) points (P < .001). Preoperative ulnar nerve symptoms were observed in 17 patients and relieved in 10 (59%) patients, and the mean Amadio score was raised from 6.9 (range, 3–9) to 7.96 (range, 4–9) points (P < .001). Through surgical treatment and postoperative rehabilitation, the mean grip strength of the patients was significantly improved from an average of 9.01 (range, 3.4–18.5) to 17.56 kg (range, 3.9–40.2) (P < .001). Five elbows developed recurrent synovitis, and one underwent total elbow arthroplasty. Postoperative complications were uncommon and not severe. ConclusionSurgical treatment is a reliable procedure for rheumatoid elbow stiffness and can be effective in improving elbow mobility, function, muscle strength, pain relief, and relief of nerve symptoms.

Giant Cell Tumor of Bone Versus Tenosynovial Giant Cell Tumor - Similarities and Differences.

Giant cell tumor of bone (GCTB) and tenosynovial giant cell tumor (TGCT) share misleadingly similar names, soft texture and brown color macroscopically, osteoclast-like multinucleated giant cells microscopically and localisation in the musculoskeletal system. However, these two tumor types are biologically and clinically two distinct entities with different natural courses of progression and considerably different modes of surgical and medical treatment. In this article, we provide a detailed update on the similarities and the differences between both tumor types.GCTB is a locally aggressive osteolytic bone tumor, commonly seen in patients in their third decade of life. It usually occurs as a solitary lesion in the meta-epiphyseal region of long bones. It can be diagnosed using plain radiographic imaging, CT radiography or MRI to estimate the tumor extent, soft tissue and joint involvement. GCTB is usually treated with intralesional excision by curettage. Systemically, it can be treated with bisphosphonates and denosumab or radiotherapy.TGCT is a rare, slowly progressing tumor of synovial tissue, affecting the joint, tendon sheath or bursa, mostly seen in middle-aged patients. TGCT is usually not visible on radiographs and MRI is mostly used to enable assessment of potential bone involvement and distinguishing between two TGCT types. Localised TGCT is mostly treated with marginal surgical resection, while diffuse TGCT is optimally treated with total synovectomy and is more difficult to remove. Additionally, radiotherapy, intraarticular injection of radioactive isotopes, anti-TNF-α antibodies and targeted medications may be used.

The not so familiar silent joint killer: Ochronosis – A case report with review of literature

Ochronosis is rarely considered a cause for knee synovitis due to its rare occurrence. It starts affecting the joint from the third decade onward causing premature joint damage. The damaged joint and surrounding tissue present as blackish decolorated mass and can surprise the operating surgeon, unless diagnosed beforehand. Prior diagnosis helps both the anesthetist and operating surgeon to better handle the associated complications of ochronosis during surgery. Diagnosis is essentially based on prior knowledge of the disease and its markers. Here, we report a rare case of ochronosis of the knee that was treated elsewhere previously as tuberculosis of the knee. A history evaluation along with intraoperative findings helped arrive at the possible diagnosis of ochronosis. Total synovectomy was done. Postoperative improvement of visual analog scale score was significant and the patient was satisfied with the pain relief attained through treatment. Early diagnosis and timely management is critical to avoid unwanted complication related to both anesthesia and surgery pertaining to the disease. Knowledge of skin markers and urine darkening helps in identifying the disease early.

The histopathological synovitis score is influenced by biopsy location in patients with knee osteoarthritis

IntroductionOsteoarthritis (OA) and rheumatoid arthritis (RA) represent the most common forms of arthritis, which are mainly caused by mechanical and inflammatory components, respectively. Determination of synovial inflammation in synovial biopsies via the histopathological Krenn score may be crucial for correct diagnosis and treatment. Specifically, it remains unclear whether synovitis scores differ among multiple biopsy locations within a single joint.Materials and methodsEighty synovial samples were taken from four standardized regions of the knee in 20 patients (ten primary OA, ten secondary OA) undergoing total knee arthroplasty (TKA) or total synovectomy. The Krenn synovitis score (grade 0–9) was determined in a blinded manner by two expert pathologists in all biopsies. Next to the inter-rater reliability, we evaluated the agreement of the determined scores among the four biopsy locations within each knee.ResultsThe inter-rater reliability between the two pathologists was very high (Cohen’s kappa = 0.712; r = 0.946; ICC = 0.972). The mean synovitis score was significantly higher in knees with secondary than in primary OA (p = 0.026). Importantly, we found clear differences between the scores of the four different biopsy locations within the individual knee joints, with an average deviation of 10.6%. These deviations were comparable in knees with primary and secondary OA (p = 0.64).ConclusionsWhile we confirmed the synovitis score as a reliable and reproducible parameter to assess the histopathological synovitis grade in the knee, the considerable variability within the joint indicates that multiple synovial biopsies from different regions should be obtained to enable reliable results of the synovitis score.

A Rare Cause of Joint Pain: Synovial Haemangioma

A 17-year-old girl was admitted with complaints of recurrent pain, swelling and tenderness in her left knee since she was 3 years old. The swelling of the knee has occasionally increased. She was diagnosed as chronic arthritis and non-steroidal anti-inflammatory drugs were recommended before admission. With non-steroidal anti-inflammatory drugs, her pain was relieved initially but only partially resolved. On admission, physical examination was unremarkable for arthritis. There was localized swelling measuring 3,5x4 cm in diameter on the upper part of left knee. Acute phase reactants and antinuclear antibodies were negative. Magnetic resonance imaging showed synovial haemangioma characterized by a well-circumscribed contour with a lobule filling the left suprapatellar bursa and space- filling formation with heterogeneous intense contrast enhancement after contrast agent administration (Figure 1). It was required open total synovectomy and mass resection (Figure 2), and histopathological findings were compatible with cavernous haemangioma. Joint pain in children can be result from a variety of acute and chronic diseases.1 Synovial hemangioma, a benign tumor that occurs in children and young adults, is a non-common cause of recurrent nontraumatic pain and swelling in the knee.2,3 It can cause cartilage erosion and degenerative joint disease in untreated cases. Therefore, early diagnosis is essential.4 Tumor and tumor like lesions such as synovial haemangiomas should be kept in mind in patients with extraordinary findings in single joint. In case of doubt, imaging methods should be used for early diagnosis and prevent long term sequel especially for intra-articular lesions.

Metallosis after knee replacement: a review.

Although metallosis is a well-known complication after total hip arthroplasty, little is known about this phenomenon after total (TKA) or unicompartmental knee arthroplasty (UKA). The aim of the present work was to review the current knowledge about the reasons and the diagnostic as well as therapeutic management of metallosis after knee arthroplasty. A literature search was performed through PubMed until April 2019. Search terms were "metallosis" in combination with "knee", "knee prosthesis", "knee arthroplasty" and "knee replacement", respectively. All publications were analyzed regarding publication year, level of evidence, number of knees/patients treated, type of prosthesis, metallosis cause, time period between primary implantation and metallosis emergence, laboratory examination, treatment, complications and follow up. A total of 38 studies reporting on a total of 97 knees were identified. 29 studies reported on metallosis after TKA, 8 after UKA, and one study after both procedures. The time period between the primary implantation and metallosis emergence ranged between 6weeks and 26years. The most common reason was the failure of a metal-backed patellar component in 40%, followed by implant/structural- and PE failure (wear/dislocation) in 27% and 18% of the cases, respectively. Complete blood cell count, serum chemistry, erythrocyte sedimentation rate or C-reactive protein serum values were not indicative to diagnose metallosis. The diagnosis was confirmed by histopathological analyses and macroscopic evaluation during surgery. Depending on the particular cause various surgical procedures have been performed. Complete prosthesis exchange was the most common one showing no complications in 89.4% of the cases. Metallosis after knee arthroplasty is a rare and perhaps underestimated or under published complication. A systematic diagnostic approach is necessary for the timely and correct diagnosis. A thorough debridement as well as a (sub)total synovectomy should be always performed. In cases with a damaged component, a partial/complete prosthesis exchange leads to the best results. Should a malalignment be the cause of the metallosis, then it should be corrected within the revision surgery.

Results of muscle strength and range of motion after total open knee synovectomy.

Scar tissue formation after synovectomy limits range of motion and causes muscle atrophy. The functional results for patients who underwent total open knee synovectomy often included questionnaires, and assessment of muscle strength was lacking in the literature. Therefore, we aimed to identify the strength and range of motion outcomes for patients who underwent total open synovectomy and to compare the results with the contralateral limb and healthy individuals. Knee range of motion and muscle strength were assessed in fourteen patients that underwent total (anterior and posterior) open knee synovectomy and were compared with the contralateral limb and with 14 healthy individuals matched by sex, age, height, and weight. The range of motion of flexion decreased 8.4% compared with the contralateral limb (95% CI - 18.9 to - 4.7, p = 0.002) and 9.9% compared with the control group (95% CI 3.9-14.9, p < 0.01). Knee extension strength decreased by 35% compared with the contralateral limb (95% CI 11.1-77.2, p = 0.01) and 37% compared with the control group (95% CI - 112.4-12.1, p = 0.01). Despite the aggressiveness of the surgical procedure, the patients achieved satisfactory functional results.

Synovial Chondromatosis in Woman with Symptoms Mimicking Early Stages Osteoarthritis: Case Report

ABSTRACT Synovial chondromatosis is a case that rarely found epidemiologically. It is a process which is benign in the synovial lining of joints, synovial sheaths, and bursae. It is the metaplastic process of synovium, which converts it into the cartilage and gets detached to become a loose body. Methods of this study are describing a case report of patient of Airlangga University Hospital that has synovial chondromatosis. A 38 years old woman, with a one-year history of pain, edema, and restriction of the left knee joint. Patient symptoms were insidious in onset, which gradually progressed. Decreased range of motion of her knee. The symptoms were mimicking of osteoarthritis. Considering the extensive involvement with multiple nodule masses inside the knee joint, we planned surgical management and open procedure. Total synovectomy was done, synovium and the masses were sent for histopathological examination which confirmed the diagnosis of synovial chondromatosis. In our case, the patient has clinical symptoms mimicking osteoarthritis of genu. Some study reported similar cases. Although synovium osteochondromatosis is a rare case and it should be kept as a differential diagnosis with chronic knee pain with swelling. Synovial chondromatosis is a rare case in the orthopedic patient. Diagnosis of synovial chondromatosis is often made following a thorough history, physical examination, and radiographic examination and histopathologic. In our case report, we present synovial chondromatosis in woman mimicking osteoarthritis. Patient treated by surgical removal of the loose bodies followed by total synovectomy. Keywords: Synovial chondromatosis, osteoarthritis, total synovectomy

Pigmented villonodular synovitis after anterior cruciate ligament reconstruction using active bioprosthetic composite artificial ligament

Pigmented villonodular synovitis (PVNS) is a proliferative disease that develops in the synovium of joints, especially the knee joints. A 52-year-old man visited our hospital with left knee pain, swelling and symptoms of collapse. Twenty-one years earlier, he had undergone anterior cruciate ligament (ACL) reconstruction using an active bioprosthetic composite (ABC) as an artificial ligament. T1 and T2 weighted magnetic resonance imaging of the knee joint showed rupture of the ABC ligament and low signal intensity of hyperplastic synovium. Arthroscopic total synovectomy without ACL reconstruction was performed and the lesion was histopathologically diagnosed as diffuse PVNS. Clinical outcomes included good pain relief and no recurrence of the disease after 5years of follow-up.

Immediate and Long-Term Outcomes Following Orthopedic Procedures in Patients with Hemophilia: A Three-Decade Retrospective Review

Introduction: Patients with hemophilia are at risk for developing hemophilic arthropathy and may require orthopedic interventions at a young age. It is unclear whether the advent of routine prophylaxis and comprehensive care have reduced the rates of orthopedic procedures in the past several decades, and whether improved supportive care have reduced perioperative complications. Aim: In this study, we aim to evaluate the overall trends of orthopedic procedures, surgical outcomes and healthcare utilization in patients with hemophilia who underwent orthopedic procedure in the past three decades. Methods: In this single-centre retrospective cohort study, adult patients with all severities of hemophilia who underwent at least one orthopedic procedure from January 1990-August 2018 at the University of Alberta Hospital were included. Demographic data, hemophilia history, details of orthopedic procedure, perioperative factor administration were collected. Temporal changes in the types of procedures, factor utilization, and outcomes were examined using descriptive analyses. Results: In the last 3 decades, 17 patients underwent 50 orthopedic procedures in our institution, including total knee arthroplasty (TKA) (n=18), TKA revision (n=8), total hip arthroplasty (n=5), ankle fusion (n=5), synovectomy (n=4), and others (n=10). Median age at the time of the procedure was 41 years (interquartile range IQR 31-48), and median BMI was 25 (IQR 22-39) (Table 1). Fourteen patients have hemophilia A and 3 have hemophilia B, including severe hemophilia in 13 (76%). Four patients (24%) have active inhibitors at the time of surgery. Ten (59%) patients had active hepatitis C infection at the time of surgery, whereas none had HIV infection. There is a reduction in the number of orthopedic surgeries performed over time (Table 2). There was a significant reduction in the length of stay from 1990-2000 to 2001-2018 (median 20 days vs 6 days, P &lt;0.001). Overall perioperative coagulation factor concentrates were prescribed for a median of 10 days (IQR 7-20), whereas active inhibitor patients received bypassing agent coverage for a longer duration (median 17 days, IQR 10-21). There was a significant reduction in the perioperative factor VIII utilization over time (P=0.02), and a similar trend in factor IX utilization (Table 2). Tranexamic acid was used perioperatively in the majority (68%) of procedures for a median of 10 days. Pharmacologic thromboprophylaxis was prescribed in 15 (30%) procedures for a median of 8 days (IQR 7-13), intermittent pneumatic device was prescribed in 2, the remaining procedures had no documented thromboprophylaxis. Postoperative complications include major bleeding (n=2) and clinically relevant non-major bleeding (n=6), prosthetic joint infection (n=10), aseptic loosening requiring revision (n=2), poor wound healing complicated by skin necrosis (n=2), and deep vein thrombosis (n=1). The 10 infectious complications occurred in 6 patients, including early prosthetic joint infection &lt;4 weeks in 6 cases, despite common use of prophylactic antibiotics in 92% of all cases. Pharmacological thromboprophylaxis was not associated with an increased risk of bleeding. There were no inhibitor development or arterial thromboses perioperatively. All complications occurred in surgeries performed prior to 2011. Conclusions: Over the past three decades, we observe a decline in the number of orthopedic procedures performed in patients with hemophilia, likely reflecting the impact of routine prophylaxis and changes in practice patterns. Orthopedic outcomes have improved over time, in conjunction with a reduction in healthcare utilization including shorter length of stay and reduced factor utilization. Disclosures Sun: Octapharma: Consultancy, Research Funding; Novo Nordisk: Consultancy.

PO 18254 - Synovial giant cell tumor of the ankle

Introduction: Synovial giant cell tumor is a benign neoplasm that is rarely reported in the form of malignant metastasis. Synovial giant cell tumor most frequently occurs in the hand, hip and knee and rarely occurs in the ankle and foot. The present study describes 2 rare cases of synovial giant cell tumor located in the hindfoot (one with diffuse disease with tibiotarsal and subtalar joint involvement and the other with signs of periarticular ankle involvement) and describes the chosen treatment. Methods: Two consecutive patients were evaluated, and a brief literature review was performed. Results: Open synovectomy was performed in both cases, with complete tumor resection and satisfactory patient progression. Conclusion: Open synovectomy was found to be a good method for the treatment of these lesions because it enabled a satisfactory approach, with good visualization of the ankle compartments and underlying joints and the ability to efficiently provide marginal excision, total synovectomy and complete tumor resection for arthrotomy, without postoperative complications.

Diffuse pigmented villonodular synovitis: An exuberant presentation

We present a case of a 44-year-old male, with a history of right knee swelling from insidious onset and two years of progressive evolution. There was not history of trauma or other associated symptoms (fever, pain, asthenia, weight loss, and other swollen joints). He was referred to the orthopedic consultation by the primary health care specialist, after unspecific knee magnetic resonance imaging (MRI) and needle arthrocentesis, followed by unsuccessful physical therapy sessions. At physical exploration it was clear a tender and voluminous swelling of the right knee, especially at the sub-quadricipital bursa, without other clear inflammatory signs (Figure 1). The patient denied other symptoms or even knee pain at exploration, although it as present on daily activities. The X-ray images were considered normal, without bony lesions. At the MRI, there was a signal increase with heterogeneous shape, especially at sub-quadriceps and suprapatellar bursa, without bony erosion (Figure 2). However, small areas of hippo-signal were observed which determine some intra-sac septations and vegetations, aspects which may be compatible with pigmented villonodular synovitis (PVNS). He has proposed to knee arthroscopy and needle arthrocentesis for final diagnosis and further treatment. It was performed under general anesthesia, the initial arthrocentesis revealed a pathognomonic xanthochromic synovial fluid (Figure 3) >120 cc and the arthroscopy images (Figure 4) were clear of vascularized polypus formations spread through the entire synovial cavity, with higher density in sub-quadricipital area. Tissue and liquid samples were acquired for cytochemical, histologic, and microbiological identification. The histologic analysis revealed characteristic of chronic inflammation with, reactive hyperplasia of synovial tissue and presence of high hemosiderin deposits in the synovial stroma (Figure 5A). At a second surgical time, after confirmation of diagnosis, the patient was submitted to total synovectomy with necessity of conversion from arthroscopic to open synovectomy (Figure 5B). Postoperative period and rehabilitation showed with no complications. At two years of follow-up there is still no clinical or imagiological sign of recurrence, and maintains annual consultation.