[Localized tenosynovial giant cell tumor : Results from the Histopathological Arthritis Register of the German Society for Orthopedic Rheumatology]

BACKGROUND

The tenosynovial giant cell tumor (pigmented villonodular synovitis) is a proliferative, mainly benign soft tissue tumor of the tendon sheaths, bursae and joints arising from the synovia. It can be divided into circumscribed localized and destructive diffuse types. Approximately 1% of all joint diseases are due to this entity. The tumor is considered as a rarity. Mostly case studies exist. For this study the focus was set on the localized type (L-TSRZT), which accounts for 90% of the diagnoses of this tumor. Given its rarity, data are limited. Therefore, the research aim was to provide data on prevalence, primary location and sensitivity of clinical versus histopathological diagnosis in a German sample.

METHODS

Based on the Histopathological Arthritis Register of the German Society for Orthopedic Rheumatology, the data of the L‑TSRZT were retrospectively analyzed (time frame 1 January 2018-28 December 2020).

RESULTS

This database contained N = 7595 cases of arthropathy. A total of n = 45 patients with the diagnosis L‑TSRZT were identified. The prevalence of the tumor was 0.6%, 95% CI [0.4%, 0.8%], or 5.9 cases per 1000. The primary location involved the finger (48.9%). In 14 of 45 cases the diagnosis was correctly determined from the clinical side, corresponding to a sensitivity of 31.1%, 95% CI [18.2%, 46.7%].

CONCLUSION

For the first time, this paper was able to provide data on a large sample for Germany. Notably, the low sensitivity of the clinical diagnosis confirms the importance of histopathology for diagnosing L‑TSRZT.

Pigmented villonodular synovitis of the flexor hallucis longus tendon: A rare cause of leg pain in a 12-year-old girl

Pigmented villonodular synovitis is an uncommon benign neoplastic proliferation associated with the synovium, bursa, or tendon sheaths; most commonly occurring in the third to fourth decade of life. It is rare in children and may be painful or painless. Magnetic resonance imaging is the diagnostic study of choice. In this report, the radiologic, ultrasound, and magnetic resonance imaging findings of pigmented villonodular synovitis of the flexor hallucis longus in a 12-year-old girl are discussed. We briefly review the surgical findings as well. To our knowledge, this is the first case report that simultaneously synthesizes the imaging findings of 3 diagnostic imaging modalities for optimal visualization and is the youngest reported case of pigmented villonodular synovitis of the flexor hallucis longus tendon.

Knee joint synovial hemangioma treated with arthroscopic resection without hemarthrosis: A case report

INTRODUCTION

Intra-articular synovial hemangioma of the knee is a relatively rare benign tumor that if left undiagnosed and treated may be followed by degenerative cartilaginous changes and osteoarthritis. However, the non-specific symptoms of synovial hemangiomas limit its early diagnosis. We report our encounter with synovial hemangioma of the knee in which the diagnosis was based on a > 20-year history of chronic pain without joint swelling or hematoma.

PRESENTATION OF CASE

A 34-year-old man with a localized vascular malformation on the upper edge of the left patella presented with pain and a restricted range of motion. CT and MRI revealed a tumorous lesion at this location. Upon excision of the lesion, the patient's symptoms disappeared, with no recurrence at the 1-year follow-up.

DISCUSSION

Accurate diagnosis and appropriate early treatment are necessary for synovial hemangiomas to forestall articular cartilage degeneration due to recurrent intra-articular hemorrhages.

CONCLUSION

Synovial hemangioma should be considered when a patient presents with recurrent knee pain, even in the absence of swelling or episodes of joint effusion.

Unusual presentation of talonavicular joint pigmented villonodular synovitis: a case report

BACKGROUND

Pigmented villonodular synovitis is a rare yet locally invasive disorder impacting synovial tissues. This case report delineates the atypical manifestation of pigmented villonodular synovitis in the talonavicular joint, detailing its diagnostic complexity and successful management.

CASE PRESENTATION

A 56-year-old Iranian patient with a 4-year history of chronic ankle pain, initially diagnosed with degenerative joint disease post-trauma based on imaging, underwent talonavicular fusion surgery. An unexpected pigmented villonodular synovitis mass was encountered during the procedure. Subsequent interventions encompassed tumor resection, talonavicular joint fusion, and allograft bone grafting. Despite the initial intervention, persistent pain and nonunion necessitated a secondary procedure, involving joint surface curettage and autograft bone grafting. At the 12-month follow-up, the patient remained pain-free without tumor recurrence.

CONCLUSION

This case report highlights the significance of considering pigmented villonodular synovitis as a crucial differential diagnosis in chronic ankle pain, even when there is evidence of degenerative joint disease and a history of trauma. Magnetic resonance imaging serves a crucial role in accurate diagnosis. Treatment necessitates precise tumor removal, appropriate bone grafting techniques and secure fixation.

LEVEL OF EVIDENCE

IV.

T2-star (T2*)-weighted magnetic resonance imaging of tenosynovial giant cell tumors

Purpose

Tenosynovial giant cell tumors (TSGCTs) are benign but aggressive lesions, and the treatment is resection. A low to intermediate signal intensity on both T1- and T2-weighted images of magnetic resonance imaging (MRI) is characteristic, which is similar to the signal intensity of muscle, and therefore can be challenging for lesion detection. T2-star (T2*)-weighted MR images reflect paramagnetic deoxyhemoglobin, methemoglobin, or hemosiderin.

Methods

In 23 TSGCT patients (6 male and 17 females), the T2*MRI findings were analyzed. The tumor locations involved 10 large joints including nine knees and one ankle, 10 small joints including six fingers and four toes, as well as three wrists/hands.

Results

Ten diffuse and 13 localized tumors were predominantly located in the large joints and small joints, respectively. The T2*-weighted images indicated three signal patterns of low, iso and high signal intensity compared to muscle. Low-, iso- and high-signal intensities were seen in 22 (96 %), 23 (100 %) and 12 (52 %) of the locations, respectively. To distinguish TSGCTs from the surrounding tissue, the low intensity T2*-weighted images and low to intermediate intensity T1-weighted images when compared to muscle and fluid, respectively were useful for the large joints. Low to intermediate intensity on T1- or T2-weighted images was useful to distinguish TSGCTs from subcutaneous tissue in the small joints.

Conclusions

MRI using T2*-, as well as T1- and T2-weighted images, may be useful to detect lesions and assess the extent of TSGCTs in a tissue-specific manner, which is important for surgical planning.

Chronic limping in childhood, what else other than juvenile idiopathic arthritis: a case series

BACKGROUND

Limping is a common clinical symptom in childhood; different clinical conditions may lead to limping and the diagnosis of the underlying cause may often be a challenge for the pediatrician.

CASE PRESENTATION

We describe the clinical manifestations, radiological pictures and disease course of other causes of limping in childhood, through a case series of seven cases and a brief discussion of each disease.

CONCLUSIONS

although trauma is the most common cause of acute limping, when there is no history of traumatic events and the limping has a chronic course, Juvenile Idiopathic Arthritis is usually the most likely clinical diagnosis. However, other some rare conditions should be taken into account if JIA is not confirmed or if it presents with atypical clinical picture.

Pigmented Villonodular Synovitis of Ankle Joint - A Case Report

Introduction

Pigmented villonodular synovitis (PVNS)is a very uncommon lesion that involves the synovium of joints, tendon sheaths, or bursae. Approximately 2.5% of cases occur around the ankle. PVNS was earlier considered to be a synovial malignancy. Complete surgical excision is curative if bony destruction is not there. Radiotherapy is rarely helpful for residual lesions.

Case Report

We share a case report on PVNS of ankle in a 22-years old male patient. Clinical diagnosis was confirmed with the help of magnetic resonance imaging and histopathology. A surgical excision with synovectomy was carried out. There were no signs of recurrence in 1.5 years follow-up.

Conclusion

Complete surgical excision with radical synovectomy is crucial for the treatment of PVNS in rare locations like the ankle joint.

Tenosynovial giant cell tumor: a case report

BACKGROUND

This case reports the synchronous diagnosis of two rare unrelated diseases; leiomyosarcoma and tenosynovial giant cell tumor of the knee. It focuses on the challenges of diagnosing tenosynovial giant cell tumor, including cognitive biases in clinical medicine that delay diagnosis. It also demonstrates the pathogenic etiology of tenosynovial giant cell tumor, evidenced by the transient deterioration of the patients' knee symptoms following the administration of prophylactic granulocyte colony-stimulating factor given as part of the chemotherapeutic regime for leiomyosarcoma.

CASE PRESENTATION

A 37-year-old Caucasian man presented with a left groin lump and left knee pain with swelling and locking. Investigations including positron emission tomography-computed tomography and biopsy revealed leiomyosarcoma in a lymph node likely related to the spermatic cord, with high-grade uptake in the left knee that was presumed to be the primary site. His knee symptoms temporarily worsened each time granulocyte colony-stimulating factor was administered with each cycle of chemotherapy for leiomyosarcoma to help combat myelosuppressive toxicity. Subsequent magnetic resonance imaging and biopsy of the knee confirmed a tenosynovial giant cell tumor. His knee symptoms relating to the tenosynovial giant cell tumor improved following the completion of his leiomyosarcoma treatment.

CONCLUSIONS

Tenosynovial giant cell tumor remains a diagnostic challenge. We discuss the key clinical features and investigations that aid prompt diagnosis. The National Comprehensive Cancer Network clinical practice guidelines for soft tissue sarcoma have recently been updated to include the pharmacological management of tenosynovial giant cell tumor. Our case discussion provides an up-to-date review of the evidence for optimal management of patients with tenosynovial giant cell tumor, with a particular focus on novel pharmacological options that exploit underlying pathogenesis.

A Novel Technique of Resecting Localized Pigmented Villonodular Synovitis of the Knee Joint

Introduction

Pigmented villonodular synovitis is an uncommon benign proliferation of the synovium. In the knee joint, it can present as a localized or a diffuse form and can mimic numerous conditions.

Case Report

We present a case report of a 54-year-old male with localized form of this condition. The diagnosis is not often made clinically but usually made with the help of magnetic resonance imaging and histopathology. We used a novel technique for resecting the tumor by arthroscopy.

Conclusion

A high index of suspicion is required for the diagnosis of the condition and arthroscopic excision results in lower morbidity and lesser recurrence rates.

Arthroscopic treatment of diffuse pigmented villonodular synovitis of the elbow

INTRODUCTION

Pigmented villonodular synovitis (PVNS) is a rare pathology of the elbow, but presents a risk of progression with cartilage destruction. Surgical treatment consists in synovectomy, as complete as possible. Arthroscopy is an excellent tool for the exploration and treatment of intra-articular lesions in the elbow, but the results in PVNS of the elbow have never been evaluated. The aim of this study was to assess the recurrence rate of PVNS of the elbow after arthroscopic synovectomy, and secondarily to assess pain, joint range of motion, functional scores and complication rate.

MATERIAL AND METHODS

We performed a retrospective study of a continuous series of 8 patients operated on between February 2012 and February 2019, with a mean age of 43.7 years. The operated side was the dominant side in 75% of cases. Surgery consisted in the most complete synovectomy possible, performed arthroscopically. Recurrence, clinical evaluation, with pain at rest and on mpvement on visual analogue scale (VAS) and joint range of motion, functional MEPS and DASH scores, and any complications were collected.

RESULTS

At a mean 66.4 months' follow-up, 2 patients required revision surgery for recurrence. At the last follow-up, VAS for pain at rest was 0.9 and 1.9 for pain on movement. MEPS score was 85.6 and DASH score 82.2. No neurological, vascular or infectious complications of arthroscopic synovectomy were found in our series.

DISCUSSION

Arthroscopic synovectomy in the treatment of PVNS of the elbow was a reliable and safe therapeutic alternative, with a low complications rate and 2 cases of recurrence (25%) in our study. This was the first study to report the results of arthroscopic surgical treatment of elbow PVNS.

LEVEL OF EVIDENCE

IV Retrospective study without control group.

Soft Tissue Pathology

A wide spectrum of pathologies can lead to soft tissue abnormalities within the ankle joint. Many of these disorders can develop into irreversible joint degeneration if left untreated. Arthroscopy is frequently used to treat these soft tissue conditions such as instability, synovitis, impingement, arthrofibrosis, and other inflammatory disorders in the rearfoot and ankle. In general, the etiology of these ankle soft tissue disorders can be classified as traumatic, inflammatory, and congenital/neoplastic. Overall, the goal of diagnosing and treating soft tissue pathologies of the ankle is to restore anatomic and physiologic motion, reduce pain, optimize functional return to activity, and decrease the chance of recurrence while minimizing complications.

Total knee arthroplasty in pigmented villonodular synovitis osteoarthritis: a systematic review of literature

PURPOSE

Pigmented Villonodular Synovitis (PVNS) is a proliferative disease arising from the synovial membrane, mainly affects large joints such as the knee (almost 80% of total). Prostheses implanted in PVNS osteoarthritis show a higher revision rate when compared to primary osteoarthritis, due to the recurrence of disease and the overall surgical complications. The purpose of this systematic review is to summarize and compare indications, clinical and functional outcomes, disease-related and surgical-related complications of total knee arthroplasty in PVNS osteoarthritis.

MATERIALS AND METHODS

A systematic review of the literature was performed with a primary search on Medline through PubMed. The PRISMA 2009 flowchart and checklist were used to edit the review. Screened studies had to provide preoperative diagnosis, previous treatments, main treatment, concomitant strategies, mean follow-up, outcomes and complications to be included in the review.

RESULTS

A total of 8 articles were finally included. Most of papers reported the use of non-constrained design implants, mainly posterior stabilized (PS) and in case of PVNS with extensive joint involvement implants with higher degree of constraint to obtain a fulfilling balancing. Recurrence of PVNS has been indicated as the major complication, followed by aseptic loosening of the implant and difficult post-operative course with an increased risk of stiffness.

CONCLUSION

Total knee arthroplasty represents a valid treatment for patients with PVNS end-stage osteoarthritis, with good clinical and functional results, even in longer follow-up. It would be advisable a multidisciplinary management and a meticulous rehabilitation and monitoring following the procedure, to reduce the emergence of recurrence and overall complications.

Total Hip Arthroplasty or Arthroscopy for Pigmented Villonodular Synovitis of the Hip: A Retrospective Study with 3-Year Follow-Up at Minimum

OBJECTIVE

Pigment Villonodular synovitis of the hip, a rare pain proliferation of the synovium, was treated successfully with total hip arthroplasty and arthroscopy. Most recent results come from small case series with no study comparing arthroscopy and arthroplasty. In this study, we aimed to show and compare the clinical outcomes of arthroscopy and total hip arthroplasty (THA) in pigment Villonodular synovitis of the hip.

METHODS

This was a retrospective clinical trial with data from patients with pigment Villonodular synovitis of the hip between 2010 and 2019. The study included 17 patients in the THA group, and 20 patients in the arthroscopy group. The clinical outcomes were evaluated at 3, 6, and 12 months, at 1 and 2 years, and every 5 years afterward. The clinical efficacy was measured using the Harris hip scores (HHSs) and visual analogue scale (VAS) score.

RESULTS

The mean HHS improved from 45.24 ± 10.36 to 78.94 ± 19.11 in the THA group (t = -6.394, P = 0.000) and 45.30 ± 11.08 to 71.60 ± 19.78 (t = -5.187, P = 0.000) in the arthroscopy group from pre-operation to the final follow-up. There is no significant difference between the two groups (t = 1.051, P = 0.301). The mean VAS improved from 3.65 ± 0.79 to 0.35 ± 0.70 (t = 12.890, P = 0.000) in the THA group and 4.05 ± 0.94 to 1.35 ± 1.79 (t = 5.979, P = 0.001) in the arthroscopy group postoperatively. There is no significant difference between the two groups (t = 1.329, P = 0.193). Recurrence of PVNS was diagnosed in four patients (20%) of the arthroscopy group and they underwent THA after arthroscopy, and the mean interval was 44.25 ± 6.98 months. All patients reached level 5 muscle strength by the final follow-up. All the patients' buckling ranges were over 105 degrees. Their internal and external hip rotation was over 15 degrees. Their hip adduction was over 20 degrees, and abduction over 30 degrees.

CONCLUSION

Both THA and arthroscopy in the setting of PVNS can improve patients' function and lead to a low rate of local recurrence. By selecting patients well for each approach, one can expect a reasonable result.

Diffuse pigmented villonodular synovitis treated with arthroscopic total synovial peel

BACKGROUND

Diffuse pigmented villonodular synovitis (PVNS) is prone to recurrence after surgery, and it is difficult to achieve a long-term complete cure.

OBJECTIVE

To reduce the recurrence rate of PVNS, the author pioneered the arthroscopic total synovial peel (ATSP).

METHODS

From March 2014 to July 2020, a total of 19 patients (6 males and 13 females) with diffuse PVNS of the knee were treated in our department and underwent ATSP. It's 'peel' rather than simple excision. This method is similar to peeling bark. Relapse rates and functional scores were determined, with follow-ups ranging from 12 to 72 months, on average 36 months.

RESULTS

Treatment efficacy was assessed by imaging and functional scores. Imaging results indicated a recurrence rate of 10.5%. In patients without recurrence, the visual analog score (VAS) decreased from 4.76 ± 2.02 preoperatively to 1.56 ± 1.15 postoperatively. The Tegner-Lysholm knee function score (TLS) score increased from 67.76 ± 15.64 preoperatively to 90.32 ± 8.32 postoperatively. Compared with the literature, ATSP significantly reduces the postoperative recurrence rate of diffuse PVNS. The preliminarily findings suggest that this approach could greatly reduce the recurrence rate of postoperative PVNS in follow-up studies.

CONCLUSION

This approach may be a viable option for treating diffuse PVNS via arthroscopy and is worthy of clinical consideration.

Novel CSF1R-positive tenosynovial giant cell tumor cell lines and their pexidartinib (PLX3397) and sotuletinib (BLZ945)-induced apoptosis

Tenosynovial giant cell tumor (TGCT) is a mesenchymal tumor derived from the synovium of the tendon sheath and joints, most frequently in the large joints. The standard of care for TGCTs is surgical resection. A new targeting approach for treating TGCTs has emerged from studies on the role of the CSF1/CSF1 receptor (CSF1R) in controlling cell survival and proliferation during the pathogenesis of TGCTs. We established four novel cell lines isolated from the primary tumor tissues of patients with TGCTs. The cell lines were designated Si-TGCT-1, Si-TGCT-2, Si-TGCT-3, and Si-TGCT-4, and the TGCT cells were characterized by CSF1R and CD68. These TGCT cells were then checked for cell proliferation using an MTT assay and three-dimensional spheroid. The responses to pexidartinib (PLX3397) and sotuletinib (BLZ945) were evaluated by two-dimensional MTT assays. All cells were positive for α‑smooth muscle actin (α‑SMA), fibroblast activation protein (FAP), CSF1R, and CD68. Except for Si-TGCT-4, all TGCT cells had high CSF1R expressions. The cells exhibited continuous growth as three-dimensional spheroids formed. Treatment with pexidartinib and sotuletinib inhibited TGCT cell growth and induced cell apoptosis correlated with the CSF1R level. Only Si-TGCT-4 cells demonstrated resistance to the drugs. In addition, the BAX/BCL-2 ratio increased in cells treated with pexidartinib and sotuletinib. With the four novel TGCT cell lines, we have an excellent model for further in vitro and in vivo studies.

Total Synovectomy and Bone Grafting/Cementation after Curettage of the Bone Lesion in Diffuse‏ Type ‏of Tenosynovial‏ Giant Cell Tumor‎: A Retrospective Cohort Study

Objectives

Although the diffuse type of tenosynovial giant cell tumor (D-TGCT) is rare, bone involvement is common in such lesions. However, the optimal management of bone lesions in D-TGCT is not well-described. In this study, we reported the outcomes of total synovectomy, curettage, and bone grafting/cementation in the treatment of D-TGCT with subchondral bone involvement. We also described the prevalence, demographic, and characteristic features of the lesions.

Methods

In a retrospective study, we included 13 patients with D-TGCT of large joints and associated subchondral cyst/cyst-like bone lesions of ≥ 5 mm that were managed with total synovectomy and curettage. Cavities with a bone defect of ≤ 30 mm (n=12) were filled with bone grafts. Cavities of > 30 mm (n=1) were augmented with bone cement. The limb function was evaluated by the Musculoskeletal Tumor Society (MSTS) score.

Results

The study population consisted of 6 (46.1%) males and 7 (53.9%) females with a mean age of 30 ± 7.9 years. The most frequent sites of involvement were the knees and ankle joints (n=5 each, 38.5%). The mean follow-up of the patients was 69.2 ± 32.9 months. The mean MSTS score of the patients was obtained at 98.2 ± 3.2 (range 90-100). The D-TGCT recurred in two patients, both of which were in the synovium. Postoperative complications were three cases of transient pain and one case of knee joint stiffness. While no patient had an osteoarthritic change in preoperative radiographs, two patients had osteoarthritic change (grade II) in the last follow-up, one in the knee and one in the hip.

Conclusion

Curettage and filling the defect with bone graft or cement are adequate treatments for managing bone lesions in D-TGCT.

Intra-labral pigmented villonodular synovitis: a rare case in two adult patients

This article discusses two rare cases of intra-labral pigmented villonodular synovitis (PVNS) of the hip. The hip joint represents the second most common location of pigmented villonodular synovitis, second to the knee [1]. The majority of hip PVNS cases either diffusely involve the synovium or are focal lesions within the joint. The lesions and synovium show foci of low signal intensity related to hemosiderin deposition, a finding that differentiates PVNS from other causes of synovial proliferation. Our case report presents two rare manifestations of PVNS lesions localized within the hip labrum. This presentation could easily be mistaken for a cyst by imaging modality. Despite the rarity of this condition, we highlight the importance of questioning the possibility of intra-labral PVNS, when patients have persistent hip pain not responding to therapy and atypical imaging findings. Highlighting this rare presentation is crucial for establishing the correct diagnosis, guiding treatment, and obtaining the best clinical outcome.

Diffuse pigmented villonodular synovitis of the knee joint: 3-year follow-up of a case report

Pigmented villonodular synovitis (PVNS) is a proliferative, recurrent and locally invasive disease of the synovium. The symptoms of the disorder are not typical and thus it is very often misdiagnosed. Most of the times, magnetic resonance imaging presents the nodular model of development and sets the basis for the diagnosis. The final diagnosis will be set by the pathological evaluation of the lesion's biopsy. PVNS may be localized (nodule with a clear boundary with/without presence of single pedicle) or diffuse (extensive involvement of the adjacent nerves and vessels). Depending on the extension of the PVNS, a different management approach is performed, lesion excision vs. resection, followed by radiotherapy respectively. We report a case of diffuse PVNS in the knee joint, treated with surgical excision and adjuvant radiotherapy as well as follow-up imaging after a time period of 3 years.

Clinical outcomes of patients with pigmented villonodular synovitis of the shoulder after arthroscopic synovectomy

BACKGROUND

Shoulder pigmented villonodular synovitis (PVNS) is a severe clinical condition, while few studies have focused on this situation due to its rarity. This study was to investigate the efficacy of arthroscopic treatment of patients diagnosed with shoulder PVNS.

METHODS

From Jan 1^st, 2010 to Dec. 31^st, 2019, 6 patients (5 females and 1 male) diagnosed with shoulder PVNS underwent arthroscopic synovectomy in our hospital and combined rotator cuff repair was performed in 3 of them. The outcomes of this study include Constant score, Visual Analogue Scale (VAS), University of California, Los Angeles (UCLA) score and American Shoulder and Elbow Surgeons (ASES) score. The data were retrieved from the patients' medical records.

RESULTS

With a mean follow-up of 52.0 months (range, 28-92 months), the mean difference of Constant, VAS, UCLA and ASES scores were 27.83 ± 21.60, 2.83 ± 2.56, 11.67 ± 10.93 and 17.83 ± 25.35, respectively. Statistically significant improvements were detected in all the patient-reported outcomes except ASES score. One of the patients suffered from recurrence. Two patients suffered from mild complications after the surgeries while both of them achieved satisfactory recovery finally.

CONCLUSION

Arthroscopic synovectomy in the setting of shoulder PVNS can improve patients' function. A concurrent rotator cuff repair is recommended if it is needed. The conclusion still needs testifying by further high-quality research with larger sample size.

Outcomes of arthroscopic management for pigmented villonodular synovitis of the hip

INTRODUCTION

Early synovectomy is considered as the main treatment of pigmented villonodular synovitis (PVNS) of the hip in young patients with preserved cartilage. The purpose of the study is to evaluate outcomes of arthroscopic management for PVNS of the hip.

METHODS

Patients who underwent primary hip arthroscopy for the treatment of histology-confirmed PVNS by the senior author between January 2012 and December 2016 were retrospectively reviewed. We excluded patients who had less than 1-year follow-up or had undergone primary surgeries with other surgeons and then received revision hip arthroscopic procedures by the senior author. The recurrence of PVNS and postoperative condition of affected hip were assessed by follow-up magnetic resonance imaging (MRI). Patient-reported outcomes of modified Harris hip score (mHHS) and 12-item International Hip Outcome Tool (iHOT-12) were collected at latest follow-up.

RESULTS

Nine patients (2 males, 7 females) with a mean age of 24.3 ± 11.2 years (range 14-44 years) were included in this study. Localized PVNS was observed in four patients, and diffuse PVNS was observed in five patients. No patient presented with advanced osteochondral destruction. Five patients received single adjuvant radiosynoviorthesis. No patient had evidence of recurrence based on follow-up MRI. Patient-reported outcomes were obtained in eight patients at mean 55.8 ± 26.1 months (range 24-84 months) after the index surgery. The mean mHHS was 94.6 ± 4.9 (range 84.7-100) and the mean iHOT-12 was 93.3 ± 20.2 (range 50-120). No patient needed secondary surgery during the follow-up period.

CONCLUSION

Arthroscopic subtotal synovectomy can offer favorable short to mid-term outcomes in the treatment of hip PVNS in case of no advanced osteochondral damage at presentation.

Two-stage TKA for tuberculosis septic arthritis of the knee masquerading as pigmented villonodular synovitis: A case report

A 25-year-old female presented with left knee pain following arthroscopic synovectomy for presumed pigmented villonodular synovitis (PVNS). Radiographs and magnetic resonance imaging demonstrated tricompartmental arthritic changes. She underwent a two-stage procedure first involving antibiotic spacer implantation, followed 1 week later by spacer removal and definitive total knee arthroplasty (TKA) once initial intraoperative culture results were negative. Subsequent cultures confirmed tuberculosis septic arthritis. Repeat evaluation 1 year postoperatively showed no complications and patient satisfaction with left knee function. This is a unique case report in the United States describing 1-year outcomes following staged TKA for tuberculosis septic arthritis masquerading as PVNS.

Knee Tuberculosis Presenting As Pigmented villonodular Synovitis

Introduction

Extra pulmonary Tuberculosis (TB) May mimic other diseases in clinical presentation which might be difficult to differentiate and diagnose. Pigmented villonodular synovitis (PVNS) may closely resemble tuberculosis of the knee joint. In younger patients, without any other co-morbid conditions TB of knee joint and PVNS in the knee might present with involvement of the isolated joint, with swelling which is painful for long duration with restriction in the range of motion. Treatment of both the conditions differs vastly and delay in the treatment can result in permanent disfiguration of the joint.

Case Report

A male 35 years old having a right knee painful swelling since last 6 months. The thorough physical examination, radiographs, and MRI suggest PVNS but an altogether different diagnosis is made after confirmatory investigations, i.e. Histopathological examination.

Conclusion

Clinical and radiological presentation of TB and PVNS can mimic each other . Therefore TB should be suspected specially in the like India (endemic). For confirmation of diagnosis hisptopathological and mycobacterial results are important.

Tenosynovial giant cell tumor-diffuse type, treated with a novel colony-stimulating factor inhibitor, pexidartinib: initial experience with MRI findings in three patients

Tenosynovial giant cell tumor-diffuse type (diffuse TSGCT) is a benign but locally aggressive proliferative disorder of the synovium. Treatment is usually surgical, although in cases of extensive disease complete synovectomy is not possible and local recurrence rates are high. Pexidartinib (trade name Turalio®), a colony-stimulating factor-1 (CSF-1) inhibitor, was shown in a recent phase III trial to effectively treat diffuse TSGCT and is FDA approved for the treatment of adult patients with symptomatic diffuse TSGCT associated with severe morbidity or functional limitations and not amenable to improvement with surgery. Pexidartinib is available only through a restricted program under a risk evaluation and mitigation strategy (REMS) because of the risk of hepatotoxicity. Magnetic resonance imaging (MRI) is the preferred imaging modality for the diagnosis and surveillance of TSGCT. Here we present three patients with diffuse TSGCT of the knee who underwent multiple MRIs over several years while on pexidartinib. We describe the disease burden and signal characteristics on MRI and correlate with the response reported in the patients' medical records. Given that the use of pexidartinib and other CSF inhibitors is likely to increase, musculoskeletal radiologists should be aware of this novel non-operative treatment and the MRI appearance of diffuse TSGCT during therapy.

Clinical outcomes of endoscopic synovectomy with adjuvant radiotherapy of pigmented villonodular synovitis of the hip: a case series of single center

Background

Though radiotherapy has been widely used for knee pigmented villonodular synovitis (PVNS), there is few literatures about radiotherapy for the treatment of PVNS hip. Thus, the purpose of this study was to analyze the clinical outcomes of endoscopic synovectomy with/without radiotherapy postoperatively of PVNS hip.

Methods

We performed a retrospective study of patients who underwent endoscopy in our hospital from November 2010 to January 2021. Inclusion criteria was patients with magnetic resonance image (MRI) signs, endoscopic findings and/or histological evidence of PVNS. Exclusion criteria was patients lost follow-up. All patients underwent synovectomy endoscopically and were divided into two groups depending on receiving postoperative radiotherapy or not. The primary outcome measurements were the recurrence of PVNS, receiving revision, and/or converting to total hip arthroplasty (THA). The secondary outcome measurements were the patient-reported outcome (PRO) collected at pre- and post-operation, which consist of Hip Outcome Score Activities of Daily Living (HOS-ADL), modified Harris Hip Score (mHHS), International Hip Outcome Tool-12 (IHOT-12), Non-arthritic Hip Scale (NAHS), and visual analog scale (VAS).

Results

In a case series of 16 patients (8 cases of male, 50%), 4 (25%) cases were localized type and 12 (75%) cases were diffuse type. The average follow-up was 44.8 ± 38.2 months (range,3 to 110). 8 (50%) cases (6 diffuse cases and 2 localized cases) received radiotherapy postoperatively, and the rest (6 diffuse cases and 2 localized cases) received endoscopic treatment alone. At the latest follow-up, 3 (18.75%) cases (2 diffuse cases and 1 localized case) who did not receive radiotherapy converted to arthroplasty. The preoperative HOS-ADL, mHHS, IHOT-12, NAHS, VAS scores of remaining 13 patients were 63.1 ± 19.1 (range,32.0 to 98.8), 54.8 ± 20.1 (range, 10.0 to 77.0), 50.9 ± 15.4 (range, 31.0 to 76.6),51.6 ± 15.9 (range, 20.0 to 84.4), 6.0 ± 1.4 (range,4.0 to 8.0) points, respectively. The latest HOS-ADL, mHHS, IHOT-12, NAHS, VAS scores of the 13 patients were 79.7 ± 10.8 (range, 58.0 to 97.6), 78.6 ± 9.1 (range,55.0 to 87.0), 74.7 ± 9.7 (range, 55.6 to 91.0), 78.9 ± 18.7 (range,20.0 to 92.5), 3.1 ± 1.2 (range,2.0 to 6.0) points respectively.

Conclusion

Endoscopic synovectomy can achieve satisfactory PRO in PVNS hip patients. Besides, postoperative adjuvant radiotherapy can achieve higher hip survivability than synovectomy alone in this present study.

Intra-Articular Tenosynovial Giant Cell Tumor Mimicking Septic Arthritis: A Report of Two Cases

Introduction

Intra-articular tenosynovial giant cell tumor (IATGCT) is a type of tenosynovial giant cell tumor that typically occurs in the synovial tissues of large joints. It is also known as pigmented villonodular synovitis. Acute onset of the pain with irritable hip symptoms is very rare. In this paper, we presented two adolescents with acute onset of hip pain mimicking septic arthritis diagnosed with intra-articular tenosynovial giant cell tumor.

Case Report

Healthy two adolescents, one male (14-year-old) and the other girl (15-year-old) with no history of the previous trauma or significant comorbidities were presented complaining of acute onset of hip pain to our emergency room. Although initial possible diagnosis was septic arthritis for both cases, laboratory findings were unequivocal for septic arthritis and magnetic resonance imaging (MRI) showed an intra-articular nodular mass. An open resection was performed and pathological evaluation revealed the masses to be intra-articular tenosynovial giant cell tumor. After 26 and 17 months follow-up there was no pain neither with activity nor in rest, hip range of motion was within normal ranges. There was no recurrence, avascular necrosis or destruction detected on control MRI for both patients.

Conclusion

IATGCT is a rare disease of the pediatric population involving the hip. Inflammation or infarction of the lesion can trigger irritable hip findings in children. This diagnosis should be kept in mind mainly in cases with serohemorrhagic aspirate and unequivocal laboratory findings.

A New Simple and Practical Clinical Classification for Tenosynovial Giant Cell Tumors of the Knee

Objective

To propose a simple and practical clinical classification for tenosynovial giant cell tumor (TGCT) of the knee.

Methods

A retrospective study was conducted to verify the value and significance of this clinical classification. TGCT growth patterns, knee joint capsule, and bone erosion were applied to establish this novel clinical classification. Seventy‐eight patients who underwent surgery for TGCT from 2008 to 2016 were identified. This novel clinical classification was retrospectively applied to patients' existing classification, and patients with different TGCT types were statistically compared to verify the significance of the clinical classification.

Results

The clinical classification included three types and four subtypes. Type 1: localized TGCT, Subtype 1a: localized intra‐articular TGCT, Subtype 1b: localized extra‐articular TGCT. Type 2: diffuse TGCT, Subtype 2a: diffuse intra‐articular TGCT with bone normal, Subtype 2b: diffuse intra‐articular TGCT with bone destruction. Type 3: diffuse TGCT across the knee joint capsule. The mean follow‐up time for the 78 patients was 59.6 months. Twenty‐one patients were in Subtype 1a, four were Subtype 1b, 38 were Subtype 2a, seven were Subtype 2b, and eight were Type 3. Oncological results and surgical complications differed significantly (P = 0.000, P = 0.000). The mean Musculoskeletal Tumor Society functional scores differed significantly at 27.8 for Type 1 patients, 22.9 for Type 2 patients, and 17.0 for Type 3 patients (P = 0.000).

Conclusions

This clinical classification can be easily used to evaluate TGCT of all knees prior to surgery or other treatments and can help determine surgical options.

Tuberculosis of the knee masquerading as pigmented villonodular synovitis: Report of two cases

Introduction and importance

The manifestation of tuberculous mimicry is challenging to diagnose, especially in extrapulmonary Tuberculosis (TB). Pigmented villonodular synovitis (PVNS) may mimic tuberculous arthritis of the knee joint. In young, otherwise healthy-appearing individuals, tuberculous arthritis and PVNS in the knee joint could present as monoarticular involvement, with painful swelling of extended duration and limited movement. The core therapies for tuberculous arthritis and PVNS are different.

Case presentation

There are two patients. First, male 25 years old presented with a painful mass at the left knee of 3-years duration. The second patient was 14 years old boy who presented with a painful mass at his left knee for ten months before being admitted to the hospital. From the physical examination, plain x-ray, and MRI, both patients are highly suggestive of PVNS. However, the histopathology result and microbial culture showed a tuberculous-specific process.

Clinical discussion

Because of its clinical manifestations, X-ray, and MRI features, patients were initially suspected of having the diffuse type of PVNS. An improper diagnosis may be due to atypical clinical presentation, wide use of antibiotics, the low specificity of diagnostic tools, and most of all, the clinician not prioritizing the possibility of tuberculous arthritis. Open biopsy and the result of the microbial culture establish the definitive diagnosis of knee tuberculosis.

Conclusion

In conclusion, the clinical and radiologic findings in TB gonitis and PVNS are occasionally similar. Therefore TB gonitis should be highly suspicious, especially in endemic areas. Histopathology results and mycobacterial culture need to determine the diagnosis.

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Tuberculosis of the knee may mimic pigmented villonodular synovitis.

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Tuberculosis of the knee must be considered in diagnosing PVNS.

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Histopathological and culture results are essential in diagnosing knee tuberculosis

Joint involvement in Noonan syndrome. A retrospective paediatric descriptive study

OBJECTIVES

Noonan syndrome is a rare genetic disorder characterized mainly by congenital heart disease, occasional intellectual disability, and varied orthopaedic, rheumatological and haematologic anomalies. Despite potentially serious functional consequences, joint involvement has been rarely studied in the literature. Our objective was to perform a retrospective study evaluating the prevalence and characteristics of joint involvement in Noonan syndrome.

METHODS

We recorded articular symptoms, including their type and frequency, in patients with Noonan syndrome followed up in French hospitals. Patients were included if the diagnosis was confirmed before the age of 20 based on the van der Burgt criteria or genetic analysis. Data are presented as frequencies or medians (ranges), and patient groups were compared using chi-square or Fisher tests.

RESULTS

Seventy-one patients were included from 4 centres. The average age was 12.5 years (range: 2-36). Musculoskeletal pain was found in 18 patients (25%) and joint stiffness in 10 (14%) located in the wrists, elbows, ankles, knees and hips, which was usually bilateral. Only one destructive form was described (multiple villonodular synovitis and a giant cell lesion of the jaw). There were no cases of systemic lupus erythaematosus (SLE) or other autoimmune arthritis. Raynaud's phenomenon was observed in 3 patients. Only 50% of joint complaints led to additional exploration. SOS1 mutations (P<0.05) and treatment with growth hormone (GH) (P<0.05) were the only factors significantly related to musculoskeletal pain. Patients treated with GH did not have more SOS1 mutations. Patients experiencing pain were not more likely to experience stiffness, joint hypermobility, or coagulation abnormalities.

CONCLUSION

Joint manifestations were frequent in Noonan syndrome, predominant in large joints, and rarely explored. Multiple villonodular synovitis is characteristic but rare. Auto-immune disorders were not described in this cohort. A more multidisciplinary approach could be recommended for the early detection of possibly disabling rheumatologic manifestations.

Pigmented Villonodular Synovitis Around the Elbow Joint That Required Upper Arm Amputation

Pigmented villonodular synovitis (PVNS) is a relatively rare benign proliferative disorder of the synovium, and it commonly occurs in the knee joint. A unique case of huge PVNS originating around the elbow joint that required upper arm amputation is reported. A 74-year-old woman had a 5-month history of right elbow pain and noticed a mass measuring 8 × 5 cm on the olecranon side. She had a past history of undergoing tumor resection and flap surgery 9 years earlier, diagnosed as a giant cell tumor involving the right elbow region. She had chronic renal failure, with a shunt on the right forearm. On magnetic resonance imaging, the tumor around the elbow joint showed low signal intensity on T1-weighted images and low to high intensity on T2-weighted images. It was thought that it was difficult to preserve the limb because of the size of the tumor and the shunt blood vessel. Therefore, upper arm amputation was performed. The histological diagnosis was PVNS. There was no recurrence of PVNS postoperatively. In the treatment of PVNS, initial surgery with complete resection of the synovial membrane and careful postoperative follow-up are considered important.

Pediatric solid intra-articular masses of the knee: prevalence, imaging features and etiologies

BACKGROUND

The etiologies of pediatric solid intra-articular soft-tissue masses are not well described and can present diagnostic dilemmas.

OBJECTIVE

Our hypothesis was that these entities have a limited differential diagnosis and are mostly benign.

MATERIALS AND METHODS

We reviewed knee magnetic resonance imaging (MRI) scans performed at our tertiary care institution between 2001 and 2019 (n=3,915). Our inclusion criterion was knee MRI with a solid intra-articular soft-tissue mass. Our exclusion criteria were cases with no masses or non-solid intra-articular lesions with clear radiologic diagnoses. Multiple radiologic characteristics were evaluated. Radiologic and histological diagnoses were collected when available. Cases without histology were assigned a suspected diagnosis.

RESULTS

Twenty-five out of 3,915 (<1%) cases met the inclusion/exclusion criteria. Twenty patients underwent biopsy. Patient age ranged from 1 to 19 years with a mean age of 12 years. Lesion size ranged from 1 to 7 cm with a mean of 3.3 cm. The top three histological diagnoses were pigmented villonodular synovitis (PVNS) (7/20, 35%), vascular malformations (2/20, 10%) and inflammatory arthritis (2/20, 10%). There was one malignant case of synovial sarcoma (1/20, 5%). Of the five cases without biopsies, PVNS was the most common diagnosis (3/5, 60%). Five out of 10 (50%) PVNS cases were focal and 5/10 (50%) were multifocal. All PVNS cases (10/10, 100%) had hypointense signal on T2.

CONCLUSION

Solid intra-articular soft-tissue masses of the knee in children are rare, with a prevalence of <1% in our study. The vast majority are benign with PVNS being the most common diagnosis.

Gouty tophus presenting as an anterior cruciate ligament mass in the knee: Case report and brief review of relevant literature

Introduction and importance

Tophacious gout presenting at the anterior cruciate ligament (ACL) is extremely rare and difficult to differentiate from other intraarticular pathology. This is mainly due to conventional diagnostic tools, such as MRI, producing ambiguous results versus pigmented villonodular synovitis (PVNS) and ganglion cysts.

Case presentation

Here we report an individual in their late-20s with a gouty tophus located at the origin of the ACL in the knee. Urate crystals on the articular cartilage in all three compartments was noted as well as on the synovium. On advanced imaging with an MRI, a large mass was seen anteriorly in the notch surrounding the ACL and posterior cruciate ligament (PCL). The tophus was biopsied and excised arthroscopically with excellent results.

Clinical discussion

An ACL mass in the knee has a very broad differential diagnosis. MRI imaging alone makes it very difficult to differentiate between PVNS and gout tophi yielding a pre-operative diagnostic challenge. Additionally, we review diagnostic challenges faced by other groups with similar cases, as well as their chosen treatment.

Conclusion

Gouty tophi arising from the origin of the ACL are extremely rare and remain difficult to diagnose due to their ambiguous nature in conventional imaging. In this report, we clearly convey the disparity in the diagnostic protocol for this type of intraarticular pathology. Future research should look to develop a superior protocol for identifying these pathologies to improve diagnostic accuracy.

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Atypical mass presenting at the origin of ACL, MRI unable to accurately diagnose.

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Excisional biopsy revealed tophacious gout, 1 of only 4 cases presenting at ACL.

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Multi-disciplinary approach needed in order to achieve a definitive diagnosis.

Management of tenosynovial giant cell tumour of the foot and ankle

AIMS

Tenosynovial giant cell tumour (TGCT) is one of the most common soft-tissue tumours of the foot and ankle and can behave in a locally aggressive manner. Tumour control can be difficult, despite the various methods of treatment available. Since treatment guidelines are lacking, the aim of this study was to review the multidisciplinary management by presenting the largest series of TGCT of the foot and ankle to date from two specialized sarcoma centres.

METHODS

The Oxford Tumour Registry and the Leiden University Medical Centre Sarcoma Registry were retrospectively reviewed for patients with histologically proven foot and ankle TGCT diagnosed between January 2002 and August 2019.

RESULTS

A total of 84 patients were included. There were 39 men and 45 women with a mean age at primary treatment of 38.3 years (9 to 72). The median follow-up was 46.5 months (interquartile range (IQR) 21.3 to 82.3). Localized-type TGCT (n = 15) predominantly affected forefoot, whereas diffuse-type TGCT (Dt-TGCT) (n = 9) tended to panarticular involvement. TGCT was not included in the radiological differential diagnosis in 20% (n = 15/75). Most patients had open rather than arthroscopic surgery (76 vs 17). The highest recurrence rates were seen with Dt-TGCT (61%; n = 23/38), panarticular involvement (83%; n = 5/8), and after arthroscopy (47%; n = 8/17). Three (4%) fusions were carried out for osteochondral destruction by Dt-TGCT. There were 14 (16%) patients with Dt-TGCT who underwent systemic treatment, mostly in refractory cases (79%; n = 11). TGCT initially decreased or stabilized in 12 patients (86%), but progressed in five (36%) during follow-up; all five underwent subsequent surgery. Side effects were reported in 12 patients (86%).

CONCLUSION

We recommend open surgical excision as the primary treatment for TGCT of the foot and ankle, particularly in patients with Dt-TGCT with extra-articular involvement. Severe osteochondral destruction may justify salvage procedures, although these are not often undertaken. Systemic treatment is indicated for unresectable or refractory cases. However, side effects are commonly experienced, and relapses may occur once treatment has ceased. Cite this article: Bone Joint J 2021;103-B(4):788-794.

Tenosynovial giant cell tumor of the distal tibiofibular joint

Tenosynovial giant cell tumors are extremely rare tumors with highly nonspecific symptoms. This benign but aggressive disease has a slow course of progression; however, it can ultimately lead to irreversible damage to a joint. Here we describe a case of a 45-year-old female with a diagnosis of tenosynovial giant cell tumors of the distal tibiofibular joint, the second case described in the literature for such location. Appropriate imaging studies and ultimately histologic studies are necessary for the correct diagnosis. Some locations are particularly unusual for these tumors making a high level of suspicion as well as treatment by an oncology orthopedic surgery specialist at a high-volume center paramount.

Magnetic resonance imaging features of intra-articular tenosynovial giant cell tumor in children

BACKGROUND

Magnetic resonance imaging (MRI) plays a critical role in disease characterization of intra-articular tenosynovial giant cell tumor.

OBJECTIVE

To characterize the MRI features of intra-articular tenosynovial giant cell tumor in children with respect to disease subtype and anatomical location.

MATERIALS AND METHODS

This retrospective study included children with tenosynovial giant cell tumor who underwent preoperative MRI between January 2006 and May 2020. Two radiologists reviewed each examination to determine disease subtype, signal intensities and the presence of an effusion, osseous changes, chondromalacia, juxtacapsular disease and concomitant joint involvement. Fisher exact, Mann-Whitney U, and Kruskal-Wallis H tests were used to compare findings between subtypes and locations.

RESULTS

Twenty-four children (16 girls, 8 boys; mean age: 13.1±3.8 years) with 19 knee and 5 ankle-hindfoot tenosynovial giant cell tumor had either diffuse (n=15) or localized (n=9) disease. An effusion (P=0.004) was significantly more common with diffuse than localized disease. There was no significant difference in MRI signal (P-range: 0.09-1) or other imaging findings (P-range: 0.12-0.67) between subtypes. Children with knee involvement were significantly more likely to present with diffuse disease while those with ankle-hindfoot involvement all presented with focal disease (P=0.004). Juxtacapsular (n=4) and concomitant proximal tibiofibular joint involvement (n=5) were observed with diffuse disease in the knee. Erosions (P=0.01) were significantly more common in the ankle than in the knee.

CONCLUSION

In our study, diffuse tenosynovial giant cell tumor was more common than localized disease, particularly in the knee where juxtacapsular and concomitant proximal tibiofibular joint disease can occur.

Atypical and bilateral pigmented villonodular synovitis of wrist in an adolescent patient: case report and literature review

BACKGROUND

Pigmented villonodular synovitis (PVNS) is a rare benign proliferative disorder of the synovium. It rarely occurs in adolescents, particularly in immature patients with bilateral manifestation.

CASE PRESENTATION

We present a case of atypical and bilateral PVNS of wrist in a 14-year-old boy. Initially, the patient presented with left wrist pain and swelling without the history of trauma. Physical examination revealed an obvious lesion in the dorsal part of left wrist. Radiographs, computed tomography (CT) and magnetic resonance imaging (MRI) showed multiple abnormal signal shadows and arthroedema in the left wrist. Arthroscopy operation was performed, and histologic examination suggested the diagnosis of PVNS. Only 10 months later, the patient presented with the similar symptoms and signs in the right wrist. But MIR and histologic examination were atypical. In this article, we also review and summarize 26 studies on 30 adolescent patients with PVNS.

CONCLUSIONS

This study provides an example of atypical and bilateral PVNS in adolescents.

Subtalar joint pigmented villonodular synovitis misdiagnosed at the first visit: A case report

BACKGROUND

Pigmented villonodular synovitis (PVNS) is an uncommon disease that usually occurs in large joints, and involvement of the subtalar joint is rare. The lack of comprehensive knowledge of subtalar joint PVNS could lead to misdiagnosis.

CASE SUMMARY

We present a 64-year-old woman who, at her first visit, complained of discomfort in the right ankle when she walked. Based on the physical signs and X-ray report, the physician failed to make the suspected diagnosis of PVNS. Eighteen months later, the patient returned with a complaint of a mass in her right lateral malleolus with intermittent blunt pain. The X-ray presented an osteophyte formation and soft tissue calcification at the margin of the subtalar joint. The laboratory tests were normal, whereas magnetic resonance imaging (MRI) showed a low-intensity area on both T1- and T2-weighted images. A suspected diagnosis of PVNS was made and later confirmed by postoperative pathology. Subsequently, the patient received radiotherapy with 32 Gy in 16 fractions. At 6 mo postoperatively, the patient only complained of discomfort after walking three blocks. The American Orthopedic Foot and Ankle Society Ankle–Hindfoot score was 97.

CONCLUSION

MRI is necessary for the diagnosis of PVNS. Early soft tissue calcification and painless joint swelling should be of concern.

Systematic review: total knee arthroplasty (TKA) in patients with pigmented villonodular synovitis (PVNS)

Background

To determine the functional outcomes, complications and revision rates following total knee arthroplasty (TKA) in patients with pigmented villonodular synovitis (PVNS).

Materials and methods

We conducted a systematic review of the literature. Five studies with a total of 552 TKAs were included for analysis. The methodological quality of the articles was evaluated using the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) scale. Functional outcomes, complications and revision rates were assessed. The mean age was 61 years (range 33–94 years) and the mean follow-up period was 61.1 months (range 0.2–35 years).

Results

All the studies reported improvement in knee function following TKA. Post-operative stiffness was the most frequently reported complication, affecting 32.7% (n = 32) of patients in our review. Symptomatic recurrence of PVNS, component loosening, tibial-component fracture, instability and periprosthetic infection were the main factors leading to the need for revision TKA.

Conclusion

The findings of this review support the use of TKA to alleviate the functional limitations and pain due to knee degeneration in patients with PVNS. The operating surgeon should be aware of the increased risk of post-operative stiffness, as well as a potentially higher risk of infection. Implant survival should also be considered inferior to the one expected for the general population undergoing TKA.

cIAP2 expression and clinical significance in pigmented villonodular synovitis

Pigmented villonodular synovitis (PVNS) is a rare hyperplasia disease of the synovium with a predilection for the knee in either a localized (LPVNS) or a diffuse form (DPVNS). But the exact cause is not clear. The aim of this study was to explore the relationship between the expression of cellular inhibitor of apoptosis 2 (cIAP2) and proliferation, apoptosis, invasive growth and postoperative recurrence in PVNS. Clinical significance of cIAP2 expression in synovium from 63 patients' knee joints with PVNS (40 DPVNS; 23 LPVNS) were investigated with 20 normal subjects acting as controls. The cIAP2 gene was screened by Human Cancer Pathway Finder PCR Array and real-time polymerase chain reaction (RT-PCR). We also used immunohistochemistry to detect cIAP2 and proliferating cell nuclear antigen (PCNA) protein expression and analyzed their relationship with PVNS type, invasive growth, and postoperative recurrence. The expression of cIAP2, PCNA, caspase-8, caspase-9 and caspase-3 protein was tested in Western blot. Screening results of Human Cancer Pathway Finder PCR array and RT-PCR showed significantly more cIAP2 mRNA in DPVNS synovium than in normal or LPVNS synovium (P < 0.05). Immunohistochemistry and western blot showed that the cIAP2 protein expression level in DPVNS was significantly higher than in LPVNS tissue (P < 0.01). As cIAP2 expression increased, the expression of PCNA increased (P < 0.05) and expression of cleaved caspase-3, -8, -9 decreased (P < 0.01). cIAP2 and PCNA overexpression were found to be related to ligament and bone erosion in PVNS and to disease recurrence (P < 0.05). This study suggested that cIAP2 overexpression plays an important role in the anti-apoptotic, proliferative and invasive growth of PVNS, which may account for the recurrence and poor prognosis of DPVNS.

Spinal pigmented villonodular synovitis and tenosynovial giant cell tumor: A report of two cases and a comprehensive systematic review

BACKGROUND AND OBJECTIVE

Pigmented villonodular synovitis (PVNS) is a lesion of uncertain etiology that involves the synovial membranes of joints or tendon sheaths, representing a diffuse and non-encapsulated form of the more common giant cell tumors of the synovium (GCTTS). PVNS was reclassified to denote a diffuse form of synovial giant cell tumor (TSGCT), while 'giant cell tumor of the tendon sheath (GCTTS)' was used for localized lesions. These pathologies rarely affect the axial skeleton. We provide an unprecedented and extensive systematic review of both lesions highlighting presentation, diagnostic considerations, treatment, prognosis, and outcomes, and we report a short case-series.

METHOD

We describe two-cases and conduct a systematic review in accordance with PRISMA guidelines.

RESULT

PVNS was identified in most of the cases reviewed (91.6 %), manifesting predominantly in the cervical spine (40 %). Patients commonly presented with neck pain (59 %), back pain (53 %), and lower back pain (81.2 %) for cervical, thoracic, and lumbar lesions, respectively. GTR occurred at rates of 94 %, 80 %, and 87.5 %. Recurrence was most common in the lumbar region (30.7 %). GCTTS cases (8%) manifested in the cervical and thoracic spine at the same frequency. We reported first case of GCTTS in the lumbosacral region. Both poses high rate of facet and epidural involvements.

CONCLUSION

Spinal PVNS and GCTTS are rare. These lesions manifest most commonly as PVNS within the cervical spine. Both types have a high rate of facet and epidural involvement, while PVNS has the highest rate of recurrence within the lumbar spine. The clinical and radiological features of these lesions make them difficult to differentiate from others with similar histogenesis, necessitating tissue diagnosis. Proper management via GTR resolves the lesion, with low rates of recurrence.

Open synovectomy treatment for intra- and extraarticular localized pigmented villonodular synovitis of the knee: a case report

Background

Pigmented villonodular synovitis (PVNS) is a rare, benign, proliferative neoplastic process that commonly affects synovial-lined anatomic spaces. The diffuse type (DPVNS) is characterized by invasion of the entire joint synovium, while the localized type (LPVNS) is characterized by a relatively normal synovial appearance. This report describes a unique case of massive intraarticular LPVNS with an extraarticular extension through the lateral patellar retinaculum. No similar cases have been found in the literature.

Case presentation

A 58-year-old woman had a history of hyperuricemia and knee trauma and presented with unilateral knee acute swelling and pain symptoms with sudden onset. Recent expansion of the LPVNS caused the development of a tender palpable soft tissue mass in the anterolateral aspect of the knee and acute reduced mobility. Preoperative magnetic resonance imaging of the knee revealed the presence of only the soft tissue mass and mild degenerative changes. Open synovectomy was performed successfully to excise the mass. Intraoperatively, macroscopic features of the bright brown inflamed synovium suggested LPVNS, which was confirmed histopathologically. Postoperatively, the symptoms of limited mobility and pain were appreciably relieved. Recurrence was not observed during the clinical follow-up at 1, 6 or 18 months after surgery.

Conclusions

Here, we report the unique case of localized pigmented villonodular synovitis of the knee in a misdiagnosed patient with intra- and extraarticular lesion, which might be attributed to the history of knee trauma and the focal defect of the lateral patellar retinaculum. Open synovectomy effectively relieved the symptoms of limited mobility and pain and no recurrence was observed prior to 18 months postoperatively. To reduce misdiagnosis, MRI examinations are recommended for all patients suspected of having PVNS, including those who have a history of hyperuricemia.

类风湿关节炎合并色素沉着绒毛结节性滑膜炎1例及文献回顾

We reported a case of rheumatoid arthritis (RA) combined with pigmented villonodular synovitis (PVNS) from Peking University People's Hospital. The clinical data were introduced and the related literature was reviewed. The clinical features, treatment and prognosis of the disease were summarized to improve clinicians' understanding of this rare disease and avoid misdiagnosis and delayed diagnosis. A 45-year-old female, with 15 years of RA history and unregular treatment, was admitted to the hospital with the complaint of aggravating pain and swelling in the right knee for 3 months. The puncture of the right knee was performed and there was a large amount of bloody synovial fluid that could not be explained by her RA history. Moreover, the magnetic resonance imaging (MRI) of the right knee revealed hemosiderin deposition with low-intensity signals on both T1-weighted and T2-weighted images which suggested PVNS to us. Then, the patient underwent knee arthroscopy and biopsy to assist in diagnosis. The arthroscopic appearance and pathology were consistent with PVNS and the hyperplastic synovium was removed during arthroscopy. After the operation, she did active functional exercises and took disease-modifying antirheumatic drugs to control RA. She recovered well and remained asymptomatic after half a year of follow-up. Also, there was no recurrence of the right knee. As we all know, RA is a systemic autoimmune disease characterized by chronic synovitis and joint damage. And PVNS is characterized by synovial proliferation and infiltrative process. Both of them are synovial involvement and the clinical manifestations are quite similar. PVNS has occasionally been reported in association with RA. So it is difficult to make a clear diagnosis of RA combined with PVNS. Literature was searched with RA+PVNS in the WanFang Medical Network Database and China National Knowledge Infrastructure and there were no related Chinese cases. Then we searched literature from PubMed with RA+PVNS. The cases were still rare and eventually 2 related articles were yielded including 2 similar patients. It is necessary to fully understand the disease development, complicated MRI appearance and various pathological morpho-logy. They can contribute to making a correct diagnosis which is effective to guide the proper treatment.

Incomplete resection increases the risk of local recurrence and negatively affects functional outcome in patients with tenosynovial giant cell tumor of the hindfoot

BACKGROUND

Diffuse tenosynovial giant cell tumors (TGCT) are more likely to occur in the hindfoot and tend to recur after surgical excision. We performed a pooled analysis of hindfoot TGCT cases to identify factors associated with local recurrence and functional outcomes.

METHODS

We retrospectively reviewed medical records of 33 patients diagnosed with TGCT (15, localized cases; 18 diffused cases) of the hindfoot between 1998 and 2017. Median follow-up was 32 months. Multivariable Cox proportional hazards regression analysis was conducted to estimate the hazard ratios for risk factors for local failure. Generalized linear regression models were used to assess whether resection status, tumor size, tumor type or bone involvement correlated with the Musculoskeletal Tumor Society (MSTS) score.

RESULTS

Local failure was reported in 30% (10/33) patients. Multivariable analysis showed that macroscopically incomplete resection was the only independent prognostic factor for poor local failure-free survival (P=.001). Incomplete resection significantly decreased MSTS score and negatively affected functional outcome (P=.047).

CONCLUSIONS

Incomplete resection increases the risk of local recurrence and negatively affects functional outcome in patients with TGCT of the hindfoot.

Pigmented villonodular synovitis associated with developmental dysplasia of the hip: A case report

INTRODUCTION

Pigmented villonodular synovitis (PVNS) of the hip joint associated with developmental dysplasia of the hip joint (DDH) is an extremely rare co-presentation. The aim of this study is to report a case of PVNS associated with DDH.

PRESENTATION OF CASE

A 26-year-old women, a known case of DDH, presented with progressive right hip pain for one month duration. She was able to perform all the right hip movements with limitation due to pain. Plain radiographs showed a hip dislocation. Through a posterior incision, a mass of brown fibro-fatty soft tissue emerged. The specimen was sent for histopathological examination, The findings were variable mixture of giant cells, hemosiderin, and brown pigmentation in the synoviocyte cytoplasm.

DISCUSSION

Although both conditions were previously described separately, the significance of co-incidence of DDH and PVNS is not well understood due to the rarity of the association.

CONCLUSION

Co-incidence of DDH with PVNS is an extremely rare finding but could be safely managed if caught early in the beginning of the disease.

Pigmented villonodular synovitis does not influence the outcomes following cruciate-retaining total knee arthroplasty: a case-control study with minimum 5-year follow-up

BACKGROUND

Pigmented villonodular synovitis (PVNS) is a rare synovial disease with benign hyperplasia, which has been successfully treated with total knee arthroplasty (TKA). The purpose of this study was to investigate the middle-term follow-up outcomes of cruciate-retaining (CR) TKA in patients with PVNS.

METHODS

From January 2012 to December 2014, a retrospective study was conducted in 17 patients with PVNS who underwent CR TKA as PVNS group. During this period, we also selected 68 patients with osteoarthritis who underwent CR TKA (control group) for comparison. The two groups matched in a 1:4 ratio based on age, sex, body mass index, and follow-up time. The range of motion, Knee Society Score, revision rate, disease recurrence, wound complications, and the survivorship curve of Kaplan-Meier implant were assessed between the two groups.

RESULTS

All patients were followed up at least 5 years. There was no difference in range of motion and Knee Society Score between the two groups before surgery and at last follow-up after surgery (p > 0.05). In the PVNS group, no patients with the recurrence of PVNS were found at the last follow-up, one patient underwent revision surgery due to periprosthetic fracture, and three patients had stiffness one year after surgery (17.6% vs 1.5%, p = 0.005; ROM 16-81°), but no revision was needed. At 7 years, the implant survivorship was 90.0% in the PVNS group and 96.6% in the control group (p = 0.54).

CONCLUSIONS

This study demonstrated that the function of patients with PVNS who underwent CR TKA had been significantly improved, and the survival rate of implants in these patients was similar to the patients with OA. Consequently, the patients with PVNS who underwent CR TKA might be an achievable option. However, these patients should pay more attention to the occurrence of postoperative stiffness complications.

Pigmented villonodular synovitis of the hip joint: Three cases demonstrating characteristic MRI features

Pigmented villonodular synovitis is a rare benign proliferative disease of synovial membranes, causing villonodular synovial hyperplasia and hemosiderin deposition. Its intra-articular forms most commonly affect the knee and less commonly the hip. PVNS of the hip is most common in the second to fifth decades and presentation is typically with pain and occasionally joint dysfunction. We review the existing literature and demonstrate characteristic magnetic resonance imaging features of pigmented villonodular synovitis in the hip joint using three biopsy-proven cases, with the aims of increasing awareness and aiding diagnosis of this rare but potentially debilitating and progressive condition. Recognition of its clinical presentation, appropriate use of magnetic resonance imaging and identification of imaging characteristics are essential to guiding biopsy interpretation and treatment.

Identification of Patient Needs and Preferences in Pigmented Villonodular Synovitis (PVNS) Using a Qualitative Online Bulletin Board Study

Introduction

Pigmented villonodular synovitis (PVNS), also known as giant-cell tumour of the tendon sheath (GCTT), is a rare, benign proliferative tumour affecting the inner lining of synovial joints and tendon sheets. Information on treatment needs of PVNS patients to inform drug development is currently scarce. We conducted an exploratory qualitative study with PVNS patients to generate insights into the objective and emotional aspects related to their medical journey and experiences of living with this disease.

Methods

A 4-day study using an online bulletin board (OBB), an asynchronous, online qualitative research platform, was conducted with patients recruited via physician referral who underwent screening questions to ensure eligibility for the study and willingness to participate. The discussion was moderated, was structured and allowed open answers in response to other participants’ posts.

Results

Eleven patients (4 from the USA, 4 from the UK and 3 from Canada; 45% female), aged 28–57 years, suffering from PVNS for 2–27 years participated in the study. Key patient insights from the study were: (1) pain was the topmost, spontaneous thought that the participants associated with PVNS, constituting a significant emotional and psychological burden; (2) surgery (arthroscopy) did not completely ameliorate symptoms associated with PVNS, as the relapse rate was high in these patients; (3) PVNS has a substantial negative financial impact on patients, their families and the healthcare system; (4) orthopaedic specialists/surgeons predominantly managed PVNS, as surgery is currently the only therapeutic option.

Conclusion

PVNS patients expressed an urgent need for a medical drug treatment, which can reduce pain, avoid relapses and provide an alternative to surgery, the current standard of care.

Electronic Supplementary Material

The online version of this article (10.1007/s12325-020-01364-4) contains supplementary material, which is available to authorized users.

Unusual manifestations of diffuse-type tenosynovial giant cell tumor in two patients: importance of radiologic-pathologic correlation

Diffuse-type tenosynovial giant cell tumor (TSGCT) is a rare, locally aggressive neoplasm. It most commonly occurs in the knee, followed by the hip, and has distinctive imaging features, including mass-like foci of low T2 signal intensity, "blooming" on gradient-echo MRI, and pronounced uptake on FDG PET/CT. Histologically, TSGCT demonstrates a neoplastic population of mononuclear cells admixed with hemosiderin-laden macrophages, foamy histiocytes, inflammatory cells, and osteoclast-like giant cells. In cases where diffuse-type TSGCT presents in an uncommon location or with atypical features, the imaging diagnosis may be challenging. Furthermore, because of its polymorphous appearance, it may be mistaken microscopically for other neoplastic and non-neoplastic histiocytic lesions. Herein, we present two cases of diffuse-type TSGCT presenting as large masses, and underscore the importance of radiologic-pathologic correlation for accurate diagnosis.

Risk factors for early osteoarthritis in tenosynovial giant cell tumour

OBJECTIVE

Tenosynovial giant cell tumour (TGCT) is locally aggressive entity affecting young people (around 4^th decade of life) and can cause joint destruction. It could be nodular or diffuse. These two varieties are histological and genetically similar, but present a different prognosis. The aim of this study is to identify risk factors for local recurrence and predisposing factors for the development of early osteoarthritis in patients with TGCT.

MATERIAL AND METHODS

We conducted a retrospective study of 35 patients with an anatomopathological diagnosis of TGCT in our Institution from 1991 to 2017. The mean follow-up was 8.2 years. Demographic variables, characteristics of the primary tumor and its evolution were collected to assess the risk factors for local recurrence and early osteoarthritis.

RESULTS

The diffuse type was identified as a risk factor for the development of osteoarthritis (p=0.01) and for local recurrence (p=0.015). Osteoarthritis was more frequent in the hip and ankle than in the knee (p=0.03). A difference of 16 months in the duration of symptoms prior to diagnosis between those who developed osteoarthritis and those who did not was observed (p=0.05).

CONCLUSIONS

The diffuse type is more aggressive than the nodular type; it is associated with a higher risk of osteoarthritis and local recurrence. The hip and ankle present a higher risk of osteoarthritis than other joints. The time of evolution of the symptoms before diagnosis and adequate treatment, negatively influences the development of osteoarthritis.