Case reportArthroscopic treatment of intra-artricularly localised pigmented villonodular synovitis of the ankle: 4 cases with long-term follow-up
Introduction
Pigmented villonodular synovitis (PVNS) is a rare, locally aggressive benign proliferative pathology of synovial tissue. It was firstly described by Chassaignac in 1852 [1], but the term PVNS was firstly introduced by Jaffe et al. [2]. The World Health Organisation (WHO) has classified these lesions separately as PVNS and giant cell tumour of tendon sheath (GCTTS) and reported that the distinction is based on the behaviour of the tumour [3]. According to WHO, PVNS lesions are classified into two as diffuse-type giant cell tumour and diffuse-type PVNS. In this taxonomy, PVNS represents destructive proliferation of synovial-like mononuclear cells, siderophages, and inflammatory cells. It also further typified according to its nature whether it infiltrates throughout the affected area beyond the joint and into the surrounding tissue [3]. GCTTS arises from synovium, bursae, and tendon sheaths. It is localised lesion and subdivided by location as intra-articular (previously known as localised PVNS) and extra-articular (previously known as nodular tenosynovitis).
The definitive aetiology is unclear. Chronic inflammation, recurrent hemarthrosis following trauma, and abnormal lipid metabolism are the topics of debate [4], [5]. Histology of PVNS reveals mononuclear stromal cells infiltrating the synovium, highly vascular villi with hyperplastic synovial cells, nodular and hemosiderin stained multi-nucleated giant cells. Clinical symptoms vary and depend on lesion location as intra-articularly or extra-articularly. Intra-articular PVNS mostly manifests with pain and swelling [6]. Radiographic features are non-specific. Radiographs may show cystic erosion with sclerotic margins on both sides of the joint. The localised PVNS usually reveals only a soft tissue mass. The magnetic resonance imaging (MRI) is usually sufficient for diagnosis and shows intra-articular masses with low signal intensity on both T1 and T2 weighted images due to hemosiderin deposits [6]. There is no standardised treatment for PVNS. Treatment options are surgical resection, radiation therapy (external beam or intra-articular injection of radioactive isotopes), or a combination of these options. Because of the reports with high recurrence rate after total excision (up to 8–46%) and aggressive nature, localised lesions should be excised thoroughly [7]. We performed a retrospective study of four patients with intra-articularly localised pigmented villonodular synovitis (PVNS) of the ankle which were treated with total arthroscopic excision and evaluated for functional results and recurrence rates.
Section snippets
Patients
The patients who underwent arthroscopic excision for histologically confirmed PVNS between January 2008 and January 2013 were reviewed retrospectively. We found four cases of intra-articularly localised PVNS of the ankle (Fig. 1). All of the procedures were performed by the senior surgeon of this study in the same institute. There was no patient lost to follow-up.
Arthroscopic evaluation
The procedures were performed in supine position and under tourniquet at the pressure of 375 mm mercury. No traction device was used
Results
There were two women and two men with a mean age of 27 (range, 17–46 years) at the time of arthroscopic surgery. The mean follow-up time was 57 months (range, 48–72 months). At first presentation, all patients had complaints of pain and limited range of motion at their ankles and recovered completely after undergoing arthroscopic excision. There was no clinical or radiological evidence of recurrence at follow-ups. Functional results were excellent. The mean MSTS at follow-up was 96,5% (range,
Discussion
This study demonstrates that intra-articularly localised PVNS lesions can be successfully treated with arthroscopy with low recurrence rate and is the first of series reporting recurrence rate and clinical outcome score of patients with intra-articularly localised PVNS of the ankle with a mean follow-up of 57 months (range, 48–72 months). Intra-articularly localised PVNS is a rarely diagnosed entity of the ankle. Nevertheless, a few case reports and case series with a limited number of patients
Conflict of interest
None.
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