Fig. 1 Anatomic structures are cleared, dissected, and protected with vessel loops.
Published 5/29/2025
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Odion Binitie, MD, FAAOS
Editor’s note: The following article is a review of a video available via the AAOS Orthopaedic Video Theater (OVT). AAOS Now routinely reviews OVT Plus videos, which are vetted by topic experts and offer CME. For more information, visit aaos.org/OVT.
Intraneural synovial sarcoma is a rare finding. Synovial sarcoma commonly presents as a slow-growing soft-tissue mass in pediatric, adolescent, and young adult patients. The most common sarcoma of a nerve is a malignant peripheral nerve sheath tumor, and a schwannoma is the most common benign nerve sheath tumor. Diagnosis is made by biopsy, with confirmation of the SSX-18 translocation. Nerve reconstruction following adequate oncologic resection provides recovery of median nerve function.
In an OVT video, James C. Wittig, MD, FAAOS, of Morristown Medical Center in New Jersey, and colleagues describe resection of a recurrent intraneural synovial sarcoma of the median nerve in a patient aged 38 years. This patient, who had had a prior resection, presented with a tender mass along the incision from his previous surgery. MRI demonstrated a recurrence in the surgical field. An open biopsy was performed and confirmed the diagnosis. He received neoadjuvant chemotherapy and radiation, followed by surgery.
During surgery, the patient was supine and the entire arm was draped. The prior longitudinal incision was resected along with the tumor. Neurovascular structures were carefully dissected and protected with vessel loops (Fig. 1). The brachial artery and ulnar nerve were preserved. The median nerve was dissected free and transected proximal and distal to the tumor. Following this step, an autograft sural nerve was harvested from both lower extremities and cabled together. This autograft was utilized to span the defect and reconstruct the nerve with an end-to-end epineural repair with microsutures and fibrin glue augmentation.
After nerve reconstruction and wound closure, the surgeons turned their attention to the flexor tenodesis. A curvilinear incision was made on the volar distal forearm. A nerve stimulator confirmed that the flexor digitorum profundus (FDP) of the middle finger was innervated by the ulnar nerve. A side-by-side tenodesis was performed on the index finger FDP to the middle and ring finger FDP.
The patient recovered well and returned to normal activity. Follow-up MRI demonstrated no recurrence at 3 months.
Odion Binitie, MD, FAAOS, is a professor of orthopaedics and oncology at Moffitt Cancer Center and the University of South Florida College of Medicine in Tampa. He is on the Editorial Board of AAOS Now.
Video details
Title: Limb-Sparing Radical Resection of an Intraneural Synovial Cell Sarcoma of the Median Nerve
Authors: Tyler Hoskins; Joseph Dominic Giacalone; Julia Alexandra Matalon; Michael Rehal, PA-C; Ajul Shah, MD; James C. Wittig, MD, FAAOS
Published: Jan. 31, 2024
Time: 8:24
Tags: Musculoskeletal Oncology, Sarcoma, Reconstruction, Tumors
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