Malignant Tumor in Knee Joint Cavity Extra-Articular Resection: Clinical Observation of 4 Cases Series

Abstract

The knee is one of the most common places to develop a primary sarcoma. Malignant bone tumors are rare conditions that may be encountered by non-oncologic surgeons only a few times in their careers, but a delay in diagnosis or a misinterpretation of data can have limb and life-threatening consequences.
Methods: A retrospective analysis was conducted on 4 cases of knee joint problems. Patients admitted to the hospital between June 2016 to March 2019. We identified 2 males and 2 females with knee joint malignancy, aged 38 ~76 years. The diagnosis was confirmed by histopathology. All 4 patients underwent total knee joint tumor resection with prosthesis replacement.
Results: The interventions were successfully completed without vascular and nerve injury, but in 1 case, the wound healing was delayed. Knee function was recovered satisfactorily after 24-37 months of followup. At the last follow-up, the knee flexion angle range for the 4 patients was 95°, 100°, 100°, and 110°, respectively, and the delay of knee extension was 5°, 10°, 10° and 5°, respectively; tissue tumor association scores were 53%, 77%, 80%, and 83%. Quadriceps muscle strength was grade 4 in two cases and grade 5 in the other two cases. No tumor recurrence or metastasis was detected, and no death occurred.
Conclusion: We identified 4 cases of malignant tumor involving the knee in which total and partial excision and reconstruction were performed.

Full text

J Orthop Sports Med 2019; 1 (4): 098-106 DOI: 10.26502/josm.51150012
Journal of Orthopaedics and Sports Medicine 98
Research Article
Malignant Tumor in Knee Joint Cavity Extra-Articular Resection:
Clinical Observation of 4 Cases Series
Sayed Abdulla Jami1, Shi Jiandang1*, Md Ariful Haque2, Zhanwen Zhou1
1Department of Spinal Surgery, General Hospital of Ningxia Medical University, Ningxia Medical University,
People’s Republic of China
2Department of Orthopedic Surgery, Kunming Medical University, Yunnan, China
*Corresponding Author: Shi Jiandang, Department of Spinal Surgery, General Hospital of Ningxia Medical
University, Ningxia Medical University 804 Shengli Street, Xingqing District, Yinchuan, 750004, Ningxia, People’s
Republic of China, Tel: 008613709512318; E- mail: shi_jiandang@163.com
Received: 16 December 2019; Accepted: 20 December 2019; Published: 30 December 2019
Abstract
Background: The knee is one of the most common places to develop a primary sarcoma. Malignant bone
tumors are rare conditions that may be encountered by non-oncologic surgeons only a few times in their
careers, but a delay in diagnosis or a misinterpretation of data can have limb and life-threatening
consequences.
Methods: A retrospective analysis was conducted on 4 cases of knee joint problems. Patients admitted to
the hospital between June 2016 to March 2019. We identified 2 males and 2 females with knee joint
malignancy, aged 38 ~76 years. The diagnosis was confirmed by histopathology. All 4 patients underwent
total knee joint tumor resection with prosthesis replacement.
Results: The interventions were successfully completed without vascular and nerve injury, but in 1 case,
the wound healing was delayed. Knee function was recovered satisfactorily after 24-37 months of follow-
up. At the last follow-up, the knee flexion angle range for the 4 patients was 95°, 100°, 100°, and 110°,
respectively, and the delay of knee extension was 5°, 10°, 10° and 5°, respectively; tissue tumor
association scores were 53%, 77%, 80%, and 83%. Quadriceps muscle strength was grade 4 in two cases
and grade 5 in the other two cases. No tumor recurrence or metastasis was detected, and no death
occurred.
Conclusion: We identified 4 cases of malignant tumor involving the knee in which total and partial excision and
reconstruction were performed.

J Orthop Sports Med 2019; 1 (4): 098-106 DOI: 10.26502/josm.51150012
Journal of Orthopaedics and Sports Medicine 99
Keywords: Malignant tumor; Knee joint; Extra-articular resection; Prosthesis implantation; Case series
1. Introduction
The area around the knee joint is a common site of malignant bone tumors. The main treatment for this type of
cancer is limb salvage surgery, which involves total resection of the tumor followed by reconstruction of the knee
structure. The probability that the tumor will invade the joint cavity is usually low and so in most cases, the swelling
around the knee joint is reduced. In rare cases, the malignant mass invades the knee joint cavity as a consequence of
biopsy or surgery leading to accidental tumor spread, pathological fractures, invasion of the joint ligament or direct
invasion of the joint [1]. The most common procedure for tumor resection Involves opening the joint capsule and
reconstructing the affected segment. According to the study of Simon et al. [2] in 16% of cases, the cancerous mass
directly penetrates the articular cartilage and invades the articular cavity, while in 9% of cases the tumor grows
around the articular cartilage, connect with the joint capsule and enters the joint cavity. Also, in some cases, tumors
were found in the intercondylar notch invading the cruciate ligament. When a malignant tumor around the knee joint
invades the knee cavity, block resection is required to treat the tumor outside the knee joint. This procedure is
complicated and requires very good knowledge of anatomy around the knee joint structures. The evaluation of bone
tumors requires a thorough history and physical examination in conjunction with proper utilization and diagnostic
understanding of additional tests and procedures. The present study presents data of 4 patients with malignant
tumors invading the knee cavity admitted to the department of orthopedics. We performed a retrospective analysis in
order to explore the diagnostic features of the disease, total extra-articular knee joint resection technique and clinical
effects of the excision.
2. Materials and Methods
2.1 General information
Patient 1 is a 66 years old female who has been complaining of swelling and pain in the left thigh for more than 2
years, which have been aggravating in the 2 months before hospital admission on June 16, 2016. Physical
examination on admission identified: claudication, distal left femur palpable, hard mass, local tenderness and limited
(0° - 95°) left knee flexion. X-ray film showed osteolytic destruction of the distal femur, with periosteum reaction
and soft tissue mass. MRI revealed that the tumor mass protruded into the suprapatellar sac leading to fluid
accumulating in the cavity. The myogenic mesenchymal tumor was confirmed by the pathological diagnosis of
distal femoral tumor biopsy. Cytologic examination of knee effusion smear revealed malignant tumor cells.
Patient 2 is a 76 years old male who has been complaining of swelling and pain in the right distal femur for years,
which started to aggravate 1 month before hospital admission on December 6, 2016. During the physical
examination, the patient was found to be bedridden, right distal femur visible swelling was identified as well as
palpable, hard mass, tenderness, and limited (0° -30°) right knee flexion. The X-ray showed dilated dissolution of
the distal right femur bone destruction, tumor discontinuity with the cortical distal femur, pathological fracture. MRI
showed the tumor invaded into the knee joint cavity. The pathological diagnosis of tumor biopsy confirmed a
malignant fibrous histiocytoma.

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Journal of Orthopaedics and Sports Medicine 100
Patient 3 is a 59 years old female with a history of 2 days of left knee joint swelling and pain after fall in 2017. She
was admitted to the hospital on February 2. Upon physical examination on admission, the patient lay on the bed, had
the left knee joint swollen. The free patellar test was positive, the left external femoral condyle was tender, and the
left knee joint was fixed in flexion position due to pain. X-ray and CT showed a lytic destruction of the left femoral
condyle with the pathological bone fold. MRI showed tumor invasion of the knee cavity (Figure 1A).
Chondrosarcoma diagnosis was confirmed by pathological biopsy examination (Figure 1B).
Patient 4 is a 38 years old male and had right knee pain for half a year, aggravating for 1 month. He was admitted to
hospital on August 23, 2017. During the physical examination on admission, no swelling of the right knee joint was
identified, floating patellar was negative, and the flexion of the right knee joint was limited (0° - 90°). The X-ray
showed the right femur with no significant bone destruction in the tibia. MRI showed intra-articular soft tissue
tumors involving inter-condylar fossa and posterior articular capsule. The tumor biopsy was performed under the
guidance of b-ultrasound, and the pathological diagnosis was synovial sarcoma.
Figure 1: Extra-articular total knee resection combined with artificial tumour type knee prosthesis replacement in a
59 years old female with distal femoral pathological fracture (1A) Pre-operative knee joint sagittal MRI shows bone
destruction at the distal femur, tumour invasion of the knee joint and superior patellar. (1B) Preoperative puncture
and pathological examination confirmed the disordered arrangement of cartilage and Chondrocyte cells of different
sizes invading surrounding bone. (1C) During the operation, the tendon of rectus femoris was retained, the patella
was cut open in coronal position, and the patellar tendon was retained. (1D) The specimens were removed during the
surgery, and X-ray film showed that resection was successful. (1E) X-ray showing the prosthesis in correct position.

J Orthop Sports Med 2019; 1 (4): 098-106 DOI: 10.26502/josm.51150012
Journal of Orthopaedics and Sports Medicine 101
2.2 Surgical methods
All 4 patients in this group underwent excision of the extra-articular tumor and partial resection of the knee joint. In
order to perform resection with tumor-free margins, we retained some quadriceps and tibia tendon and we applied a
balloon tourniquet. The anterior medial incision of the knee was made, and the biopsy site was removed. The flap
should be fully dissociated on both sides and be sharp outside the suprapatellar free quadriceps femoris tendon,
avoiding the upper sac in operation. The medial tibial edge was freed using the oscillating saw to perform the
coronal osteotomy of the patella cut with swing saw. Dividing the thickness of the tibia ensures that the osteotomy
does not enter the knee joint. We dissociated the patellar tendon from the patella between the lower fat pads, we
preserved the patellar tendon and we flipped the extensor device (Figure 1C)
Figure 2: Sarcomas involving the knee joint diagnostic and treatment. EAR represents Extra-articular resection, and
IAR represents Intra-articular resection.
Line of femur section bone and preoperative location of the osteotomy plane were determined according to MRI.
The distance between the femoral osteotomy and the swollen portion of the knee was 3-5 cm, thus preventing the
rupture of the joint cavity. Then, the distal end of the femur was lifted, blood vessels were protected and freed on the
inside, and the branches into the joint were ligate and cut. The entire knee joint was raised and separated from the
posterior compartment structure. The internal and lateral head of the gastrocnemius anatomizes distally to cover the
posterior capsule and obtain a safe margin. At the tibia, the osteotomy plane is level with the tip of the fibula head,
approximately 12 mm below the tibial plateau. Tibial tubercle was retained to maintain patellar tendon attachment.

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Journal of Orthopaedics and Sports Medicine 102
Osteotomy plane was situated lower than semi-membrane tendon and posterior articulation ligament and it stops at
the tibial attachment, avoiding residual posterior cruciate ligament. On the tibia, the flatness of the osteotomy cuts
the popliteal muscle sharply. After a tibial osteotomy, the tumor was entirely removed (Figure 1D). The
reconstruction methods were used in combination with artificial tumor knee prosthesis. The prosthesis was
intramedullary fixed with bone cement without the use of the tibial prosthesis (Figure 1E).
2.3 Efficacy evaluation
Postoperative knee function was evaluated by the international association of bone and soft tissue tumors
(Musculoskeletal Tumour Society, MSTS) scoring criteria. Using muscle strength, the grading method (0 to 5)
evaluates the quadriceps muscle strength.
3. Results
All the 4 patients were operated successfully, and the operation time was 2 ~ 2.5 hours. After surgery on the 10th
day, there was local necrosis of the skin margin in a patient. After debridement, the skin was sutured and healed
again. All of the patient’s surgery area did not appear Infection, patella fracture, prosthesis loosening, and other
prosthesis complications. There were no local recurrence and lung metastases observed in the other 3 cases. All the
4 patients were followed up for 7, 8, 9 and 16 months, the range of motion of knee flexion activities was 95°, 100°,
100°, 110°, and the knee extension was delayed 5°, 10°, 10°, and 5°. MSTS scores were 53%, 77%, 80%, and 83%
respectively. Quadriceps muscle strength was 4, 4, 5, and 5, respectively.
4. Discussion
4.1 Diagnosis of tumor invasion of the knee cavity
MRI is highly sensitive to the diagnosis of tumor invasion into the joint cavity, especially contrast-enhanced T1 WI.
Schima et al. [3] treated 46 patients with osteosarcoma around the joint; Postoperative pathology confirmed that 10
patients had tumor invasion into the articular cavity, which was consistent with the MRI examination results; 11
other patients underwent surgery, preoperative MR suggesting tumor invasion into the joint cavity, but postoperative
pathological findings were false positive due to the inflammatory changes around the tumor; it can lead to false
statement or result with a specificity of only 69%. Anract et al. [4] performed total extra-articular knee resection on
9 patients, including 2 patients with preoperative MRI showing invasion of femoral trochlear and of the cruciate
ligament, but postoperative pathology revealed a false positive result; therefore, the authors suggest that patients
with suspected joint cavity invasion, arthroscopy should be specially performed for the lesion located in the joint. In
some cases, a preoperative MRI examination could not determine whether the joint was affected or not, so a small
incision biopsy was performed to evaluate the properties of joint effusion. After that, it is decided to perform an
extra-articular resection for joint repair. [5]. Shahid et al. [6] proposed a detailed diagnostic process: first, perform
an MRI check; if MRI cannot clear whether the joint is involved, the next step is to perform puncture cytology or
minimally invasive arthroscopic biopsy. In the present study, patients 2 & 3 had pathologic fracture; MRI showed
tumor invasion of the joint cavity, and a diagnostic biopsy was performed. Patient 1 MRI showed a tumor protruding
into the suprapatellar region; the cytological examination revealed tumor cells as evidence of invasion of the joint
cavity. Patient 4 had a tumor in the intercondylar fossa and to prevent the tumor from spreading, we used

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Journal of Orthopaedics and Sports Medicine 103
ultrasound-guided needle biopsy to confirm the diagnosis. We believe that the nature of the tumor should be clearly
defined before surgery. In order to determine if the joint cavity is involved, one can use a needle biopsy or
minimally invasive check to avoid tumor spread.
4.2 Anatomical and surgical points of total knee arthroplasty
There are 13 synovial sacs around the knee joint. Among them, the synovial sac connection with the knee joint
cavity can be detected according to connection probability as follows: the suprapatellar bursa was 80%, the popliteal
bursa was 100. 0%, the semi-membrane bursa was 20.0%, and the medial gastrocnemius bursa was 24.1% [7].
Extra-articular total knee resection requires the removal of the synovial capsule, suprapatellar capsule, and the knee
extensor device (situated in front of the knee cavity and composed of quadriceps femoris, patella, and patellar
ligament).
There are 2 types of extensor device resection: complete and partial resection.
4.2.1 Complete resection of the extensor device
Anract et al. [4] reported 9 patients who underwent resection and reconstruction of the knee extension devices
through gastrocnemius medial head flap. Capanna et al. [1] completely resected the knee extension device in 14
patients and reconstructed the knee extension device with composite allograft tibia, patellar tendon, and part of the
quadriceps tendon.
4.2.2 Partial resection of the extensor device
The purpose of this resection type is to improve the knee extension function after surgery. During the operation, the
quadriceps femoris and the suprapatellar capsule were sharply separated. The superficial quadriceps tendon was
retained, the patella was cut in a coronal position, all or part of the patellar tendon was retained, and the subpatellar
fat pad was removed together with the tumor. The anatomical basis for retaining the partial knee extensor is the deep
subpatellar bursa between the patellar ligament and the subpatellar fat pad; research studies have found that the deep
subpatellar bursa does not communicate with the articular cavity [8]. Therefore, theoretically, intraoperative
resection of the entire sub-patellar fat pad, joint capsule and the retention of the patellar ligament is possible.
We found 7 articles (147 patients) published during 2000-2016 on total extra-articular knee arthroplasty [1, 4-6, 9-
11]; among them, 28 cases underwent complete knee extension device resection and in 125 cases partial excision
was performed. All 4 patients from our group received partial resection of the knee extension device. Preoperative
MRI helped us to determine the extent of the quadriceps that needed to be removed. The patella was subjected to
coronal osteotomy with an oscillating saw to avoid entering the articular cavity and to retain the patellar ligament
and the sub-patellar pad was removed along with the tumor. The popliteal, semi-membranous, and medial
gastrocnemius sacs are located behind the knee joint on the lateral border of the lateral condyle of the femur, so the
popliteal sac is always connected to the knee cavity. To ensure a good surgical incision margin, the popliteal sac
cannot be exposed during the operation. The popliteal muscle needs to be cut off in the tibial osteotomy plane. The
medial and lateral head of the gastrocnemius is dissected to the distal side, and the semi-membranous muscle is
stopped to the proximal end after the joint capsule was covered, the muscle was cut off, and the medial

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Journal of Orthopaedics and Sports Medicine 104
gastrocnemius capsule and semi-membrane muscle capsule were removed simultaneously to safe the margin. The
insertion of the posterior cruciate ligament is located below the posterior tibial plateau; as usual, tibial plateau
osteotomy was performed by the method of knee joint surface replacement the cruciate ligament, the posterior joint
capsule can rupture and cause the tumor to contaminate normal tissue. Yan et al. [12] measured the distance from
the farthest end of the tibial attachment of the posterior cruciate ligament to the tip of the fibula separation is (2.8 ±
2.8 mm). Therefore, there is no involvement of the tibia in the extra-articular total knee resection; tibial plateau
osteotomy needs to be flat fibula tip level, which can be cut, in addition to the posterior joint capsule and semi-
membrane muscle insertion, can retain the patellar ligament insertion. In 2016, Gilg et al. [13] discussed whether
extra-articular total knee resection was needed, in addition to a literature review of the upper tibia-fibular joint,
identifying 4 articles in which through cadaver studies 10% -4% of the upper tibiofibular bone was detected to be
connected with the knee cavity. Also, the upper tibiofibular joint was validated by direct arthrography and a load of
muscle capsule was 100% connected with the knee joint cavity. The recurrence rate of upper tibiofibular joint
resection was 4%-8%, so it is uncertain whether the removal of the upper tibiofibular joint will reduce local
recurrence. In this 4 cases group, the tibia was truncated at the level of fibula micro cephalous in all patients, and the
upper tibiofibular joint was not resected. The author believes that although the tibiofibular bone may be connected
with the knee joint cavity, whether or not to remove the superior tibiofibular joint should also be carefully examined
before surgery, and the signs of distal femoral tumors such as the involvement of the superior tibiofibular bone can
be retained intraoperatively. However, the author concludes that extra-articular resection of the knee allows for good
oncologic and functional outcomes.
4.3 Clinical outcome of total knee arthroplasty
Because of the need to remove more bone and knee extension devices, total external knee resection was performed.
Kendall et al. [9] compared the postoperative results of extra-articular resection and intra-articular resection of
tumors in 9 patients. In 56 % of the case, postoperative infection (4 patients) and local recurrence (1 patient) were
assessed by MSTS points. Postoperative infection was found in 1 patient after intra-articular resection without local
recurrence. In that case, the MSTS score was 80%, and the postoperative function was better than that of the extra-
articular resection group (p=0,03). Therefore, preoperative diagnosis of tumor invasion of the joint cavity must be
made in support of an appropriate choice of surgical method. Taking into consideration the small number of cases
reported in the literature [1, 4], [9-11] the treatment of knee devices varies, with extra-articular total knee resection
for swelling. The results differ depending on the ontological or functional point of view.
Most cases of central extra-articular total knee resection were reported by Hardes et al. [5]. Among 59 patients,
partial resection of the knee extension device was performed in 55 patients and total resection in 4 patients. During
an average follow-up of 56 months, recurrence was observed in 2 cases (3%), infection around the prosthesis in 22
cases and prosthesis wear in 12 cases. There were 10 cases of prosthesis loosening, 6 cases of periprosthetic fracture
and 1 case of prosthesis fracture. The MSTS score was 73%, with average knee flexion of 72°. Shahid et al. [6]
reported a recurrence rate of 29% in 42 patients with partial knee extension devices, with MSTS score of 86.7%,
average knee flexion of 102°, 3° average elongation delay. Soft osteosarcoma was identified in 8 cases and
underwent extra-articular surgery, with local recurrence in 4 patients. According to the authors, surgical resection of

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Journal of Orthopaedics and Sports Medicine 105
the entire knee joint in patients with chondrosarcoma should be considered carefully. The 4 patients in this group
were followed up for an average of 18.5 months (range 26 to 37 months). No local recurrence or lung metastases
were observed. Knee flexion mean curve was 101°, the mean knee extension delay was 7.5 °, and the mean MSTS
score was 73%. However, the survival rate, recurrence, and outcomes of each type of malignant bone tumor vary.
5. Conclusion
Careful analysis of preoperative imaging data combined with the necessary intra-articular biopsy is helpful in order
to achieve a correct diagnosis of malignant tumor invading the knee cavity. During the procedure, the integrity of
the knee capsule was ensured, and the excision of the tumor was completed, followed by prosthesis placement
prosthesis and soft tissue reconstruction. We obtained a very good outcome in terms of joint functionality. The
sample size discussed in this study is small and therefore, a more comprehensive statistical analysis is not possible.
A larger cohort study should provide more detailed information relevant for clinical diagnosis and treatment of this
rare type of bone malignancy.
Ethical Approval
Hospital ethical committee approved this manuscript for publication.
Source of Funding
Not applicable.
Abbreviations
Not applicable.
Authors’ Contributions
SAJ, SJ, and MAH designed the manuscript; MAH conducted follow-up procedures; SJ guided and revised
manuscript; SAJ, MAH, and ZZ wrote different parts of the manuscript; ZZ helped to translate Chinese to English;
All authors approved the final manuscript.
Statement of Informed Consent
Research-informed consent was obtained from the institutional protocol.
Statement of Human and Animal Rights
The ethical standards of the responsible committee on human experimentation (institutional and national) and the
recommendations of the Helsinki Declaration of 1975, as revised in 2000 and 2008 were followed accordingly.
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Citation: Sayed Abdulla Jami, Shi Jiandang, Md Ariful Haque, Zhanwen Zhou. Malignant tumor in knee
joint cavity extra-articular resection: clinical observation of 4 cases series. Journal of Orthopaedics and Sports
Medicine 1 (2019):098-106