Result of arthroscopic treatment of pigmented villonodular synovitis of the knee

Purpose:We report 10 years’ experience in arthroscopic treatment of pigmented villonodular synovitis (PVNS) of the knee in a series of patients affected by the localized or diffuse form of the disease. The purpose of the study is to critically examine the results of arthroscopic synovectomy in the knee affected by PVNS, to determine the safety and effectiveness of the procedure.Type of Study:Retrospective case analysis.Methods:The study population consists of 19 patients, with an average follow-up of 60 months (minimum, 12; maximum, 128). All patients underwent knee arthroscopy. The 3 standard portals were used; posteromedial and posterolateral portals were added if required. Four patients were affected by localized PVNS and were subject to partial synovectomy with excision of the pathologic tissue. The remaining 15 patients presented a diffuse form of PVNS; 7 of them underwent extended arthroscopic synovectomy and 8 underwent partial synovectomy. The diagnosis was confirmed by synovial biopsy.Results:In the group affected by the localized form of PVNS, the arthroscopic local excision resulted in a complete and persistent regression of the pathology. Among the patients affected by the diffuse form of PVNS, clinical results were better and the recurrence rate was lower in the group treated with extended synovectomy. No relevant complications were encountered. In particular, no cases of infection, stiffness, or neurovascular lesions were seen.Conclusions:Arthroscopic synovectomy is an appropriate treatment for knee PVNS. Extended synovectomy must be performed in all cases of diffuse PVNS.     

Use of polymethylmethacrylate to treat pigmented villonodular synovitis in the posterior compartment of the knee

Pigmented villonodular synovitis (PVNS) is a benign process that mainly affects the knee joint. There are two types of PVNS, a localised and a diffuse form. Although adjuvant therapies are possible, the treatment consists of arthroscopic or open synovectomy of the affected area. The most common complication is local recurrence. We report the case of a patient with PVNS and osteolysis of the femoral condyle, treated with anterior arthroscopic synovectomy and posterior approach for the treatment of the femoral condyle erosion. The bone erosion was treated with polymethylmethacrylate (PMMA) cement. There are no publications indexed in our knowledge that explain the treatment of PVNS associated with bone erosion by PMMA. Nine years after the procedure, the patient is leading a fully active life with no evidence of active disease.     

Results of total knee arthroplasty in patients with gonarthrosis resulting from the delayed diagnosis of PVNS: a case series

Pigmented villonodular synovitis (PVNS) is a benign tumor that affects synovial lined joints, tendon sheaths and bursae. It is most commonly seen in one knee joint. The recommended treatment is total synovectomy, while radiotherapy can be used as adjuvant therapy for patients at risk for recurrence. The aim of our study was to show that the devastating effects of inactive diffuse PVNS may not be recognized for years and to evaluate the efficiency of aggressive total synovectomy on patients with PVNS during a follow-up period of 5 years. In the present study, 5 knees of four patients who had been previously followed due to gonarthrosis and diagnosed with PVNS during total knee arthroplasty (TKA) were followed and evaluated for a mean duration of 68 months. Mean age of the patients was 61.2 (52–66). All patients were women. One patient had right knee involvement, two had left knee involvement, and one had both knees involved. All patients had diffuse PVNS. Total synovectomy was performed in all patients in addition to TKA. During the follow-up, recurrence was not seen in any of the patients and prosthesis loosening was not detected. The aim of the present study was to evaluate the effectiveness of total synovectomy over the 5 years following the operation and to show that the devastating effects of inactive PVNS may sometimes be overlooked for years before being recognized during the treatment of the gonarthrosis that develops due to the disease. Although the disease is generally monoarticular, the study also presents a patient with bilateral PVNS.     

Combined partial arthroscopic synovectomy and radiation therapy for diffuse pigmented villonodular synovitis of the knee

We present the results of combined partial arthroscopic synovectomy and low-dose external-beam radiation therapy (RT) in the treatment of diffuse pigmented villonodular synovitis (PVNS) of the knee. Mechanical synovectomy is an effective tool in treating PVNS of the knee, but when used alone it may be insufficient to eliminate all affected tissue. Intra-articular radiation or external-beam radiation may be added to mechanical synovectomy to treat recurrence but is not routinely done at the time of initial synovectomy. Combining intra-articular synovectomy with RT at the initial treatment for PVNS of the knee may reduce the recurrence rate. We present a prospective study of the treatment of 22 patients with clinical, ultrasonic, and histologically confirmed findings of diffuse PVNS of the knee. Characteristic clinical findings included pain, swelling, and erythema. These patients were treated by the Arthroscopic Surgery Group of the Orthopaedic Service at the Hospital “Hermanos Ameijeiras” in Havana, Cuba from 1990 to 1998. The protocol included anterior (patellofemoral, medial, and lateral) arthroscopic synovectomy and postoperative RT with a total dose of 2,600 cGy. This combination therapy was effective in reducing symptoms of pain and edema, and in improving overall function of patients. Nineteen patients (86%) had good or excellent results at an average follow-up of 33 months (range, 26 to 76 months). Three patients had residual stiffness and swelling, 2 of whom also had pain. Three had clinically and ultrasonically confirmed recurrence of disease and were treated with repeat arthroscopic synovectomy without harmful effects from RT. In all of the cases requiring repeat arthroscopic synovectomy, we observed fibrous bands secondary to reorganization of synovial inflamed tissue, meniscal retraction, and microscopic findings of fibrosis and cellular paucity. Partial arthroscopic synovectomy combined with low-dose RT in anti-inflammatory doses produced good results in the treatment of PVNS without significant complications in our patient series. Partial arthroscopic synovectomy of the knee for PVNS may be combined with RT to reduce the risk of disease recurrence. Adjuvant RT should also be considered for patients receiving a radical synovectomy to treat inaccessible or hidden disease sites. Rates of recurrence with combined partial (anterior) synovectomy and RT approach that of complete synovectomy in this series. Combining RT with radical arthroscopic synovectomy might further reduce recurrence rates.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 17, No 5 (May-June), 2001: pp 527–531     

Arthroscopic treatment of pigmented villonodular synovitis of the knee.

Pigmented villonodular synovitis (PVNS) is a rare disease, with multiple forms, anatomic sites, and treatment methods having been described. During a 10-year period, 14 patients, 7 male and 7 female, average age 35 years (range, 19 to 64 years) were treated for PVNS with arthroscopic partial or total synovectomy. Average follow-up was 42 months (range, 8 to 83 months). Twelve patients had diffuse and 2 had a localized form. Results were assessed subjectively, clinically, and radiographically, and were rated as excellent, good, fair, or poor. There were no complications and 10 patients (72%) were rated as excellent or good, 2 patients (14%) as fair, and 2 patients (14%) as poor. The recurrence rate was 14% and occurred in the group with diffuse PVNS. Radiographs did not show any bone erosion. The most widely accepted treatment for PVNS is synovectomy, and both open and arthroscopic synovectomy have been advocated as treatment. Advantages of arthroscopic treatment include accurate evaluation of the knee joint, treatment of other pathology, more rapid rehabilitation, decreased risk of joint stiffness, and less pain. In our experience, it appears that arthroscopic synovectomy is an effective method of treatment of this disorder.     

色素沉着绒毛结节性滑膜炎行全髋关节置换术治疗的临床评估

目的回顾性研究全髋关节置换术结合滑膜切除治疗晚期髋关节色素沉着绒毛结节性滑膜炎(PVNS)的临床效果。方法对2000年10月至2010年6月间行髋关节切开滑膜清理加人工髋关节置换术治疗的13例晚期髋关节PVNS感染性患者进行回顾性研究,其中8例为局限型,5例为弥漫型,平均年龄33.7岁(21～65岁)。患者术前活动受限症状明显,术前检查提示关节面破坏,关节间隙狭窄,严重的伴有股骨头变形。术中采用关节切开滑膜广泛清理人工髋关节置换。随访分析患者功能恢复情况,比较术前、术后Harris评分及复发情况。结果 10例患者平均术后随访5.6年(0.5～10.3年),未出现复发,假体稳定,Harris评分从术前的47.6分提高到90.8分,能进行日常活动。3例出现复发,其中1例再次行切开清理术,术后良好;1例目前暂时行放射治疗;1例因复发面积广泛压迫下肢血液循环,减容手术无效最终行髋关节离断术。结论全髋关节置换结合增生滑膜切除是治疗局限型PVNS伴有骨质破坏的合适手术方式,能极大改善临床症状,复发率较低。对于弥漫型的治疗,复发率较高,仍待观察。     

Pigmented villonodular synovitis of the knee: average five-year follow-up of arthroscopic treatment

We have reviewed the results of arthroscopic treatment of pigmented villonodular synovitis (PVNS) with reference to both recurrence and to function. Between 1985 and 1995, a single surgeon treated eight patients. At an average 5-year follow-up, all patients were interviewed and had assessment of Hospital for Special Surgery (HSS) knee score for both the affected and unaffected knees. Also recorded were age, sex, and whether disease was recurrent, localized, or diffuse. Disease recurred in 4 patients, all with diffuse PVNS, and 3 of them required a further arthroscopic synovectomy at a mean of 16 months after the index procedure. All patients had good or excellent functional results. There was no significant difference between HSS knee scores for affected and unaffected knees. Arthroscopic synovectomy is a successful treatment in patients with localized PVNS of the knee and results in a knee that is functionally not different from its unaffected partner.     

Low-dose external beam radiotherapy as a postoperative treatment for patients with diffuse pigmented villonodular synovitis of the knee

Background and purpose Pigmented villonodular synovitis (PVNS) is a rare proliferative disorder involving synovial membranes, and patients with PVNS have a variable prognosis. We retrospectively analyzed clinical outcomes after synovectomy plus low-dose external beam radiotherapy for diffuse PVNS of the knee.

Methods We reviewed the medical records of 23 patients who underwent postoperative radiotherapy between 1998 and 2007. 19 patients had primary disease and 4 had recurrent disease with an average of 2.5 prior surgeries. After synovectomy (17 arthroscopic surgeries; 6 open), all 23 patients received 4-MV or 6-MV external beam radiotherapy with a median dose of 20 (12–34) Gy in 10 fractions.

Results At a median follow-up of 9 (0.8–12) years, 4 patients had recurrent disease, with a median disease-free interval of 5 years. Of these 4 patients, 3 received salvage synovectomy and regained local control. Univariate analysis showed that age, sex, history of trauma, and total dose of radiation were not predictive of local control. 22 patients reported excellent or good joint function, and 1 who refused salvage synovectomy had poor joint function. None of the patients experienced grade 3 or higher radiation-related toxicity or radiation-induced secondary malignancies.

Interpretation Postoperative external beam radiotherapy is an effective and acceptable modality to prevent local recurrence and preserve joint function in patients with diffuse PVNS of the knee. Low-dose (20 Gy) radiotherapy appears to be as effective as moderate-dose treatment (around 35 Gy).     

Cementless Total Hip Arthroplasty Performed in Patients With Pigmented Villonodular Synovitis

The authors retrospectively reviewed all patients with pigmented villonodular synovitis (PVNS) of the hip treated by cementless total hip arthroplasty (THA) combined with synovectomy. Eight patients were reviewed and observed for an average of 8.9 years (range, 4.3-13.5 years). Mean preoperative Harris hip scores improved from 49.3 to 96.6 points, and all patients were able to regularly perform moderate daily living activities. None of the patients had clinical or radiographic evidence of recurrent PVNS. Osteolysis occurred in 4 hips, and 2 revision surgeries were performed during follow-up. Cementless THA combined with synovectomy is an adequate therapeutic choice for patients with PVNS demonstrating end-stage joint destruction and appears to be effective at improving clinical results and preventing disease recurrence.     

关节镜术治疗色素绒毛结节性滑膜炎

目的：讨论关节镜下治疗色素沉着绒毛结节性滑膜炎。方法：1987年6月以来共行关节镜下滑膜刨削术治疗21例,其中膝关节19例,腕和踝关节各1例。结果：无手术并发症,病人早期恢复良好。全部病例经过平均3年8个月随访,优良率为80.9%。局限型疗效好于弥漫型。复发3例,复发率14.3%,全部为弥漫型,再次手术亦有效。结论：关节镜术诊断和治疗色素沉着绒毛结了性滑膜炎均有明显的优点。     

Pigmented villonodular synovitis: a retrospective study of seventy five cases (eighty one joints)

Purpose

Pigmented villonodular synovitis (PVNS) is a relatively rare, benign proliferation lesion of the synovium of large joints, but there is not much information available about the disease’s aetiology, clinical history, differential diagnosis, treatment, and long-term effects. We conducted a study to analyse these aspects of PVNS.

Methods

We reviewed all clinical data for 75 patients with PVNS (81 joints) who were treated either by synovectomy alone or synovectomy plus arthroplasty.

Results

In all cases, the diagnosis of PVNS was confirmed by pathological examination. The ratio of males to females was 27:48, and the average age of patients was 46 years (range, 15–80 years). Lesions were located in the knee, hip, or ankle, and pain and swelling were the main symptoms. Of 75 patients, 42 had a history of trauma to the involved joint. Forty-one patients (43 joints) underwent synovectomy alone, and 34 patients (38 joints) underwent synovectomy and arthroplasty together. Of the 75 patients, 61 had full follow-up data. Twelve patients had recurrent legions detected by pathological examinations; four patients had more than two recurrences. Moreover, five patients developed PVNS after arthroplasty.

Conclusions

PVNS occurs most often in middle-aged women and most frequently involves the knee, followed by the hip and ankle. The disease’s etiology is varied and unclear. Surgical excision alone or with arthroplasty is an effective treatment, but there is a high rate of recurrence.     

Recurrent pigmented villonodular synovitis (PVNS)

AIM: The pigmented vilionodular synovitis (PVNS) is a tumour like disease of unknown origin that often shows recurrence. The pathogenesis is still unknown and therefore the question of the right therapy is not resolved. MATERIAL: With a case report of a patient with recurrence after two arthroscopic synovectomies, PVNS is discussed against the background of the clinical, histological, and radiological features. RESULTS: We performed an open synovectomy and cystic lesions in both condyles of the femur and proximal tibia were filled with homologous and autologous cancellous bone. Three months later the patient had no pain and the bone density in the former cystic lesions was appropriate. DISCUSSION: The pathogenesis is still unknown. Diagnosis often is obtained much too late due to missing specific symptoms. PVNS occurs in local forms as well as in a diffuse growth pattern. Recurrence rates of up to 78% are very high. Besides arthroscopic and open synovectomy, the treatment with radiosynoviorthesis must be considered. Depending on the growth pattern, the tumour masses, and the affected joint, the therapy has to be chosen very carefully and sometimes different forms have to be combined if a recurrence--free result is to be achieved.     

Pigmented villonodular synovitis of the knee: results from 13 cases

Arthroscopy is an indispensable tool in the diagnosis, treatment, and postoperative follow-up of pigmented villonodular synovitis (PVNS) and enables classification of PVNS into three forms: diffuse, localized, and mixed. A series of 13 cases of PVNS of the knee is presented; 12 patients underwent surgery. According to the anatomic type of PVNS found, the authors used extensive classic surgery or endoscopy. Follow-up averaged 4.2 years (range, 1-10 years). The best results were obtained in cases of localized PVNS. Overall, nine patients were totally asymptomatic at follow-up. Four patients experienced some pain when fatigued or with changes in the weather. There was no recurrence of symptoms.     

MRI Diagnosis of Recurrent Pigmented Villonodular Synovitis Following Total Joint Arthroplasty

Pigmented villonodular synovitis (PVNS) can recur after complete synovectomy and even after total joint replacement. In the authors’ experience, there is a misconception that MRI may not be useful to diagnose PVNS in the setting of a total joint replacement due to dephasing artifact from metal. While there are case reports of PVNS in patients with total joint replacement diagnosed surgically, to our knowledge, diagnosis of recurrent PVNS by MRI following total joint replacement has not been reported. This report illustrates the utility of MRI in the diagnosis of recurrent PVNS following total joint replacement by reviewing two cases of pathologically correlated PVNS recurrence following arthroplasty, and two cases in which PVNS recurrence is strongly suspected, though pathological correlation is not available.     

Pigmented Villonodular Synovitis of the Flexor Hallucis Longus Tendon Treated by Means of Tendoscopy and Endoscopic Synovectomy

Pigmented villonodular synovitis (PVNS) of the tendon sheath (tenosynovial giant cell tumor) is a rare disorder that is often misdiagnosed because of slow growth and an atypical presentation. Open surgical excision is the treatment of choice, although recurrence is a common complication. In this report, a case of PVNS of the flexor hallucis longus tendon in the ankle and hindfoot is described. The diagnosis was confirmed by endoscopic inspection and biopsy, and complete synovectomy was performed through the endoscope. The patient remained disease free after 24 months of follow up.     

Clinical and oncological outcomes after surgical excision of pigmented villonodular synovitis at the foot and ankle

BackgroundPigmented villonodular synovitis (PVNS) is a rare benign neoplastic disease of the synovium of joints and tendon sheaths, which may be locally aggressive. It can be broadly classified into localised disease or more diffuse forms, with the latter more prone to recurrence after surgical excision. We describe our experience in the management of foot and ankle PVNS, focusing on the diffuse type.MethodsPatients with PVNS were identified from a histology database from 2000 to 2010 at the University Hospitals of Leicester. The primary aim was to determine oncological outcomes and evaluate clinical outcomes with the Toronto Extremity Salvage Score (TESS) and the American Academy of Foot and Ankle Surgeons (AOFAS) scores.Results30 patients, 16 males and 14 females with a mean age of 37 ± 15 years, who underwent surgery, were identified. There were 22 nodular PVNS and 8 diffuse PVNS. The diffuse PVNS was more likely to be in the hindfoot (75%, 6/8), of which 50% (3/6) had osteoarthritis at presentation. The localised PVNS was mostly located in the forefoot (91%, 20/22). None of the localised PVNS had a recurrence. The surgical recurrence rate in this series was similar to the pooled recurrence rate from the literature [12.5% (1/8) compared to 12.2% (6/49)]. The mean TESS and AOFAS scores were 86 and 78, respectively.ConclusionsDiffuse PVNS is more likely to occur in the hindfoot and nodular PVNS is more common in the forefoot. Aggressive synovectomy alone is an effective treatment for diffuse PVNS, with good oncological and clinical outcomes.     

Treatment of Diffuse Pigmented Villonodular Synovitis of the Knee with Combined Surgical and Radiosynovectomy

Treatment of extensive diffuse pigmented villonodular synovitis (PVNS) of large joints by isolated surgical resection is unsatisfactory, with high rates of local recurrence. Post-synovectomy adjuvant treatment with external beam radiation therapy or intra-articular injection of radioactive material as yttrium-90 (⁹⁰Y) yielded better results. Between January 2005 and January 2007, 12 patients (eight men and four women aged 19–49 years) with extensive diffuse PVNS of the knee were treated. All patients had an adjuvant post-operative external beam radiation therapy (2,600–3,000 cGy) conventionally fractionated 200 cGy/fraction, five fractions/week, 6–8 weeks after surgery. Mean follow-up time was 27 months (range from 20 to 36 months). All patients were followed up using clinical assessment, magnetic resonance imaging, and plain X-ray. In all patients, neither evidence of disease recurrence nor progression of bone or articular destruction was noted. No complications were noticed after surgery or after post-operative external beam radiation therapy. A combination of debulking surgery using anterior and posterior approach with adjuvant post-operative external beam radiation therapy for extensive diffuse PVNS of the knee joint is a reliable treatment method, with good results in regard to the incidence of local recurrence and functional outcome. Level of evidence: level IV—retrospective case series     

Recurrent aneurysmal bone cyst of the proximal phalanx treated with cryosurgery: a case report

A recurrent aneurysmal bone cyst of the proximal phalanx treated with curettage, cryosurgery, and bone grafting is presented. There is no evidence of recurrence after 5 years. Although cryosurgery is commonly used as an adjuvant for intralesional treatment for aneurysmal bone cyst, there have been no reports of its use for the treatment of a lesion arising in the hand.     

Subcutaneous pigmented villonodular synovitis caused by portal contamination during knee arthroscopy and open synovectomy

The etiology of pigmented villonodular synovitis (PVNS) is not clear. Researchers have suggested that localized nodular synovitis is an inflammatory process, but more recent studies tend to describe the lesion as benign synovial neoplasm with the potential of local recurrence. Although the theoretical risk of secondarily seeding the remainder of the knee is evident, this is the first report of a subcutaneous PVNS caused by portal contamination during knee arthroscopy and open synovectomy. It supports a neoplastic origin of this lesion.