Arthroscopic Excision of a Localized Tenosynovial Giant Cell Tumor of the Knee: A Case Report.

BACKGROUND AND AIM: A tenosynovial giant cell tumor (TGCT) is a proliferative lesion of the synovial membrane of the joints, tendon sheaths and/or bursae. There are two described subtypes, including the localized and diffuse forms. A TGCT can also be intraarticular or extraarticular. An intraarticular localized tenosynovial giant cell tumor (L-TGCT) of the knee is characterized by nodular hyperplasic synovial tissue that can remain asymptomatic for a long time, but as the mass grows, it may cause mechanical symptoms that may require surgical treatment. The aim of our study is to present a rare case of an L-TGCT of the knee joint treated with an arthroscopic excision. CASE REPORT: We describe the case of a 17-year-old female with pain, swelling and knee locking in the absence of trauma. The magnetic resonance imaging (MRI) displayed a well-circumscribed small mass in the anterior medial compartment, adherent to the infrapatellar fat pad. The lesion presented the typical MRI characteristics of an intraarticular localized TGCT. The patient was treated with an arthroscopic mass removal and partial synovectomy. The gross pathology showed an ovoid nodule that was covered by a fibrous capsule; a histopathology examination confirmed the diagnosis. The patient was able to return to normal daily activities one month after surgery; at the three-year follow-up, she was free of symptoms with no evidence of disease on the MRI. CONCLUSION: In patients with a small-dimension L-TGCT in the anterior compartment of the knee that presents an MRI pattern and causes mechanical symptoms, an arthroscopic en-bloc excision can be performed that results in good outcomes and a rapid return to preinjury levels.

Treatment of a subcutaneous tibialis anterior tendon rupture with a semitendinosus autograft.

The subcutaneous rupture of the tibialis anterior tendon is a rare and silent lesion which can lead to foot and ankle dysfunction with gait difficulty. The treatment can be either conservative or surgical. Conservative management is reserved for inactive patients and those with a general or local contraindication to surgery, whereas surgical repair includes direct and rotational suture, as well as tendon transfer and auto- or allograft. The choice of surgical treatment is based on multiple factors, including the symptoms, the timespan from injury to treatment, the anatomopathological pattern of the lesion, and the patient's age and level of activity. Large defects present a particular reconstructive challenge, and there is no consensus on the optimal method of treatment. That being said, one of the options is an autograft using the semitendinosus hamstring tendon. We present a case of a 69-year-old woman who sustained a hyperflexion trauma to her left ankle. Three months later, ultrasound examination and a magnetic resonance imaging showed a complete tibialis anterior rupture with a gap of more than 10 cm. The patient was successfully treated with surgical repair. An autograft of the semitendinosus tendon was used to bridge the gap. The tibialis anterior rupture is a rare lesion that must be promptly diagnosed and treated, especially in physically active patients. Large defects pose particular challenges. Surgical management was found to be the treatment of choice. In the case of a lesion with a major gap, semitendinosus grafting can be successfully employed.

Treatment options for secondary osteonecrosis of the knee.

Knee osteonecrosis is a debilitating progressive degenerative disease characterized by subchondral bone ischemia. It can lead to localized necrosis, tissue death, and progressive joint destruction. For this reason, it is essential to diagnose and treat this disease early to avoid subchondral collapse, chondral damage, and end-stage osteoarthritis, where the only solution is total knee arthroplasty. Three types of knee osteonecrosis have been documented in the literature: spontaneous or primitive, secondary, and post arthroscopy. Spontaneous osteonecrosis is the most common type studied in the literature. Secondary osteonecrosis of the knee is a rare disease and, unlike the spontaneous one, involves patients younger than 50 years. It presents a particular set of pathological, clinical, imaging, and progression features. The management of secondary osteonecrosis is determined by the stage of the disorder, the clinical manifestation, the size and location of the lesions, whether the involvement is unilateral or bilateral, the patient's age, level of activity, general health, and life expectancy. This review aims to present the recent evidence on treatment options for secondary osteonecrosis of the knee, including conservative treatment, joint preserving surgery, and knee replacement.

Assessment and Management of Loose Bodies in the Knee Joint and Related Disease: A Narrative Review.

BACKGROUND: Loose bodies are frequently encountered during clinical activity and are a common finding during knee arthroscopy. Usually, treatment consists of the removal of loose bodies, which can be challenging even for experienced surgeons. The excision alone is not always the complete treatment, because loose bodies are generally secondary to other diseases that can cause persistent symptoms with the risk of new loose body formation. The aim of this narrative review is to show the clinical, imaging, and arthroscopic evaluation of loose bodies in order to plan optimal treatment. METHODS: A comprehensive search of PubMed was conducted to find the most recent and relevant studies investigating aetiopathogenesis, the assessment tools, and the therapeutic strategies for loose bodies in the knee and their related diseases. RESULTS: When dealing with a loose body, the first issue is the evaluation of the intra-articular fragment (location, size, number, symptoms) and its aetiopathogenesis by identifying the underlying pathology (e.g., osteochondritis dissecans, osteoarthritis, chondral defect, tumour-like lesions, rheumatoid arthritis, etc.). In the case of symptomatic intra-articular loose bodies, treatment consists of fragment removal and the management of related diseases (e.g.., lifestyle modification, physiotherapy, pharmacological, and surgical treatment). CONCLUSION: Loose bodies are not separate entities and in addition to their pathological aspect, must be evaluated within the context of the underlying disease. Correct assessment and comprehensive management allow for relief of symptomatology and prevention of loose body formation by removal and treatment of the associated diseases.

Total knee arthroplasty in a young patient with achondroplasia.

Achondroplasia is a genetic skeletal dysplasia, characterised by dwarfism, with upper and lower limb deformities, that can lead to knee osteoarthritis; the surgical treatment is a challenge due to the particular joint anatomy variances. We present a 40-year-old woman, affected by achondroplasia with severe left knee osteoarthritis; the patient was treated conservatively with poor results. Between the ages of 12 and 17 years, she underwent multiple operative procedures for lower limb lengthening and a partial correction of the valgus deformity, by applying an external fixator. The patient was successfully treated with cemented posterior stabilised, fixed-bearing, total knee arthroplasty. The patient affected by achondroplasia, with severe knee osteoarthritis, should be considered for total joint replacement, which can be carried out with or without additional extra-articular osteotomy for alignment correction. Due to skeletal dysplasia in joint deformities, knee replacement requires careful preoperative planning and special technical considerations.

Arthroscopic anterior cruciate ligament reconstruction in a patient with multiple hereditary exostoses.

Background Multiple hereditary exostoses (MHE) also known as Multiple Osteochondromas is a rare benign bone tumour disease, characterized by multiple osteocartilaginous masses. The knee is one of the most affected sites. Anterior cruciate ligament (ACL) surgery is the most common and generally most successful surgical knee procedure; however, the association between MHE and ACL reconstruction is very rare and may represent a challenging procedure because of the anatomical anomaly related to presence of multiple masses around the knee. Here, we present a case report of ACL reconstruction in a patient affected by multiple exostoses. Case report The patient was a 30-year-old woman affected by MHE, with an ACL tear arising after knee trauma. As the patient complained of pain, swelling and the knee "giving way", she successfully underwent arthroscopic-assisted ACL reconstruction using quadrupled hamstring tendon grafts, with femoral suspension and double tibial fixations. Conclusion Symptomatic ACL tears in a patient affected by MHE should be considered for arthroscopic reconstruction, which requires that particular attention be paid to tendons harvesting, tunnel placement and the choice of graft fixation system, given the presence of multiple masses around the knee.

Management of suprapatellar synovial plica, a common cause of anterior knee pain: a clinical review.

BACKGROUND AND AIM OF THE WORK: Suprapatellar synovial plica is caused by a congenital thickening of the synovial membrane and is generally asymptomatic. In the literature, suprapatellar plicae are described as one of the causes of anterior knee pain however, their real role in determining symptoms is controversial. The aim of the current paper is to describe the anatomy, classifications, pathophysiology, symptoms and management of suprapatellar plica syndrome, as well as the differential diagnosis from other causes of anterior knee pain. METHOD: Via a search within the MEDLINE/PubMed database, a current review was conducted, and the results summarized. RESULTS: Due to idiopathic, traumatic or inflammatory conditions, plicae can become pathological, causing anterior knee pain with possible knee clicking, swelling, giving way and locking after prolonged flexion of the knee. The diagnosis should be formulated based on an accurate medical history and clinical examination, followed by an appropriate imaging study. However, arthroscopy remains the "golden standard" for detecting all synovial plica. CONCLUSIONS: In patients with anterior knee pain, where doubt is present in the imaging investigation for intraarticular or periarticular lesions, pathological suprapatellar synovial plica must be suspected. The treatment should initially be conservative, but in cases where symptoms persist, patients should undergo arthroscopy to confirm diagnosis and to determine a suitable treatment. In the presence of pathological plica associated with cartilage damage of the femoral condyle or patella at the time of diagnostic arthroscopy, plicae excision leads to favourable results in a high number of cases.

ARTHROPLASTY IN ALKAPTONURIC OCHRONOSIS.

Ochronotic degenerative arthropathy occurs in patients with alkaptonuria. Alkaptonuria disorder is an extremely rare disease characterized by black pigmentation of various tissues (e.g., cartilage and connective tissue). Ochronotic arthropathy is a disabling disease that primarily affects the large joints. Like other metabolic diseases that involve the musculoskeletal system, care must be taken with regard to the quality of the affected bones, tendons and ligaments, and therefore the stability and survival of joint prosthesis. The following is a report of a 66-year-old man affected by several musculoskeletal manifestations of alkaptonuria with severe joints disruption, who was successfully treated with total left hip and total right knee replacements. Surgical, anesthesiological and postoperative management of these patients may require more vigilance due to the associated comorbidities of this disorder.

Two-Stage Revision Total Knee Arthroplasty for Suspected Periprosthetic Joint Infection and Metal and Bone Cement Hypersensitivity.

Hypersensitivity to implant components and periprosthetic joint infection should be detected before all revision arthroplasty, as misdiagnosis can lead to replacement loosening and the need for further revision procedures. We describe the case of a 69-year-old woman presenting a history of a painful cemented total knee replacement. Postoperative investigations showed loosening of X-ray components, suspected periprosthetic joint infection, and patch test hypersensitivity to nickel sulfate and methyl methacrylate. Two months later, a more specific patch test indicated non-allergy to the solid scratch of one bone cement. The patient underwent a two-stage revision with prosthesis removal and the temporary application of a specific cement spacer followed by the successful reimplantation of a cemented revision prosthesis. All candidates for the revision arthroplasty procedure must be investigated for hypersensitivity to metal and bone cement in order to avoid complications related to prosthesis intolerance and the need for further revision surgery; in the presence of hypersensitivity to bone cement and periprosthetic joint infection with a two-stage revision indication, the patient must be submitted to further patch tests with scratches of solid bone cement.