Open synovectomy with cryosurgical adjuvant for treatment of diffuse pigmented villonodular synovitis of the knee

Pigmented villonodular synovitis (PVNS) is an uncommon, benign disorder usually affecting the synovial membrane of large joints. The diffuse form of PVNS is extremely difficult to control, and long-term recurrence inevitably results in arthrodesis or arthroplasty. Current treatments include surgical, chemical, and radiation synovectomy, but all have significant failure rates. In hope of obtaining a more complete synovectomy, we used cryosurgery as an adjuvant to open synovectomy in three patients. Two patients presented with multiple failed arthroscopic synovectomies, and one patient presented with arthroscopically unresectable PVNS. The surgical approach involved take down and repair of the anterior meniscal attachments, and direct entry into the posterior space through medial and lateral femoral capsular attachments. Cryosurgical surface spray was used on all non-cartilaginous surfaces. At follow-up of 14, 30, and 31 months, all three patients remained symptom-free and there were no indications of clinical recurrence. There were no obvious complications or morbidity from the cryosurgical procedure and all patients had excellent functional recovery. All patients returned to sports and their jobs without restrictions. In the past, it has been shown that cryosurgery is a safe and effective treatment modality for proliferative joint disease. We propose the use of adjuvant cryosurgery for PVNS patients selected for open synovectomy.     

开放手术与关节镜下滑膜切除治疗膝关节绒毛结节性滑膜炎的比较

目的比较开放滑膜切除（OG）与关节镜下滑膜切除（AG）两种方法治疗膝关节弥漫型色素沉着绒毛结节性滑膜炎（PVNS）的复发率、复发时间、Lysholm和IKDC膝关节评分。方法 46例术后病理证实为PVNS患者分别行OG（19例）和AG（27例）治疗。OG组采用膝关节前后联合入路进行滑膜切除,AG组通过高位前外侧、标准前内侧、后内外侧以及髌上外侧的关节镜入路完成滑膜切除。结果 46例均获12个月以上随访：OG组为12～60（31±14.7）个月,AG组为12～72（35±17.8）个月。复发率：OG组为15.8%（3/19）,AG组为18.5%（5/27）（P〉0.05）。复发时间：OG组为2～4年,AG组为0.5～4年。两组的膝关节活动度、Lysholm和IKDC膝关节评分：OG组分别为（134.2±22.1）°、（79.8±8.4）分、（81.9±9.3）分,AG组分别为（139.2±17.9）°、（81.6±9.3）分、（85.2±7.6）分,两组各项比较差异均无统计学意义（P值分别为0.397、0.504、0.193）。除AG组1例复发于术后6个月外,余复发病例均〉2年。结论两种方案的复发率相当,膝关节评分也无明显差异,均可作为弥漫型PVNS的治疗选择。     

Pigmented villonodular synovitis of the knee. The results of total arthroscopic synovectomy, partial, arthroscopic synovectomy, and arthroscopic local excision.

Twenty-five patients who had had a diagnosis of pigmented villonodular synovitis of the knee were followed for an average of four and one-half years (range, two to ten years) after arthroscopic treatment. Five patients had had localized lesions and had been managed with local resection; all five had improvement, with no apparent recurrence. The remaining twenty patients had had diffuse disease. Of these twenty, eleven had had a complete arthroscopic synovectomy. All eleven had definite improvement in pain and function, and almost all had a decrease in synovitis and an increase in the range of motion of the knee; the disease recurred in only one. The other nine patients had had a partial arthroscopic synovectomy. Although most had some improvement in function and range of motion and a decrease in pain and synovitis, the disease recurred in five of the nine. Thus, in the patients who had had diffuse pigmented villonodular synovitis, the rate of recurrence was lower in those who had had a complete arthroscopic synovectomy than in those who had had a partial arthroscopic synovectomy (p = 0.01).     

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.     

关节镜下和/或切开治疗膝关节弥漫型色素沉着绒毛结节性滑膜炎疗效分析

目的探讨关节镜下和/或切开手术辅以术后关节外放疗治疗膝关节弥漫型色素沉着绒毛结节性滑膜炎(pigmented villonodular synovitis,PVNS)的方法和疗效。方法 2000年9月-2010年8月,收治97例单膝弥漫型PVNS。男38例,女59例;年龄8～75岁,中位年龄33岁。病程1周～30年;复发患者10例。左膝52例,右膝45例。术前膝关节伸直(1.9±2.3)°,屈曲(122.9±5.6)°;Lysholm膝关节评分为(43.2±6.7)分,国际膝关节文献委员会(IKDC)膝关节功能主观评分为(53.2±5.7)分。根据是否合并关节外病变及病变部位,82例采用关节镜下关节前后病变滑膜切除术,3例采用关节镜下关节内病变滑膜切除联合小切口切除关节外病灶,9例采用关节镜下关节内病变滑膜切除及后方关节外软组织内病灶切除术,3例分期切除病灶并植骨。术后76例接受关节外放疗。结果术中1例损伤腘动脉,3例损伤腘静脉分支;术后3 d 1例膝关节血肿形成。其余患者切口均Ⅰ期愈合,无神经损伤等并发症发生。患者均获随访,随访时间1年3个月～11年2个月,中位时间61个月。89例患者随访期间无复发,术后15个月膝关节伸直(0.2±1.3)°,屈曲(135.9±6.6)°,Lysholm膝关节评分为(89.8±5.8)分,IKDC膝关节功能主观评分为(87.8±5.8)分,与术前比较差异均有统计学意义(P<0.05)。8例于术后6个月～8年复发,再次手术后患者膝关节轻度活动受限,无疼痛、肿胀。结论根据膝关节病变范围及程度,选择关节镜下和/或切开手术辅以关节外放疗治疗膝关节弥漫型PVNS可取得较好疗效。术后未接受正规放疗是复发重要因素之一,复发者病变易导致骨质破坏。     

Arthroscopic synovectomy in pigmented villonodular synovitis of the knee: clinical series and outcome

Purpose

The aim of this study was to evaluate the long-term results of arthroscopic excision of pigmented villonodular synovitis (PVNS) of the knee joint.

Methods

We retrospectively assessed the results of arthroscopic excision of PVNS done in 40 patients from 1987 to 2012 by the senior author (JVS). No radiotherapy was given to any patient. All patients were followed for a mean of seven years. At follow-up functional assessment was done using the Lysholm score. Recurrence-free survival and recurrence-free survival probability were calculated.

Results

No recurrence was noted in the localised variety. In the diffuse variety the five year recurrence-free survival probability was 57 %. Twelve patients developed recurrences between three months and two years. No recurrence was noted after two years. The mean recurrence interval was 6.25 months.

Conclusions

We concluded from this series that arthroscopic excision is an effective treatment for localised as well as diffuse PVNS. Recurrences can also be successfully dealt with by arthroscopic excision with excellent functional outcome.     

单纯关节镜下滑膜切除与联合术后放疗治疗膝关节色素沉着绒毛结节性滑膜炎疗效的比较研究

目的比较单纯关节镜治疗弥漫型色素沉着绒毛结节性滑膜炎（DPVNS）与联合术后放疗的复发率和关节评分的差异。方法对92例在关节镜下滑膜切除术的首次治疗的单侧全关节内（无关节外病变）DPVNS,87例术后1个月复查MR滑膜切除干净无DPVNS残留征象,并完成24个月以上随访的患者,分为单纯关节镜下滑膜切除术（AS）组40例和关节镜下滑膜切除术联合术后放疗（AS＋RT）组47例,根据DPVNS病变部位分为膝关节前关节囊型、后关节囊型、累及前后关节囊的全关节囊型等3种类型,AS组中前关节囊型11例、后关节囊型10例、全关节囊型19例,（AS＋RT）组中前关节囊型13例、后关节囊型11例、全关节囊型23例,评估各型各组的复发率、膝关节活动度和膝关节功能评分。结果全关节囊型AS组复发率高于（AS＋RT）组（2=4.101,P〈0.05）;前关节囊型、后关节囊型和全关节囊型的膝关节活动度、Lysholm和IKDC评分无统计学差异（P〉0.05）。结论关节镜下滑膜切除术能够很好地切除前关节囊或后关节囊的滑膜,术后复查MR未发现DPVNS残留情况可以不联合放疗,但对于病变遍布前、后关节囊的全关节囊型DPVNS,建议常规联合放疗以减少复发率。     

膝关节镜下诊治局灶性色素沉着绒毛结节性滑膜炎的临床疗效

目的 探讨采用关节镜技术诊治膝关节局灶性色素沉着绒毛结节性滑膜炎(localized pigmented villonodular synovitis,LPVNS)的临床疗效.方法 2004年6月至2007年9月,关节镜下辅助诊治12例LPVNS患者,男5例,女7例;年龄22～53岁,平均36.3岁.病程最短1个月,最长84个月,平均19.5个月.关节镜下行关节内肿物和局部滑膜切除术,根据膝关节Lysholm评分评估术后疗效.结果 膝关节镜检查发现2例伴内侧半月板前角损伤,1例伴外侧半月板损伤,4例内侧滑膜皱襞增生Ⅲ度,3例髌股关节炎Ⅱ度,其中1例伴内外侧髁软骨Ⅲ度磨损.3例肿物来源于内侧半月板前角附着处滑膜,1例在外侧半月板前角附着处滑膜,3例在髌下脂肪垫,1例在髁间窝,2例在内侧沟,1例在外侧沟.1 例来源于膝关节后纵隔内侧面滑膜.肿物大小平均1.7 cm×1.4 cm×0.8 cm(0.5 cm×0.5 cm×0.5 cm～3 cm×3 cm×2 cm);2例无蒂,10例带蒂,术后组织切片均明确LPVNS的诊断.术后无一例发生膝关节感染.术后随访6～45个月,平均19.9个月.7例无任何不适,3例膝关节下蹲时存在疼痛,1例活动后肿胀,1例行走后疼痛.术后膝关节Lysholm评分为78～100分,平均96.3分;8例优,3例良,1例中.结论 关节镜技术是诊治膝关节LPVNS的一种有效方法 .     

Localized pigmented villonodular synovitis of the knee

Eight patients with localized pigmented villonodular synovitis (LPVNS) of the knee were treated with arthroscopic and open techniques, with diagnosis confirmed by histological examination. Average patient age was 29 years (range: 13-50 years). At arthroscopy, all lesions except one were in the anterior compartment of the involved knee. Treatment consisted of complete local excision with partial synovectomy. This procedure was completed arthroscopically in seven patients. No recurrence was reported at average 24-month follow-up (range: 12-33 months). Arthroscopy is a valuable tool in the diagnosis and treatment of LPVNS.     

关节镜联合髌上囊小切口滑膜切除术治疗膝关节弥漫型色素沉着绒毛结节性滑膜炎的疗效分析

目的：探讨应用关节镜结合髌上囊小切口切开滑膜切除治疗膝关节弥漫型色素沉着绒毛结节性滑膜炎（ PVNS）患者的疗效。方法本组对2006年1月至2011年12月因膝关节弥漫型PVNS的32例患者进行回顾性分析,该组患者全部采用膝关节镜结合髌上囊局部切开滑膜切除的治疗方法。本研究对患者的基本情况、治疗方法、复发率和症状进展进行的记录,最短随访时间为7个月（平均中位数为49.8个月;范围7～141个月）。结果应用膝关节镜结合髌上囊局部切开滑膜切除方法治疗PVNS的复发率低（6.3％）,肿胀和疼痛术后好转,其中明显好转没有疼痛和活动不适的为50％,而关节炎持续进展的为11.1％,但是没有患者在最后随访期内发展进行膝关节置换。最常见的并发症为血肿,发生率为3％,但是没有发现对患者术后疗效产生明显影响。术前KSS临床评分为（62.7±17.7）分;功能评分为（45.0±24.0）分,术后临床KSS评分（85.2±10.9）分;功能评分（79.5±12.3）分,比较均有统计学差异（临床KSS评分：t＝4.456,P＜0.001;功能KSS评分：t＝5.279,P＜0.001）;而Lysholm评分术前（64.7±15.0）分,术后提高到（83.2±8.4）分,二者间比较有统计学差异（ t＝4.451,P＜0.001）。结论结合相关文献报道,膝关节镜结合髌上囊局部切开滑膜切除方法是治疗膝关节弥漫型PVNS的较好方法,有着较低的复发率和并发症。     

Localized pigmented villonodular synovitis of the knee

Localized pigmented villonodular synovitis (PVNS) of the knee is a rare, idiopathic condition presenting with symptoms that can be confused with various other intra-articular pathologies. The condition is usually monoarticular, the knee being most commonly affected. If totally excised, complete cure can be achieved and recurrence is very rarely reported. In this report, we present 4 cases of patients with different symptomatology but all with PVNS of the knee who underwent arthroscopic treatment. At short-term follow-up, all patients had complete recovery of their symptoms with no apparent recurrence.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 17, No 6 (July-August), 2001: E23     

Localized pigmented villonodular synovitis of the knee

Pigmented villonodular synovitis (PVNS) is a well-recognized lesion that may affect any joint but is frequently found in the knee. It is a rare condition, especially in the localized form, and is still cause for discussion regarding to its pathogenesis and treatment. We report four cases of localized PVNS each one presenting with different clinical signs and symptoms. In one of our cases, a pedunculated mass and villous-like projections of the surrounding synovium were associated. Each case was studied with magnetic resonance imaging, treated arthroscopically, and the diagnosis confirmed by histological examination. Arthroscopy is an effective tool for both diagnosis and treatment.Arthroscopy 1998 Jul-Aug;14(5):532-6     

Treatment of advanced primary and recurrent diffuse pigmented villonodular synovitis of the knee

BACKGROUND: Diffuse pigmented villonodular synovitis of the knee is a difficult tumor to eradicate. We report our experience with a combined open posterior and anterior synovectomy with and without adjuvant postoperative radiation therapy in patients with advanced extracapsular disease. METHODS: A single surgeon operated on forty patients, with an average age of thirty-five years (range, fourteen to sixty-eight years), who had diffuse pigmented villonodular synovitis of the knee. All patients had been referred to us after having initially undergone arthroscopic or open surgical procedures without eradication of the disease. Patients were retrospectively placed into one of three groups: Group I received surgery alone (five patients), Group II had surgery and intra-articular radiation synovectomy with use of dysprosium-165 (thirty patients), and Group III had surgery and external beam radiation (five patients). Adjuvant radiation was performed three months postoperatively. Magnetic resonance imaging was used for all patients for preoperative staging and postoperative follow-up. RESULTS: The average Knee Society score for the entire series improved from 61 points preoperatively to 92 points at the time of follow-up, at an average of five years (range, 1.5 to eight years) (p < 0.001). There was also a significant (p < 0.001) increase in the average range of motion of the knees across all groups. On the basis of the Knee Society scores, thirty-seven patients (93%) had a good or excellent result, two patients had a fair result, and one patient had a poor result. Complications included stiffness requiring manipulation in three knees, one case of reflex sympathetic dystrophy, advanced osteoarthritis leading to a total knee replacement in four patients, and seven recurrences (a prevalence of 18%) after operative treatment and radiation therapy. CONCLUSIONS: This surgical technique allows excellent visualization and removal of intra-articular and extra-articular diffuse pigmented villonodular tissue and yields excellent functional results and a low prevalence of knee stiffness. However, the rate of recurrence detected by magnetic resonance imaging was 18%. Adjuvant intra-articular radiation therapy may be beneficial for eradication of small foci of residual disease, but complete resection of all pigmented villonodular tissue appears to be the key to preventing recurrence. Magnetic resonance imaging was essential for accurate preoperative staging of the tumor and for follow-up since the presence of residual disease did not reliably correlate with the clinical findings. Patients with minimal degenerative arthritis and primary or recurrent extra-articular disease will benefit most from this approach.     

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.     

A rare case of diffuse pigmented villonodular synovitis after total knee arthroplasty

Pigmented villonodular synovitis is a benign, proliferative disorder of unknown etiology that mainly affects the synovium of the joint, bursa, and the tendon sheath. The most common joint affected is the knee. Pigmented villonodular synovitis presents in either of 2 distinct forms, localized or diffuse. In this report, we describe a case of diffuse pigmented villonodular synovitis that presented in the knee 18 months after total knee arthroplasty. The diagnosis was suggested by histologic analysis of bloody aspirate and by abnormal synovial proliferation noted at arthroscopy and confirmed by histologic analysis of the resected tissue.     

关节镜下诊治膝关节弥漫性色素沉着绒毛结节性滑膜炎

目的 探讨采用关节镜技术诊治膝关节弥漫性色素沉着绒毛结节性滑膜炎的临床疗效.方法 自2009年3月至2011年5月关节镜下诊治膝关节弥漫性色素沉着绒毛结节性滑膜炎7例,先行后内、后外侧间室的清理,然后清理髁间窝,交叉韧带表面,前内、外侧间室,内、外侧沟,最后行髌上囊清理,病变组织均送病检.术后常规放置引流管,按计划指导功能训练.结果 本组7例患者有4例MRI发现结节病变,诊断为弥漫性绒毛结节性滑膜炎;3例镜检发现术前穿刺液为鲜血或淡黄色液或褐色液.1例伴外侧半月板复杂撕裂;2例合并不同程度的骨关节炎.无一例发生膝关节感染.术后2例行放疗.全部患者获得随访,随访时间12.0~32.0个月,平均21.4月,无膝关节活动受限,未见复发病例.所有患者对术后疗效表示满意.Lysholm膝关节的功能评分由术前的50.7分增加到86.6分.结论 关节镜技术诊治膝关节弥漫性色素沉着绒毛结节性滑膜炎是一种创伤小,恢复快,病灶切除彻底,能有效地避免复发的治疗方法.     

Magnetic resonance imaging evaluation and arthroscopic resection of localized pigmented villonodular synovitis of the knee

Diagnosis of localized pigmented villonodular synovitis is clinically difficult, and plain radiographs are usually normal. This article presents five patients with localized pigmented villonodular synovitis of the knee. Symptoms suggested a meniscal lesion in three patients and a loose body in two. Magnetic resonance imaging performed prior to arthroscopic resection revealed a preoperative diagnosis of a tumor in all five patients. Magnetic resonance imaging is a valuable clinical tool for the assessment of intra-articular soft-tissue tumors of the knee that may otherwise be misdiagnosed.     

Diagnosis and surgical therapy of diffuse pigmented villonodular synovitis of the hip joint

Pigmented villonodular synovitis (PVNS) of the hip is a monoarticular proliferative process involving the synovial membrane. A chronic inflammation as well as a neoplastic process have been proposed in the literature. PVNS is usually found in adults aged 20-50 years, without sex predilection. The knee is by far the commonest location, followed by the hip. We present a detailed case report of a 25-year-old man with PVNS of the hip. The physical examination was completely normal. Radiographs of the hip show erosions in the head and neck of the femur and the acetabulum. Magnetic resonance imaging showed a suspected malignant soft tissue mass involving the hip joint. The diagnosis of PVNS was confirmed by arthroscopy and biopsy, and the treatment of choice was an open synovectomy. One year after the operation the clinical examination was normal.