Localized pigmented villonodular synovitis of the knee: diagnostic challenge and arthroscopic treatment: a report of three cases

Giant cell tumor of tendon sheath in the wrist that damaged the extensor indicis proprius tendon: a case report and literature review

BACKGROUND

Giant cell tumor of the tendon sheath (GCTTS) is a benign soft tissue (synovial membrane) tumor that rarely involves the hands or wrists. And Tendon impairment caused by GCTTS is extremely rare.

CASE PRESENTATION

Here, we reported a case of a 60-year-old female with a 10-year history of gradually increasing mass in her left dorsal wrist. The EIP tendon was partially impaired by the mass.The patient was treated with surgical excision of the mass and reconstruction of the EIP tendon. The histopathological examination suggested the presence of GCTTS. After surgery, the patient had adequate functional recovery and no tumor recurrence after 2 years' follow-up.

CONCLUSION

GCTTS in hands and wrists rarely damages the tendon. Early diagnosis and proactive interventions may likely contribute to good prognostic outcomes.

Prognosis of Advanced Tenosynovial Giant Cell Tumor of the Knee Diagnosed During Total Knee Arthroplasty

BACKGROUND

Tenosynovial giant cell tumor (TGCT) is a relatively rare disease often misdiagnosed as osteoarthritis. Synovectomy or arthroplasty is the recommended treatment option, but recurrence is common after surgery. This study aimed to determine the prognosis of patients with advanced TGCT that was diagnosed incidentally during total knee arthroplasty (TKA) for osteoarthritis and treated by synovectomy.

METHODS

From January 2008 to July 2011, TGCT was diagnosed incidentally in 10 patients (a total of 11 individual knees) undergoing posterior-stabilized TKA for an initial diagnosis of osteoarthritis. TGCT was confirmed by histopathology of biopsy specimens. Partial synovectomy was performed for localized-type TGCT (3 knees, 3 patients) and total synovectomy for diffuse-type TGCT (8 knees, 7 patients).

RESULTS

All patients were female with a mean age of 61.7 ± 6.6 (range 50-70) years. No postoperative infection, nerve injury, or deep venous thrombosis occurred. All patients were followed up for a mean period of 60.9 ± 6.6 (39-83) months, and no recurrence of TGCT occurred. X-ray imaging showed no apparent radiolucent lines around the prosthesis, and no prosthetic loosening, subsidence, or osteolysis. The joints were stable, with a significantly improved range of motion following surgery (109.5° ± 8.8° vs 80.5° ± 16.8°, P < .01). The Knee Society scores for knee joint (90.0 ± 4.1 vs 40.5 ± 8.1) and knee function (81.8 ± 7.5 vs 35.0 ± 13.8) were both significantly improved after surgery (P < .01).

CONCLUSION

Inactive TGCT could not be diagnosed preoperatively. TKA combined with synovectomy is effective in the treatment of advanced TGCT with degenerative lesions.

Unusual Presentation of Anterior Knee Pain in Elite Female Athletes: Report of Two Cases

Two elite female athletes presented with anterior knee pain with range of motion and reproducible tenderness to palpation. Diagnostic arthroscopy was performed in both cases resulting in excision of a nodular pigmented villonodular synovitis (PVNS) in the first patient and scar tissue in the second patient. Correct diagnosis of anterior knee pain in the elite female athlete can present a challenge to clinicians. Although patellofe-moral pain is the most common diagnosis, other uncommon causes include PVNS and residual scar formation in patients with a history of surgery or trauma. Magnetic resonance imaging (MRI) images are helpful in confirming the diagnosis, however, in a subset of patients, the physician must rely on clinical suspicion and physical exam to make the proper diagnosis. Given the possibility of a false negative MRI images, patients with persistent anterior knee pain with a history of knee surgeries and focal tenderness reproducible on physical exam may benefit from a diagnostic arthroscopy.

A rare case of giant cell tumour arising from anterior cruciate ligament: Its diagnosis and management

Tenosynovial giant cell tumour is a locally aggressive tumour arising from the synovia of the fibrous tissue surrounding the joints, tendon sheaths and tendons. Areas of predilection are the hand, and in the case of synovial joints, the knee joint is particularly affected. We describe a rare case of an intra-articular localized tenosynovial giant cell tumour arising from the anterior cruciate ligament (ACL) in a 27 year male who presented with pain and giving way of his left knee without prior history of any trauma. Tests for internal derangement of knee were negative. MRI reported an ACL tear with a heterogeneous fibrous mass attached to the distal part, most probably an organized haematoma. It was decided to do a diagnostic arthroscopy before proceeding for ACL reconstruction. Arthroscopy revealed a purple coloured mass attached to distal part of ACL. The mass was removed piecemeal using an additional posterolateral portal. ACL was found intact. Histopathology reported it to be tenosynovial giant cell tumour. The patient was asymptomatic at each subsequent follow up. It is a rare diagnosis which presented as an ACL tear; in such suspected cases it is prudent to perform a diagnostic arthroscopy before going for ACL reconstruction.

Localized form of pigmented villonodular synovitis of the knee: the meniscal mime

The localized form of pigmented villonodular synovitis of the knee is a rare condition with non-specific symptoms. This makes diagnosis especially difficult when the meniscus is affected. A full assessment with several imaging modalities can help support the preoperative diagnosis. But in the case reported here, the full clinical and paraclinical assessment (X-rays, CT arthrography and MRI) was wrong--the localized form of pigmented villonodular synovitis had mimicked a lateral meniscus injury and was only detected during arthroscopy. The lesion was excised surgically and the diagnosis was confirmed through postoperative histopathology.

Intra-articular tenosynovial giant cell tumor arising from the posterior cruciate ligament

Tenosynovial giant cell tumors originate from the synovial tissue of the joints, tendon sheaths, mucosal bursas, and fibrous tissues adjacent to tendons. The disease presents in localized and diffused forms. Large joints, such as the knee, are not frequently affected. Magnetic resonance imaging has been reported to be the best noninvasive technique to diagnose these tumors. Magnetic resonance imaging diagnosis has to be confirmed by histopathological examination. Few reports exist of tenosynovial giant cell tumors arising from the posterior cruciate ligament. This article describes a case of an 18-year-old man with no history of trauma but with a 2-year history of mild, ongoing, and worsening right knee pain and swelling localized in the popliteal region. Clinical examination of the knee was negative. Magnetic resonance imaging revealed an intra-articular mass measuring 4.8×2.1×2.7 cm in the posterior region of the knee attached to the posterior cruciate ligament. Arthroscopy was performed using the posterior approach through the posterolateral and posteromedial portals. A specimen of the lesion was removed arthroscopically for histopathological examination, and a wide resection of the mass was performed with a shaver and a radiofrequency ablation device. Histopathological examination confirmed the diagnosis of a tenosynovial giant cell tumor. No recurrence had occurred at 2-year follow-up. Magnetic resonance imaging and histopathological examination may help in achieving a correct diagnosis, and arthroscopic excision using a posterior approach may be the treatment of choice by surgeons.

Prise en charge de la synovite villonodulaire hémopigmentée du genou et de ses récidives

PURPOSE OF THE STUDY

The objective of this retrospective study was to analyze clinical observations in pigmented villonodular synovitis (PVNS) of the knee as well as response to treatment in order to better define the diagnostic approach and surgical treatment and follow-up of this rare benign proliferative disease of the synovial observed primarily in the knee joint.

MATERIAL AND METHODS

Twenty-eight patients (13 men and 15 women) were treated for PVNS in our unit between 1996 and 2004. Twenty patients had diffuse disease and eight localized disease. In the localized forms, symptoms mimicked those provoked by intra-articular foreign bodies or meniscal tears (n = 6) and had been present for 14 months on average at first consultation. Mean age at treatment onset was 40 years (range 20-62). Arthroscopic or open surgery was used for resection. In the diffuse forms, symptoms had begun 15 months on average before first consultation and were mainly spontaneous hemarthrosis or diffuse non-specific knee pain. Mean age at treatment onset was 38 years (range 15-59). Bone lesions were observed in four patients. Synoviorthesis or surgical synovectomy were performed. Mean follow-up was 97 months (range 12-309). Outcome was compared between the different aspects of localized and diffuse PVNS and treatment modalities.

RESULTS

In the localized forms, there were no complications after surgical treatment and there were no cases of recurrence (one surgical revision at four months following incomplete resection). For the diffuse forms, the cumulative recurrence rate was 50%. Mean time to recurrence was 37 months. Three patients developed a stiff knee after open synovectomy. Surgical treatment was required in four patients seen late after development of bony lesions (total knee arthroplasty in three). Clinical outcome was good with a gain in knee flexion.

DISCUSSION

MRI is essential for the topographic diagnosis and to guide surgical treatment. In severe or advanced primary diffuse disease or in the event of local recurrence, adjuvant synoviorthesis can be proposed four to eight weeks after initial surgery. The risk of recurrence for diffuse forms warrants an annual MRI for the first four years.

Bone tumors around the knee: risks and benefits of arthroscopic procedures

Although most primary bone tumors and soft tissue tumors arise around the knee joint, many patients with tumoral conditions attribute their symptoms to traumatic events. This may lead to misdiagnosis and mistakes in selection of therapeutic approach. Arthroscopy is the preferred method for diagnosis and treatment of knee joint disease, but even a minimally invasive procedure may have adverse consequences in the presence of an unsuspected neoplasm. Thus, evaluation of all patients who may benefit from knee arthroscopy requires a careful and systematic workup that consists of appropriate noninvasive imaging studies and thoughtful consideration regarding the need for magnetic resonance imaging. Arthroscopic biopsy and treatment are recommended for selected intra-articular tumors. In addition, arthroscopy is a useful adjunct during surgical treatment of patients with certain juxta-articular benign bone tumors. In this Current Concepts review, we consider the risks and benefits of arthroscopy in the presence of tumors about the knee joint.

Localized pigmented villonodular synovitis in the anteromedial compartment of the knee associated with cartilage lesions of the medial femoral condyle: report of a case and review of the literature

Localized pigmented villonodular synovitis (PVNS) of the knee is an uncommon entity, presenting with different clinical signs and symptoms. We report on a case of a 42-year-old woman who presented with a 3-year history of knee pain and mechanical problems such as locking. On examination she was found to have a palpable and painful mass over the anteromedial joint line. Magnetic resonance imaging (MRI) revealed a soft tissue mass in the anteromedial compartment of the knee joint. The lesion was completely resected arthroscopically, and histologic examination confirmed the diagnosis of localized PVNS. The patient was free of symptoms, and MRI examination showed no evidence of recurrence at 1-year follow-up.

Arthroscopic treatment of solitary benign intra-articular lesions of the knee that cause mechanical symptoms

PURPOSE

Most cases of knee locking and giving-way are caused by meniscal tears, loose bodies, or chondral lesions. Intra-articular benign tumors or tumor-like lesions can present with symptoms that resemble acute mechanical derangement. From a database of 2,200 arthroscopic interventions, 19 cases of intra-articular masses that presented with catching and locking symptoms in the knee were retrospectively analyzed.

TYPE OF STUDY

Case series.

METHODS

Our review revealed 33 patients with benign intra-articular masses in the knee joint. Nineteen of these individuals had sought medical attention for mechanical symptoms of catching or locking. The other 14 patients had a variety of symptoms including pain, swelling, and limitation of knee motion, but did not have mechanical symptoms. Age, sex, history of trauma, knee pain and effusion, medical illnesses, physical examination, arthroscopic findings, and pathologic findings were noted.

RESULTS

The average age of the 6 male and 13 female patients was 37.5 years (range, 18 to 58 years). Preoperative magnetic resonance imaging confirmed the diagnosis in 7 cases and 12 cases were diagnosed during knee arthroscopy. The mean follow-up time after surgery was 52.5 months (range, 6 to 120 months). Pathologic examination of the lesions revealed 15 cases of localized pigmented villonodular synovitis (79%), 1 lipoma arborescens (5%), 1 pseudocyst (5%), and 2 nonspecific synovial masses (11%). None of the lesions showed malignant transformation.

CONCLUSIONS

Solitary benign intra-articular lesions should be considered a rare cause of mechanical knee symptoms. Localized pigmented villonodular synovitis originating from the extensor mechanism or fat pad is the most common solitary intra-articular mass lesion in the knee and usually arises in the patellofemoral compartment. Recurrence has not occurred in our series, which includes 14 of 19 patients with greater than 24 months follow-up.

LEVEL OF EVIDENCE

Level IV.

Patello-femoral joint pain due to unusual location of localised pigmented villonodular synovitis-a case report

Localised pigmented villonodular synovitis (PVNS) is a rare condition usually affecting the knee. It can be a difficult condition to manage with an average delay in diagnosis of 4.4 years. We describe a case of a localised PVNS lesion interposed between the patello-femoral joint, presenting as 'anterior knee pain'. To our knowledge this has not previously been reported. The lesion was completely excised at arthroscopy resulting in complete resolution of symptoms. Solitary lesions of PVNS should also be considered in the differential diagnosis of unexplained 'anterior knee pain'.