This document defines and discusses pigmented villonodular synovitis (PVNS), a benign tumor of the synovium. It most commonly affects large joints like the knee and hip in adults. While the exact cause is unknown, repetitive trauma is thought to play a role in many cases. PVNS can be either localized or diffuse. Treatment involves complete synovectomy, which can be performed either arthroscopically or via open surgery, with the goal of removing all affected synovial tissue. Radiation therapy may also be used in some cases. Prognosis is generally good for localized PVNS but recurrence is more common when disease is diffuse.

1. By: Dr. Bipul Borthakur
Professor,
Dept of Orthopaedics, SMCH

2. DEFINITION
 Pigmented Villonodular Synovitis (PVNS) is a
slow growing tumor lesion of uncertain
etiology arising from the synovial
membrane, characterized by pigmented
villous and nodular outgrowths of the synovial
membrane of the bursae or tendon sheath
 Since bursae and tendon sheaths are related
to synovium in origin, they too are sites of
xanthomatous growth

3. PREVALENCE
 Age: 3rd to 4th decade of life, rare in children
 Sex: no sex based predilection
 Incidence: 1.8 per million
 Appendicular skeleton, especially large joints
such as knee and hip joints are frequently
involved
 No predilection for any laterality

4. ETIOPATHOGENESIS
Repetitive trauma (50% cases)
Recurrent local hemorrhage to
affected joint
Proliferation of synovium of
joints, tendon sheaths or bursae
Progressive erosive arthropathies
(especially in haemophilics)

5. ETIOPATHOGENESIS
 It is a reactive condition, and not a true
neoplasm
 Recurrent atraumatic haemarthrosis is a
characteristic feature
 Often aggressive, with marked extra-articular
extension

6. TYPES: INTRA AND EXTRA-ARTICULAR
INTRAARTICULAR
 Monoarticular involvement( most common),
mimicking arthritis
 Granowitz described two forms:
 Localised form
 Diffuse form

7.  Localized form
 Focal involvement of the synovium
 Nodular/ sessile or pedunculated well circumscribed masses
 Diffuse form
 More common
 Affect virtually the entire synovium
EXTRAARTICULAR
 Tendon sheath and bursae PVNS

8. SITES
 MC site: knee > hip > shoulder
 Knee:
 Anterior compartment commonly involved
 Mostly menisco-capsular junction
 MC site: synovium in the region of anterior horn of medical
meniscus
 Infrapatellar fat pad, suprapatellar pouch, intercondylar notch,
anterior horn of lateral meniscus, and medial and lateral recesses of
knee
 Uncommon: elbow, ankle, foot, wrist
 Rare: spine, tendon sheaths

9. CLINICAL FEATURES
Symptoms Signs
 Pain: 80%
 Swelling: 75%
 Stiffness
 Locking
 catching
 Instability
 Palpable mass: 12%
 Effusion – floating
patella
 Tenderness
 Decreased ROM
 Usually not palpable;
In localised variety,
can show a joint
mouse

10. TYPE SPECIFIC FEATURES
LOCALIZED PVNS
 Initially painless
 If untreated, caused continuous pain and
discomfort, limiting activities of daily living
 At knee, mostly presents with signs and
symptoms of meniscal pathology
 Locking
 Catching
 Instability
 Well circumscribed soft tissue mass

11. DIFFUSE PVNS
 Slow, insidious onset pain
 Swelling
 Stiffness
 Most of or all of the joint involved
 Decreased ROM
 Poorly localised/ ill defined mass
 May encroach on nearby neurovascular structures
 Osteoarthritis: continued inflammation and joint erosions
lead to articular cartilage destruction

12. INVESTIGATION : X-RAY
 Soft tissue swelling
 Cysts, bony erosions in joint-
mimicks gout.
 Osteoporosis is characteristically
absent
 Can affect epiphysis in children

13.  Reciprocal bony lesions on
opposite sides of joint, despite
articular preservation- highly
suggestive
 Degenerative changes,
osteoarthritic changes

14. MRI
 Investigation of choice
 LPVNS:
 Nodular mass (periarticular or
synovial)
 bone erosion
 DPVNS:
 extensive mass and thickening of
joint lining
 destruction of bone and cartilage

15. ULTRASONOGRAPHY
 Loculated joint effusion
 Complex heterogenous echogenic
masses with markedly thickened
synovium
ASPIRATION
 Blood tinged thick orange brown
fluid containing cholesterol in large
amounts

16. ARTHROSCOPY
 Diagnostic and
therapeutic value
 Direct visualisation
of synovium
 Normal arthroscopic
findings however does
not exclude PVNS

17. HISTOPATHOLOGY
 Synovium looks like a “shaggy carpet”
 Histiocytes
 lipid laden macrophages
 hemosiderin containing cells
 frequent giant cells
 Subsynovial nodular proliferation of
large round, polyhedral or spindle cells
with prominent cytoplasm and pale
nuclei

18. DIFFERENTIAL DIAGNOSIS
 Hemophilic lobular synovitis
 Menisceal tear or other ligamentous injury
 Synovial chondromatosis
 Osteoarthritis
 Gouty arthritis
 Rheumatoid arthritis

19. TREATMENT
 Local excision- for nodular form
 Total Synovectomy- arthroscopic or open
 Radiotherapy
 Advanced cases: Arthrodesis/ arthroplasty +
extensive synovectomy

20. SYNOVECTOMY
Open :
 Anterior approach or medial
parapatellar approach: for the
diffuse form
 Posterior approach done
subsequently for extensions into
the popliteal fossa

21. SYNOVECTOMY
Arthroscopic:
 Gained popularity because of
several advantages over open
technique
 Preferred for LPVNS
 Higher recurrence rate in DPVNS
 Vascular or neurological injury:
especially in posterior extra-
articular extension or fibrosis after
irradiation

22. RADIOTHERAPY
 3500- 4000 cGy
 Radiation induced synovectomy
 Intra-articular radiation
synovectomy with Yttrium-90
 Use: Recurrence

23. PROGNOSIS
LPVNS: DPVNS:
 Excellent prognosis
 Low recurrence rate: 8%
 Complete surgical
excision is difficult
 Recurrence rate: upto 46%

24. THANK YOU
“yajñārthātkarmaṇo’nyatra loko’yaṃ karmabandhanaḥ
tadarthaṃ karma kaunteya muktasaṅgaḥ samācara”
“Man is bound by his own action except when it is performed for the sake of sacrifice.
Therefore, Arjuna, efficiently perform your duty, free from attachment, for the sake of
sacrifice alone.”