|Year : 2019 | Volume
| Issue : 3 | Page : 53-56
Is arthroscopic surgery adequate to treat pigmented villonodular synovitis of the knee joint?
Vijay Chandru, Supreeth Nekkanti, R Madhukesh, Sumit Sudan, M Rishikesh
Department of Orthopaedics, Jagadguru Sri Shivarathreeshwara Hospital, Mysore, India
|Date of Submission||21-Mar-2019|
|Date of Acceptance||08-Jul-2019|
|Date of Web Publication||9-Sep-2019|
Department of Orthopaedics, Jagadguru Sri Shivarathreeshwara Hospital, Mysore
Source of Support: None, Conflict of Interest: None
Background and objective: Pigmented villonodular synovitis (PVNS) is characterized by inflammation and deposition of hemosiderin in the synovium. There is no clear consensus on the exact treatment protocol of PVNS. This study aimed to understand the effectiveness of arthroscopic surgery for PVNS of the knee joint.
Subject and methods: We reported a case of 21-year-old male who presented with a progressive painful diffuse swelling of the knee joint. Radiographic imaging revealed PVNS of the knee which was confirmed by arthroscopy. The patient underwent radiotherapy after arthroscopic surgery for 8 weeks. This study has been submitted after due approval from the institutional review board of Jagadguru Sri Shivarathreeshwara Hospital, India.
Results: Patient was followed up for 1 year with no evidence of recurrence.
Conclusion: Arthroscopy coupled with postoperative radiotherapy is useful in inhibiting PVNS and preventing its recurrence.
Keywords: arthroscopy; follow-up; histopathology; knee joint; MRI; pigmented villonodular synovitis; radiotherapy; synovectomy
|How to cite this article:|
Chandru V, Nekkanti S, Madhukesh R, Sudan S, Rishikesh M. Is arthroscopic surgery adequate to treat pigmented villonodular synovitis of the knee joint?. Clin Trials Orthop Disord 2019;4:53-6
|How to cite this URL:|
Chandru V, Nekkanti S, Madhukesh R, Sudan S, Rishikesh M. Is arthroscopic surgery adequate to treat pigmented villonodular synovitis of the knee joint?. Clin Trials Orthop Disord [serial online] 2019 [cited 2019 Sep 19];4:53-6. Available from: http://www.clinicalto.com/text.asp?2019/4/3/53/265976
| Introduction|| |
The term pigmented villonodular synovitis (PVNS) was coined by Jaffe in 1941., World Health Organization defined PVNS to describe a tumor lesion of the soft tissue and bone tumor pathology and genetics. Finis et al. described the pathology of PVNS to be due to the uninterrupted proliferation of local lesions induced by inhibition of apoptosis-related molecules. The biological behavior and clinical manifestation of this disease are diverse and complex with a high recurrence rate. The etiology of PVNS is primarily inflammatory rather than neoplastic. The target tissue of PVNS varies from synovium of large joints to tenosynovium, tendon sheaths and bursa. Synovial lesions are of two kinds–the localised nodular form and the diffuse form., The most common site of involvement of PVNS is the knee joint (80%)., Other sites which can be involved in order of frequency are hip, ankle, small joints of the hand and feet, shoulder,,, and elbow joint. We report a case of PVNS of the knee joint in a 21-year-old male patient successfully treated by anterior arthroscopic synovectomy and postoperative radiotherapy.
| Subject and methods|| |
We reported a 21-year-old male patient who presented with a progressive swelling of his left knee joint since 1 year. The knee was painful with varying intensities which increased on bending his knee, sitting cross-legged and squatting. On clinical examination, there was an evident diffuse swelling of the knee. Synovial thickening was present, and his range of pain-free movement of the affected knee joint was measured to be 0–100 degrees using a goniometer. This study was conducted in accordance with the Declaration of Helsinki and approved by the Institutional Review Board of Jagadguru Sri Shivarathreeshwara Hospital, India. The patient signed the written informed consent.
| Results|| |
MRI of his knee joint showed multiple septate nodular cystic lesions with low signal intensity on T1 images, and hyperintense of proton density weighted images with foci of bleed seen in suprapatellar pouches, intracapsular anterior and posterior compartments of the knee, popliteal fossa. The largest lesion size measured was 26 mm × 15 mm [Figure 1]A, [Figure 1]B, [Figure 1]c.
|Figure 1: MRI photographs of the knee joint.|
Note: (A) Sagittal sections showing the extent of the largest lesion measured 26 mm × 15 mm (arrow). (B, C) Coronal sections showing the extent of synovial lesions. Multiple septate nodular cystic lesions with low signal intensity on T1 images, and hyperintense of proton density weighted images with foci of bleed seen in suprapatellar pouches, intracapsular anterior and posterior compartments of the knee, popliteal fossa.
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A diagnostic arthroscopy was performed and we found multiple pigmented finger like villi distributed throughout the knee joint. An arthroscopic anterior synovectomy was performed. The resected synovium was greyish brown measuring 4.5 cm × 3.0 cm [Figure 2]. Histopathological results with Gram staining showed extensive cellular hyperplasia, foamy macrophages, hemosiderin laden macrophages, plenty of multinuclear giant cells suggestive of tenosynovial PVNS [Figure 3]. The patient was subjected to postoperative radiotherapy of 32 grey units of four sessions every week for 8 weeks. The patient was relieved of pain and swelling following treatment and regained a good range of movement of the knee joint [Figure 4]A, [Figure 4]B. The patient was pain free and continued his routine activity of daily living within 3 weeks post-surgery. The patient was followed up for one year after surgery and there was no evidence of recurrence of the disease.
|Figure 2: Intraoperative photograph of the synovium resected.|
Note: Greyish brown measuring 4.5 cm × 3.0 cm.
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|Figure 3: Histopathological results with Gram staining.|
Note: Extensive cellular hyperplasia, foamy macrophages, hemosiderin laden macrophages, plenty of multinuclear giant cells suggestive of tenosynovial pigmented villonodular synovitis. Original magnification, 10× in A and 25× in B.
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|Figure 4: Postoperative photographs.|
Note: The range of movements of the knee joint and straight leg raising of the involved lower limb (A) and knee extension (B).
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| Discussion|| |
Various theories exist to explain the pathogenesis of PVNS. The common accepted hypotheses are inflammatory synovial hyperplasia, abnormality in lipid metabolism, repetitive trauma and hemorrhage. Minor repetitive trauma due to hyalinization and fibrosis leads to the cells of the synovium to enter a proliferative hypervascular cellular phase which is believed to be the most common cause of PVNS.
PVNS exists in three forms: (a) isolated lesion occurring within a tendon sheath, most often seen in the hand, (b) localized PVNS, occurring most commonly in the knee and presenting most commonly with mechanical symptoms, and (c) diffuse PVNS, presenting with chronic pain and swelling, most commonly in the knee, hip and ankle.
The diagnosis of PVNS is challenging due to lack of pathognomic clinical characteristics of the disease. Aspiration of the joint yields a brown/dark red fluid which is diagnostic of PVNS. MRI also shows prolonged T1 and T2 signals depending on the degree of effusion and synovial hyperplasia. MRI images depend on the fat, fibrous tissue and iron present in tissues. Excess hemosiderin deposition in the tissues of PVNS causes shortening of T1 and T2 relaxation times. Hemosiderin has magnetic susceptibility properties which induce a characteristic late “blooming effect” which is best appreciated in gradient echo sequences. However, confirmatory diagnosis can be made only on histopathological studied of the tissue biopsy. High signal on T1 sequences usually represents lipid-laden macrophages or hemorrhages. Bright T2 images represent loculated areas of fluid trapped within the synovial membrane. Lesions of PVNS usually enhance on gadolinium administration.
The treatment of PVNS has been debated, and arthroscopic synovectomy seems to be the preferred treatment choice compared to open synovectomies. Arthroscopic synovectomy ensures easy tissue reach for biopsy and is used to evaluate the type and extent of the disease with a minimal incision. This allows the surgeon to evaluate other associated lesions without having to open the joint. Due to the minimal incision and soft tissue dissection, recovery is relatively quick compared to open synovectomy. Arthroscopy itself cannot remove all the pathological tissue. Hence, an adjuvant treatment modality in the form of chemical synovectomy or radiotherapy is usually employed. Blanco et al. used external beam radiotherapy and achieved 86% success rates in his case series. Only 15.8% of the patients in his study experienced a recurrence of symptoms. Recurrence of disease was evaluated by ultrasound examination or clinical examination. Shabat et al. used postoperative intraarticular radiotherapy in ten patients of PVNS. He reported no recurrence of disease in all the 10 patients at the end of six-year follow-up. Chin et al. studied the effects of intraarticular radiotherapy and reported that the success of the radiotherapy largely depends on the thorough resection of the lesion during initial surgery especially in large or diffuse lesions. Li et al. studied the effects of postoperative radiotherapy in 26 cases of PVNS and found no recurrence in any of the patients at the end of 4.5-year follow-up.
Aurégan et al. performed anterior and posterior arthroscopic synovectomy in seven out of 28 patients of diffuse PVNS followed by postoperative chemosynovectomy with osmic acid. Due to the current derecognition of osmic acid, other alternatives such as hexatrione, yttrium silicate and yttrium citrate are used for chemosynovectomy.
Rodriguez-Merchan reviewed the literature of 270 cases of PVNS of the knee. He compared the results of open versus arthroscopic synovectomies in terms of recurrence rates, complication rates and incidence of secondary osteoarthritis. The mean duration of follow-up of the cases was 6.9 years. He reported a higher recurrence rate with open synovectomy (26.7%) compared to arthroscopic synovectomy (24.6%) with a P-value of 0.7203. He also found a higher complication rate with open synovectomy (5.7%) compared to arthroscopic synovectomy (3.2%) with a P-value of 0.34. Secondary osteoarthritis developed in 20% of the patients who underwent open synovectomy compared to 17.1% of patients who underwent arthroscopic synovectomy (P = 0.7906). The common complications encountered after arthroscopic synovectomy were prepatellar pain, articular effusion and persistent quadriceps atrophy. Knee stiffness, reduced the range of motion and hemarthrosis were common after open synovectomies. Jabalameli et al. reported a recurrence of diffuse PVNS in two patients; one of which underwent arthroscopic outer synovectomy and the other open posterior synovectomy after 4-year follow-up. The recurrence in these patients could be attributed to the fact that postoperative radiotherapy or chemosynovectomy was not done.
Recurrence of disease is seen when there is an incomplete removal of diseased tissue. The recurrence rate of diffuse PVNS varies from 5–35%., Liu et al. reviewed 97 cases of PVNS of the knee joint and reported good results with arthroscopic synovectomy. He further emphasized the role of proper post-operative radiotherapy dosage to minimize the recurrence rates. Koca et al. also seconded the importance of correct dosage and frequency of postoperative radiotherapy. Aurégan et al. further studied the factors that influence the recurrence of the disease. Involvement of large joint, incomplete synovectomy, history of recurrence of disease and extraarticular involvement were the most common factors that influenced recurrence of PVNS.,,
Clinical examination and surgical treatment of the patient: VC, RM. Review of literature and data collection and preparation of report: SN. Data collection, follow-up measurements/clinical examination of the patient, assisting in surgery: SS, MR. All authors approved the final version of the paper.
Conflicts of interest
The authors have no conflicts of interests to declare.
Institutional review board statement
This study has been submitted after due approval from the Institutional Review Board of Jagadguru Sri Shivarathreeshwara Hospital, India. This study was conducted in accordance with the Declaration of Helsinki. Written informed consent was obtained from the patient.
Declaration of patient consent
The authors certify that they have obtained the patient consent form. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initial will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.
This study followed the Recommendations for the Conduct, Reporting, Editing and Publication of Scholarly Work in Medical Journals developed by the International Committee of Medical Journal Editors.
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| References|| |
Dorwart RH, Genant HK, Johnston WH, Morris JM. Pigmented villonodular synovitis of synovial joints: clinical, pathologic, and radiologic features. AJR Am J Roentgenol
Jaffe HL, Lichtenstein L, Sutro CJ. Pigmented villonodular synovitis: Bursitis and tenosynovitis. Arch Pathol
Finis K, Sültmann H, Ruschhaupt M, et al. Analysis of pigmented villonodular synovitis with genome-wide complementary DNA microarray and tissue array technology reveals insight into potential novel therapeutic approaches. Arthritis Rheum
Sharma H, Rana B, Mahendra A, Jane MJ, Reid R. Outcome of 17 pigmented villonodular synovitis (PVNS) of the knee at 6 years mean follow-up. Knee
Sharma V, Cheng EY. Outcomes after excision of pigmented villonodular synovitis of the knee. Clin Orthop Relat Res
Dorwart RH, Genant HK, Johnston WH, Morris JM. Pigmented villonodular synovitis of the shoulder: radiologic-pathologic assessment. AJR Am J Roentgenol
Byers PD, Cotton RE, Deacon OW, et al. The diagnosis and treatment of pigmented villonodular synovitis. J Bone Joint Surg Br
Wold LE, Swee RG. Giant cell tumor of the small bones of the hands and feet. Semin Diagn Pathol
Rhee PC, Sassoon AA, Sayeed SA, Stuart MS, Dahm DL. Arthroscopic treatment of localized pigmented villonodular synovitis: long-term functional results. Am J Orthop
Li W, Sun X, Lin J, Ji W, Ruan D. Arthroscopic synovectomy and postoperative assisted radiotherapy for treating diffuse pigmented villonodular synovitis of the knee: an observational retrospective study. Pak J Med Sci
Gokhale N, Purohit S, Bhosale PB. Pigmented villonodular synovitis presenting as a popliteal cyst. J Orthop Case Rep
Hughes TH, Sartoris DJ, Schweitzer ME, Resnick DL. Pigmented villonodular synovitis: MRI characteristics. Skeletal Radiol
Blanco CE, Leon HO, Guthrie TB. Combined partial arthroscopic synovectomy and radiation therapy for diffuse pigmented villonodular synovitis of the knee. Arthroscopy
Shabat S, Kollender Y, Merimsky O, et al. The use of surgery and yttrium 90 in the management of extensive and diffuse pigmented villonodular synovitis of large joints. Rheumatology (Oxford)
Chin KR, Barr SJ, Winalski C, Zurakowski D, Brick GW. Treatment of advanced primary and recurrent diffuse pigmented villonodular synovitis of the knee. J Bone Joint Surg Am
Aurégan JC, Bohu Y, Lefevre N, et al. Primary arthroscopic synovectomy for pigmented villo-nodular synovitis of the knee: recurrence rate and functional outcomes after a mean follow-up of seven years. Orthop Traumatol Surg Res
Aurégan JC, Klouche S, Bohu Y, Lefèvre N, Herman S, Hardy P. Treatment of pigmented villonodular synovitis of the knee. Arthroscopy
Kamaleshwaran KK, Rajan D, Krishnan B, et al. Use of yttrium-90 hydroxyapatite radiosynovectomy as a primary modality of treatment in diffuse pigmented villonodular synovitis of the knee joint: a first case report. Indian J Nucl Med
Rodriguez-Merchan EC. Review article: Open versus arthroscopic synovectomy for pigmented villonodular synovitis of the knee. J Orthop Surg (Hong Kong)
de Carvalho LH, Soares LF, Gonçalves MB, Temponi EF, de Melo Silva O. Long-term success in the treatment of diffuse pigmented villonodular synovitis of the knee with subtotal synovectomy and radiotherapy. Arthroscopy
Akinci O, Akalin Y, İncesu M, Eren A. Long-term results of surgical treatment of pigmented villonodular synovitis of the knee. Acta Orthop Traumatol Turc
Nakahara H, Matsuda S, Harimaya K, et al. Clinical results of open synovectomy for treatment of diffuse pigmented villonodular synovitis of the knee: case series and review of literature. Knee
Colman MW, Ye J, Weiss KR, Goodman MA, McGough RL. Does combined open and arthroscopic synovectomy for diffuse PVNS of the knee improve recurrence rates? Clin Orthop Relat Res
Jabalameli M, Jamshidi K, Radi M, Hadi H, Bagherifard A. Surgical outcomes of 26 patients with pigmented villonodular synovitis (PVNS) of the knee at a mean follow-up of 4 years: introducing a novel technique. Med J Islam Repub Iran
Rauh PB, Bernard J, Craig DM. Pigmented villonodular synovitis of the knee: average five-year follow-up of arthroscopic treatment. J South Orthop Assoc
Chiari C, Pirich C, Brannath W, Kotz R, Trieb K. What affects the recurrence and clinical outcome of pigmented villonodular synovitis? Clin Orthop Relat Res
Liu D, Li Q, Jiang X, Tang X, Li J. Effectiveness of arthroscopy and/or arthrotomy therapy for diffuse pigmented villonodular synovitis of the knee. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi
Koca G, Ozsoy H, Atilgan HI, et al. A low recurrence rate is possible with a combination of surgery and radiosynovectomy for diffuse pigmented villonodular synovitis of the knee. Clin Nucl Med
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