Clinical Image

Diffuse pigmented villonodular synovitis: An exuberant finding

Jorge Sena¹

Gabriel Xavier²

Luís Machado³

Carla Brazão⁴

¹ 5th year Resident, Department of Orthopedic Surgery and Traumatology Hospital Espírito Santo de Évora, Évora Portugal

² Specialist Surgeon, Department of Orthopedic Surgery and Traumatology Hospital Espírito Santo de Évora, Évora Portugal

³ Specialist Surgeon, Department of Orthopedic Surgery and Traumatology Hospital Beatriz Ângelo, Lisboa Portugal

⁴ 1st year Resident, Department of Orthopedic Surgery and Traumatology Hospital Espírito Santo de Évora, Évora Portugal

Address correspondence to:

Jorge Sena

Ruy Luís Gomes n293, 2925-689 Azeitão-Setúbal,

Portugal

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Article ID: 100018Z14SJ2019

doi: 10.5348/100018Z14SJ2019CR

How to cite this article

Sena J, Xavier G, Machado L, Brazão C. Diffuse pigmented villonodular synovitis: An exuberant finding. J Case Rep Images Orthop Rheum 2019;4:100018Z14SJ2019.

ABSTRACT

No abstract

Keywords: Diffuse pigmented villonodular synovitis, Gonalgia, Secondary osteoarthritis, Synovectomy

Case Report

A 70-year-old man presented at our institution with functional limitation and bilateral gonalgia. The X-ray showed aspects compatible with bilateral tricompartmental gonarthrosis (grade IV). We proposed the patient to total left knee arthroplasty.

Discussion

Pigmented villonodular synovitis (PVNS) is a rare (1.8 per million) proliferative of the synovium. The knee is the most commonly affected site (28–70%). Despite being a benign condition, PVNS is often aggressive, resulting in secondary osteoarthritis. Monoarticular involvement occurs in two forms: localized and diffuse. The latter is more common, with a high recurrence rate [1].

Intraoperatively, we verified after incision of the fascia and opening to the articular space, an exuberant brownish/reddish fibroelastic mass that filled the entire articular space (Figure 1).

This finding was in favor of diffuse intra-articular pigmented villonodular synovitis. We performed extended synovectomy and sent the piece for pathological analysis. After synovectomy, we continued to perform total knee arthroplasty. The anatomopathological results confirmed the diagnostic hypothesis (Figure 2).

This rare condition usually appears at younger ages [1],[2] and progresses with pain and recurrent hemarthrosis and may produce degenerative changes [1],[2],[3]. In these situations, the recommended treatment is synovectomy [1],[2],[3] and total knee arthroplasty [3]. Given this finding, the surgeons maintained the surgical proposal of total arthroplasty, previously performing an extensive synovectomy, recommended in this situation.

In this case PVNS was just an exuberant finding that did not change treatment (Figure 3).

Figure 1: Lush brown fibroelastic mass in the knee joint space.

Figure 2: Pathology of lesion biopsy (Hematoxylin and eosin staining): (A) Hyperplastic synovial composed of macrophages containing hemosiderin; (B) Alveolar fissures and spaces lined with synovial cells, multinucleated giant cells and epithelioid cells.

Figure 3: Control X-ray after total knee arthroplasty.

Conclusion

Pigmented villonodular synovitis is a diagnostic challenge due to the low specificity of its symptoms and subtle radiological characteristics, constituting a pathology that should be considered in the management of gonalgia, especially in young adults. Surgical excision is the gold standard method in the treatment of PVNS, and the role of arthroscopy in treating the diffuse form of PVNS is debatable. Total arthroplasty should be considered in cases of persistent relapses and advanced osteoarthritis. In this present case, PVNS was an accidental finding during the left knee joint replacement procedure. The surgeons maintained the surgical proposal of total arthroplasty, previously performing an extensive synovectomy, recommended in this situation. After eight months postoperatively, the patient is well, without pain complaints and with full range of motion.

REFERENCES

Temponi EF, Barros AAG, Paganini VO, Barbosa VAK, Badet R, Carvalho Júnior LH. Diffuse pigmented villonodular synovitis in knee joint: Diagnosis and treatment. Rev Bras Ortop 2017;52(4):450–7. [CrossRef] [Pubmed] Back to citation no. 1

Casp AJ, Browne JA, Durig NE, Werner BC. Complications after total knee arthroplasty in patients with pigmented villonodular synovitis. J Arthroplasty 2019;34(1):36–9. [CrossRef] [Pubmed] Back to citation no. 1

Mollon B, Lee A, Busse JW, et al. The effect of surgical synovectomy and radiotherapy on the rate of recurrence of pigmented villonodular synovitis of the knee: An individual patient meta-analysis. Bone Joint J 2015;97-B(4):550–7. [CrossRef] [Pubmed] Back to citation no. 1

SUPPORTING INFORMATION

Author Contributions

Jorge Sena - Substantial contributions to conception and design, Acquisition of data, Analysis of data, Interpretation of data, Drafting the article, Revising it critically for important intellectual content, Final approval of the version to be published

Gabriel Xavier - Substantial contributions to conception and design, Acquisition of data, Analysis of data, Interpretation of data, Drafting the article, Revising it critically for important intellectual content, Final approval of the version to be published

Luís Machado - Substantial contributions to conception and design, Acquisition of data, Analysis of data, Interpretation of data, Drafting the article, Revising it critically for important intellectual content, Final approval of the version to be published

Carla Brazão - Substantial contributions to conception and design, Acquisition of data, Analysis of data, Interpretation of data, Drafting the article, Revising it critically for important intellectual content, Final approval of the version to be published

Data Availability Statement

The corresponding author is the guarantor of submission.

Consent For Publication

Written informed consent was obtained from the patient for publication of this article.

Data Availability

All relevant data are within the paper and its Supporting Information files.

Competing Interests

Authors declare no conflict of interest.

Copyright

© 2019 Jorge Sena et al. This article is distributed under the terms of Creative Commons Attribution License which permits unrestricted use, distribution and reproduction in any medium provided the original author(s) and original publisher are properly credited. Please see the copyright policy on the journal website for more information.