Arthroscopic Resection of Localized Pigmented Villonodular Synovitis of the Knee

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Localized pigmented villonodular synovitis (PVNS) is a rare, benign, proliferative disease of the synovial membrane of joints & can mimic other pathology like loose body, meniscal tear & soft tissue sarcomas etc. Diagnosis of these lesions can be difficult clinically & magnetic resonance imaging may be helpful. Surgical resection of the tumor is the treatment of choice. Arthroscopic resection is superior to an open procedure & has distinct advantages.

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Arthroscopic Resection of Localized Pigmented Villonodular Synovitis of the Knee

  1. 1. Arthroscopic Resection of Localized Pigmented Villonodular Synovitis of the Knee
  2. 2. Apollo Medicine 2012 December Volume 9, Number 4; pp. 339e342 Case Report Arthroscopic resection of localized pigmented villonodular synovitis of the knee Raju Vaishyaa,*, Sheikh Irfanb ABSTRACT We report a rare case of localized pigmented villonodular synovitis (xanthoma) of the knee. Awareness about this condition is crucial to its diagnosis. Arthroscopic complete resection of this benign tumor was successfully done. Technical tips of arthroscopic surgery are described herewith. Copyright © 2012, Indraprastha Medical Corporation Ltd. All rights reserved. Keywords: Xanthoma, Pigmented villonodular synovitis, Intra-articular knee swelling, PVNS INTRODUCTION Localized pigmented villonodular synovitis (PVNS) is a rare, benign, proliferative disease of the synovial membrane of joints & can mimic other pathology like loose body, meniscal tear & soft tissue sarcomas etc. Diagnosis of these lesions can be difficult clinically & magnetic resonance imaging may be helpful. Surgical resection of the tumor is the treatment of choice. Arthroscopic resection is superior to an open procedure & has distinct advantages. CASE REPORT A 32-year-old male presented with complaints of intermittent locking of right knee & discomfort whilst walking for last 1 year. He also observed swelling in the same knee since 3 months. The symptoms were progressively increasing in nature. He had no history of trauma, fever, rigors and chills, weight loss or fatigue. On examination a swelling was noticed in the antero-medial portion of right knee with dimensions of 2 by 3 cm. The swelling was soft in consistency, nontender, mobile and was coming from a within the joint. All ranges of movements of the knee were within normal limit. The tests for knee stability and menisci were normal. MRI of the right knee revealed an intra-articular focal rounded mass (20 Â 15 mm) in anterior knee joint space (Fig. 1). It was anterior to the meniscus and is seen compressing the Hoffa’s fat pad on its anterior surface. It displays low to intermediate signal on T2WI, suggestive of localized PVNS. Arthroscopy of the knee joint was done under tourniquet control, which showed a localized nodular swelling within the joint coming from the anteromedial aspect of the synovial lining, nonadherent to the surrounding soft tissues except at its stalk near the infrapatellar fat pad. It was yellowish brown in colour & soft in consistency (Fig. 2). This localized swelling was excised completely arthroscopically (Fig. 3). The arthroscopy was done using 4 mm, 30 telescope through standard anterolateral portal. Shaving of the lesion was done through anteromedial portal, using 5 mm meniscal power shaver. Suction was used with the shaving this helped in bringing the tumor to the tip of the shaver helped in resection. Histopathological examination revealed focal areas of hemosiderin-laden histiocytes (Fig. 4), foam cells Sr Consultant, bDNB Student, Department of Orthopaedic Surgery, Indraprastha Apollo Hospitals, New Delhi 110076, India. Corresponding author. Tel.: þ91 9810123331, email: raju.vaishya@gmail.com Received: 20.7.2012; Accepted: 27.8.2012; Available online 5.9.2012 Copyright Ó 2012, Indraprastha Medical Corporation Ltd. All rights reserved. * http://dx.doi.org/10.1016/j.apme.2012.08.011
  3. 3. 340 Apollo Medicine 2012 December; Vol. 9, No. 4 Vaishya and Irfan Fig. 3 Arthroscopic picture after complete resection of tumor. At 6 months follow up there was complete resolution of his symptoms with no sign or symptoms of recurrence of the tumor. DISCUSSION Fig. 1 MRI scan showing intraarticular lesion in anterior compartment. containing lipid, and proliferation of multinucleated giant cells and fibroblasts (Fig. 5), consistent with the diagnosis of pigmented villonodular synovitis. Fig. 2 Arthroscopic picture showing a well defined soft tissue lesion. Villous, inflammatory nodular neoplasms of the synovial membrane were first described in the 19th century. Because of their uncertain pathogenetic classification, these lesions of the synovial membrane were given various different names, such as xanthomatous giant cell tumor, histiocytic giant cell tumor, xanthoma, benign synovialoma, haemorrhagic villous arthritis and localized pigmented villonodular synovitis (PVNS). The term PVNS was introduced by Jaffe et al1 in 1941 and subsequently gained general acceptance. Pigmented villonodular synovitis (PVNS) is a synovial Fig. 4 Histopathological picture showing haemosiderin laden macrophages.
  4. 4. Arthroscopic resection of localized pigmented villonodular synovitis of the knee Fig. 5 Foam cells containing lipid, and proliferation of multinucleated giant cells and fibroblasts. proliferation disorder that remains a diagnostic difficulty because of its nonspecific presentation and subtle radiographic findings. Clues gathered through the history, physical examination, and radiographic studies could aid in reaching the diagnosis. Despite magnetic resonance imaging (MRI) sensitivity in revealing findings consistent with PVNS, these findings are neither constant nor specific for PVNS.2 At present, generalized pigmented villonodular synovitis (GVNS) is differentiated from localized pigmented villonodular synovitis (LVS). LVS is further subdivided into an articular (ALNS) form and an extra-articular (ELNS) form.3 Myers and Masi4 describe 166 cases, with ELNS occurring in 70.5%, GVNS in 23.5%, and ALNS in only 6%. ALNS is thus rare, with an estimated prevalence of 1.8 per 1 million population. Most patients with PVNS are in their thirties.4,5 There is no specific sex predilection.5,6 The involvement of several joints has only been described for GVNS.6,7 The etiology of pigmented villonodular synovitis remains controversial.3,8 The most widely held theory is that the disease is an inflammatory reaction of the synovium.1,3 However, some evidence exists that it is a benign neoplastic process.9 It is nearly always monoarticular. The knee is the most common joint involved, representing 80% of cases, followed by the hip (15%) and the ankle (5%). The onset of symptoms is typically insidious. The average duration of symptoms before diagnosis has been reported to be between 10 and 26 months (range 2e72 months). The lesion is manifested by nonspecific clinical symptoms such as locking, giving away, localized tenderness, pain, diminished range of motion, mass effect, swelling, stiffness, snapping, or instability.10 Localized PVNS of the knee can present with an insidious onset or in association with trauma. It usually affects adults in their third to fourth decade. The patient may present with pain, Case Report 341 commonly anterior, as well as mechanical symptoms such as locking, catching, popping, instability, or swelling. The pain is seldom severe.9 Physical findings associated with localized PVNS of the knee may include pain exacerbated by forced flexion or flexion under mechanical loading. Clinical findings consistent with mechanical internal derangement can mimic meniscal pathology or foreign body. Rarely, a palpable mobile mass is noted on exam.5 Radiographs usually are normal except in 15% of cases which show radioluscent lesion, osteopenia or degenerative changes. Aspirated synovial fluid is typically xanthochromic or serosanguinous. MR images demonstrate various appearances ranging from low signal through isointense to hyperintense signals on spin-echo images, reflecting the presence of blood and its degradation products. Hemosiderin appears as low signal on T1- and T2-weighted images. Although magnetic resonance imaging is reasonably sensitive to demonstrating findings consistent with localized PVNS, it is not specific. Localized PVNS on MRI can easily be mistaken for loose body, meniscal pathology, hematoma, synovial hemangioma, malignant neoplasm, or fibroxanthoma.5 Typical findings include a well-circumscribed lesion with focal hypointense areas on T1- and T2- weighted images, reflecting the amount of hemosiderin present.9 Several authors have described the arthroscopic appearance of localized PVNS.2,5,7e9 Localized PVNS most commonly appears as a pedunculated, mildly pigmented, nodular mass that is brown or yellow in color.11 Locations of origin that have been reported included the meniscus, the meniscosynovial junction, the fat pad, and the medial and lateral gutters.1,5,8,11 Howke et al reported the most frequent location of origin to be the medial and anterior compartments. While surgical treatment of the diffuse type is associated with a high recurrence rate, many authors have reported good results with arthroscopic local resection of the localized type.5,7e9,11 Arthroscopic resection of localized PVNS, first described by Flandry in 1986,2 is a wellrecognized, successful procedure. Unlike the results for the diffuse type of PVNS, recurrence of the localized type after arthroscopic local resection is rare.8 Also, arthroscopy has been noted to be superior to arthrotomy for exploration of the posterior compartment of the knee, an area where localized PVNS has been noted to originate. Arthroscopic resection is better, because whole swelling can be resected adequately under arthroscopic vision, without damaging other intraarticular structures. Significant morbidity after arthroscopic resection is rare. Hence, we recommend arthroscopic resection of localized PVNS lesions. Jaffe described the histologic findings of PVNS as fibrous or hyalinized stroma, pigment deposition, histiocytic infiltrate, and giant cells within a synovial capsule.1 Proliferating synovial cells are often noted in ill-defined
  5. 5. 342 Apollo Medicine 2012 December; Vol. 9, No. 4 nodules accompanied by a random distribution of giant cells.5 Macrophage activity is often noted with phagocytosis of hemosiderin and lipids. An awareness high index of suspicion is also required to diagnose treat these benign lesions. CONFLICTS OF INTEREST All authors have none to declare. REFERENCES 1. Jaffe HL, Lichtenstein L, Suro CJ. Pigmented villonodular synovitis, bursitis and tenosynovitis. Arch Pathol. 1941;31: 731e765. 2. Bouali Henda, Deppert Eric J, Leventhal Lawrence J, Reeves Brian, Pope Thomas. Pigmented villonodular synovitis: a disease in evolution. J Rheumatol. 2004;31:1659e1662. 3. Granowitz SP, D’Antonio J, Mankin HL. The pathogenesis and long-term end results of pigmented villonodular synovitis. Clin Orthop. 1976;114:335e351. 4. Myers BW, Masi AT. Pigmented villonodular synovitis and tenosynovitis: a clinical epidemiologic study of 166 cases and literature review. Medicine (Baltimore). 1980;59:223e238. Vaishya and Irfan 5. Campanacci M. Pigmented villonodular synovitis, tenosynovitis and bursitis. In: Bone and Soft Tissue Tumors. Vienna: Springer Verlag; 1990. p. 1103e1119. 6. Kay RM, Eckardt JJ, Mirra JM. Multifocal pigmented villonodular synovitis in a child. A case report. Clin Orthop. 1996;322:194e197. 7. Wagner ML, Spjut HJ, Dutton RV, Glassman AL, Askew JB. Polyarticular pigmented villonodular synovitis. Am J Roentgenol. 1981;136:821e823. 8. Singh R, Grewal DS, Chakravarti RN. Experimental production of pigmented villonodular synovitis in the knee and ankle joints of rhesus monkeys. J Pathol. 1969;98:137e142. 9. Rao AS, Vigorita VJ. Pigmented villonodular synovitis (giantcell tumor of the tendon sheath and synovial membrane). A review of eighty-one cases. J Bone Joint Surg Am. 1984;66: 76e94. 10. Martin RCG II, Osborne DL, Edwards MJ, Wrightson W, McMasters KM. Giant cell tumor of tendon sheath, tenosynovial giant cell tumor, and pigmented villonodular synovitis: defining the presentation, surgical therapy and recurrence. Oncol Rep. 2000;7:413e419. 11. Dorwart RH, Genant HK, Johnston WH, Morris JM. Pigmented villonodular synovitis of synovial joints: clinical, pathologic, and radiologic features. AJR Am J Roentgenol. 1984;143:877e885.
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