Localized pigmented villonodular synovitis of the ankle: Expect the unexpected

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Highlights

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    PVNS of the ankle is seen more often than reported.

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    Ankle complaints warrant a structured diagnostic algorithm.

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    Arthroscopy is an excellent option for treating LPVNS of the ankle joint.

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    Complete resection of the altered synovial tissue is paramount to avoid recurrence.

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    Pathohistological examination has the final say in determining the diagnosis.

Abstract

Background

We present the technique, results and discuss arthroscopic treatment of the localized form of pigmented villonodular synovitis (LPVNS) of the ankle.

Methods

Medical records of five patients diagnosed and treated for ankle LPVNS with a minimum five-year followup were retrospectively reviewed. All patients were treated arthroscopically, altered synovial tissue was resected and a sample of tissue was sent for pathohistological examination for the definitive diagnosis.

Results

No recurrence was noted at a mean followup of 6.5 years, both clinically and by MRI at one year postoperatively. Patients were evaluated using the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot score, and an improvement was noted from an average score of 65.6 prior to treatment to 94.6 at final followup.

Conclusion

Considering the results of this case series, and the absence of complications, arthroscopy is a viable option for treating LPVNS of the ankle.

Introduction

Pigmented villonodular synovitis (PVNS) is a proliferative synovial tissue disorder that affects the synovial lining of joints, tendon sheaths and bursae, and occasionally invades and destroys surrounding soft tissues and bone. Considering the extent of synovial tissue involvement, a localized (LPVNS) and diffuse (DPVNS) form of this disorder can be distinguished, both of which may be intra-articular and extra-articular [1]. These two forms most likely constitute two ends of the gamut of one disease. This difference is noted in the World Health Organization classification, in which DPVNS is termed “diffuse-type giant cell tumour” (Dt-GCT) ICD-O code 9251/0 while LPVNS (intra-articular) and giant-cell tumours of tendon sheaths (GCTTS) (extra-articular) are coded as 9252/0 [2].

PVNS is typically monoarticular and most frequently involves the knee, followed by the hip, foot, wrist and ankle to a lesser extent [3]. The incidence of PVNS in the ankle is about 2.5% out of all PVNS cases [4]. Regardless of the joint in question, treatment of choice for PVNS is surgical excision of pathologic tissue, which can be aided by radiotherapy or isotopic synoviorthesis in recurring and locally widespread cases [5], [6], [7].

In this retrospective case analysis we present five patients with LPVNS of the ankle, treated with arthroscopic resection of the altered synovial tissue, diagnosed by pathohistological examination and followed for a minimum of five years. The primary aim of this paper is to show that arthroscopically performed resection of altered synovial tissue of LPVNS is a safe and effective treatment modality. A secondary aim is to raise awareness about LPVNS in orthopaedic surgeons and to question its touted rarity, in general as well as in the ankle.

Section snippets

Methods

Clinical, radiological and histological records of five patients with ankle LPVNS treated at our Department by a single surgeon, in the period from September 2006 to March 2010, were retrospectively reviewed by an independent examiner not involved in the treatment process.

All patients presented with similar symptoms, such as swelling and pain to various extents, without any previous trauma to the ankle joint. After thorough physical examination, plain radiographs and magnetic resonance imaging

Results

Five patients (four females, one male) were treated for unilateral LPVNS of the ankle joint (Table 1). The average patient age was 35 (range, 30–40) years. Average time of onset of symptoms to time of diagnosis at surgery was 4 (range, 6 months to 10) years. Mean followup was 6.5 (range, 5–8.5) years. Plain radiographs showed bony erosions in three patients. These erosions were marginal, located on the ventral part of the distal tibia in three patients, of which one also had a cyst surrounded

Discussion

Considering the good results and an absence of complications at a minimum five years followup in this case series, arthroscopy is a viable option for treating LPVNS of the ankle. It is important to note that due to unexpectedness of PVNS, as well as the fact that it resembles a broad scope of pathological entities, it wasn’t strongly suspected as the diagnosis in four out of five patients presented here. The patient in whom we suspected LPVNS had already been diagnosed and treated for it

Conclusion

We once again stress the importance of allowing ourselves to think about LPVNS as a possible pathology in the ankle. Although they might not help with establishing the exact diagnosis prior to surgery, plain radiographs and MRI scans should be used to acquire a clear look into the mass and its relations with neighbouring anatomical structures. It is imperative to remove all pathological tissue with minimal disruption of normal anatomy in order to avoid joint damage and degenerative changes.

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