Tumors Around The Knee—What Orthopaedists Should Know

Tumors around the knee can present in a multitude of ways, often simulating other more common symptomatic conditions, or simply being incidental findings unrelated to a patient's presenting pain. In many cases, some providers may find these conditions to be both challenging and frightening. Sometimes, such concern is warranted, while in most cases surgeons can appropriately and safely manage such lesions by following evidence-based algorithms. Correct initial evaluation, biopsy, diagnosis, treatment, and/or referral can be critical to the successful treatment of these conditions. Occasionally, these patients are directly referred to an orthopaedic oncologist initially, but more commonly their first orthopaedic evaluation is performed by a general orthopaedist, sports surgeon, arthroplasty surgeon, or traumatologist. These patients comprise a small minority of clinical evaluations in the typical practice; however, it is imperative to correctly identify these cases and initiate an appropriate treatment course. In the setting of primary malignancy, the costs of incorrect diagnosis and management can be catastrophic. Delays in diagnosis have been shown to lead to medicolegal risks due to a larger tumor burden, higher chance of limb amputation, and lower life expectancy.[1] Unplanned sarcoma excision requires a larger reexcision in all cases, adding unnecessary morbidity for the patient and more than doubling the cost of patient care to the system.[2] Over half of reported legal case resolutions regarding extremity sarcoma malpractice have favored the plaintiff, with a delay in diagnosis being the most common complaint, followed by unnecessary amputation and misdiagnosis. Indemnity payments from these claims were almost 10 times higher than those for other medical and surgical specialties.[3] In metastatic disease with resultant pathologic fracture, the orthopaedic surgeon is frequently the first health care provider to diagnose cancer and initiate treatment discussions with the patient. As such, virtually all orthopaedic surgeons play an essential role in the care of these patients. Therefore, it is important to maintain a good working knowledge of how to recognize and evaluate these cases, as well as when treatment can be performed by a surgeon who is not a subspecialist or highly experienced in this arena.

Two manuscripts, “Management of Pathologic Fractures Around the Knee: Part 1Distal Femur” and “Part 2–Proximal Tibia,” provide the groundwork for performing a thorough patient work-up along with an easy-to-follow clinical algorithm to assist in primary tumor identification including necessary laboratory evaluation and medical imaging. The key principles of obtaining a tissue biopsy are discussed. Perioperative adjunctive treatment options are explored. Surgical fixation and reconstruction options based on the extent of disease are presented. These articles provide essential information for patient management in the setting of metastatic disease to the skeleton.

In “Management of Primary Aggressive Tumors of the Knee,” identifying characteristics and recommended treatment approaches are provided for the most common benign and malignant tumors encountered around the knee. These include giant cell tumor, chondroblastoma, chondromyxoid fibroma, osteosarcoma, and chondrosarcoma. This article provides the key components of preoperative and surgical management of these conditions. We again provide an easy-to-follow clinical algorithm with detailed information regarding laboratory analysis, necessary medical imaging, obtaining a tissue biopsy, patient prognosis, perioperative management, and surgical treatment options. The main takeaway from this article is that improper management of a primary malignant tumor around the knee can preclude limb salvage and, in some cases, may decrease life expectancy. Consultation with, and/or referral to, an orthopaedic oncologist is recommended and should concerns arise during patient evaluation.

Lastly, “Evaluation and Management of Intra-Articular Tumors of the Knee” provides a concise overview of the five most commonly occurring intra-articular knee tumors on the following accounts: pigmented villonodular synovitis, synovial chondromatosis, lipoma arborescens, synovial hemangioma, and primary sarcoma. For each of these tumors, the etiology, typical patient presentation, classic imaging findings, surgical treatment options, and rates of recurrence are reviewed.

The purpose of this special section series is to highlight key patient presentations, diagnostic evaluations, and treatment options for patients with primary (benign and malignant) lesions and metastatic tumors around the knee for orthopaedic surgeons with limited clinical experience in the field of oncology. We hope these articles help to better prepare orthopaedic surgeons to expediently identify and direct treatment for patients presenting with tumors around the knee.

Publication History

Article published online:
20 June 2022

• References

• 1 Clark MA, Thomas JM. Delay in referral to a specialist soft-tissue sarcoma unit. Eur J Surg Oncol 2005; 31 (04) 443-448
• 2 Alamanda VK, Delisca GO, Mathis SL. et al. The financial burden of reexcising incompletely excised soft tissue sarcomas: a cost analysis. Ann Surg Oncol 2013; 20 (09) 2808-2814
• 3 Mesko NW, Mesko JL, Gaffney LM, Halpern JL, Schwartz HS, Holt GE. Medical malpractice and sarcoma care–a thirty-three year review of case resolutions, inciting factors, and at risk physician specialties surrounding a rare diagnosis. J Surg Oncol 2014; 110 (08) 919-929