| Purpose: The objective of this study was to compare of open surgery, arthroscopic surgery and radiotherapy for treatment of diffuse pigmented villonodular synovitis of intra-articular knee joint.Methods: There were 39 patients in total with knee PVNS who were admitted to our hospital from 2003-1 to 2013-1 due to discomforts like knee joint swelling and pain. 3 patients failed to do follow-up check in 1 year after discharge, while the other 36 patients did in 3 months, 6 months and 1 year respectively after the surgery. Patients needed follow-up once a year after the first year of surgery. Patients’ age varied from 7 to 72 years old with an average of 41.5±15.82 years old. For the proportion of male and female patients, there were 17 male patients and 19 female patients. So the female was in the majority. Patients were divided into three groups according to treatment methods:Group A :There were 7 patients in group A. The average age of Group A was 46.29±5.13(range, 28 to 62) years old. Group A is arthrotomy group with ordinary knee arthrotomy for lesion removal. The incision type was starting from the middle of prepatellar part and open the joint capsule along the way about 0.5cm from the inner edge of patella and remove the lesion in the anterior capsule. Determine whether to add a popliteal incision to remove the lesion in the posterior capsule according to the MRI images. Group B: Group B consisted of 21 patients with simple arthroscopic surgery for lesion removal. The average age of Group B was 38.71± 4.03(range, 7 to 72) years old. Add arthroscopic incision from inside and outside the knee to remove the lesion in the anterior capsule according to the preoperative MRI images and the pigmented and diffuse condition of the synovium seen during the surgery. Group C: Group C consisted of 8 patients. The average age was 44.6±2.80(range, 33 to 56) years old. Group C is for local radiotherapy after arthroscopic synovectomy. Radiotherapy was given to the affected knee 2-6 weeks after the surgery. Use CT simulation orientation and send the 3D CT images to the treatment planning system. Refer to the document of ICRU50 and 62 to outline Clinical Target Volume(CTV)(including tumor location, complete joint and 2 cm within the scope of surgical scar edge). Planning Target Volume(PTV) was generated by planning system and was defined as evenly extending the CTV boundary for 0.5 cm on the basis of 3D image. Make an Intensity Modulated Radiation Therapy(IMRT) plan. The prescribed dosage was 40Gy-46 Gy / 20-23 f, 5 times a week. Complete Blood Count should be monitored during the radiotherapy, and joint was allowed to move but needed to lighten load. The typical part of the lesion was taken during the surgery and sent for pathological examination. The result confirmed the diagnosis of PVNS. For patients who had joint swelling and pain after the surgery, MRI should be done again to make sure of relapse. According to the preoperative and finally follow-up Lysholm score and the recurrence rate,we compared the advantages and disadvantages of three kinds of treatments.Results:The shortest period of follow-up was24 months, while the longest was up to 104 months. And the average was 60.4±24.54 months. There were no statistically differences within the three groups in terms of genders and ages. Group A:The average period of follow-up was 62.57±21.38(range, 34 to 104) months. 1 patient had a relapse in 14 months after the surgery and the relapse rate was 14.3%. The relapse lesion was located at the posterior capsule. The Lysholm score was38.00±1.83 preoperatively and 79.50±3.95(range, 75 to 86) postoperatively in the Group A. Group B: The average period of follow-up was 57.43±25.85(range, 24 to 99) months. 1 patient wasn’t given any treatment due to the chronic injury of anterior cruciate ligament. 3 patients had a relapse in 11-25 months after the surgery and the relapse rate was 14.3%. 1 patient had a relapse in 11 months after the surgery and the relapse lesion was located at the posterior capsule. This patient underwent arthroscopic surgery for twice followed by postoperative radiotherapy. The pathological result confirmed the diagnosis of PVNS and he didn’t have any relapse during the next two years of follow- up. Another 1 patient had a relapse in 25 months and the relapse lesion was located at the infrapatellar part and the posterior capsule but he refused reoperation. Another patient refused reoperation had a relapse in 14 months and the relapse lesion was located at the posterior capsule. He refused reoperation and got Intra-articular radiotherapy from other hospital. The Lysholm score was39.90±4.60(range, 36 to 58) preoperatively and 89.33±2.25(range, 43 to 96) postoperatively in the Group B. For group C, the average period of follow-up was 66.50±25.23(range, 29 to 90) months. No one had any relapse. The Lysholm score was37.38±2.45(range, 33 to 41) preoperatively and 87.62±3.89(range, 94 to 82) postoperatively in the Group C. Patients in three groups all had a great improvement of their joint function. Lysholm score at last follow-up A <B = C(P<0.05). The recurrence rate has no obvious difference(P>0.05).Conclusions: Both arthrotomy and arthroscopic synovectomy have no significant effect on postoperative relapse. But arthroscopic surgery is less invasive. It also has advantages like quicker recovery, lower risk of joint stiffness and better knee appearance, etc. So we recommend arthroscopic synovectomy. There is no effect on the knee function rehabilitation and relapse rate by giving local radiotherapy after synovectomy so far, but it still requires long-term observation and follow-up, as well as a larger sample. |
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