Purpose: In order to investigate if arthroscopic synovectomy is effective for non-responder by infliximab, anti-TNF-α antibody, for rheumatoid arthritis (RA), we assessed 7 patients including 10 arthroscopic synovectomy including in knee joint, in shoulder joint and in ankle joints respectively. Materials and Methods: We performed arthroscopic synovectomy in 10 joints of 7 patients to compare CRP and DAS28 before and after surgery at 6 and 50 weeks. Those patients include 1 male and 6 female from 49 to 68 years old with average of 62 years old. 3 patients was underwent arthroscopic synovectomy after 4 times of infliximab, 2 patients were after 5 times and 2 patient was 6 times. All patients were initially responder to infliximab and MTX but gradually the effect decreased, the average of CRP was 3.45±0.4 (2.7–5.6) mg/dl at the surgery. The indication of operation was that after treatment infliximab CRP was more than 2.5 mg/dl and the numbers of arthritis joints were limited to within five joints of relatively large joints such as knee, shoulder including ankles and wrists. After arthroscopic synovectomy we continued infliximab treatment with MTX in routine manner. Results: We detected synovium proliferation with vascular increase in patella femoral (PF) joint and around the meniscus and femoral and tibial side of the anterior cruciate ligament (ACL) in the knee joints. We also found synovial proliferation in rotator interval (RI) in the glenohumeral joint and fatty changing in subacromial bursa (SAB) in shoulder. In ankle joint we found synovial proliferation with white meniscoid between tibiofibular joint to develop impingement. Serum CRP was improved from 3.45±0.4 to 1.12±0.2 at 6 weeks, 1.22±0.4 at 50 weeks after arthroscopic synovectomy. There is no severe side effects by arthroscopic synovectomy during infliximab treatment, however 1 patient had slight rash that was improved. DAS28 was improved from 5.58±0.23, to 3.87±0.47 at 6 weeks, improved to 2.58±1.49 at 50 weeks after arthroscopic synovectomy. Conclusion: It is possible that arthroscopic synovectomy can be one of the effective method to continue infliximab treatment when its efficacy decreased or in non-respond of infliximab for RA patients

Synovitis of the smaller hand joints leads to soft-tissue and bony affections. Radiologically Larsen/Dale/Eek (LDE) distinguish 6 stages of increasing destruction. Tendon ruptures, swan-neck and buttonhole deformities may occur. In early stages, when the ligament- and capsule structures require no balancing therapy, arthroscopic synovectomy may be indicated in order to prevent fast deteriorating of the joints and disability. We perform the endoscopic procedure in the MCP- and PIP-joints, when an oligoarticular situation is present or single digits are affected, provided that the surrounding soft tissues are intact, in LDE-stages 0 to 2/3. We use the laser additionally for completion of the synovectomy and for shrinking of the capsule. Technically it is necessary to have an short optical device of 1. 0 diameter, miniaturised instruments, shaver and the laser at one’s disposal. The radial and the ulnar incision proximal to the joint are used. A pilot study of 12 patients with an arthroscopic, laser-assisted synovectomy in 20 joints of various digits (LDE 0 – 2) are opposed to 10 patients with an open synovectomy of 24 joints. The follow-up-period amounts to 9 months (6 – 9). We have looked after the reccurrence rate, the time-lag until the patients are pain-free, the necessary rehabilitation measures, the progression of the LDE-stages, and the subjective judment of the patients. Both groups had no recurrence of the synovitis in the joints cared for surgically. The period until the patients were free of complaints in the arthroscopic group amounts to 4 days, opposed to 10 days in the open surgery group. Radiologically both groups revealed no further bony destruction according to LDE. 12 physiotherapy treatments after open synovectomy are twice the amount needed for the endoscopic group. This is true also for the time away from work: 14 days against 7 days. The arthroscopically treated patients remark favorably the discrete scars, the relatively pain-free perioperative period, low tissue trauma, quick rehabilitation. In open surgery the patients complain about large scars and long postoperative swelling of the joints. We can not guarantee the completeness of the synovectomy in both procedures. The effect of the intraoperative lavage and the assistance of the laser are not entirely clear either. The arthroscopic synovectomy itself is technically easy to perform. Although in this pilot study we have small numbers only, the results suggest that arthroscopic synovectomy is low in tissue trauma, quick in rehabilitation, perfect in patient acceptance and followed by a very short time away from work compared to open surgery

To determine the long term outcome and complications associated with arthroscopic synovectomy in 22 knees with rheumatoid arthritis. A consecutive series of 22 knees in 18 patients with seropositive RA underwent arthroscopic synovectomy for painful and swollen knees unresponsive to medical treatment. All operations were performed by the senior author. The mean age at operation was 44 years (22–64). All pre-operative Xrays showed Larsen grade 2 or less and no knees demonstrated marked joint laxity. Knee Society scores were recorded pre-operatively and at review, with a mean follow-up of 8 years(6–16). Two out of 22 knees (9%) have undergone TKR at 1 and 2 years post synovectomy. Two patients underwent further synovectomy for persistent symptoms but have since remained well. No per-operative complications were recorded but one large haemarthrosis and one stiff knee requiring manipulation were seen. The mean clinical and function scores increased by 22 and 15 points respectively at follow-up. The mean length of stay was 3 days and radiographs of the 20 knees not undergoing prosthetic replacement have all shown a small progression of degenerative radiological change. This long-term study shows that arthroscopic synovectomy in appropriately selected patients with RA is a safe and reliable procedure with a low complication rate. The surgery is technically demanding but involves a shorter in-patient stay than with open synovectomy. The development of radiological degenerative changes were seen with all patients at review

The short-term assessment of 14 arthroscopic synovectomies of the elbow in 11 patients with rheumatoid arthritis showed that 93% achieved a short-term rating of excellent or good on the Mayo Elbow Performance Score. At the most recent assessment at an average of 42 months, however, only 57% maintained excellent or good results; four had required total elbow replacement. Although rehabilitation is facilitated by an arthroscopic procedure the results deteriorate more rapidly than after open synovectomy. This may be due to the limitations of the arthroscopic technique and is consistent with experience of the similar procedure in the knee. Recognition of the short-term gain and the potential for serious nerve injury should be considered when offering arthroscopic synovectomy

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

Aim of study: To determine the long term outcome and complications associated with arthroscopic synovectomy in 22 knees with rheumatoid arthritis. Methods: A consecutive series of 22 knees in 18 patients with seropositive RA underwent arthroscopic synovectomy for painful and swollen knees unresponsive to medical treatment. All operations were performed by the senior author. The mean age at operation was 44 years(22–64). All pre-operative Xrays showed Larsen grade 2 or less and no knees demonstrated marked joint laxity. Knee Society scores were recorded pre-operatively and at review, with a mean follow-up of 8 years (6–16). Results: Two out of 22 knees(9%) have undergone TKR at 1 and 2 years post synovectomy. One patient underwent a further synovectomy for persistent swelling at 2 years and has since remained well. No per-operative complications were recorded but one large haemarthrosis and one stiff knee requiring manipulation were seen. The mean clinical and function scores increased by 22 and 15 points respectively at follow-up. The mean length of stay was 3 days and Xrays of the 20 knees not undergoing prosthetic replacement have all shown a small progression of degenerative radiological change. Conclusion: This long-term study shows that arthroscopic synovectomy in appropriately selected patients with RA is a safe and reliable procedure with a low complication rate. The surgery is technically demanding but involves a shorter in-patient stay than with open synovectomy. The development of radiological degenerative changes were seen with all patients at review

Purpose: Synovium proliferation of rheumatoid arthritis (RA) is a key role in development of destruction in articular joints. Arthroscopic synovectomy is quite useful for resection synovium less invasively for RA patients. However there are few papers about shoulder joint synovectomy of rheumatoid arthritis. Ho-YAG laser is also effective to decrease synovium proliferation. The advantage of using Ho-YAG laser is effective to pannus even in deep zone of bone erosion. In this paper, we treated 13 shoulders of 11 patients of RA by using Ho-YAG laser to assess whether Ho-YAGH laser is effective in shoulder arthroscopic synovectomy of RA. Materials and Methods: We treated 13 shoulders in 11 patients of RA, including 8 in stage II, 4 in stage III, 1 in stage IV. The duration of RA is an average of 4, 6 years. The follow-up period is an average of 14 months. We compared CRP, DAS28 and MRI findings before and after surgery. Those patients were taking DMARDs such as MTX in 8 patients, steroid in 3 patients infliximab in 1 patient and etanercept in 1 patient. We used 4.0 mm arthroscope, VAPR and shaver for synovectomy. Ho-YAG laser set to 10W to bone erosion area to reach deep zone of pannus and to resect synovium. Results: We found villous synovium proliferation with vascularity in rotator interval and supraspinatus tendon in shoulder joint. In subacromial bursa, yellow fat tissue and white fibrous soft tissue was detected almost all shoulders. After synovectomy by using Ho-YAG laser, CRP was decreased from an average of 3.6 to 0.8 and DAS28 was also decreased an average of 5.4 to 3.7 at 14 month after surgery. MRI showed decreased pannus with synovium and joint destruction was not preceding after 14 month. Discussion: Ho-YAG laser is effective for using shoulder arthroscopic synovectomy especially to treat pannus in bone erosion. The amount of energy of Ho-YAG laser for synovectomy is not clear so far. We used 10W for 5 second in each area that could be effective to decrease pannus formation. We would further investigate in the basic experimental levels to confirm Ho-YAG laser efficacy

Introduction. Synovectomy in children with juvenile rheumatoid arthritis (JRA) and psoriatic arthritis (PSA) is still subject of controversial discussion. Our results of arthroscopic synovectomy of the knee in children with chronic inflammatory joint disease are presented. Material. From 1989–1997 27 synovectomies were performed in 27 children with inflammatory arthritis (15 JRA, 12 PSA). Average age at surgery was 12. 5 y (2. 9–17. 8 y). Mean follow-up was 4. 9 years. Methods. Onset of disease and conservative therapy was documented. Each patient was physically and radiologically examined preoperatively and 24 children postoperatively (mean follow-up 4. 9 years). For arthroscopic shaver-assisted synovectomy of the knee we used minimum 4 portals and normally 6 portals (2 anterior, 2 suprapatellar and 2 posterior portals). In addition to the physical examination we used a special clinical score (Laurin 1974). We compared the pre- and postoperative limits of active and passive knee movement. We performed sonographs and radiographs of the infected joint. Radiography was classified following the Larsen-Scale. Patient and parents gave their opinion whether the operation was successful. Before surgery all children had intensive drug and physical therapy for 8–62 months (42 month). In the course of conservative treatment, knees had local joint treatment with triamcinolonhex-acetomid (THA), normally for three times before surgery. Preoperative X-rays showed Larsen stage I in 3 knee joints and Larsen stage 0 in the other knees. Results. In 85% of the children, we found good or excellent surgical outcome. 2 joints achieved fair and 2 joints poor outcome. Concerning subjective outcome 22 (82%) children had been very satisfied (56%) or satisfied (26%). 25 of the children’s parents would agree in the same surgical procedure again. In 6 knee joints we found recurrent synovitis. 2 of these knee joints were reoperated (30 and 22 month postoperatively with satisfying result), the other 4 joints were treated with THA i. a.. The 2 reoperations were regarded as poor result. We had no postoperative complications and the normal hospitalisation was 15 days. Prior to surgery, 12 knee joints had an average deficit of active knee extension of 10° (5–20°). Postoperatively, no extension deficit was found anymore in 25 of the knees. Compared to the contralateral knees, a flexion deficit of 10° (5–15°) was obtained postoperatively. At sonography, no joint effusion could be revealed. Postoperative X-rays showed no progression in Larsen stage. Outcome in children with oligoarthritis was better than in those with polyarthritic disease. Discussion. Early arthroscopic synovectomy of the knee in children with chronic inflammatory joint disease is, in case of failure of conservative treatment, a useful method of treatment. We propose early synovectomy of the knee joint as an essential part of the treatment scheme for children with inflammatory joint disease

We investigated the clinical response to arthroscopic synovectomy in patients with undifferentiated chronic monoarthritis (UCMA) of the wrist. Arthroscopic synovectomy was performed on 20 wrists in 20 patients with UCMA of the wrist who had not responded to non-steroidal anti-inflammatory drugs. The mean duration of symptoms at the time of surgery was 4.3 months (3 to 7) and the mean follow-up was 51.8 months (24 to 94). Inflamed synovium was completely removed from the radiocarpal, midcarpal and distal radioulnar joints using more portals than normal. After surgery, nine patients had early remission of synovitis and 11 with uncontrolled synovitis received antirheumatic medication. Overall, there was significant improvement in terms of pain relief, range of movement and Mayo score. Radiological deterioration was seen in five patients who were diagnosed as having rheumatoid arthritis during the follow-up period. Lymphoid follicles and severe lymphocyte infiltration were seen more often in synovial biopsies from patients with uncontrolled synovitis. These results suggest that arthroscopic synovectomy provides pain relief and functional improvement, and allows rapid resolution of synovitis in about half of patients with UCMA of the wrist

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

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

We retrospectively reviewed 30 patients with a diffuse-type giant-cell tumour (Dt-GCT) (previously known as pigmented villonodular synovitis) around the knee in order to assess the influence of the type of surgery on the functional outcome and quality of life (QOL). Between 1980 and 2001, 15 of these tumours had been treated primarily at our tertiary referral centre and 15 had been referred from elsewhere with recurrent lesions. The mean follow-up was 64 months (24 to 393). Functional outcome and QOL were assessed with range of movement and the Knee injury and Osteoarthritis Outcome Score (KOOS), the Musculoskeletal Tumour Society (MSTS) score, the Toronto Extremity Salvage Score (TESS) and the SF-36 questionnaire. There was recurrence in four of 14 patients treated initially by open synovectomy. Local control was achieved after a second operation in 13 of 14 (93%). Recurrence occurred in 15 of 16 patients treated initially by arthroscopic synovectomy. These patients underwent a mean of 1.8 arthroscopies (one to eight) before open synovectomy. This achieved local control in 8 of 15 (53%) after the first synovectomy and in 12 of 15 (80%) after two. The functional outcome and QOL of patients who had undergone primary arthroscopic synovectomy and its attendant subsequent surgical procedures were compared with those who had had a primary open synovectomy using the following measures: range of movement (114º versus 127º; p = 0.03); KOOS (48 versus 71; p = 0.003); MSTS (19 versus 24; p = 0.02); TESS (75 versus 86; p = 0.03); and SF-36 (62 versus 80; p = 0.01). Those who had undergone open synovectomy needed fewer subsequent operations. Most patients who had been referred with a recurrence had undergone an initial arthroscopic synovectomy followed by multiple further synovectomies. At the final follow-up of eight years (2 to 32), these patients had impaired function and QOL compared with those who had undergone open synovectomy initially. We conclude that the natural history of Dt-GCT in patients who are treated by arthroscopic synovectomy has an unfavourable outcome, and that primary open synovectomy should be undertaken to prevent recurrence or residual disease. Cite this article: Bone Joint J 2014; 96-B:1111–18

Diffuse-type Tenosynovial Giant-Cell Tumour (d-TGCT) of large joints is a rare, locally aggressive, soft tissue tumour affecting predominantly the knee. Previously classified as Pigmented Villonodular Synovitis (PVNS), this monoarticular disease arises from the synovial lining and is more common in younger adults. Given the diffuse and aggressive nature of this tumour, local control is often difficult and recurrence rates are high. Current literature is comprised primarily of small, and a few larger but heterogeneous, observational studies. Both arthroscopic and open synovectomy techniques, or combinations thereof, have been described for the treatment of d-TGCT of the knee. There is, however, no consensus on the best approach to minimize recurrence of d-TGCT of the knee. Some limited evidence would suggest that a staged, open anterior and posterior synovectomy might be of benefit in reducing recurrence. To our knowledge, no case series has specifically looked at the recurrence rate of d-TGCT of the knee following a staged, open, posterior and anterior approach. We hypothesized that this approach may provide better recurrence rates as suggested by larger more heterogeneous series. A retrospective review of the local pathology database was performed to identify all cases of d-TGCT or PVNS of the knee treated surgically at our institution over the past 15 years. All cases were treated by a single fellowship-trained orthopaedic oncology surgeon, using a consistent, staged, open, posterior and anterior approach for synovectomy. All cases were confirmed by histopathology and followed-up with regular repeat MRI to monitor for recurrence. Medical records of these patients were reviewed to extract demographic information, as well as outcomes data, specifically recurrence rate and complications. Any adjuvant treatments or subsequent surgical interventions were noted. Twenty-three patients with a minimum follow-up of two years were identified. Mean age was 36.3 at the time of treatment. There were 10 females and 13 males. Mean follow-up was seven and a half years. Fourteen of 23 (60.9%) had no previous treatment. Five of 23 had a previous arthroscopic synovectomy, one of 23 had a previous combined anterior arthroscopic and posterior open synovectomy, and three of 23 had a previous open synovectomy. Mean time between stages was 87 days (2.9 months). Seven of 23 (30.4%) patients had a recurrence. Of these, three of seven (42.9%) were treated with Imatinib, and four of seven (57.1%) were treated with repeat surgery (three of four arthroscopic and one of four open). Recurrence rates of d-TGCT in the literature vary widely but tend to be high. In our retrospective study, a staged, open, anterior and posterior synovectomy provides recurrence rates that are lower than rates previously reported in the literature. These findings support prior data suggesting this approach may result in better rates of recurrence for this highly recurrent difficult to treat tumour

Diffuse-type Tenosynovial Giant-Cell Tumour (d-TGCT) of large joints is a rare, locally aggressive, soft tissue tumour affecting predominantly the knee. Previously classified as Pigmented Villonodular Synovitis (PVNS), this monoarticular disease arises from the synovial lining and is more common in younger adults. Given the diffuse and aggressive nature of this tumour, local control is often difficult and recurrence rates are high. Current literature is comprised primarily of small, and a few larger but heterogeneous, observational studies. Both arthroscopic and open synovectomy techniques, or combinations thereof, have been described for the treatment of d-TGCT of the knee. There is, however, no consensus on the best approach to minimize recurrence of d-TGCT of the knee. Some limited evidence would suggest that a staged, open anterior and posterior synovectomy might be of benefit in reducing recurrence. To our knowledge, no case series has specifically looked at the recurrence rate of d-TGCT of the knee following a staged, open, posterior and anterior approach. We hypothesized that this approach may provide better recurrence rates as suggested by larger more heterogeneous series. A retrospective review of the local pathology database was performed to identify all cases of d-TGCT or PVNS of the knee treated surgically at our institution over the past 15 years. All cases were treated by a single fellowship-trained orthopaedic oncology surgeon, using a consistent, staged, open, posterior and anterior approach for synovectomy. All cases were confirmed by histopathology and followed-up with regular repeat MRI to monitor for recurrence. Medical records of these patients were reviewed to extract demographic information, as well as outcomes data, specifically recurrence rate and complications. Any adjuvant treatments or subsequent surgical interventions were noted. Twenty-three patients with a minimum follow-up of two years were identified. Mean age was 36.3 at the time of treatment. There were 10 females and 13 males. Mean follow-up was seven and a half years. Fourteen of 23 (60.9%) had no previous treatment. Five of 23 had a previous arthroscopic synovectomy, one of 23 had a previous combined anterior arthroscopic and posterior open synovectomy, and three of 23 had a previous open synovectomy. Mean time between stages was 87 days (2.9 months). Seven of 23 (30.4%) patients had a recurrence. Of these, three of seven (42.9%) were treated with Imatinib, and four of seven (57.1%) were treated with repeat surgery (three of four arthroscopic and one of four open). Recurrence rates of d-TGCT in the literature vary widely but tend to be high. In our retrospective study, a staged, open, anterior and posterior synovectomy provides recurrence rates that are lower than rates previously reported in the literature. These findings support prior data suggesting this approach may result in better rates of recurrence for this highly recurrent difficult to treat tumour

Aim: To test the hypothesis that open surgical synovectomy of the knee results in better long-term control of chronic inflammatory synovitis of the knee than arthroscopic synovectomy. Method: To test this hypothesis a prospective clinical trial was carried out involving three groups of patients:- In Group I (22 cases in 18 patients) arthroscopic synovectomy was performed by a surgeon experienced in arthroscopy (Bartlett). In Group II (15 cases in 11 patients) open surgical synovectomy / debridement was performed (Rush). In Group III (10 cases in seven patients) arthroscopic lavage was carried without synovectomy (Rush) and this acted as a “control” group. The patients were followed up for some 10 years. At the final review the clinical and functional scores were recorded using the H.S.S. knee score system. There are obvious problems in comparing two or three groups of patients from two separate units and these are discussed. Results: The results showed that in both groups (i.e. Groups I & II) there was a significant shift to the right in the clinical and functional scores. This did not occur in the “control” group. In Group I, two cases out of 22 came to total knee replacement. In Group II, four cases out of 15 and in Group III, five cases out of 10 came to knee replacement. Conclusions: It was concluded that knee synovectomy was a worthwhile procedure and that arthroscopic synovectomy was just as good and probably better than open surgical synovectomy but it needs to be done early and by a surgeon with experience in carrying out this difficult procedure

Aim The aim of this study was to identify the presentation, management and outcomes this rare disease using the large series of patients treated at our unit. Material and Methods We reviewed the medical records and x-rays of all the patients who were referred – treated for PVNS around the knee joint between 1990 and 2002. Results 42 patients totally were treated or had second opinion for PVNS disease. 37 have been analysed in detail. Their mean age was 33 years old and 11 patients were below 17 years of age. There was a predilection for females with 22 (59.5%) out of 37 patients. There was average 3.3 years period of time with swelling/knee symptoms before diagnosis . The MRI scan was the cornerstone for the patient’s assessment. It has proved useful in recurrent disease and posterior ”Bakers cyst” disease. 2 of the patients had been managed with arthroscopic synovectomy alone, 10 patients have undergone simultaneous arthroscopic synovectomy combined with open excision of any “Bakers cyst” disease. 10 had “open synovectomy”. 3 patients have had radiotherapy .3 patients have had TKR Complications included 3 superficial wound infections, 1 DVT, 1 PE, 1 stress fracture after radical bone curettage, common temporary/refractory stiffness (needing physio/ MUAs). Recurrence was high and managed with repeat arthroscopic synovectomy. Conclusion PVNS is a rare disorder with typical mono-articular involvement affecting most commonly the knee joint. MRI and biopsy is the gold standard for the establishment of diagnosis and often needs a combined approach with arthroscopic and open posterior cyst excision. Radiotherapy is helpful in aggressive cases. TKR is suggested when there is associated articular erosion. The patient should be warned about the long course of treatment and often multiple procedures because of high recurrence rates

Giant cell tumours (GCT) of the synovium and tendon sheath can be classified into two forms: localised (giant cell tumour of the tendon sheath, or nodular tenosynovitis) and diffuse (diffuse-type giant cell tumour or pigmented villonodular synovitis). The former principally affects the small joints. It presents as a solitary slow-growing tumour with a characteristic appearance on MRI and is treated by surgical excision. There is a significant risk of multiple recurrences with aggressive diffuse disease. A multidisciplinary approach with dedicated MRI, histological assessment and planned surgery with either adjuvant radiotherapy or systemic targeted therapy is required to improve outcomes in recurrent and refractory diffuse-type GCT. Although arthroscopic synovectomy through several portals has been advocated as an alternative to arthrotomy, there is a significant risk of inadequate excision and recurrence, particularly in the posterior compartment of the knee. For local disease partial arthroscopic synovectomy may be sufficient, at the risk of recurrence. For both local and diffuse intra-articular disease open surgery is advised for recurrent disease. Marginal excision with focal disease will suffice, not dissimilar to the treatment of GCT of tendon sheath. For recurrent and extra-articular soft-tissue disease adjuvant therapy, including intra-articular radioactive colloid or moderate-dose external beam radiotherapy, should be considered

Pigmented villonodular synovitis (PVNS) is a rare proliferative process of the synovium which most commonly affects the knee and occurs in either a localised (LPVNS) or a diffuse form (DPVNS). The effect of different methods of surgical synovectomy and adjuvant radiotherapy on the rate of recurrence is unclear. We conducted a systematic review and identified 35 observational studies in English which reported the use of surgical synovectomy to treat PVNS of the knee. A meta-analysis included 630 patients, 137 (21.8%) of whom had a recurrence after synovectomy. For patients with DPVNS, low-quality evidence found that the rate of recurrence was reduced by both open synovectomy (odds ration (OR) = 0.47; 95% CI 0.25 to 0.90; p = 0.024) and combined open and arthroscopic synovectomy (OR = 0.19, 95% CI = 0.06 to 0.58; p = 0.003) compared with arthroscopic surgery. Very low-quality evidence found that the rate of recurrence of DPVNS was reduced by peri-operative radiotherapy (OR = 0.31, 95% CI 0.14 to 0.70; p = 0.01). Very low-quality evidence suggested that the rate of recurrence of LPVNS was not related to the surgical approach. . This meta-analysis suggests that open synovectomy or synovectomy combined with peri-operative radiotherapy for DPVNS is associated with a reduced rate of recurrence. Large long-term prospective multicentre observational studies, with a focus on both rate of recurrence and function, are required to confirm these findings. Cite this article: Bone Joint J 2015;97-B:550–7

We describe a case of highly refractory synovial chondromatosis, which recurred despite four arthroscopic synovectomies, a chemical synovectomy, two open synovectomies and an arthrodesis. A review of the literature revealed one similar case. Both presented with marked joint stiffness suggesting a poor prognosis. Although arthrodesis may relieve short-term symptoms it does not prevent further recurrence of disease

Ultrasound screening has shown that the shoulder joint is almost always involved in rheumatoid arthritis. But only few of rheumatoid patients suffering from omarthritis are in considerable pain. Loss of strength and mobility is often compensated by the adjacent joints. Low patients demands, as pain and swelling can be treated often temporarely successfully by corticoid injections and the need of a wide exposure of the shoulder joint when performing an open synovectomy are the reasons of the low rate of synovectomies performed in rheumatoid shoulder joints. The clinical outcome after synovectomies in rheumatoid omarthritis is generally superior to those of knee synovectomies and shows a reliable reduction of pain, swelling and an increase of ROM. The surgical trauma in open synovectomy of the shoulder results in an impairment of the complex muscle co-ordination of the shoulder and a painful long-lasting aftertreatment. This disadvantages can be prevented when using arthroscopic techniques. The advantages of the arthroscopic technique are mostly obvious in the shoulder joint. The reduced surgical trauma of the periarticular tissue leaving the proprioreception intact results in reduced postoperative pain, allowing early mobilisation and shorter rehabilitation. Arthroscopic surgery of the shoulder is performed with the patient in beach- chair position under general anesthesia. We use a standard 5mm arthroscope and a motorised synovial resector. To prevent bleeding it is advantageous to utilise cooled non-ionic irrigation solution with epinephrin in addition pressurised by a roller pump. Synovectomy of the glenohumeral joint and of the subacromial bursa is performed via four portals. Potential hazards like injury to the periarticular vessels and nerves or damage of the joint cartilage especially in stiff shoulders can only be prevented with careful proceeding. Active and passive physiotherapy starts on the first postoperative day. Our first series of 12 shoulder arthroscopies done 1989–1991 was followed 3. 8 years postoperatively. Swelling and pain at rest disappeared rapidly after surgery. Pain during motion took longer to subside. At the end of follow-up patients reported slight pain on motion in five shoulders. Postoperatively all patients reported improvement of pain. There was one recurrence of swelling due to bursitis. In this patient no bursectomy was done during shoulder arthroscopy, which is now done as a routine. There was subjectively and objectively an increase of strength postoperatively. ROM showed immediate postoperative improvement, although a slight reduction was noticed during the follow-up period. In 1990–1999 we performed 52 arthroscopical synovectomies of rheumatoid shoulders. 31 shoulders could be followed by questionnaire at a mean of 6. 5years postoperatively. Pain at rest and pain on motion was improved in about 80% and 74% respectively. Recurrence of swelling was reported by 26% of the patients. Five patients has to be operated again. The clinical outcome compare favourably with the results published about open shoulder synovectomy. Five patients with large humeral cysts were treated with arthroscopic synovectomy, arthroscopically assisted curettage and bone grafting of the cyst via a small incision at the major tuberculum. Until now none of the patients suffered from humeral collaps, no shoulder has to be replaced. In painful rheumatoid omarthritis swelling and pain can be improved reliably with arthroscopic synovectomy. The reduced surgical trauma of minimal invasive synovectomy should raise the rate of early preventive surgery

Pigmented villonodular synovitis is a monoarticular proliferative process most commonly involving the synovium of the knee joint. There is considerable debate with regards to diagnosis and effective treatment. We present our experience of managing PVNS of the knee joint over a 12 year period. Twenty-eight patients were reviewed. MRI was used to establish recurrence in symptomatic patients rather than routine screening and to identify posterior disease prior to surgery. Eight patients had localised disease and were all treated with open synovectomy and excision of the lesion, with no evidence of recurrence. Twenty patients had diffuse disease, eight treated arthroscopically and twelve with open total synovectomy. Nineteen patients (95%) had recurrence on MRI, however, only five (25%) had evidence of clinical recurrence. There were no significant complications following arthroscopic synovectomy. Open synovectomy, in contrast, was associated with three wound infections and two thrombo-embolisms. Three patients had Complex regional pain syndrome. We believe diffuse disease should be treated with arthroscopic synovectomy which is associated with minimal morbidity and can be repeated to maintain disease control. Radiotherapy is helpful in very aggressive cases. TKR was used when there was associated articular erosion