Arthroscopic Resection of Localized Pigmented Villonodular Synovitis of the Knee

Arthroscopic resection of localized pigmented villonodular synovitisof the knee

Raju Vaishyaa,*, Sheikh Irfanb

ABSTRACT

We report a rare case of localized pigmented villonodular synovitis (xanthoma) of the knee. Awareness about thiscondition 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) isa rare, benign, proliferative disease of the synovialmembrane of joints & can mimic other pathology like loosebody, meniscal tear & soft tissue sarcomas etc. Diagnosis ofthese lesions can be difficult clinically & magnetic reso-nance imaging may be helpful. Surgical resection of thetumor is the treatment of choice. Arthroscopic resection issuperior to an open procedure & has distinct advantages.

CASE REPORT

A 32-year-old male presented with complaints of intermit-tent locking of right knee & discomfort whilst walkingfor last 1 year. He also observed swelling in the sameknee since 3 months. The symptoms were progressivelyincreasing in nature. He had no history of trauma, fever,rigors and chills, weight loss or fatigue. On examinationa swelling was noticed in the antero-medial portion of rightknee with dimensions of 2 by 3 cm. The swelling was softin consistency, nontender, mobile and was coming from

within the joint. All ranges of movements of the kneewere within normal limit. The tests for knee stability andmenisci were normal. MRI of the right knee revealed anintra-articular focal rounded mass (20 � 15 mm) in anteriorknee joint space (Fig. 1). It was anterior to the meniscus andis seen compressing the Hoffa’s fat pad on its anteriorsurface. It displays low to intermediate signal on T2WI,suggestive of localized PVNS.

Arthroscopy of the knee joint was done under tourniquetcontrol, which showed a localized nodular swelling withinthe joint coming from the anteromedial aspect of the syno-vial lining, nonadherent to the surrounding soft tissuesexcept at its stalk near the infrapatellar fat pad. It wasyellowish brown in colour & soft in consistency (Fig. 2).This localized swelling was excised completely arthro-scopically (Fig. 3). The arthroscopy was done using4 mm, 30� telescope through standard anterolateral portal.Shaving of the lesion was done through anteromedialportal, using 5 mm meniscal power shaver. Suction wasused with the shaving & this helped in bringing the tumorto the tip of the shaver & helped in resection.

Histopathological examination revealed focal areas ofhemosiderin-laden histiocytes (Fig. 4), foam cells

aSr 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 5.9.2012Copyright � 2012, Indraprastha Medical Corporation Ltd. All rights reserved.http://dx.doi.org/10.1016/j.apme.2012.08.011

Apollo Medicine 2012 DecemberVolume 9, Number 4; pp. 339e342 Case Report

containing lipid, and proliferation of multinucleated giantcells and fibroblasts (Fig. 5), consistent with the diagnosisof pigmented villonodular synovitis.

At 6 months follow up there was complete resolution ofhis symptoms with no sign or symptoms of recurrence ofthe tumor.

DISCUSSION

Villous, inflammatory nodular neoplasms of the synovialmembrane were first described in the 19th century. Becauseof their uncertain pathogenetic classification, these lesionsof the synovial membrane were given various differentnames, such as xanthomatous giant cell tumor, histiocyticgiant cell tumor, xanthoma, benign synovialoma, haemor-rhagic villous arthritis and localized pigmented villonodularsynovitis (PVNS). The term PVNS was introduced by Jaffeet al1 in 1941 and subsequently gained general acceptance.Pigmented villonodular synovitis (PVNS) is a synovial

Fig. 1 MRI scan showing intraarticular lesion in anteriorcompartment.

Fig. 2 Arthroscopic picture showing a well defined soft tissuelesion.

Fig. 3 Arthroscopic picture after complete resection of tumor.

Fig. 4 Histopathological picture showing haemosiderin ladenmacrophages.

340 Apollo Medicine 2012 December; Vol. 9, No. 4 Vaishya and Irfan

proliferation disorder that remains a diagnostic difficultybecause of its nonspecific presentation and subtle radio-graphic findings. Clues gathered through the history, phys-ical examination, and radiographic studies could aid inreaching the diagnosis. Despite magnetic resonanceimaging (MRI) sensitivity in revealing findings consistentwith PVNS, these findings are neither constant nor specificfor PVNS.2 At present, generalized pigmented villonodularsynovitis (GVNS) is differentiated from localized pig-mented villonodular synovitis (LVS). LVS is further subdi-vided into an articular (ALNS) form and an extra-articular(ELNS) form.3 Myers and Masi4 describe 166 cases, withELNS occurring in 70.5%, GVNS in 23.5%, and ALNSin only 6%. ALNS is thus rare, with an estimated preva-lence of 1.8 per 1 million population. Most patients withPVNS are in their thirties.4,5 There is no specific sex predi-lection.5,6 The involvement of several joints has only beendescribed for GVNS.6,7

The etiology of pigmented villonodular synovitis remainscontroversial.3,8 The most widely held theory is that thedisease is an inflammatory reaction of the synovium.1,3

However, some evidence exists that it is a benign neoplasticprocess.9 It is nearly always monoarticular. The knee is themost common joint involved, representing 80% of cases, fol-lowed by the hip (15%) and the ankle (5%).

The onset of symptoms is typically insidious. Theaverage duration of symptoms before diagnosis has been re-ported to be between 10 and 26 months (range 2e72months). The lesion is manifested by nonspecific clinicalsymptoms such as locking, giving away, localized tender-ness, pain, diminished range of motion, mass effect,swelling, stiffness, snapping, or instability.10 LocalizedPVNS of the knee can present with an insidious onset orin association with trauma. It usually affects adults in theirthird to fourth decade. The patient may present with pain,

commonly anterior, as well as mechanical symptoms suchas locking, catching, popping, instability, or swelling. Thepain is seldom severe.9 Physical findings associated withlocalized PVNS of the knee may include pain exacerbatedby forced flexion or flexion under mechanical loading.Clinical findings consistent with mechanical internalderangement can mimic meniscal pathology or foreignbody. Rarely, a palpable mobile mass is noted on exam.5

Radiographs usually are normal except in 15% of caseswhich show radioluscent lesion, osteopenia or degenerativechanges. Aspirated synovial fluid is typically xanthochromicor serosanguinous. MR images demonstrate various appear-ances ranging from low signal through isointense to hyperin-tense signals on spin-echo images, reflecting the presence ofblood and its degradation products. Hemosiderin appears aslow signal on T1- and T2-weighted images. Althoughmagnetic resonance imaging is reasonably sensitive todemonstrating findings consistent with localized PVNS, itis not specific. Localized PVNS on MRI can easily bemistaken for loose body, meniscal pathology, hematoma,synovial hemangioma, malignant neoplasm, or fibroxan-thoma.5 Typical findings include a well-circumscribed lesionwith focal hypointense areas on T1- and T2- weightedimages, reflecting the amount of hemosiderin present.9

Several authors have described the arthroscopic appear-ance of localized PVNS.2,5,7e9 Localized PVNS mostcommonly appears as a pedunculated, mildly pigmented,nodular mass that is brown or yellow in color.11 Locationsof origin that have been reported included the meniscus, themeniscosynovial junction, the fat pad, and the medial andlateral gutters.1,5,8,11 Howke et al reported the most frequentlocation of origin to be the medial and anterior compart-ments. While surgical treatment of the diffuse type is asso-ciated with a high recurrence rate, many authors havereported good results with arthroscopic local resection ofthe localized type.5,7e9,11 Arthroscopic resection of local-ized PVNS, first described by Flandry in 1986,2 is a well-recognized, successful procedure. Unlike the results forthe diffuse type of PVNS, recurrence of the localized typeafter arthroscopic local resection is rare.8 Also, arthroscopyhas been noted to be superior to arthrotomy for explorationof the posterior compartment of the knee, an area wherelocalized PVNS has been noted to originate. Arthroscopicresection is better, because whole swelling can be resectedadequately under arthroscopic vision, without damagingother intraarticular structures. Significant morbidity afterarthroscopic resection is rare. Hence, we recommendarthroscopic resection of localized PVNS lesions.

Jaffe described the histologic findings of PVNS asfibrous or hyalinized stroma, pigment deposition, histio-cytic infiltrate, and giant cells within a synovial capsule.1

Proliferating synovial cells are often noted in ill-defined

Fig. 5 Foam cells containing lipid, and proliferation ofmultinucleated giant cells and fibroblasts.

Arthroscopic resection of localized pigmented villonodular synovitis of the knee Case Report 341

nodules accompanied by a random distribution of giantcells.5 Macrophage activity is often noted with phagocy-tosis of hemosiderin and lipids.

An awareness & high index of suspicion is also requiredto diagnose & treat these benign lesions.

CONFLICTS OF INTEREST

All authors have none to declare.

REFERENCES

1. Jaffe HL, Lichtenstein L, Suro CJ. Pigmented villonodularsynovitis, 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 pathogenesisand long-term end results of pigmented villonodular synovitis.Clin Orthop. 1976;114:335e351.

4. Myers BW, Masi AT. Pigmented villonodular synovitis andtenosynovitis: a clinical epidemiologic study of 166 cases andliterature review. Medicine (Baltimore). 1980;59:223e238.

5. Campanacci M. Pigmented villonodular synovitis, tenosyno-vitis and bursitis. In: Bone and Soft Tissue Tumors. Vienna:Springer Verlag; 1990. p. 1103e1119.

6. Kay RM, Eckardt JJ, Mirra JM. Multifocal pigmented villo-nodular 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 Roent-genol. 1981;136:821e823.

8. Singh R, Grewal DS, Chakravarti RN. Experimental produc-tion of pigmented villonodular synovitis in the knee and anklejoints of rhesus monkeys. J Pathol. 1969;98:137e142.

9. Rao AS, Vigorita VJ. Pigmented villonodular synovitis (giant-cell tumor of the tendon sheath and synovial membrane). Areview 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, tenosyno-vial 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. Pig-mented villonodular synovitis of synovial joints: clinical,pathologic, and radiologic features. AJR Am J Roentgenol.1984;143:877e885.

342 Apollo Medicine 2012 December; Vol. 9, No. 4 Vaishya and Irfan

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