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TUMORS
260
mens removed for otosclerosis proved to be avascular
necrosis in 25% of the specimens (W197). The clinical
and radiographic findings in Legg-Calve-Perthes disease were the subject of several reviews (C147,G51,
H121,M345,N40,W206).
Aseptic necrosis was described as a complication
of dislocation of the metacarpophalangeal joint (G92).
Avascular necrosis in a 9-year-old girl treated with cor-
ticosteroids was presented, emphasizing that this complication of steroid therapy is no respecter of ages
(H2 13). Freiberg’s disease (osteochondrosis of the second metatarsal head) was successfully treated in a 12year-old girl with silicone rubber implants (B200). An
additional series of steroid-induced avascular necrosis
of the femoral head was reported (C229).
TUMORS
Benign neoplasms
Synovial chondromatosis. Histopathologic study
of 30 patients with synovial osteochondromatosis revealed that the process appeared to follow a 3-phase
temporal sequence: 1) active intrasynovial disease only,
without loose bodies, 2) transitional phase, with both
active intrasynovial proliferation and loose bodies, and
3) multiple free osteochondral bodies without demonstrable intrasynovial disease (M237). Three patients in
this series had residual extrasynovial cartilaginous lesions which persisted and grew after synovectomy, causing recurrence of clinical symptoms in the absence of
recurrent intrasynovial disease.
A number of case reports of synovial chondromatosis of the temporomandibular joint were presented (A43,M243,R120,127). The initial diagnosis in 1
patient was possible parotid tumor (M243). Patients
were most frequently female, a reversal of the sex incidence found with the more common involvement of
the knee, hip, or shoulder (R127).
Four patients with extraarticular synovial chondromatosis and 1 with combined intra- and extraarticular involvement were described (S2 10). Such lesions were thought to arise in tendon sheaths or bursae,
and the importance of recognizing their synovial origin
in order to avoid an erroneous diagnosis of chondrosarcoma was emphasized. Report of a tenosynovial chondroma in a 73-year-old woman stressed the same point
and noted that these tumors were benign and that,
whereas they occasionally recurred, they did not metastasize (S280).
Pigmented villonodular synovitis. A 2 1-year-old
black woman with a history of intermittent locking,
swelling, and pain in her right knee and a palpable
loose body around the medial aspect of the joint was
found on surgery to have localized villonodular synovitis (W 182). A preoperative contrast arthrogram had
been normal. However, in a 40-year-old man, arthrography demonstrated the characteristic synovial pattern
of diffuse, pigmented villonodular synovitis (PVS) prior
to surgical intervention (H28).
Two patients with multiple joint involvement
with PVS were described (C225, L130). In a 55-year-old
woman, involvement of the right third and left second
distal interphalangeal finger joints was initially thought
to represent Heberden’s node formation until the characteristic pathologic changes were demonstrated in the
excised tissue (C225). A 7-year-old girl underwent synovectomies of the left elbow and the flexon tendon
sheaths of both feet with a pathologic diagnosis of PVS
(L130). However, between ages 8 and 14, she continued
to have swelling of various joints and at age 14 underwent a synovectomy of the right knee and, in the following 18 months, synovectomies of both ankles and the
right elbow. Some pathologists believed that the lesions
might represent synovial hemangioma. The patient also
had pulmonic stenosis, borderline intelligence, and scoliosis, suggesting the possibility of a more generalized
disease process.
Two case reports of PVS mimicking primary
bone neoplasm appeared (J43,K98). Histologic features
of both PVS and synovial chondromatosis were observed in synovial tissue from the temporomandibular
joint of a 62-year-old woman initially suspected of having a parotid tumor (R5).
Eleven patients with giant cell tumors of tendon
sheath (pigmented villonodular tenosynovitis) were examined by light and electron microscopy ((253). The giant cells were found to have many similarities to normal
osteoclasts, while the stromal cells had similarities to
primitive mesenchymal cells, osteoblasts, fibroblasts,
TUMORS
and histocytes. The suggestion was made that such tumors were derived from mesenchymal cells with partial
osseous differentiation.
A similar study of 5 patients with giant cell tumors of the tendon sheath revealed that they were composed mostly of type A and B synovial cells, but also
contained fibroblastic cells with intracytoplasmic filaments, as well as “monocytic” and “lymphocytic” cells
(A60). The giant cells were considered to be derived
from the fusion of type A synovial cells, whereas foam
cells were derived from both A and B cells. These lesions were considered to be borderline between reactive
and neoplastic processes.
Synovial hemangioma. Light and electron microscopic findings were reported regarding a synovial hemangioma occurring in the knee of a 4-year-old girl
(W209). The morphologic changes observed suggested
that synovial cells had undergone adaptation as a result
of the repeated local interstitial hemorrhage.
Synovial cysts. Two patients were described in
whom synovial cysts arising from the hip presented as
inguinal masses which were initially suspected of being
malignant (W135).
Malignant neoplasms
Synovial sarcoma. Synovial sarcoma is an uncommon malignant tumor which usually arises in the
soft tissues of the extremities, usually in relation to
joints, bursae, or tendon sheaths. Synovial sarcomas
arising in rare primary sites were the subject of 2 case
reports. A 29-year-old man with progressive disturbance
of deglutition and speech, choking sensations, and mild
respiratory distress was found to have a pedunculated
synovial sarcoma arising from the anterolateral pharyngeal wall (G18). What was believed to be the first example of primary synovial sarcoma of the soft palate
was reported in a 19-year-old man (M102).
A 34-year-old man who had had localized pain
and tenderness near the right greater trochanter for 1%
years underwent surgery because of suspicion of a
glomus tumor (13). A minute synovial sarcoma which
had not been palpable preoperatively was excised, and
the patient remained free of pain or evidence of tumor
on followup 24 months later.
The diagnosis of synovial sarcoma in a 60-yearold man with a slowly growing tumor in his right sole
for 3 years was established on the basis of cytologic
findings in fine-needle biopsy material processed by the
membrane filter technique (K139). The ultrastructural
findings in 3 malignant synoviomas were described
26 1
(D1 1 1). Two of the cases showed the expected biphasic
cellular structure, with both epithelial and fibroblastic
elements, while the third consisted mainly of spindle
cells, with little epithelial differentiation and no clear division into cell types.
Chondrosarcoma. Several papers dealt with
chondrosarcoma of the bones of the hands, a tumor
which may recur locally and which may metastasize to
the lung in approximately 10% of cases (P50,R102,T91).
Amputation of the involved digit or ray was considered
the most satisfactory treatment. Four cases were presented in which a low-grade, well-differentiated
chondrosarcoma underwent a sudden differentiation to
a highly malignant fibrosarcoma (M 143).
Seven cases of juxtacortical chondrosarcoma involving the shaft of a long bone, usually the femur, were
reported (S60). In 2 patients, 2 different long bones were
affected. Prognosis was judged to be better than with
central chondrosarcomas with similar histology.
An uncommon course of mesenchymal chondrosarcoma, a highly lethal tumor with a predilection for
young patients, was reported in a young girl with demonstrated recurrence of tumor over many months, but
who remained apparently free of tumor after lung resection and disarticulation of the left hip (P73).
The synthesis of high levels of chorionic gonadotropin by a chondrosarcoma was documented (M7).
The overall accuracy of 67galliumscanning in 33
patients with soft-tissue sarcoma or chondrosarcoma
was 95% (K49). Preliminary evaluation of computerized
tomography in the diagnosis of neoplastic and nonneoplastic musculoskeletal disorders suggested that it
sometimes provided unique information leading to the
correct diagnosis and was useful in defining the full extent of lesions, especially those involving the soft tissues
(W1w
Metastatic neoplasms. A 67-year-old man with
acute pain, swelling, and redness in the left ankle and
hindfoot and associated hyperuricemia was thought to
have gout but failed to respond to conventional therapy
(B 132). On open biopsy of the calcaneus, transitional
cell carcinoma, consistent with a metastasis from a bladder tumor removed 4 years earlier, was demonstrated.
Two patients with squamous cell carcinoma of
the lung with metastases to the phalanges were reported
(V2). Painful swelling of the right ring finger of 2
months duration was the presenting complaint in a 52year-old man found to have a primary tumor in the
right upper lobe with metastasis to the finger.
A 48-year-old man with inoperable squamous
cell cancer of the left lung was treated with radio- and
JOINT STRUCTURE AND FUNCTION
262
chemotherapy, and 2 months later developed an inflamed, tender right great toe initially diagnosed as
gout. However, it was later considered to be a metastasis
on the basis of radiologic appearance and the subsequent development of destructive bony lesions of the
right fourth finger.
A 53-year-old man who had developed pain in
his left shoulder after reroofing his house was treated
conservatively for degenerative arthritis and later adhesive capsulitis. He was then found to have extensive
bone destruction of the right humeral head and shaft
with a pathologic fracture of the greater tuberosity on
repeat radiography 1 year later (K3). Because of the patient’s recollection of a single episode of gross hematuria 5 months after the shoulder symptoms began,
studies were performed which led to the diagnosis of
adenocarcinoma of the kidney.
The rare example of metastasis of malignant
melanoma to the thumb was reported (G40). Seven patients with malignant disease mimicking arthritis of the
hip were described (M171). Hip symptoms were the
main complaint of all and had been present at the time
of final diagnosis for periods ranging from 2 weeks to 16
months. The medical history was of definite diagnostic
importance in only 2 patients, and the physical examination in only 1. A high index of suspicion of underlying malignancy was therefore suggested for every patient presenting with monarticular hip arthritis. Three
patients were described in whom malignant bone tumor
was associated with mild and nonspecific inflammatory
episodes in the adjacent joint (L7).
Severe bone pain and acute arthritis of the right
knee in a 60-year-old man with chronic myelomonocytic leukemia responded dramatically to cytosine
arabimoside therapy (D 137).
JOINT STRUCTURE AND FUNCTION
Structural studies
Embryologic experiments with the chick elbow
joint suggested that cells in the joint anlage follow a
specific pathway of differentiation governed by instructions present from the very early stages of limb development (H157). Removal of the presumptive joint region
led to fusion of the limb components, whereas removal
of the distal joint component did not interfere with normal development of the proximal element. This latter
finding was interpreted to mean that joint modeling was
not substantially influenced by the mechanical forces
resulting from differential growth of associated cartilage
elements.
An interesting study of isolated synovial intimal
cells from pig synovial membrane emphasized the similarities of synovial intimal cells to mononuclear phagocytes and proposed that they might be part of a “mononuclear phagocyte system” (B45). These data also
indicated that intimal synoviocytes belong to a single
cell type, assuming the A or B form as a consequence of
local environmental influences. A comparative ultrastructural study of the type B intimal synovial cells (as
distinguished from the histiocytic type A cells) was carried out in tissue from the mouse, rat, rabbit, guinea pig,
and human, and the distinctive morphologic features
were once again confirmed by electron microscopy
(L124). Special attention to the morphology and possible secretory functions of the type B ceUs was given in
an electron microscopic study of the development of synovial membrane and joint cavity in the mouse metatarsophalangeal joint (L 125).
The somatomedin activity in unfractionated synovial fluid from the ox was said to be present in substantially lower concentrations than in serum when
measured by bioassay (C160). [The methods used in this
study do not permit separation of somatomedin activity
from the many other growth factors which might be
found in serum and joint fluid. Ed.]
Mechanoreceptors have long been thought to be
responsible for sense of joint position and movement
(kinaesthesia). Current information suggests that specialized nerve endings in skin, muscle, and tendons may
also be important in kinaesthesia (T82). Such information would seem to explain the fact that patients undergoing joint replacement seldom show significant impairment of position sense. A communication between a
knee joint and the gastrocnemio-semimembranosus
bursa was found more frequently in older individuals
and thought to be an acquired condition (L133,135,
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