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

INTRODUCTION: 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. MATERIALS AND METHODS: 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 2 weeks. Patients were followed up after 2 weeks, 1 month, 2 months, and 6 months. 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. RESULTS: Thirty-one patients with the mean age of 54.5 ± 12.2 years and the mean disease duration of 12 ± 6.5 years 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 2 weeks, but it was reduced significantly after 1, 2, and 6 months. 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. CONCLUSION: 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.

Management of Primary Synovial Osteochondromatosis in the Ankle Joint With a Combined Posterior-Anterior Arthroscopic Procedure: A Case Report.

Primary synovial osteochondromatosis (PSO), a seldom-seen synovial proliferative disease involving chondral metaplasia, presents a unique challenge when affecting the ankle joint. Controversy exists regarding whether a combined posterior-anterior approach with total synovectomy is necessary to avert recurrence or malignancy. An 18-year-old Caucasian male presented to the outpatient clinic with clinical and imaging findings indicative of a stage III PSO. The surgical intervention involved a combined posterior-anterior arthroscopic approach with the removal of multiple loose bodies and complete synovectomy, resulting in complete relief of symptoms without recurrence at the 12-month follow-up. Pathological examination confirmed the diagnosis. The management of PSO in the ankle joint using a combined posterior-anterior arthroscopic approach with complete synovectomy demonstrated effectiveness in this case. Regular follow-ups are essential for monitoring long-term outcomes and detecting potential recurrence or malignant transformation.

Microwave ablation of synovial hypertrophy in recurrent monoarthritis: The results of extended cohort and long-term follow-up.

OBJECTIVES: Recurrent monoarthritis (RM) is a major challenge of many rheumatic diseases. Ablation is a well-known technique in the treatment of benign or malign lesions of different etiologies. We aimed to to investigate the success and safety of microwave ablation (MWA) as an adjunctive therapy in a cohort of medical treatment-resistant RM. METHODS: Patients with RM associated with different inflammatory diseases were included. MWA was performed after measuring the size of synovial hypertrophy with 15 or 20-watt power and different durations until microbubbles were shown indicating necrosis. Both clinical and radiologic data were recorded. RESULTS: We applied MWA in total of 24 knee joints of 10 female and 12 male patients aged between 22-71 years. Median intra-articular aspiration (IAA) need in the last 6 months before MWA was 5 (0-15). The median follow-up was 10 (3-16) months. Overall IAA count in the last 6 months before MWA in total of 144 months was 129 and decreased to 7 in post-MWA in total of 226 months (0.89 vs 0.03 per month, p< 0.001). The second MWA session was needed for 3 patients and a third session for 1. Functional disability and pain scores were improved significantly (median score from 9 to 1, p< 0.00001, in both). In magnetic resonance imaging, follow-up significant regression in synovial hypertrophy size was shown especially after 6th month. No complication was observed during the procedure or follow-up. CONCLUSION: As a less invasive technique compared with the surgical approach, MWA of synovial hypertrophy showed significant clinical improvement in RM safely. MWA seems promising as a treatment option candidate in the management of RM.

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.

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.

Arthroscopic ankle surgery in people with haemophilia.

INTRODUCTION: People with haemophilia (PWH) not administered primary haematological prophylaxis since childhood, that is, those treated haematologically on demand or not treated at all, often experience the degeneration of the ankles, leading to pain and functional impairment. AIM: To analyse the outcomes and complications of arthroscopic ankle surgery performed on PWH. METHODS: For this narrative review of the literature, a search was conducted in PubMed on 2, December 2023, using the keywords "haemophilia", "ankle" and "arthroscopy". Of the 29 articles identified, 15 specifically related to ankle arthroscopy in PWH were selected (inclusion criterion). The remaining articles did not meet this requirement (exclusion criterion) and were therefore eliminated. RESULTS: Arthroscopic procedures (arthroscopic synovectomy, debridement and arthrodesis of the ankle) are increasingly used in the surgical treatment of haemophilic ankle arthropathy. Although arthroscopic ankle surgery offers good outcomes in patients with haemophilia, the procedure is not free of complications, which range from 7.9% for arthroscopic ankle debridement to 13.1% in arthroscopic ankle synovectomy and 17.8% in arthroscopic ankle arthrodesis, respectively. The non-union rate of arthroscopic ankle arthrodesis is 7.1% (2/28). CONCLUSION: Although arthroscopic interventions in the haemophilic ankle (synovectomy, debridement, arthrodesis) offer good functional outcomes, they are associated with a non-negligible rate of complications. Arthroscopic ankle surgery in PWH is major surgery and should be treated as such.

Recurrence-Free Survival after Synovectomy and Subsequent Radiosynoviorthesis in Patients with Synovitis of the Knee-A Retrospective Data Analysis.

BACKGROUND: Persistent knee synovitis leads to joint discomfort, incapacitating inflammation, and functional limitations. The conventional approach has involved surgical procedures to eliminate the actively inflamed synovial membrane. This study aims to investigate the recurrence-free survival and functional outcome after synovectomy and subsequent radiosynoviorthesis (RSO) in patients with knee synovitis. METHODS: Thirty-seven knees diagnosed with pigmented villonodular synovitis (PVNS), rheumatoid arthritis (RA), and peripheral spondyloarthritis underwent synovectomy and subsequent RSO between May 2005 and October 2016. The mean age was 34.9 ± 15.1 years, and the mean follow-up period was 84 ± 36.4 months. Clinical outcomes were assessed using the Oxford Knee Score and the presence of swelling and pain at the last follow-up. Recurrence-free survival denotes the duration from synovectomy to surgical re-synovectomy. RESULTS: In general, twelve knees underwent re-synovectomy after a mean follow-up of 34.8 ± 24.9 months. The recurrence-free survival was 83.8% at two years, 71.3% at five years, and 61.7% at ten years. The subgroup analysis revealed recurrence-free survival at two years in 63.6% of patients with PVNS, 86.7% of those with RA, and 100% of individuals with peripheral spondyloarthritis. CONCLUSIONS: This study demonstrates that combined therapy for synovitis is an effective approach, significantly improving clinical outcomes.

Surgery of joints.

Crude forms of musculoskeletal surgery have been performed through history for the treatment of deformity, pain and the horrors of battle. In more modern times Muller is credited with the first synovectomy in rheumatoid arthritis in 1884, and a Synovectomy was first performed by Richard von Volkmann (1830-1889) for joint tuberculosis. Chemical synovectomy consisting of the intra-articular injection of various agents was popular for a while but is now largely discarded. Joint resection for sepsis and tuberculosis has been documented since the early 1800s, and also joint arthrodesis, and osteotomy. Modern arthroscopic techniques have added the utility of faster intra-joint inspection and treatment while reduced surgical time exposure and often applied with the use of limb regional anaesthetic nerve blocks, to avoid general anaesthetic. Joint arthroplasty has been developed since1800s, with the use of many artificial joint components. There have been many notable pioneers of this work who are documented in this text, among them Austin T. Moore (1899-1963), George McKee (1906-1991) and Sir John Charnley (1911-1982). The success of joint arthroplasty to the hip, knee, shoulder and other joints has resulted in life-changing benefit for hundreds of arthritis and injury sufferers.

A Missed Case of Synovial Osteochondromatosis.

Synovial osteochondromatosis or synovial chondromatosis is a benign joint pathology characterized by the development of multiple cartilaginous nodules or loose bodies in the synovial membrane that typically arise in the larger joints of the body. It usually presents as joint pain and, as seen in the present case, can occasionally be missed. Diagnosis involves a combination of clinical evaluation, imaging studies, and histopathological evaluation (which is confirmatory). Treatment depends on the severity of the disease, symptoms, and the patient's social situation, and may include monitoring for asymptomatic cases, non-surgical management (pain medications and physical therapy), or surgical intervention. Surgical intervention may include arthroscopic removal of loose bodies, synovectomy, or reconstruction/replacement in severe situations. Prognosis has a direct relationship to how early the disease is diagnosed. Early intervention with appropriate management can help alleviate symptoms; however, if left unmanaged, it can lead to joint damage and osteoarthritis or very rarely, malignant transformation into chondrosarcoma. This report describes the case of a 62-year-old female with complaints of bilateral knee pain who was originally diagnosed with osteoarthritis based on clinical exam and X-rays. Two magnetic resonance imaging (MRI) scans were done three years apart, with synovial osteochondromatosis being on the differential after the second scan. A left knee major synovectomy was conducted after the second MRI reading, where rubbery masses of tissue along with loose fragments were removed. Fluid from the tissue masses was sent to culture and pathology for interpretation. Two weeks post the surgery, the patient's pain improved tremendously, with adequate ambulation independently. Histopathology came back positive for synovial osteochondromatosis. This case report highlights the importance of keeping this joint pathology on the differential when treating patients with joint pain and interpreting imaging.

Oncological and functional outcomes of modified arthroscopic resection for intra-articular tenosynovial giant cell tumor of the knee using multiple portals.

BACKGROUND: Arthroscopic resection of tenosynovial giant cell tumor (TS-GCT) presents favorable outcomes. However, there are reportedly higher recurrence rates in patients who had incomplete resection. To minimize incomplete resection, we established a multiple portal approach depending on the location of the disease. In this study, we aimed to retrospectively evaluate the clinical outcomes of arthroscopic resection for both localized and diffuse types of TS-GCT of the knee. METHODS: From 2009 to 2019, 13 patients who underwent arthroscopic synovectomy of the knee and were histologically diagnosed with TS-GCT were included in this study. The pre- and postoperative range of motion (ROM) of the knee was measured. The Japanese Orthopaedic Association (JOA) score and the Knee Injury and Osteoarthritis Outcome Score (KOOS) were assessed at the final follow-up examination. Magnetic resonance imaging was performed to detect incomplete resection or local recurrence. RESULTS: Among the 13 patients, seven and six had localized and diffuse type TS-GCT, respectively. Regarding the knee ROM, preoperative knee flexion in patients with the localized type was limited compared with that in those with the diffuse type. However, the ROM was significantly improved in patients with both types postoperatively. The JOA score and KOOS of patients with both types at the final follow-up were favorable, and there were no significant differences between both types. There was neither recurrence nor incomplete resection in any patient for both types. CONCLUSION: All patients, regardless of the TS-GCT type, achieved favorable outcomes after arthroscopic surgery; especially, the failure rate was 0%.

Formulation and In-vivo Characterization of 177Lu-tin-colloid as a Radiosynovectomy Agent.

INTRODUCTION: Arthritis is an inflammatory disorder that affects one or more joints of the body for various reasons, including autoimmune disorders, trauma, or infection. In many cases, traditional long-term treatment with various drug combinations (NSAIDs, diseasemodifying antirheumatic drugs, systemic corticosteroids, etc.) can provide relief, but many joints require additional local treatment. Radiosynovectomy (RSV) is an alternative method to current treatment options. Both the global supply shortage of 90Y in recent years and the increasing use of 177Lu-labeled radiopharmaceuticals in the field of nuclear medicine have made it possible to develop 177Lu-labeled microparticles and test them in small groups as RSV agents. This study aimed to develop the 177Lu labeled tin colloid formulation and demonstrate its invivo characterization. MATERIAL AND METHODS: Particle size, shape, and labelling efficiency of the four formulations developed were determined. The formula with the highest labelling efficiency was selected for further studies. The quality of the formulation was evaluated based on radionuclidic, radiochemical, and microbial purity. In-vitro stability was evaluated by determining the labelling efficiency. In-vitro stability was tested in PBS and synovial fluid. The biological characterization was assessed using SPECT/CT after injecting the formulation into the normal knee joints of the rabbits. RESULTS: Aggregated colloidal particles were spherical with a particle size of <5µm. Labelling efficiency and radiochemical purity were >95 and 97.65% (Rf=0.2), respectively. The formulation was stable in vitro for up to 72 hours, both in PBS and synovial fluid. The formulation was homogeneously distributed in the joint at 0 and 1 hour after injection, and radioactivity- related involvement and inguinal lymph node involvement due to possible leakage were not detected in the late period. No pyrogenic/allergic side effects were observed during this period. CONCLUSION: 177Lu-tin-colloid was successfully prepared under optimized reaction conditions with high binding efficiency and radiochemical purity. The radiolabeled colloid was found to be stable in-vitro both in PBS and synovial fluid at room temperature. Serial PCET/CT images revealed that the activity was completely retained within the synovial cavity, with no activity leakage out of the joint until 48 hours after the injection. With the support of the results from further clinical studies, it may be possible for the formulation to enter clinical use.

Pigmented Villonodular Synovitis of Ankle Joint - A Case Report.

Introduction: Pigmented villonodular synovitis (PVNS)is a very uncommon lesion that involves the synovium of joints, tendon sheaths, or bursae. Approximately 2.5% of cases occur around the ankle. PVNS was earlier considered to be a synovial malignancy. Complete surgical excision is curative if bony destruction is not there. Radiotherapy is rarely helpful for residual lesions. Case Report: We share a case report on PVNS of ankle in a 22-years old male patient. Clinical diagnosis was confirmed with the help of magnetic resonance imaging and histopathology. A surgical excision with synovectomy was carried out. There were no signs of recurrence in 1.5 years follow-up. Conclusion: Complete surgical excision with radical synovectomy is crucial for the treatment of PVNS in rare locations like the ankle joint.

A Case of Atraumatic Acute Carpal Tunnel Syndrome Requiring Emergency Surgery.

Acute carpal tunnel syndrome (ACTS) is an urgent condition in which symptoms progress rapidly on an hourly basis, and emergency surgery may be required to treat it. ACTS often occurs after a traumatic event such as a fracture of the distal radius, and rarely occurs non-traumatically. We present a case of a 60-year-old male with ACTS secondary to acute synovitis due to rheumatoid arthritis. The patient complained of strong numbness from the thumb to the ring finger and pain in the palm, and he was unable to actively flex or extend his fingers. In addition, severe tenderness was observed in the palm; on the contralateral side, no obvious tenderness of the forearm and wrist joint was observed. Due to the intolerable pain and numbness, ACTS was suspected. Internal pressure from the forearm to the palm was measured, and it was found that the internal pressure of the carpal tunnel was elevated at 150 mmHg. Based on these findings, non-traumatic ACTS was diagnosed, and emergency surgery was performed. The transverse carpal ligament was exposed, an incision was made from the distal end, and the proximal part was fully incised to the forearm fascia so that the carpal tunnel was completely released. The synovial membranes around the median nerve were peeled off, confirming that the nerve had been loosened sufficiently. After the operation, finger pain and numbness improved dramatically from the day after surgery. Proper diagnosis and prompt treatment with surgical median nerve decompression are crucial for good functional recovery in these patients.

A Case Report Of "Synovial Chondromatosis Of Elbow" Treated With Synovectomy.

Introduction: Synovial chondromatosis is a rare non- malignant bone tumor. Most commonly middle aged people are affected . This condition most commonly occurs in knee joints, and rarely, it may occur in other joints. Patient usually complaints of pain, swelling and restrictions of movements at the affected joint. Diagnosis is made through thorough clinical examination and Radiological investigation. Condition is treated with open synovectomy with the removal of loose bodies. If not treated in time the patient might develop early osteoarthritic changes and rarely develop into malignancy in few cases. Case Report: A 43 year old female came with complaints of pain and stiffness over the right elbow which aggravates on movements without alleged history of trauma. The patient was diagnosed with synovial chondromatosis after appropriate radiological investigation. The patient underwent open synovectomy and post operatively adequate physiotherapy was initiated at the operated elbow. After 6 months of follow-up, the patient improved clinically and functionally. Conclusion: Synovial chondromatosis of the elbow is a rare benign orthopedic condition that appears as multiple hyaline cartilage nodules within sub synovial connective tissue. Complete excision of synovium is necessary to prevent the recurrence and for better clinical outcome.

Influência do tratamento fisioterapêutico na independência funcional de pessoas com hemofilia submetidas à sinovectomia radioativa / Influence of physiotherapeutic treatment on the functional independence of people with hemophilia submitted to radioactive sinovectomy

A sinovectomia radioativa (SR) é considerada o tratamento de eleição no controle da sinovite crônica não responsiva ao tratamento conservador, sendo recomendado tratamento fisioterapêutico para a melhora da funcionalidade. Objetivo: Verificar a influência do tratamento fisioterapêutico na independência funcional e saúde articular de hemofílicos após tratamento com SR. Método: Trata-se de um estudo descritivo, retrospectivo, analítico e metodologia quali-quantitativa. Realizou-se avaliação fisioterapêutica, aplicação do HJHS para avaliação da saúde articular e Escore FISH para avaliação da independência funcional. Os participantes foram subdivididos em dois grupos de acordo com a realização ou não da fisioterapia após a SR. Resultados: Participaram do estudo 8 pessoas com hemofilia A, sexo masculino, média de idade de 19±5,3 anos. Foram 12 articulações submetidas a SR, dessas 41,67% cotovelos, 33,33% joelhos e 25% tornozelos. Na comparação dos grupos, não houve diferença estatística entre os eles nas variáveis: saúde articular e a Independência Funcional. Conclusão: O estudo é uma primeira tentativa de descrever o impacto da fisioterapia na independência funcional e saúde articular de hemofílicos submetidos à SR. Embora possua limitações, foi possível observar que o grupo que não realizou fisioterapia apresentava melhor saúde articular e melhor independência funcional previamente à SR em comparação ao grupo que realizou fisioterapia; porém, o grupo fisioterapia apresentava pior quadro global, com a funcionalidade impactada por outras articulações e não somente aquela tratada com SR, apresentando maior número de articulações alvo.

Radioactive synovectomy (RS) is considered the treatment of choice in the control of chronic synovitis resistant to conservative treatment, and physiotherapy is recommended to improve functionality after procedure. Objective: The aim was to verify the effects of physiotherapy on functional independence and joint health after RS. Method: This is a descriptive, retrospective, analytical study with qualitative/quantitative methodology. Physiotherapeutic evaluation, Hemophilia Joint Health Score (HJHS) application for joint outcome assessment and Functional Independence Score in Hemophilia (FISH) were used to measure the patient's functional ability. The participants were divided into two groups: one group underwent a physiotherapy program and one not treated with physiotherapy after RS. Results: The study included 8 people with hemophilia A, all male, their mean age was 19±5.3 years. Twelve joints were submitted to RS, in which 41.67% elbows, 33.33% knees and 25% ankles. In the comparison of the groups, there was no statistically significant difference between them in joint health and functional independence. Conclusion: The study is a first attempt to describe the impact of physiotherapy on functional independence and joint health of hemophilic patients submitted to SR. Although this study has limitations, it was possible to observe that the group not treated with physiotherapy had better joint health and better functional independence prior to SR compared to the group that underwent physiotherapy, but the group treated with physiotherapy had worse overall health and have their functionality impacted by joints other than those treated with RS, presenting a higher number of target joints.

Recurrent diffuse tenosynovial giant cell tumor of the knee treated with adjuvant radiotherapy: A case report.

INTRODUCTION: TGCT (tenosynovial giant cell tumor) is a mono-articular proliferative condition that begins in the synovial membranes. Diffuse TGCT (DTGCT) has more prominent symptoms with high risks of recurrency. CASE PRESENTATION: In this case, we presented a 32-year-old male with recurrent case of DTGCT. The patient has been treated with arthroscopic synovectomy with the recurrence of disease. The patient was finally treated by open synovectomy combined with arthroscopy followed by adjuvant radiotherapy. DISCUSSION: The aim of this case is to report the success of open synovectomy combined with arthroscopy followed by 31 cycle of adjuvant radiotherapy in the recurrent case of DTGCT. CONCLUSION: Open synovectomy combined with arthroscopic synovectomy followed by adjuvant RT is a promising treatment modality in patient with DTGCT.

Treatment of Early Undifferentiated Chronic Monoarthritis of the Wrist by Arthroscopic Wrist Synovectomy Combined with Partial Denervation.

OBJECTIVE: Undifferentiated chronic monosecarthritis (UCMA) is a group of inflammatory joint diseases that has the potential to progress to other diseases and can seriously affect patients' quality of life. There is yet no unified consensus regarding treatment of UCMA. This study aimed to investigate the efficacy of arthroscopic synovectomy combined with partial wrist denervation in treating Larsen 1-3 UCMA. METHODS: In this case series, we reviewed 14 patients with UCMA treated by arthroscopic synovectomy combined with partial denervation from February 2017 to June 2020. The mean duration of symptoms was 17.4 months (range, 4-60 months), and the mean follow-up was 13.3 months (range, 6-23 months). The anterior and posterior interosseous nerves were severed at the distal forearm, and the radiocarpal, midcarpal, and distal radial ulnar joint synovial membranes were arthroscopically resected at the wrist. The clinical evaluation indices included the visual analogue scale score (VAS) for pain, grip strength, range of (active) motion of the wrist, total active motion, and Mayo wrist score. Larsen's scoring method was used as the imaging evaluation index. RESULTS: At the last follow-up, significant clinical improvements were observed in the visual analogue scale (VAS) score for pain (6.0 (5.0-6.3) vs 1.0 (1.0-2.3), P = 0.001) and Mayo wrist score (42.1 ± 9.7 vs 61.8 ± 12.3, P < 0.0001). No significant changes were found in grip strength (15.9 ± 4.5 vs 16.6 ± 4.7, P = 0.230) or the flexion-extension arc (58.9 ± 39.0 vs 64.3 ± 36.5, P = 0.317), although the mean and median did show positive changes. Among the three patients who showed progress in imaging, there was no significant difference in their pain and functional scores compared to those who did not progress. One patient underwent total wrist fusion 17 months after the operation. CONCLUSION: Arthroscopic wrist synovectomy combined with partial wrist denervation can provide sustained pain relief and functional recovery for patients with Larsen 1-3 UCMA.

Surgical Treatment of Juvenile Idiopathic Arthritis in the Era of Novel Drug Therapies.

Juvenile idiopathic arthritis is the most common chronic rheumatic disease encountered in children under the age of sixteen and causes significant impairments in daily life. Over the last two decades, the introduction of new drug treatments (including disease-modifying antirheumatic drugs and biologics) has changed the course of this disease, thus reducing the indication for surgery. However, some patients fail to respond to drug therapy and thus require personalized surgical management, e.g., the local reduction of joint effusion or a synovial pannus (via intra-articular corticosteroid injections, synovectomy, or soft tissue release), and management of the sequelae of arthritis (such as growth disorders and joint degeneration). Here, we provide an overview of the surgical indications and outcomes of the following interventions: intra-articular corticosteroid injections, synovectomy, soft tissue release, surgery for growth disorders, and arthroplasty.

Arthroscopic Capsular Shrinkage Is Safe and Effective in the Treatment of Midcarpal Instability in a Pediatric Population: A Single-Center Experience of 51 Cases.

Objective Treatment of palmar midcarpal instability (PMCI) remains controversial and children can develop PMCI from asymptomatic hypermobility. Recently, case series have been published regarding the use of arthroscopic thermal shrinkage of the capsule in adults. Reports of the use of the technique in children and adolescents are rare, and there are no published case series. Methods In a tertiary hand center for children's hand and wrist conditions, 51 patients were treated with arthroscopy for PMCI between 2014 and 2021. Eighteen out of 51 patients carried additional diagnosis of juvenile idiopathic arthritis (JIA) or a congenital arthritis. Data were collected including range of movement, visual analog scale (VAS) at rest and with load, and grip strength. Data were used to determine the safety and efficacy of this treatment in pediatric and adolescent patients. Results Mean follow-up was 11.9 months. The procedure was well tolerated and no complications were recorded. Range of movement was preserved postoperatively. In all groups VAS scores at rest and with load improved. Those who underwent arthroscopic capsular shrinkage (ACS) had significantly greater improvement in VAS with load, compared with those who underwent arthroscopic synovectomy alone ( p = 0.04). Comparing those treated with underlying JIA versus those without, there was no difference in postoperative range of movement, but there was significantly greater improvement for the non-JIA group in terms of both VAS at rest ( p = 0.02) and VAS with load ( p = 0.02). Those with JIA and hypermobility stabilized postoperatively, and those with JIA with signs of early carpal collapse and no hypermobility achieved improved range of movement, in terms of flexion ( p = 0.02), extension ( p = 0.03), and radial deviation ( p = 0.01). Conclusion ACS is a well-tolerated, safe, and effective procedure for PMCI in children and adolescents. It improves pain and instability at rest and with load, and offers benefit over open synovectomy alone. This is the first case series describing the usefulness of the procedure in children and adolescents, and demonstrates effective use of the technique in experienced hands in a specialist center. Level of Evidence This is a Level IV study.