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Original article
Arthroscopic resection of benign tumors of the knee posterior compartment: A report of 15 cases T. Masquefa ∗ , B. Dunet , N. Verdier , J. Pallaro , T. Fabre , C. Tournier Service d’orthopédie traumatologie, hôpital Pellegrin, place Amélie-Raba-Leon, 33076 Bordeaux cedex, France
a r t i c l e
i n f o
Article history: Received 11 December 2014 Accepted 14 May 2015 Keywords: Knee Arthroscopy Intra-articular tumor Synovectomy Posterior compartment
a b s t r a c t Introduction: The management of tumors located in the posterior compartment of the knee, whatever the nature of the tumor, remains surgical excision and can be done by open surgery or under arthroscopic control. The objective of this study was to evaluate the arthroscopic management of intra-articular tumors of the posterior compartment of the knee. The hypothesis is that tumors or tumor-like lesions confined to the posterior compartment are accessible by arthroscopy with low iatrogenic risk. Materials and methods: All patients with an intra-articular tumor of the posterior compartment of the knee were enrolled between 2009 and 2013. The surgical management consisted of arthroscopic resection. Patients underwent postoperative MRI, repeated at last follow-up. The outcomes were the occurrence of complications, functional evaluation using the Lysholm Knee Scoring Scale, and the recurrence rate. Results: Fifteen patients were included. All patients had a complete resection. One case of delayed healing of the arthroscopic entry point was observed. At a mean 22 months, the mean Lysholm Knee Score increased from 74 (± 8.5) preoperatively to 92 (± 7.7) postoperatively, a significant increase of 18 points (P = 0.001). One patient had a recurrence of osteochondromatosis, requiring removal of a foreign body. Discussion: Resection of posterior intra-articular tumors of the knee using arthroscopy is possible, subject to a learning curve. © 2015 Published by Elsevier Masson SAS.
1. Introduction Intra-articular tumors or tumor-like disesases of the posterior compartment of the knee are rare. These are predominantly located in the anterior compartment. Posterior locations in certain knee diseases can suggest a tumor aspect. Few intra-articular tumors of the posterior compartment of the knee have been described to date. Only cases of fibroma [1], synovial and meniscal cyst [2–4], mucoid cyst [5,6], synovial sarcoma [7–9], localized pigmented villonodular synovitis [10–17], and hemangioma [18] have been reported. The objective of surgical management is to obtain complete excision of the tumor with a minimal risk of complications and functional sequelae. Contrary to tumor resection or open synovectomy [19] via the posterior approach, arthroscopic management could reduce the functional sequelae of the knee and decrease the rate of complications, notably during posterior synovectomies, for a recurrence rate comparable to that already demonstrated for pigmented villonodular synovitis of the knee [20].
∗ Corresponding author. Tel.: +33 6 75 01 54 02. E-mail address: [email protected] (T. Masquefa).
The objective of this study was to assess the arthroscopic management of 15 patients presenting an intra-articular tumor or a tumor-like disease of the posterior compartment of the knee. We hypothesized that tumors or tumor-like diseases confined to the posterior compartment are accessible to arthroscopy with a low iatrogenic risk rate.
2. Material and methods Fifteen patients treated between 2009 and 2013 presenting an intra-articular tumor of the knee involving at least the posterior compartment were retrospectively included. The medical files were discussed with osteoarticular radiologists and none of these tumors was considered malignant. The patients’ mean age was 37 years (range, 17–59 years) with eight females and seven males. Of these 15 patients, one who had a synovial cyst was lost to follow-up. The mean follow-up of the remaining 14 patients was 22 months (range, 6–49 months). Three of the patients were treated for localized pigmented villonodular synovitis in the posterior compartment (Figs. 1 and 2), three for posterior meniscus synovial cysts, three for osteochondromatosis, three for mucoid synovial cysts of the posterior cruciate
http://dx.doi.org/10.1016/j.otsr.2015.05.001 1877-0568/© 2015 Published by Elsevier Masson SAS.
Please cite this article in press as: Masquefa T, et al. Arthroscopic resection of benign tumors of the knee posterior compartment: A report of 15 cases. Orthop Traumatol Surg Res (2015), http://dx.doi.org/10.1016/j.otsr.2015.05.001
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Fig. 1. MRI, sagittal T1 and T2 sequences, located behind the posterior cruciate ligament.
Fig. 2. Arthroscopic view of localized pigmented villonodular synovitis.
ligament (PCL), two for aspecific chronic synovitis, and one for intra-articular hemangioma (Fig. 3). The series included seven diffuse locations in the two posterior compartments of the knee, six at the base of the PCL, one posterolateral, and one posteromedial.
Fig. 3. Posteromedial arthroscopic view of an intra-articular hemangioma.
In all cases, management consisted of arthroscopic surgical resection of the intra-articular tumor of the knee. The evaluation criteria were the quality of the resection, the occurrence of complications, and the functional evaluation of the knee using the Lysholm Knee Scoring Scale (LKSS). We also studied the overall recurrence rate. Two senior surgeons operated on all the patients using a standardized procedure. The mean duration of the intervention was 50 min (range, 40–90 min). The patients were operated under general anaesthesia, in the decubitus dorsal position with a tourniquet. The knee was maintained in 90◦ flexion. In this position, the common fibular nerve and the popliteal artery were folded back, thus limiting iatrogenic risks [21–23], as was the sartorial branch of the saphenous nerve located approximately 10 mm behind the entry point of the posteromedial approach. All the patients underwent preliminary arthroscopic exploration of the anterior compartment of the knee with a 4.5-mm arthroscope and 30◦ fore oblique using the classic anterolateral, anteromedial approaches, alternatively for visualization and instrumentation. The anterolateral and anteromedial approaches were placed adjacent to the edge of the patellar tendon 1 cm above the joint space, thus allowing easier passage into the posterior compartment of the knee going through the femoral notch [24,25]. For reasons of symmetry, the arthroscopy of the posterior compartment was always initiated by the posteromedial approach. This entry point was positioned using anterolateral arthroscopic guidance, passing the arthroscope at the medial edge of the PCL so as to access the posterior compartment. The entry point was identified using transillumination [26,27]. Located behind the lateral collateral ligament and above the tendon of the femoral biceps muscle and thus avoiding the common fibular nerve, the posterolateral approach was established in the same way, passing the arthroscope in the posterior compartment via the anteromedial approach, at the lateral edge of the anterior cruciate ligament (ACL). One patient (synovial cyst) required resection via the exclusively posterolateral instrument portal and the anteromedial optical portal. Two other resections were exclusively performed via the posteromedial arthroscopy portal and the anterolateral optical portal, for a medial posterior meniscal cyst and a synovial cyst. The three cases of diffuse osteochondromatosis in both posterior compartments were treated by alternating the posteromedial
Please cite this article in press as: Masquefa T, et al. Arthroscopic resection of benign tumors of the knee posterior compartment: A report of 15 cases. Orthop Traumatol Surg Res (2015), http://dx.doi.org/10.1016/j.otsr.2015.05.001
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Table 1 Population. Patients
Sex
Age
Preoperative Lysholm
Postoperative Lysholm
MRI
Posterior synovial cyst Aspecific chronic synovitis Osteochondromatosis Mucoid synovial cyst of PCL Osteochondromatosis Osteochondromatosis Aspecific chronic synovitis Localized posterior villonodular synovitis Localized posterior villonodular synovitis Mucoid synovial cyst of PCL Localized posterior hemangioma Localized posterior villonodular synovitis Mucoid synovial cyst of PCL Medial posterior meniscal synovial cyst Posterior synovial cyst
M F F F F M F M M M F F M M M
34 43 59 22 41 30 55 43 17 42 37 19 25 42 40
73 78 60 65 65 70 65 75 70 75 82 86 85 85 Lost to follow-up
100 86 90 90 80 90 75 95 100 90 100 95 100 95
No recurrence No recurrence No recurrence No recurrence Recurrence No recurrence No recurrence No recurrence No recurrence No recurrence No recurrence No recurrence No recurrence No recurrence
PCL: posterior cruciate ligament.
and posterolateral arthroscopy portals, obviating the need for a transseptal approach. Nine patients required a transseptal approach established using the “back and forth” technique with a Wissinger obturator according to the technique described by Louisia et al. [28]. These were three cases of localized pigmented villonodular synovitis, one in the medial compartment and two in the lateral compartment; three cases of mucoid synovial cysts of the PCL; two cases of diffuse aspecific chronic synovitis in both posterior compartments; and one case of localized hemangioma located behind the PCL. The posteromedial and posterolateral approaches combined in this transseptal approach made it possible to obtain a single posterior compartment, since the instrument and optical portals were interchangeable. Once the mass had been resected, a final verification of the knee joint was made to determine the quality of the resection and detect any bleeding before closing with a suction Redon drain inserted into the anterior compartment. The tissue samples were all immersed in formol and then embedded in paraffin; five 1-mm-thick sections of paraffin were made and colored with hematoxylin–eosin–saffron (HES) for the anatomopathological examination. The drain was removed 48 h later and passive and active rehabilitation was initiated immediately. Weight-bearing was allowed with a knee extension orthosis for 4 weeks. The patients retrospectively underwent a functional assessment based on the pre- and postoperative LKSS, which provided the means of paired series with the Friedman test; P < 0.05 was considered significant. The patients also underwent postoperative MRI to determine the quality of the resection at 1 year and then every year. 3. Results The mean hospital stay was 4 days (range, 3–11 days). No serious intraoperative or postoperative complications were observed. One patient presented a joint fistula from a posterolateral arthroscopic orifice, resulting in delayed healing with no other consequences [29]. For the 14 patients evaluated (Table 1), the preoperative mean Lysholm Score was 74 (± 8.5) and the postoperative score was 92 (± 7.7), a significant increase of 18 points (P = 0.001) (Table 2).
All the resections were deemed complete on MRI. A single recurrence was noted: a case of diffuse osteochondromatosis of the posterior compartment that was reoperated at 18 months to remove a loose body arthroscopically. Of the 14 patients followed up, postoperative MRI assessment of the knee joint showed complete excision with absence of recurrence at a mean follow-up of 22 months in 13 patients (93%).
4. Discussion The main result of this study is that benign tumors or tumor-like diseases of the posterior compartment of the knee are accessible to arthroscopy with low iatrogenic risk. Treatment is surgical, either by open excision or arthroscopy. In the present arthroscopic series, a significant increase in the functional score was noted. Despite the learning curve, no serious complication was observed. One posterior joint fistula that resolved spontaneously was observed, a relatively specific complication of posterior arthroscopic procedures [29]. The low statistical power as well as the retrospective design are limitations of this study. The study of recurrence rates also remains highly debatable given the very heterogeneous population because the recurrence rate is closely related to the type of tumor. However, the recurrence rate in this series was very low for a surgical technique that showed no intraoperative complications. Loriaut et al. [30] observed four recurrences in a group of cases of localized pigmented villonodular synovitis (20%) and reported a median Lysholm Score of 85 at 75 months of follow-up. Many authors have developed arthroscopic management of pigmented villonodular synovitis for both localized and diffused forms. The recurrence rates remain comparable with open synovectomy. Auregan et al. [20] reported 29% recurrence. Zvijac et al. [31] reported that arthroscopic treatment of pigmented villonodular synovitis could improve functional recuperation, reduce the incidence of postoperative stiffness, and decrease joint pain. The recent meta-analysis published by Auregan et al. [32] analyzing 60 studies with a total of 1019 patients found no difference in terms of local recurrence of localized or diffuse pigmented villonodular synovitis after arthroscopic or open management. However, there was a low level of postoperative complications
Table 2 Functional results assessed using the Lysholm Knee Scoring Scale.
Lysholm Score
Preoperative (mean ± standard deviation; range)
Postoperative (mean ± standard deviation; range)
Significance
73.8 ± 8.5; 60–86
91.8 ± 7.7; 75–100
P < 0.001
Please cite this article in press as: Masquefa T, et al. Arthroscopic resection of benign tumors of the knee posterior compartment: A report of 15 cases. Orthop Traumatol Surg Res (2015), http://dx.doi.org/10.1016/j.otsr.2015.05.001
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after arthroscopic management of diffuse pigmented villonodular synovitis cases. Arthroscopy of the posterior compartment remains a difficult technical procedure, possibly leading to a high iatrogenic risk in inexperienced hands. The technical risks of arthroscopy of the posterior compartment correspond to the basic risks of any anterior arthroscopic procedure [29]. More specifically, even if there is a theoretical vascular risk [23], most importantly a popliteal artery lesion [33,34], to our knowledge, its incidence has not been established [27,35]. Among the nerve lesions (saphenous nerve [36], common fibular nerve, and tibial nerve), the most frequent neurological complication remains saphenous nerve branch lesions: 7–22% depending on the series [21]. We nevertheless had no intraoperative complications in our patients treated with posterior arthroscopy. Postoperative recovery was uneventful compared to open surgery. Arthroscopy reduces surgical morbidity, limits the surgical insult of the anterior and posterior compartments, and allows better exploration of the knee compartments. The postoperative risk of infection is lower [37], as is the risk of thromboembolic events [38,39]. The technical difficulties mean that there is a learning curve. After arthroscopy, the return to professional and sports activities is more rapid. In case of recurrence, revision, notably with Trickey approach, remains possible. The study’s hypothesis has been confirmed and the study shows that excision of benign intra-articular tumors of the posterior compartment of the knee is accessible with arthroscopy. This technique seems effective, providing a good functional result and low iatrogenic risk. It remains a demanding surgical technique, however, requiring a high level of skill in the posterior arthroscopic approaches because iatrogenic risks do exist. Disclosure of interest The authors declare that they have no conflicts of interest concerning this article. References [1] Ahn JH, Lee YS, Lee DH, Ha HC. Intraarticular fibroma of the posterior compartment in the knee. A case report. Knee 2008;15:155–8. [2] Yoo JH, Kim EH, Min KD, Lee BI. Arthroscopic excision of the ganglion in the posterior septum by posterior trans-septal portal: report of two cases. Arch Orthop Trauma Surg 2009;129:1047–51. [3] Shetty GM, Nha KW, Wang KH, Choi JY, Kim DH, Chae DJ. Central popliteal mass due to communicating posterior cruciate ligament cyst: an indication for a combined approach. Arthroscopy 2009;25:1051–3. [4] Shaikh N, Abdel-Galil K, Compson J. An unusual complication of knee arthroscopy: portal site synovial cyst. Knee 2004;11:501–2. [5] Parkar AP, Vanhoenacker FM, Adriaensen ME. Bilateral mucoid degeneration of the posterior cruciate ligaments. JBR-BTR 2013;96:298–300. [6] Cho SD, Youm YS, Lee CC, Seo DK, Kim TW. Mucoid degeneration of both ACL and PCL. Clin Orthop Surg 2012;4:167–70. [7] McLain R, Buckwalter J, Platz CE. Synovial sarcoma of the knee: missed diagnosis despite biopsy and arthroscopic synovectomy. A case report. J Bone Joint Surg Am 1990;72:1092–4. [8] Muscolo DL, Ayerza MA, Makino A, Costa-Paz M, Aponte-Tinao LA. Tumors about the knee misdiagnosed as athletic injuries. J Bone Joint Surg Am 2003;85–A:1209–14. [9] Namba Y, Kawai A, Naito N, Morimoto Y, Hanakawa S, Inoue H. Intraarticular synovial sarcoma confirmed by SYT-SSX fusion transcript. Clin Orthop Relat Res 2002:221–6. [10] Muscolo DL, Makino A, Costa-Paz M, Ayerza MA. Localized pigmented villonodular synovitis of the posterior compartment of the knee: diagnosis with magnetic resonance imaging. Arthroscopy 1995;11:482–5.
[11] Ozalay M, Tandogan RN, Akpinar S, Cesur N, Hersekli MA, Ozkoc G, et al. Arthroscopic treatment of solitary benign intra-articular lesions of the knee that cause mechanical symptoms. Arthroscopy 2005;21:12–8. [12] Ares-Rodriguez O, Seijas R, Carrera-Calderer L, Albareda-Carreras D. Use of polymethylmethacrylate to treat pigmented villonodular synovitis in the posterior compartment of the knee. Arch Orthop Trauma Surg 2008;128:651–5. [13] Calmet J, Hernandez-Hermoso J, Gine J, Jimeno F. Localized pigmented villonodular synovitis in an unusual location in the knee. Arthroscopy 2003;19:144–9. [14] Stubbs AJ, Higgins LD. Pigmented villonodular synovitis of the knee: disease of the popliteus tendon and posterolateral compartment. Arthroscopy 2005;21:893. [15] Kim RS, Lee JY, Lee KY. Localized pigmented villonodular synovitis attached to the posterior cruciate ligament of the knee. Arthroscopy 2003;19:E32–5. [16] Williams AM, Myers PT. Localized pigmented villonodular synovitis: a rare cause of locking of the knee. Arthroscopy 1997;13:515–6. [17] Le Tiec T, Hulet C, Locker B, Beguin J, Vielpeau C. [Villonodular synovitis of the knee. Analysis of a series of 17 cases and review of the literature]. Rev Chir Orthop Reparatrice Appar Mot 1998;84:607–16. [18] Dunet B, Tournier C, Pallaro J, Boullet F, Fabre T. Arthroscopic treatment of an intra-articular hemangioma in the posterior compartment of the knee. Orthop Traumatol Surg Res 2014;100:337–9. [19] Sharma V, Cheng EY. Outcomes after excision of pigmented villonodular synovitis of the knee. Clin Orthop Relat Res 2009;467:2852–8. [20] Auregan JC, Bohu Y, Lefevre N, Klouche S, Naouri JF, Herman S, et al. Primary arthroscopic synovectomy for pigmented villo-nodular synovitis of the knee: recurrence rate and functional outcomes after a mean follow-up of seven years. Orthop Traumatol Surg Res 2013;99:937–43. [21] Kramer DE, Bahk MS, Cascio BM, Cosgarea AJ. Posterior knee arthroscopy: anatomy, technique, application. J Bone Joint Surg Am 2006;88:110–21. [22] Matava MJ, Sethi NS, Totty WG. Proximity of the posterior cruciate ligament insertion to the popliteal artery as a function of the knee flexion angle: implications for posterior cruciate ligament reconstruction. Arthroscopy 2000;16:796–804. [23] Cosgarea AJ, Kramer DE, Bahk MS, Totty WG, Matava MJ. Proximity of the popliteal artery to the PCL during simulated knee arthroscopy: implications for establishing the posterior trans-septal portal. J Knee Surg 2006;19: 181–5. [24] Lubowitz JH, Rossi MJ, Baker BS, Guttmann D. Arthroscopic visualization of the posterior compartments of the knee. Arthroscopy 2004;20:675–80. [25] Amin KB, Cosgarea AJ, Kaeding CC. The value of intercondylar notch visualization of the posteromedial and posterolateral compartments during knee arthroscopy. Arthroscopy 1999;15:813–7. [26] Gold DL, Schaner PJ, Sapega AA. The posteromedial portal in knee arthroscopy: an analysis of diagnostic and surgical utility. Arthroscopy 1995;11:139–45. [27] Ahn JH, Ha CW. Posterior trans-septal portal for arthroscopic surgery of the knee joint. Arthroscopy 2000;16:774–9. [28] Louisia S, Charrois O, Beaufils P. Posterior “back and forth” approach in arthroscopic surgery on the posterior knee compartments. Arthroscopy 2003;19(3):321–5. [29] Allum R. Complications of arthroscopy of the knee. J Bone Joint Surg Br 2002;84:937–45. [30] Loriaut P, Djian P, Boyer T, Bonvarlet JP, Delin C, Makridis KG. Arthroscopic treatment of localized pigmented villonodular synovitis of the knee. Knee Surg Sports Traumatol Arthrosc 2012;20:1550–3. [31] Zvijac JE, Lau AC, Hechtman KS, Uribe JW, Tjin ATEW. Arthroscopic treatment of pigmented villonodular synovitis of the knee. Arthroscopy 1999;15: 613–7. [32] Auregan JC, Klouche S, Bohu Y, Lefevre N, Herman S, Hardy P. Treatment of pigmented villonodular synovitis of the knee. Arthroscopy 2014;30:1327–41. [33] Bernhoff K, Bjorck M. Iatrogenic popliteal artery injury in non arthroplasty knee surgery. Bone Joint J 2015;97-B:192–6. [34] Jeffries JT, Gainor BJ, Allen WC, Cikrit D. Injury to the popliteal artery as a complication of arthroscopic surgery. A report of two cases. J Bone Joint Surg Am 1987;69:783–5. [35] De Ponti A, Sansone V, Malchere M. Result of arthroscopic treatment of pigmented villonodular synovitis of the knee. Arthroscopy 2003;19:602–7. [36] Ogilvie-Harris DJ, Biggs DJ, Mackay M, Weisleder L. Posterior portals for arthroscopic surgery of the knee. Arthroscopy 1994;10:608–13. [37] Hagino T, Ochiai S, Watanabe Y, Senga S, Wako M, Ando T, et al. Complications after arthroscopic knee surgery. Arch Orthop Trauma Surg 2014;134:1561–4. [38] Greene JW, Deshmukh AJ, Cushner FD. Thromboembolic complications in arthroscopic surgery. Sports Med Arthrosc 2013;21:69–74. [39] Sun Y, Chen D, Xu Z, Shi D, Dai J, Qin J, et al. Incidence of symptomatic and asymptomatic venous thromboembolism after elective knee arthroscopic surgery: a retrospective study with routinely applied venography. Arthroscopy 2014;30:818–22.
Please cite this article in press as: Masquefa T, et al. Arthroscopic resection of benign tumors of the knee posterior compartment: A report of 15 cases. Orthop Traumatol Surg Res (2015), http://dx.doi.org/10.1016/j.otsr.2015.05.001
ARTICLE IN PRESS
OTSR-1242; No. of Pages 4
Orthopaedics & Traumatology: Surgery & Research xxx (2015) xxx–xxx
Available online at
ScienceDirect www.sciencedirect.com
Original article
Arthroscopic resection of benign tumors of the knee posterior compartment: A report of 15 cases T. Masquefa ∗ , B. Dunet , N. Verdier , J. Pallaro , T. Fabre , C. Tournier Service d’orthopédie traumatologie, hôpital Pellegrin, place Amélie-Raba-Leon, 33076 Bordeaux cedex, France
a r t i c l e
i n f o
Article history: Received 11 December 2014 Accepted 14 May 2015 Keywords: Knee Arthroscopy Intra-articular tumor Synovectomy Posterior compartment
a b s t r a c t Introduction: The management of tumors located in the posterior compartment of the knee, whatever the nature of the tumor, remains surgical excision and can be done by open surgery or under arthroscopic control. The objective of this study was to evaluate the arthroscopic management of intra-articular tumors of the posterior compartment of the knee. The hypothesis is that tumors or tumor-like lesions confined to the posterior compartment are accessible by arthroscopy with low iatrogenic risk. Materials and methods: All patients with an intra-articular tumor of the posterior compartment of the knee were enrolled between 2009 and 2013. The surgical management consisted of arthroscopic resection. Patients underwent postoperative MRI, repeated at last follow-up. The outcomes were the occurrence of complications, functional evaluation using the Lysholm Knee Scoring Scale, and the recurrence rate. Results: Fifteen patients were included. All patients had a complete resection. One case of delayed healing of the arthroscopic entry point was observed. At a mean 22 months, the mean Lysholm Knee Score increased from 74 (± 8.5) preoperatively to 92 (± 7.7) postoperatively, a significant increase of 18 points (P = 0.001). One patient had a recurrence of osteochondromatosis, requiring removal of a foreign body. Discussion: Resection of posterior intra-articular tumors of the knee using arthroscopy is possible, subject to a learning curve. © 2015 Published by Elsevier Masson SAS.
1. Introduction Intra-articular tumors or tumor-like disesases of the posterior compartment of the knee are rare. These are predominantly located in the anterior compartment. Posterior locations in certain knee diseases can suggest a tumor aspect. Few intra-articular tumors of the posterior compartment of the knee have been described to date. Only cases of fibroma [1], synovial and meniscal cyst [2–4], mucoid cyst [5,6], synovial sarcoma [7–9], localized pigmented villonodular synovitis [10–17], and hemangioma [18] have been reported. The objective of surgical management is to obtain complete excision of the tumor with a minimal risk of complications and functional sequelae. Contrary to tumor resection or open synovectomy [19] via the posterior approach, arthroscopic management could reduce the functional sequelae of the knee and decrease the rate of complications, notably during posterior synovectomies, for a recurrence rate comparable to that already demonstrated for pigmented villonodular synovitis of the knee [20].
∗ Corresponding author. Tel.: +33 6 75 01 54 02. E-mail address: [email protected] (T. Masquefa).
The objective of this study was to assess the arthroscopic management of 15 patients presenting an intra-articular tumor or a tumor-like disease of the posterior compartment of the knee. We hypothesized that tumors or tumor-like diseases confined to the posterior compartment are accessible to arthroscopy with a low iatrogenic risk rate.
2. Material and methods Fifteen patients treated between 2009 and 2013 presenting an intra-articular tumor of the knee involving at least the posterior compartment were retrospectively included. The medical files were discussed with osteoarticular radiologists and none of these tumors was considered malignant. The patients’ mean age was 37 years (range, 17–59 years) with eight females and seven males. Of these 15 patients, one who had a synovial cyst was lost to follow-up. The mean follow-up of the remaining 14 patients was 22 months (range, 6–49 months). Three of the patients were treated for localized pigmented villonodular synovitis in the posterior compartment (Figs. 1 and 2), three for posterior meniscus synovial cysts, three for osteochondromatosis, three for mucoid synovial cysts of the posterior cruciate
http://dx.doi.org/10.1016/j.otsr.2015.05.001 1877-0568/© 2015 Published by Elsevier Masson SAS.
Please cite this article in press as: Masquefa T, et al. Arthroscopic resection of benign tumors of the knee posterior compartment: A report of 15 cases. Orthop Traumatol Surg Res (2015), http://dx.doi.org/10.1016/j.otsr.2015.05.001
G Model OTSR-1242; No. of Pages 4 2
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Fig. 1. MRI, sagittal T1 and T2 sequences, located behind the posterior cruciate ligament.
Fig. 2. Arthroscopic view of localized pigmented villonodular synovitis.
ligament (PCL), two for aspecific chronic synovitis, and one for intra-articular hemangioma (Fig. 3). The series included seven diffuse locations in the two posterior compartments of the knee, six at the base of the PCL, one posterolateral, and one posteromedial.
Fig. 3. Posteromedial arthroscopic view of an intra-articular hemangioma.
In all cases, management consisted of arthroscopic surgical resection of the intra-articular tumor of the knee. The evaluation criteria were the quality of the resection, the occurrence of complications, and the functional evaluation of the knee using the Lysholm Knee Scoring Scale (LKSS). We also studied the overall recurrence rate. Two senior surgeons operated on all the patients using a standardized procedure. The mean duration of the intervention was 50 min (range, 40–90 min). The patients were operated under general anaesthesia, in the decubitus dorsal position with a tourniquet. The knee was maintained in 90◦ flexion. In this position, the common fibular nerve and the popliteal artery were folded back, thus limiting iatrogenic risks [21–23], as was the sartorial branch of the saphenous nerve located approximately 10 mm behind the entry point of the posteromedial approach. All the patients underwent preliminary arthroscopic exploration of the anterior compartment of the knee with a 4.5-mm arthroscope and 30◦ fore oblique using the classic anterolateral, anteromedial approaches, alternatively for visualization and instrumentation. The anterolateral and anteromedial approaches were placed adjacent to the edge of the patellar tendon 1 cm above the joint space, thus allowing easier passage into the posterior compartment of the knee going through the femoral notch [24,25]. For reasons of symmetry, the arthroscopy of the posterior compartment was always initiated by the posteromedial approach. This entry point was positioned using anterolateral arthroscopic guidance, passing the arthroscope at the medial edge of the PCL so as to access the posterior compartment. The entry point was identified using transillumination [26,27]. Located behind the lateral collateral ligament and above the tendon of the femoral biceps muscle and thus avoiding the common fibular nerve, the posterolateral approach was established in the same way, passing the arthroscope in the posterior compartment via the anteromedial approach, at the lateral edge of the anterior cruciate ligament (ACL). One patient (synovial cyst) required resection via the exclusively posterolateral instrument portal and the anteromedial optical portal. Two other resections were exclusively performed via the posteromedial arthroscopy portal and the anterolateral optical portal, for a medial posterior meniscal cyst and a synovial cyst. The three cases of diffuse osteochondromatosis in both posterior compartments were treated by alternating the posteromedial
Please cite this article in press as: Masquefa T, et al. Arthroscopic resection of benign tumors of the knee posterior compartment: A report of 15 cases. Orthop Traumatol Surg Res (2015), http://dx.doi.org/10.1016/j.otsr.2015.05.001
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Table 1 Population. Patients
Sex
Age
Preoperative Lysholm
Postoperative Lysholm
MRI
Posterior synovial cyst Aspecific chronic synovitis Osteochondromatosis Mucoid synovial cyst of PCL Osteochondromatosis Osteochondromatosis Aspecific chronic synovitis Localized posterior villonodular synovitis Localized posterior villonodular synovitis Mucoid synovial cyst of PCL Localized posterior hemangioma Localized posterior villonodular synovitis Mucoid synovial cyst of PCL Medial posterior meniscal synovial cyst Posterior synovial cyst
M F F F F M F M M M F F M M M
34 43 59 22 41 30 55 43 17 42 37 19 25 42 40
73 78 60 65 65 70 65 75 70 75 82 86 85 85 Lost to follow-up
100 86 90 90 80 90 75 95 100 90 100 95 100 95
No recurrence No recurrence No recurrence No recurrence Recurrence No recurrence No recurrence No recurrence No recurrence No recurrence No recurrence No recurrence No recurrence No recurrence
PCL: posterior cruciate ligament.
and posterolateral arthroscopy portals, obviating the need for a transseptal approach. Nine patients required a transseptal approach established using the “back and forth” technique with a Wissinger obturator according to the technique described by Louisia et al. [28]. These were three cases of localized pigmented villonodular synovitis, one in the medial compartment and two in the lateral compartment; three cases of mucoid synovial cysts of the PCL; two cases of diffuse aspecific chronic synovitis in both posterior compartments; and one case of localized hemangioma located behind the PCL. The posteromedial and posterolateral approaches combined in this transseptal approach made it possible to obtain a single posterior compartment, since the instrument and optical portals were interchangeable. Once the mass had been resected, a final verification of the knee joint was made to determine the quality of the resection and detect any bleeding before closing with a suction Redon drain inserted into the anterior compartment. The tissue samples were all immersed in formol and then embedded in paraffin; five 1-mm-thick sections of paraffin were made and colored with hematoxylin–eosin–saffron (HES) for the anatomopathological examination. The drain was removed 48 h later and passive and active rehabilitation was initiated immediately. Weight-bearing was allowed with a knee extension orthosis for 4 weeks. The patients retrospectively underwent a functional assessment based on the pre- and postoperative LKSS, which provided the means of paired series with the Friedman test; P < 0.05 was considered significant. The patients also underwent postoperative MRI to determine the quality of the resection at 1 year and then every year. 3. Results The mean hospital stay was 4 days (range, 3–11 days). No serious intraoperative or postoperative complications were observed. One patient presented a joint fistula from a posterolateral arthroscopic orifice, resulting in delayed healing with no other consequences [29]. For the 14 patients evaluated (Table 1), the preoperative mean Lysholm Score was 74 (± 8.5) and the postoperative score was 92 (± 7.7), a significant increase of 18 points (P = 0.001) (Table 2).
All the resections were deemed complete on MRI. A single recurrence was noted: a case of diffuse osteochondromatosis of the posterior compartment that was reoperated at 18 months to remove a loose body arthroscopically. Of the 14 patients followed up, postoperative MRI assessment of the knee joint showed complete excision with absence of recurrence at a mean follow-up of 22 months in 13 patients (93%).
4. Discussion The main result of this study is that benign tumors or tumor-like diseases of the posterior compartment of the knee are accessible to arthroscopy with low iatrogenic risk. Treatment is surgical, either by open excision or arthroscopy. In the present arthroscopic series, a significant increase in the functional score was noted. Despite the learning curve, no serious complication was observed. One posterior joint fistula that resolved spontaneously was observed, a relatively specific complication of posterior arthroscopic procedures [29]. The low statistical power as well as the retrospective design are limitations of this study. The study of recurrence rates also remains highly debatable given the very heterogeneous population because the recurrence rate is closely related to the type of tumor. However, the recurrence rate in this series was very low for a surgical technique that showed no intraoperative complications. Loriaut et al. [30] observed four recurrences in a group of cases of localized pigmented villonodular synovitis (20%) and reported a median Lysholm Score of 85 at 75 months of follow-up. Many authors have developed arthroscopic management of pigmented villonodular synovitis for both localized and diffused forms. The recurrence rates remain comparable with open synovectomy. Auregan et al. [20] reported 29% recurrence. Zvijac et al. [31] reported that arthroscopic treatment of pigmented villonodular synovitis could improve functional recuperation, reduce the incidence of postoperative stiffness, and decrease joint pain. The recent meta-analysis published by Auregan et al. [32] analyzing 60 studies with a total of 1019 patients found no difference in terms of local recurrence of localized or diffuse pigmented villonodular synovitis after arthroscopic or open management. However, there was a low level of postoperative complications
Table 2 Functional results assessed using the Lysholm Knee Scoring Scale.
Lysholm Score
Preoperative (mean ± standard deviation; range)
Postoperative (mean ± standard deviation; range)
Significance
73.8 ± 8.5; 60–86
91.8 ± 7.7; 75–100
P < 0.001
Please cite this article in press as: Masquefa T, et al. Arthroscopic resection of benign tumors of the knee posterior compartment: A report of 15 cases. Orthop Traumatol Surg Res (2015), http://dx.doi.org/10.1016/j.otsr.2015.05.001
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after arthroscopic management of diffuse pigmented villonodular synovitis cases. Arthroscopy of the posterior compartment remains a difficult technical procedure, possibly leading to a high iatrogenic risk in inexperienced hands. The technical risks of arthroscopy of the posterior compartment correspond to the basic risks of any anterior arthroscopic procedure [29]. More specifically, even if there is a theoretical vascular risk [23], most importantly a popliteal artery lesion [33,34], to our knowledge, its incidence has not been established [27,35]. Among the nerve lesions (saphenous nerve [36], common fibular nerve, and tibial nerve), the most frequent neurological complication remains saphenous nerve branch lesions: 7–22% depending on the series [21]. We nevertheless had no intraoperative complications in our patients treated with posterior arthroscopy. Postoperative recovery was uneventful compared to open surgery. Arthroscopy reduces surgical morbidity, limits the surgical insult of the anterior and posterior compartments, and allows better exploration of the knee compartments. The postoperative risk of infection is lower [37], as is the risk of thromboembolic events [38,39]. The technical difficulties mean that there is a learning curve. After arthroscopy, the return to professional and sports activities is more rapid. In case of recurrence, revision, notably with Trickey approach, remains possible. The study’s hypothesis has been confirmed and the study shows that excision of benign intra-articular tumors of the posterior compartment of the knee is accessible with arthroscopy. This technique seems effective, providing a good functional result and low iatrogenic risk. It remains a demanding surgical technique, however, requiring a high level of skill in the posterior arthroscopic approaches because iatrogenic risks do exist. Disclosure of interest The authors declare that they have no conflicts of interest concerning this article. References [1] Ahn JH, Lee YS, Lee DH, Ha HC. Intraarticular fibroma of the posterior compartment in the knee. A case report. Knee 2008;15:155–8. [2] Yoo JH, Kim EH, Min KD, Lee BI. Arthroscopic excision of the ganglion in the posterior septum by posterior trans-septal portal: report of two cases. Arch Orthop Trauma Surg 2009;129:1047–51. [3] Shetty GM, Nha KW, Wang KH, Choi JY, Kim DH, Chae DJ. Central popliteal mass due to communicating posterior cruciate ligament cyst: an indication for a combined approach. Arthroscopy 2009;25:1051–3. [4] Shaikh N, Abdel-Galil K, Compson J. An unusual complication of knee arthroscopy: portal site synovial cyst. Knee 2004;11:501–2. [5] Parkar AP, Vanhoenacker FM, Adriaensen ME. Bilateral mucoid degeneration of the posterior cruciate ligaments. JBR-BTR 2013;96:298–300. [6] Cho SD, Youm YS, Lee CC, Seo DK, Kim TW. Mucoid degeneration of both ACL and PCL. Clin Orthop Surg 2012;4:167–70. [7] McLain R, Buckwalter J, Platz CE. Synovial sarcoma of the knee: missed diagnosis despite biopsy and arthroscopic synovectomy. A case report. J Bone Joint Surg Am 1990;72:1092–4. [8] Muscolo DL, Ayerza MA, Makino A, Costa-Paz M, Aponte-Tinao LA. Tumors about the knee misdiagnosed as athletic injuries. J Bone Joint Surg Am 2003;85–A:1209–14. [9] Namba Y, Kawai A, Naito N, Morimoto Y, Hanakawa S, Inoue H. Intraarticular synovial sarcoma confirmed by SYT-SSX fusion transcript. Clin Orthop Relat Res 2002:221–6. [10] Muscolo DL, Makino A, Costa-Paz M, Ayerza MA. Localized pigmented villonodular synovitis of the posterior compartment of the knee: diagnosis with magnetic resonance imaging. Arthroscopy 1995;11:482–5.
[11] Ozalay M, Tandogan RN, Akpinar S, Cesur N, Hersekli MA, Ozkoc G, et al. Arthroscopic treatment of solitary benign intra-articular lesions of the knee that cause mechanical symptoms. Arthroscopy 2005;21:12–8. [12] Ares-Rodriguez O, Seijas R, Carrera-Calderer L, Albareda-Carreras D. Use of polymethylmethacrylate to treat pigmented villonodular synovitis in the posterior compartment of the knee. Arch Orthop Trauma Surg 2008;128:651–5. [13] Calmet J, Hernandez-Hermoso J, Gine J, Jimeno F. Localized pigmented villonodular synovitis in an unusual location in the knee. Arthroscopy 2003;19:144–9. [14] Stubbs AJ, Higgins LD. Pigmented villonodular synovitis of the knee: disease of the popliteus tendon and posterolateral compartment. Arthroscopy 2005;21:893. [15] Kim RS, Lee JY, Lee KY. Localized pigmented villonodular synovitis attached to the posterior cruciate ligament of the knee. Arthroscopy 2003;19:E32–5. [16] Williams AM, Myers PT. Localized pigmented villonodular synovitis: a rare cause of locking of the knee. Arthroscopy 1997;13:515–6. [17] Le Tiec T, Hulet C, Locker B, Beguin J, Vielpeau C. [Villonodular synovitis of the knee. Analysis of a series of 17 cases and review of the literature]. Rev Chir Orthop Reparatrice Appar Mot 1998;84:607–16. [18] Dunet B, Tournier C, Pallaro J, Boullet F, Fabre T. Arthroscopic treatment of an intra-articular hemangioma in the posterior compartment of the knee. Orthop Traumatol Surg Res 2014;100:337–9. [19] Sharma V, Cheng EY. Outcomes after excision of pigmented villonodular synovitis of the knee. Clin Orthop Relat Res 2009;467:2852–8. [20] Auregan JC, Bohu Y, Lefevre N, Klouche S, Naouri JF, Herman S, et al. Primary arthroscopic synovectomy for pigmented villo-nodular synovitis of the knee: recurrence rate and functional outcomes after a mean follow-up of seven years. Orthop Traumatol Surg Res 2013;99:937–43. [21] Kramer DE, Bahk MS, Cascio BM, Cosgarea AJ. Posterior knee arthroscopy: anatomy, technique, application. J Bone Joint Surg Am 2006;88:110–21. [22] Matava MJ, Sethi NS, Totty WG. Proximity of the posterior cruciate ligament insertion to the popliteal artery as a function of the knee flexion angle: implications for posterior cruciate ligament reconstruction. Arthroscopy 2000;16:796–804. [23] Cosgarea AJ, Kramer DE, Bahk MS, Totty WG, Matava MJ. Proximity of the popliteal artery to the PCL during simulated knee arthroscopy: implications for establishing the posterior trans-septal portal. J Knee Surg 2006;19: 181–5. [24] Lubowitz JH, Rossi MJ, Baker BS, Guttmann D. Arthroscopic visualization of the posterior compartments of the knee. Arthroscopy 2004;20:675–80. [25] Amin KB, Cosgarea AJ, Kaeding CC. The value of intercondylar notch visualization of the posteromedial and posterolateral compartments during knee arthroscopy. Arthroscopy 1999;15:813–7. [26] Gold DL, Schaner PJ, Sapega AA. The posteromedial portal in knee arthroscopy: an analysis of diagnostic and surgical utility. Arthroscopy 1995;11:139–45. [27] Ahn JH, Ha CW. Posterior trans-septal portal for arthroscopic surgery of the knee joint. Arthroscopy 2000;16:774–9. [28] Louisia S, Charrois O, Beaufils P. Posterior “back and forth” approach in arthroscopic surgery on the posterior knee compartments. Arthroscopy 2003;19(3):321–5. [29] Allum R. Complications of arthroscopy of the knee. J Bone Joint Surg Br 2002;84:937–45. [30] Loriaut P, Djian P, Boyer T, Bonvarlet JP, Delin C, Makridis KG. Arthroscopic treatment of localized pigmented villonodular synovitis of the knee. Knee Surg Sports Traumatol Arthrosc 2012;20:1550–3. [31] Zvijac JE, Lau AC, Hechtman KS, Uribe JW, Tjin ATEW. Arthroscopic treatment of pigmented villonodular synovitis of the knee. Arthroscopy 1999;15: 613–7. [32] Auregan JC, Klouche S, Bohu Y, Lefevre N, Herman S, Hardy P. Treatment of pigmented villonodular synovitis of the knee. Arthroscopy 2014;30:1327–41. [33] Bernhoff K, Bjorck M. Iatrogenic popliteal artery injury in non arthroplasty knee surgery. Bone Joint J 2015;97-B:192–6. [34] Jeffries JT, Gainor BJ, Allen WC, Cikrit D. Injury to the popliteal artery as a complication of arthroscopic surgery. A report of two cases. J Bone Joint Surg Am 1987;69:783–5. [35] De Ponti A, Sansone V, Malchere M. Result of arthroscopic treatment of pigmented villonodular synovitis of the knee. Arthroscopy 2003;19:602–7. [36] Ogilvie-Harris DJ, Biggs DJ, Mackay M, Weisleder L. Posterior portals for arthroscopic surgery of the knee. Arthroscopy 1994;10:608–13. [37] Hagino T, Ochiai S, Watanabe Y, Senga S, Wako M, Ando T, et al. Complications after arthroscopic knee surgery. Arch Orthop Trauma Surg 2014;134:1561–4. [38] Greene JW, Deshmukh AJ, Cushner FD. Thromboembolic complications in arthroscopic surgery. Sports Med Arthrosc 2013;21:69–74. [39] Sun Y, Chen D, Xu Z, Shi D, Dai J, Qin J, et al. Incidence of symptomatic and asymptomatic venous thromboembolism after elective knee arthroscopic surgery: a retrospective study with routinely applied venography. Arthroscopy 2014;30:818–22.
Please cite this article in press as: Masquefa T, et al. Arthroscopic resection of benign tumors of the knee posterior compartment: A report of 15 cases. Orthop Traumatol Surg Res (2015), http://dx.doi.org/10.1016/j.otsr.2015.05.001
