arthroscopic resection of localized pigmented villonodular synovitis of the knee
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DESCRIPTIONLocalized 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.
- 1. Arthroscopic Resection of Localized Pigmented Villonodular Synovitis of the Knee
2. Apollo Medicine 2012 December Volume 9, Number 4; pp. 339e342Case ReportArthroscopic resection of localized pigmented villonodular synovitis of the knee Raju Vaishyaa,*, Sheikh IrfanbABSTRACT 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, PVNSINTRODUCTION 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 difcult 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 fromawithin 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 15 mm) in anterior knee joint space (Fig. 1). It was anterior to the meniscus and is seen compressing the Hoffas 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 shavingthis helped in bringing the tumor to the tip of the shaverhelped in resection. Histopathological examination revealed focal areas of hemosiderin-laden histiocytes (Fig. 4), foam cellsSr Consultant, bDNB Student, Department of Orthopaedic Surgery, Indraprastha Apollo Hospitals, New Delhi 110076, India. Corresponding author. Tel.: 91 9810123331, email: email@example.com Received: 20.7.2012; Accepted: 27.8.2012; Available online 5.9.2012 Copyright 2012, Indraprastha Medical Corporation Ltd. All rights reserved.*http://dx.doi.org/10.1016/j.apme.2012.08.011 3. 340Apollo Medicine 2012 December; Vol. 9, No. 4Vaishya and IrfanFig. 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.DISCUSSIONFig. 1 MRI scan showing intraarticular lesion in anterior compartment.containing lipid, and proliferation of multinucleated giant cells and broblasts (Fig. 5), consistent with the diagnosis of pigmented villonodular synovitis.Fig. 2 Arthroscopic picture showing a well dened soft tissue lesion.Villous, inammatory nodular neoplasms of the synovial membrane were rst described in the 19th century. Because of their uncertain pathogenetic classication, 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 synovialFig. 4 Histopathological picture showing haemosiderin laden macrophages. 4. Arthroscopic resection of localized pigmented villonodular synovitis of the kneeFig. 5 Foam cells containing lipid, and proliferation of multinucleated giant cells and broblasts.proliferation disorder that remains a diagnostic difculty because of its nonspecic presentation and subtle radiographic ndings. Clues gathered through the history, physical examination, and radiographic studies could aid in reaching the diagnosis. Despite magnetic resonance imaging (MRI) sensitivity in revealing ndings consistent with PVNS, these ndings are neither constant nor specic 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 specic 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 inammatory 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 nonspecic 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 Report341commonly anterior, as well as mechanical symptoms such as locking, catching, popping, instability, or swelling. The pain is seldom severe.9 Physical ndings associated with localized PVNS of the knee may include pain exacerbated by forced exion or exion under mechanical loading. Clinical ndings 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 uid is typically xanthochromic or serosanguinous. MR images demonstrate various appearances ranging from low signal through isointense to hyperintense signals on spin-echo images, reecting 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 ndings consistent with localized PVNS, it is not specic. Localized PVNS on MRI can easily be mistaken for loose body, meniscal pathology, hematoma, synovial hemangioma, malignant neoplasm, or broxanthoma.5 Typical ndings include a well-circumscribed lesion with focal hypointense areas on T1- and T2- weighted images, reecting 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, rst 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. Signicant morbidity after arthroscopic resection is rare. Hence, we recommend arthroscopic resection of localized PVNS lesions. Jaffe described the histologic ndings of PVNS as brous or hyalinized stroma, pigment deposition, histiocytic inltrate, and giant cells within a synovial capsule.1 Proliferating synovial cells are often noted in ill-dened 5. 342Apollo Medicine 2012 December; Vol. 9, No. 4nodules accompanied by a random distribution of giant cells.5 Macrophage activity is often noted with phagocytosis of hemosiderin and lipids. An awarenesshigh index of suspicion is also required to diagnosetreat these benign lesions.CONFLICTS OF INTEREST All authors have none to declare.REFERENCES 1. Jaffe HL,