Primary Arthroscopic Synovectomy for Pigmented Villo-Nodular Synovitis of the Knee 939

Home , Synovectomy

Orthopaedics & Traumatology: Surgery & Research (2013) 99, 937—943

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ORIGINAL ARTICLE

Primary arthroscopic synovectomy for

pigmented villo-nodular synovitis of the

knee: Recurrence rate and functional

outcomes after a mean follow-up of seven years

a,∗ a,b,c b,c a,b,c

J.C. Aurégan , Y. Bohu , N. Lefevre , S. Klouche ,

c b,c a,d

J.F. Naouri , S. Herman , P. Hardy

Hôpitaux Universitaires Paris Île-de-France Ouest, AP—HP, 92100 Boulogne-Billancourt, France

Institut de l’Appareil Locomoteur Nollet, 75017 Paris, France

Sport Clinical Center, Paris V, 75005 Paris, France

Université de Versailles Saint-Quentin-en-Yvelines, UFR des Sciences de la Santé, 78035 Versailles, France

Accepted: 21 August 2013

KEYWORDS Summary

Synovitis; Background: Pigmented villo-nodular synovitis (PVNS) is an uncommon proliferative condition of

Pigmented the synovial membrane that chieﬂy affects the knee. Arthroscopic synovectomy may carry lower

villo-nodular; morbidity rates but higher recurrence rates than open synovectomy. Here, our objective was

Knee; to evaluate recurrence rates and functional outcomes after primary arthroscopic synovectomy

Surgery; for PVNS of the knee.

Arthroscopic Hypothesis: Primary arthroscopic synovectomy preserves knee function while producing low

synovectomy recurrence and complication rates.

Materials and methods: We retrospectively included consecutive patients with histologically

documented PVNS managed with primary arthroscopic synovectomy at two centres between

1998 and 2011. Twenty-three patients, 13 men and 10 women with a mean age of 41 ± 12 years,

were reviewed including 16 patients with nodular and 7 with diffuse form of this disease.

Patients with localized disease underwent partial synovectomy and those with diffuse disease

complete synovectomy followed by chemical synovectomy of any residual lesions. The primary

outcome measure was recurrence. Secondary outcome measures were the Tegner-Lysholm and

Ogilvie-Harris scores.

Results: Follow-up data were obtained after a mean of 7 ± 4 years in 21 patients (14 with nodu-

lar and 7 with diffuse disease), of whom 2 had recurrences, after 2 and 5 years, respectively.

∗

Corresponding author.

E-mail addresses: [email protected], [email protected] (J.C. Aurégan).

938 J.C. Aurégan et al.

At last follow-up, neither patient had any evidence of recurrence. The mean Tegner-Lysholm

score was signiﬁcantly improved (from 68 ± 10 to 90 ± 8, P = 0.0004) and the mean Ogilvie-Harris

score indicated excellent function (11 ± 1).

Discussion: Primary arthroscopic synovectomy ensures satisfactory control of PVNS while pre-

serving knee function. A full recovery remains possible even in patients with diffuse disease. In

the event of a recurrence, open synovectomy can be performed.

Level of evidence: Level IV, retrospective study of consecutive patients.

Introduction and 2011 were eligible, including those with recurrent PVNS

after arthroscopic synovectomy. We did not include patients

Pigmented villo-nodular synovitis (PVNS) is an idiopathic with extra-articular lesions and/or a history of open syn-

benign proliferative disorder of the synovial membrane with ovectomy of the same knee and/or recurrent PVNS after

an estimated incidence of 1.8/10 population [1]. Although open surgery at the same knee.

no age group is exempt, younger patients seem predomi- During the study period, 28 patients underwent surgery

nantly affected, with no difference between genders [1]. in either centre for PVNS of the knee (Fig. 1). Among them,

The knee is the main site of involvement [2,3] but any joint 2 had superﬁcial lesions extending extra-articularly and

can be affected [4]. Untreated PVNS rapidly results in irre- were managed with open surgery. Of the 26 arthroscopically

versible joint destruction. treated patients, 3 had recurrent diffuse PVNS after pri-

In 1976, Granowitz et al. [5] distinguished two variants mary open synovectomy performed elsewhere and were

of PVNS based on whether the intra-articular lesions were therefore not included in our study. Of the 23 included

localised (nodular PVNS) or affected the entire synovium patients, 7 had diffuse and 16 nodular disease. There were

(diffuse PVNS). Extra-articular extension of the lesions to 13 men and 10 women with a mean age of 41 12 years.

the adjacent muscles and tendons can occur, chieﬂy in dif- Among these 23 patients, 3 had recurrent PVNS, includ-

fuse forms [6]. ing 1 after partial arthroscopic synovectomy for nodular

Complete surgical excision of all the lesions is the disease and 2 after incomplete arthroscopic synovectomy

standard treatment for PVNS [7]. The surgical modalities for diffuse disease. Mean maximum knee ﬂexion was

◦

are poorly standardised, however, as the low incidence of 126 12 .

PVNS precludes large treatment trials. In general, open total Magnetic resonance imaging (MRI) was performed in

synovectomy is preferred in diffuse PVNS [8] and arthro- 22 of the 23 patients (Figs. 2 and 3). Changes suggesting

scopic synovectomy is reserved for localised nodular PVNS PVNS were recorded including thickening and heterogeneity

[9,10]. Compared to open synovectomy, arthroscopic syn- of the synovial membrane with post-gadolinium enhance-

ovectomy may ensure better preservation of knee function ment and low-signal foci consistent with hemosiderin

while producing acceptable local recurrence rates and few deposits within the joint [13]. The ﬁndings indicated def-

complications [10,11]. Both the local recurrence rate and inite PVNS in 14 patients and possible PVNS in 6 patients,

knee function recovery have been reported to vary with the whereas 2 patients had no suggestive MRI features. MRI

extent of the lesions [12]. Nevertheless, PVNS is probably also served to assess the extent of the synovial lesions.

a continuum with no clear-cut separation between nodu- In 1 patient, a metallic foreign body precluded MRI

lar and diffuse forms. The better functional outcomes with and computed arthrotomography was performed instead:

arthroscopy compared to open surgery constitute a rationale no changes suggesting PVNS were found. The diagno-

for broadening the indications of arthroscopic treatment. sis was conﬁrmed postoperatively in all 23 patients by

Here, our main objective was to evaluate outcomes after histological examination of the synovial membrane speci-

primary arthroscopic synovectomy for nodular or diffuse men.

PVNS. Our study hypothesis was that primary arthroscopic

synovectomy would preserve knee function while producing

low recurrence and complication rates.

Surgical technique

The 23 procedures were performed by 3 senior surgeons.

Material and methods

◦

A 30 arthroscope was used. A synovial membrane biopsy

was obtained routinely. Synovectomy was achieved using

We conducted a retrospective study in two centres special-

a motorised shaver with a 5.5-mm blade and the three

ized in arthroscopic surgery of the knee. In both centres, all

standard portals (antero-medial, antero-lateral, and supero-

patients with PVNS of the knee were managed with primary

lateral). In patients with nodular lesions conﬁned to the

arthroscopic synovectomy.

anterior knee, the posterior knee was not explored rou-

tinely. Posterior synovectomy in patients with diffuse

Patient selection disease (Fig. 4) or posterior nodular disease (Fig. 5) was per-

formed via the postero-medial and postero-lateral portals.

All patients managed with arthroscopic synovectomy for his- The postero-medial approach was achieved by transillumi-

tologically documented PVNS of the knee between 1998 nation [9].

Primary arthroscopic synovectomy for pigmented villo-nodular synovitis of the knee 939

P VNS of the knee (N=28 )

MRI

(N=27/28 ) Excl uded

(N=5)

Lo calized PVNS Diffuse PVNS

Typ e of PVNS (N=16 ) (N=7)

Arthroscopic localised synovectomy Arthroscopic total synovectomy

No Yes

Ri sk of residual

les ion (Y / N)

No adjuv ant treatment Chemical synovectomy at 3 months

(N=16 localised and 2 diffuse) (N=5)

Figure 1 Patient ﬂow chart (PVNS = pigmented villo-nodular synovitis; MRI = magnetic resonance imaging).

Postoperative chemical synovectomy Tegner-Lysholm score categories were 0—64, poor; 65—83,

fair; and 84—100, excellent. Ogilvie-Harris scores were cat-

In patients with diffuse PVNS, the joint cavity was care- egorized as follows: 0—3, poor; 4—6, fair; 7—9, good; and

fully explored after total synovectomy to assess the risk 10—12, excellent.

of residual lesions. When the risk was deemed non-

existent, no additional treatment was given. Otherwise, Statistical analysis

chemical synovectomy was performed 3 to 6 months after

the arthroscopic procedure. Osmic acid was used until

STATA.10 (StataCorp, College Station, TX, USA) was used

2007, when the French drug safety agency withdrew this

for the statistical analyses. Given the small sample size,

compound, and triamcinolone hexacetonide (Hexatrione )

we chose non-parametric tests. Quantitative variables were

thereafter.

compared using the Mann-Whitney test or Wilcoxon test for

paired data. Values of P smaller than 0.05 were considered signiﬁcant.

Postoperative management

A drain was placed routinely in the joint cavity then removed Results

after 24 to 72 hours. Passive and active rehabilitation ther-

apy was started on the ﬁrst postoperative day and continued Of the 23 patients, 2 were lost to follow-up, after 2 months

for 1 month. A knee-extension splint was worn between the and 13 years, respectively. Both had nodular disease and

rehabilitation sessions for 1 month to avoid ﬂexion contrac- neither experienced recurrences. These 2 patients were

ture. Patients were re-evaluated after 1, 3, 6, and 12 months excluded from the analyses. Mean follow-up in the remaining

then once a year. MRI with gadolinium injection was per- 21 patients was 7 4 years.

formed after 1 year. For this study, all patients were asked

to come in for re-evaluation. Complications

A 25-year-old woman with diffuse PVNS managed by

Outcome measures

total arthroscopic synovectomy experienced postoperative

haemarthrosis. Surgical drainage of the joint was required

The primary evaluation criterion was the rate of local recur-

1 month after surgery.

rence at last follow-up. Local recurrence was suspected

based on the clinical and or MRI ﬁndings then conﬁrmed

histologically. Recurrence rate

Secondary outcome measures were the scores at last

follow-up on two knee-function scales, the Tegner-Lysholm MRI was performed 1 year postoperatively in 17 of the

Knee Scoring Scale for general knee function [14] and the 23 patients and showed no signs of recurrence. Neverthe-

Ogilvie-Harris scale developed speciﬁcally for PVNS [12]. less, histologically documented recurrences developed in

940 J.C. Aurégan et al.

Figure 2 Magnetic resonance imaging in a patient with nodular pigmented villo-nodular synovitis of the knee. a: coronal section,

T2 fast spin-echo Fat-Sat sequence: well-delineated intra-articular ovoid mass overhanging the anterior inter-meniscal ligament on

the midline, generating higher signal than the surrounding tissue, and surrounded by a low-signal shell; b: sagittal section, T2 fast

spin-echo Fat-Sat sequence: mass in contact with Hoffa’s triangle, with no evidence of inﬁltration. Markedly low signal from the

shell. Heterogeneous content, with relative high signal contrasting with low-signal foci. No joint effusion; c: axial section, T2 fast

spin-echo Fat-Sat sequence: the mass is located on the midline; d: sagittal section, T1 sequence: ovoid mass anterior to the insertion

of the anterior cruciate ligament, from which it is clearly separated. The mass is sharply marginated. Its content generates high

signal relative to the gastrocnemius muscle and is surrounded by a low-signal shell.

2 patients, both with diffuse disease. A 41-year-old man Repeat arthroscopy was performed in 2 patients with per-

with diffuse PVNS of the right knee initially treated with sistent pain suggesting a recurrence despite the absence of

total arthroscopic synovectomy followed 3 months later by MRI abnormalities. The gross and histological features of the

chemical synovectomy had normal MRI ﬁndings after 1 year synovial membrane ruled out a recurrence.

but was diagnosed with a recurrence 5 years after the

arthroscopic procedure. He was managed with open total Functional outcomes

synovectomy and had no evidence of recurrence 3 years

later. The other patient was a 27-year-old man with diffuse The mean Tegner-Lysholm score improved signiﬁcantly

PVNS of the left knee. He underwent incomplete arthro- from 68 ± 10 pre-operatively to 90 ± 8 at last follow-up

scopic synovectomy at another centre then experienced a (P = 0.0004). Mean values at last follow-up were not signiﬁ-

recurrence managed with arthroscopic total synovectomy cantly different between the groups with diffuse and nodular

at one of the study centres. The risk of residual lesions was disease (90 ± 7 and 90 ± 10, respectively, P = 0.91). The

deemed non-existent and chemical synovectomy was there- mean Ogilvie-Harris score at last follow-up was 11 ± 1 over-

fore not performed. A recurrence was diagnosed 2 years all, with no signiﬁcant difference between the groups with

later and managed with arthroscopic total synovectomy. nodular and diffuse disease (11 ± 1 and 10 ± 1, respectively;

At last follow-up 6 months later, he had no signs of recur- P = 0.53). Both score values indicated excellent functional

rence. outcomes at last follow-up.

Primary arthroscopic synovectomy for pigmented villo-nodular synovitis of the knee 941

Figure 3 Magnetic resonance imaging in a patient with diffuse villo-nodular synovitis of the knee. T1-sequence before (a) and

after (b) injection. Diffuse thickening and enhancement of the anterior and posterior synovial membrane. Joint effusion.

Figure 4 Arthroscopic appearance of diffuse pigmented villo-nodular synovitis of the knee. The arthroscope has been inserted

via the antero-lateral portal and the quadricipital recess is being explored. Villi are seen to line the entire joint surface. Note the

typical appearance of thick tan-coloured villi with pinpoint haemorrhagic effusions.

Discussion Mean functional scores in our study were excellent in

both nodular and diffuse disease. No signiﬁcant difference

in function was found between these two groups, but only

This study shows that primary arthroscopic synovectomy for

7 patients had diffuse lesions. In previous studies, func-

PVNS of the knee is associated with few complications and

tional outcomes seemed better in nodular disease and varied

produces an overall low recurrence rate while preserving

with the treatment modality. In a study of 20 patients with

knee function.

nodular PVNS managed with arthroscopic synovectomy, the

Whereas nodular PVNS is associated with few or no

median Tegner-Lysholm score at last follow-up indicated

recurrences [10,15], diffuse PVNS can recur regardless of

excellent function (85.5; range, 83—88) [17]. In 25 patients

the treatment modality used [16]. In our study, none of the

managed arthroscopically for diffuse (n = 20) or nodular

patients with nodular disease experienced recurrences, in

(n = 5) PVNS, the mean postoperative Ogilvie-Harris score

keeping with ﬁndings from two other case-series studies

was 11.3 (excellent) after nodule excision, 7.8 (good) after

[10,15]. In contrast, in a study of 20 patients with nodu-

partial synovectomy, and 9.3 (good) after total synovectomy

lar PVNS, 4 (20%) patients had recurrences [17]. Recurrence

[12]. In contrast to arthroscopic surgery, open surgery is

rates after open synovectomy for nodular PVNS have ranged

often associated with range-of-motion limitation (24% [22]

from 0% [18] to 15% [19] and 29% [8]. In our patients with

to 50% [21] of patients).

diffuse disease, the 29% (2/7 patients) recurrence rate is

Thus, routine primary arthroscopic synovectomy allows

consistent with recurrence rates reported after open syn-

removal of the largest possible number of lesions while prob-

ovectomy (25% [20], 33%, [21], and 46% [19]). However, one

ably providing better function than open surgery and also

group reported a recurrence rate of only 8% [22].

942 J.C. Aurégan et al.

Figure 5 Arthroscopic appearance of nodular pigmented villo-nodular synovitis of the knee. The arthroscope has been inserted

via the antero-lateral portal. The nodule ﬁlls the intercondylar notch and exhibits the typical tan colour. Note the anterior cruciate

ligament behind the nodule. The nodule is appended from a well-vascularised pedicle. c and d: the normal synovium lining the roof

of the notch is considerably lighter in colour, contrasting with the dark colour of the nodule.

producing a low complication rate. However, arthroscopic felt the second procedure had removed all the lesions and

synovectomy for PVNS is a highly specialised procedure asso- consequently did not prescribe chemical synovectomy. The

ciated with a long and arduous learning curve. number of patients with recurrences was too small for a mul-

In our patients, posterior synovectomy was performed via tivariate analysis aimed at identifying factors independently

the standard posterior portals. Another option consists in the associated with recurrences.

back-and-forth technique, which may be valuable particu- Our study has several limitations. The data were col-

larly in patients with diffuse lesions [9,23]. lected retrospectively, but nearly all the patients were

Osmic acid was used for chemical synovectomy until re-evaluated speciﬁcally for the study. The sample size was

2007, when the French drug safety agency withdrew small, in keeping with the low incidence of PVNS. Among

approval of this compound based on an unfavourable previous studies, few included more than 23 patients [8,20].

risk/beneﬁt assessment [24]. Osmic acid is no longer used Finally, although the mean follow-up of 7 years is satisfac-

in humans. Alternatives for local chemical synovectomy are tory, follow-up in some patients was only 12 months, limiting

® 90

Hexatrione and radiopharmaceuticals such as yttrium ( Y) the validity of their ﬁnal outcome assessments.

citrate and yttrium ( Y) silicate. External beam radiation

therapy combined with total synovectomy may provide good

outcomes, most notably in patients at high risk for recur- Conclusion

rence [25], but has not been proven effective by level-I

evidence. Primary arthroscopic synovectomy, either partial in nodular

Factors associated with local PVNS recurrence include disease or total in diffuse disease, with subsequent chemi-

diffuse disease, involvement of a large joint, incomplete cal synovectomy if appropriate, ensures satisfactory disease

synovectomy, a history of recurrence, and extra-articular control while preserving knee function. The chances for a

involvement [6,8,20,26]. In our study, both patients with full recovery are preserved even in patients with diffuse

recurrences had diffuse disease and 1 of them also had a lesions. In addition, open synovectomy can be performed

history of prior recurrence. In this last patient, the surgeon in the event of a recurrence.

Primary arthroscopic synovectomy for pigmented villo-nodular synovitis of the knee 943

Disclosure of interest [12] Ogilvie-Harris DJ, McLean J, Zarnett ME. Pigmented villon-

odular synovitis of the knee: the results of total arthroscopic

synovectomy, partial arthroscopic synovectomy and arthro-

The authors declare that they have no conﬂicts of interest

scopic local excision. J Bone Joint Surg Am 1992;74:119—23.

concerning this article.

[13] Mandelbaum BR, Grant TT, Hartzman S, et al. The use of MRI to

assist in diagnosis of pigmented villonodular synovitis of knee

Acknowledgements joint. Clin Orthop Relat Res 1988;231:135—9.

[14] Tegner Y, Lysholm J. Rating systems in the evaluation of knee

ligament injuries. Clin Orthop Relat Res 1985;198:43—9.

We are deeply grateful to Ms. Pauline Ajoux, scientiﬁc sec-

[15] Ozalay M, Tando˘gan RN, Akpinar S, Cesur N, Hersekli MA,

retary, for her valuable assistance.

Ozkoc¸ G, et al. Arthroscopic treatment of solitary benign intra-

articular lesions of the knee that cause mechanical symptoms.

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