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Research Article | DOI: https://doi.org/10.31579/2692-9392/135
1 Departement of Orthopedic Hag Elsafi Teaching Hospital-Khartoum, Sudan.
2 Departement of Pediatric Orthopedic Excellence Trauma Centre Khartoum, Sudan.
3 Departement of Orthopedic Hag Elsafi Teaching Hospital-Khartoum, Sudan.
*Corresponding Author: Mohamed Hamid Awadelseid, Departement of Pediatric Orthopedic Excellence Trauma Centre Khartoum, Sudan.
Citation: Gaafar Siddig Awad Alseed, Mohamed Hamid Awadelseid and Omer Yaseen Almubarak, (2022) Outcome of Arthroscopic
Synovectomy for Diffuse Pigmented Villonodular Synovitis of The Knee in Sudanese Patients. J. Archives of Medical Case Reports and Case Study,
6(3); DOI:10.31579/2692-9392/135
Copyright: ©2022 Mohamed Hamid Awadelseid, This is an open-access article distributed under the terms of the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Received: 30 June 2022 | Accepted: 12 July 2022 | Published: 25 July 2022
Keywords: knee; pigmented villonodular synovitis; arthroscopic synovectomy
Background: Diffuse pigmented villonodular synovitis (DPVNS) of the knee is a difficult tumor to eradicate, the gold standard treatment has traditionally been surgical excision with total synovectomy of the affected joint, either with an open or arthroscopic approach. In this study, we are focusing on arthroscopic surgical synovectomy.
Objectives: Aimed to study the outcome of arthroscopic synovectomy for diffuse pigmented villonodular synovitis of the knee in Haj Alsafi Teaching Hospital.
Methodology: Observational retrospective hospital-based study, performed in the Orthopedic Department, 12 patients (8 males and 4 females) with the diffuse form of PVNS of the knee were enrolled in the study after qualification. The clinical diagnosis was confirmed by magnetic resonance imaging and post-surgical histo-pathological examination. All patients underwent complete synovectomy through standard anterior, medial and lateral, then medial, lateral suprapatellar and posteromedial portals. Each patient was evaluated before and after treatment and followed up for a minimum of 18 months (range: 18 – 54 months) using the Lysholm score and International Knee Documentation Committee (IKDC) score.
Results: The average age group of patients was (9–63years) with male predominance (66.7 %). Left knee more frequently affected (58.3%). None of the study participants had previous surgical history 100%. Both Lysholm and IKDCscores were significantly improved in all study participants. Regarding paired sample statistics, the mean for the score preoperatively and postoperatively was improved from 54.9 to77.9. Recurrence reported in one participant (8.3%). There was a statistical association between pre and post-operative LYSHOLM and IKDC scores and recurrence, hence p-value =0.000.
Conclusion:Arthroscopic synovectomy is an appropriate treatment for knee DPVNS with a good clinical and functional outcome and with a low recurrence rate.
The human knee is the largest joint in the musculoskeletal system,which supports the body weight and facilitates locomotion. The knee consistsof two distinct articulations, the tibiofemoral and the patellofemoral joints [1]. The tibiofemoral joint is one of the most complexarticulations of the human body and its main tissuesare the femur, tibia, fibula,articular cartilages, menisci,and ligaments. The tibiofemoral joint enables the relative motion of the femur and tibia, which is facilitated through mechanical contacts between the cartilages and menisci [2].
Joint capsule: The capsule surroundsthe knee joint. It has a tough,fibrous outer membraneand an inner synovial membrane,which produces joint fluid (synovialfluid). This fluid lubricates the joint and nourishes the articular cartilage that coats the ends of the bones in the joint.Numerous bursae or small fluid sacs are like folds in the capsule around the knee joint which provide extra flexibility and stretch to the capsule. Articular Cartilage is a thin, elastic connective tissue protects the bone by absorbing shock. Cartilage also ensures that joint surfaces slide easily over each other for smooth knee movement.Meniscal cartilage is fibrous with a good tensile strength, separating the bones of the knee and acting as a shock absorber. The meniscus can often be torn in forceful, twisting injuries.There are two c-shapedmenisci in the knee– the medial meniscus and the lateral meniscus.
Ligaments:There are four main ligaments which strap the bones of the knee joint together. They are the anterior cruciate ligament (ACL), the posterior cruciate ligament (PCL), the medial collateral ligament (MCL) and the lateral collateral ligament (LCL). The ligaments surrounding the knee joint offer stabilityby limiting movementsand, together with several menisci and bursae, protect the articular capsule.The knee joint consists of three “compartments” or sections:medial compartment (inner half of the knee),lateral compartment (outer half of the knee) and patellofemoral compartment (behind the knee).Pigmented villonodular synovitis (PVNS) is a rare proliferative process that affects the synovial joints, tendon sheaths, and bursae. In 1852, Chassaignac [3] reported the first case of a lesion in the flexor tendon sheath of the second and third fingers;this was subsequently reported in other joints. In 1941, Jaffe et al [4] coined the term “pigmented villonodular synovitis”; subsequently, Granowitzet al [5] expandedthe terminology, distinguishing the localized (LPVNS) and diffuse (DPVNS) forms from other synoviallesions. Recently, the World Health Organization (WHO) has defined PVNS and giant cell tumor to be equivalent terms [6].
The estimated incidence of PVNS ranges around 1.8 per million, It is usuallymonoarticular, affecting large joints. The knee is the most affected site (28%-70%), but cases in the hip, ankle, shoulder, and elbow are often observed [7].
The disease presents in two forms, localized or diffuse, and both types have similar appearance: a synovial membranecharacterized by inflammation and presence of hemosiderin deposits[8]. Microscopically, it is characterized by the presenceof lipid-laden macrophages, multinucleated giant cells, hemosiderin deposits,and proliferation of fibroblasts and stromal cells. LPVNS is characterized by discrete or pedunculated nodular lesions. In turn, DPVNS is the most common presentation, involving intra-articular tissues; it may have extra-articular The human knee is the largest joint in the musculoskeletal system,which supports the body weight and facilitates locomotion. The knee consistsof two distinct articulations, the tibiofemoral and the patellofemoral joints [1]. The tibiofemoral joint is one of the most complexarticulations of the human body and its main tissuesare the
femur, tibia, fibula,articular cartilages, menisci,and ligaments. The tibiofemoral joint enables the relative motion of the femur and tibia, which is facilitated through mechanical contacts between the cartilages and menisci [2].
Joint capsule: The capsule surroundsthe knee joint. It has a tough,fibrous outer membraneand an inner synovial membrane,which produces joint fluid (synovialfluid). This fluid lubricates the joint and
nourishes the articular cartilage that coats the ends of the bones in the joint.Numerous bursae or small fluid sacs are like folds in the capsule around the knee joint which provide extra flexibility and stretch to the capsule. Articular Cartilage is a thin, elastic connective tissue protects the bone by absorbing shock. Cartilage also ensures that joint surfaces slide easily over each other for smooth knee movement.Meniscal cartilage is fibrous with a good tensile strength, separating the bones of the knee and acting as a shock absorber. The meniscus can often be torn in forceful, twisting injuries.There are two c-shapedmenisci in the knee– the medial meniscus and the lateral meniscus.
Ligaments:There are four main ligaments which strap the bones of the knee joint together. They are the anterior cruciate ligament (ACL), the posterior cruciate ligament (PCL), the medial collateral ligament (MCL) and the lateral collateral ligament (LCL). The ligaments surrounding the knee joint offer stabilityby limiting movementsand, together with several menisci and bursae, protect the articular capsule.The knee joint consists of three “compartments” or sections:medial compartment (inner half of the knee),lateral compartment (outer half of the knee) and patellofemoral compartment (behind the knee).Pigmented villonodular synovitis (PVNS) is a rare proliferative process that affects the synovial joints, tendon sheaths, and bursae. In 1852, Chassaignac [3] reported the first case of a lesion in the flexor tendon sheath of the second and third fingers;this was subsequently reported in other joints. In 1941, Jaffe et al [4] coined the term “pigmented villonodular synovitis”; subsequently, Granowitzet al [5] expandedthe terminology, distinguishing the localized (LPVNS) and diffuse (DPVNS) forms from other synoviallesions. Recently, the World Health Organization (WHO) has defined PVNS and giant cell tumor to be equivalent terms [6].
The estimated incidence of PVNS ranges around 1.8 per million, It is usuallymonoarticular, affecting large joints. The knee is the most affected site (28%-70%), but cases in the hip, ankle, shoulder, and elbow are often observed [7].
The disease presents in two forms, localized or diffuse, and both types have similar appearance: a synovial membranecharacterized by inflammation and presence of hemosiderin deposits[8]. Microscopically, it is characterized by the presenceof lipid-laden macrophages, multinucleated giant cells, hemosiderin deposits,and proliferation of fibroblasts and stromal cells. LPVNS is characterized by discrete or pedunculated nodular lesions. In turn, DPVNS is the most common presentation, involving intra-articular tissues; it may have extra-articular extension, behaving as a chronic process [9].
In the last 100 years, little progress has been made regarding treatment. The goal of PVNS treatment is to remove all synovial tissue in order torelieve pain, decrease the risk of joint destruction, and prevent local recurrence. Several treatment optionshave been proposedfor this disease in cases of genicular involvement, ranging from observation and radical local surgery to total knee arthroplasty [10]. Pigmentedvillonodular synovitis (PVNS) is a benign, locally aggressive, neoplastic process of the joints,particularly the synovialmembrane or tendonsheaths. PVNS can affect various joints, with 1.8 new cases per million persons per year [11] Studies from the US and UK report a greater prevalence among males [12], whereas retrospective studies in China report a female predominance [13]. As do series from France, Portugal, and Italy.PVNS usually occurs in the age of 30s or 40s to 50s [14].
PVNS most commonly affects the large joints, such as the knees, hips, and ankles, There is a predilection for the knee, with rates as high as 74% PVNS often presents with pain and swelling of the joint [15]. Proper diagnosis is often delayed from 16 months to even 5 years owing to the nonspecific symptoms [16].
General objectives:
To study the outcome of arthroscopic synovectomy for diffuse pigmented villonodular synovitis of the knee in Sudanese patients.
Specific objectives:
To determine the functional and clinical outcomeof the knee post arthroscopic synovectomy.
Methodology: This is Observational retrospective hospital based study. All patientsunderwent arthroscopic synovectomy for diffuse pigmented villonodular synovitis of the knee.
Inclusion criteria:
- Patients of DPVNS of the knee treated with arthroscopic synovectomy.
- Follow up more than 18 months.
-Patients of all ages
-Both sexes
Exclusion criteria:
DPVNS other than the knee.
Patients treated with other surgical and non surgical modalities.
Total coverage for all patients due to rare cases. The datasheets from hospital statistical department availablejust for 12 patients.Data collection carried out by the principal investigator, from patient’s data sheets composed of:
•Lysholm knee scoring scale.
•International Knee Documentation Committee Score (IKDCS score).
The collected data was analyzed by using Statistical Package for the Social Studies Program SPSS, V. 24.0. IBM then presented as figures, frequency and percentage tables.
An ethical approval obtained from Sudan medical specialization board (SMSB).
Surgical Technique:
Arthroscopy was performed in supine position under spinal anaesthesia with a tourniquet applied high on the thigh. The knee was flexed 90 degrees by draping the leg over the edge of the operative table. Standard lateral and medialportals were made. The 30 degree arthroscope was used. The procedure done with complete synovectomy of the anterior compartment, posterior compartment and suprapatellar pouch. Anterior compartment: was started with medial part synovectomy, with applying valgus stress, medial submeniscal synovectomy was done. Then, the notch area and in between ACL and PCL. Then, the lateral part and also, lateral sub meniscal area with applying the figureof four positions. All were meticulously shaved and cleaned. The posterior compartment: (posteromedial, posterolateral and middle third septum) was approached using posteromedial portal. The suprapatellar pouch: was completely shaved through medial and lateral suprapatellar portals, including thelateral gutter, the popliteal hiatus area, and the medial gutter. The synovium was shaved till post capsule i.e. shaving the reddish synovium till reaching white area, and it is our suggestion that less damage post capsule causes less chance of extravasation and probably compartment syndrome. Portals were not sutured except the entrance of the drain. Arthroscopic electro-ablation was done just when an oozing vessel seen.In this study, synovectomy was performed using different shavers (5.5mm, 4.5mm,3.5mm shaver blades diameter, straight and curved) to ensure adequacy of debridement.
extension, behaving as a chronic process [9].
In the last 100 years, little progress has been made regarding treatment. The goal of PVNS treatment is to remove all synovial tissue in order torelieve pain, decrease the risk of joint destruction, and prevent local recurrence. Several treatment optionshave been proposedfor this disease in cases of genicular involvement, ranging from observation and radical local surgery to total knee arthroplasty [10]. Pigmentedvillonodular synovitis (PVNS) is a benign, locally aggressive, neoplastic process of the joints,particularly the synovialmembrane or tendonsheaths. PVNS can affect various joints, with 1.8 new cases per million persons per year [11] Studies from the US and UK report a greater prevalence among males [12], whereas retrospective studies in China report a female predominance [13]. As do series from France, Portugal, and Italy.PVNS usually occurs in the age of 30s or 40s to 50s [14].
PVNS most commonly affects the large joints, such as the knees, hips, and ankles, There is a predilection for the knee, with rates as high as 74% PVNS often presents with pain and swelling of the joint [15]. Proper diagnosis is often delayed from 16 months to even 5 years owing to the nonspecific symptoms [16].
General objectives:
To study the outcome of arthroscopic synovectomy for diffuse pigmented villonodular synovitis of the knee in Sudanese patients.
Specific objectives:
To determine the functional and clinical outcomeof the knee post arthroscopic synovectomy.
Methodology: This is Observational retrospective hospital based study. All patientsunderwent arthroscopic synovectomy for diffuse pigmented villonodular synovitis of the knee.
Inclusion criteria:
- Patients of DPVNS of the knee treated with arthroscopic synovectomy.
- Follow up more than 18 months.
-Patients of all ages
-Both sexes
Exclusion criteria:
DPVNS other than the knee.
Patients treated with other surgical and non surgical modalities.
Total coverage for all patients due to rare cases. The datasheets from hospital statistical department availablejust for 12 patients.Data collection carried out by the principal investigator, from patient’s data sheets composed of:
Lysholm knee scoring scale.
International Knee Documentation Committee Score (IKDCS score).
The collected data was analyzed by using Statistical Package for the Social Studies Program SPSS, V. 24.0. IBM then presented as figures, frequency and percentage tables.
An ethical approval obtained from Sudan medical specialization board (SMSB).
Surgical Technique:
Arthroscopy was performed in supine position under spinal anaesthesia with a tourniquet applied high on the thigh. The knee was flexed 90 degrees by draping the leg over the edge of the operative table. Standard lateral and medialportals were made. The 30 degree arthroscope was used. The procedure done with complete synovectomy of the anterior compartment, posterior compartment and suprapatellar pouch. Anterior compartment: was started with medial part synovectomy, with applying valgus stress, medial submeniscal synovectomy was done. Then, the notch area and in between ACL and PCL. Then, the lateral part and also, lateral sub meniscal area with applying the figureof four positions. All were meticulously shaved and cleaned. The posterior compartment: (posteromedial, posterolateral and middle third septum) was approached using posteromedial portal. The suprapatellar pouch: was completely shaved through medial and lateral suprapatellar portals, including thelateral gutter, the popliteal hiatus area, and the medial gutter. The synovium was shaved till post capsule i.e. shaving the reddish synovium till reaching white area, and it is our suggestion that less damage post capsule causes less chance of extravasation and probably compartment syndrome. Portals were not sutured except the entrance of the drain. Arthroscopic electro-ablation was done just when an oozing vessel seen.In this study, synovectomy was performed using different shavers (5.5mm, 4.5mm,3.5mm shaver blades diameter, straight and curved) to ensure adequacy of debridement.
Baseline characteristics of patients: This study includes 12 patients 8 (66.7%) males and 4 females, their mean age was 29 years (range:9 – 63 years), 2 (16.7%) cases were children (9 and 11years).
The Left limb was affected in 7 cases (58.3%) and the right one 5. Patients were followed up for a minimum of 18 months (range: 18 – 54 months). The clinical diagnosis was confirmed by magnetic resonance imaging and post-surgical pathologic examination. In these patients, the most frequent preoperative symptoms were joint effusion, true recurring hemarthrosis, and mild pain. In some cases, the presence of articular locking or pseudo locking was noticed.
Clinical and functional outcomes: All cases underwent arthroscopic synovectomy and evaluated before treatment and at the final follow up visit using the Lysholm score and International Knee Documentation Committee score (IKDCs).
No patient reports a history of previous knee surgery and all of them have an excellent knee function before the injury (IKDC score prior injury was 10 for 10 cases and 9 for 2 cases, (table1). There were no complications during or after the arthroscopic procedure. One patient (8.3%) displayed evidence of local recurrence (figure 1) after 30 months of synovectomy which was confirmed by MRI, and he developed the disease in the other knee. The limitation of joint motion, Lysholm knee joint function score and IKDC score were improved significantly postoperatively. Regarding paired sample statistics, the mean for the score preoperatively and postoperatively was improved from 54.9 to 77.9
There was a statistical association between preoperative and postoperative LYSHOLM and IKDC scores and recurrence, hence p- value =0.000.
8.3% of the study participants had history of recurrence, as shown in figure (1) below:
Figure 1: Recurrence history among study participants, n=12
No | Age years |
Gender | Follow- up months | R/L knee | IKDC prior injury | LYSHOL M score pre | LYSHOL M score post | IKCDs score % | Previous surgery |
Recur |
| 1 | 11 | Male | 36 | Right | 10 | 51 | 74 | 74. 7 | No | No |
| 2 | 63 | Male | 18 | Left | 9 | 51 | 80 | 79.3 | No | No |
| 3 | 17 | Male | 30 | Left | 10 | 38 | 56 | 56.3 | No | Yes |
| 4 | 30 | Male | 28 | Right | 10 | 60 | 80 | 81.6 | No | No |
| 5 | 26 | Male | 43 | Left | 10 | 57 | 70 | 71.2 | No | No |
| 6 | 42 | Female | 53 | Left | 10 | 62 | 90 | 90.8 | No | No |
| 7 | 28 | Female | 34 | Left | 10 | 49 | 78 | 78.7 | No | No |
| 8 | 21 | Male | 48 | Right | 10 | 72 | 87 | 87.3 | No | No |
| 9 | 19 | Male | 48 | Right | 10 | 53 | 69 | 70.1 | No | No |
| 10 | 54 | Female | 54 | Left | 9 | 52 | 75 | 74.7 | No | No |
| 11 | 9 | Female | 39 | Right | 10 | 47 | 90 | 91.9 | No | No |
| 12 | 30 | Male | 36 | Left | 10 | 69 | 86 | 86.2 | No | No |
LYSHOLM: Maximum possible points =100
IKDC s: Maximum possible points =87
IKDC Score: = (sum of item /maximum score) x 100 = ……. %
IKDC prior injury: Functionof the knee before the illness, scores of 0 to 10 with 10 being normal,excellent function and 0 being the inabilityto perform any of the usual daily activities which may include sport.
Table (1): General data of the patients
PVNS is a rare diseaseof which the diagnosis is often delayed.This may result in the extension of the disease and the involvement of the adjacent soft and bone tissues. The disease may become gradually more aggressive and recurrence occurs frequently. PVNS must be considered in patients who present with joint effusion and develop contracture, and their examinations should be performed accordingly. If possible, the probability of recurrence should be minimizedthrough aggressive radicalsynovectomy. There is no definitive treatment method. The mainstay of treatment has been surgical or arthroscopic synovectomy. Arthroscopic synovectomy has reduced morbidity and is well tolerated by patients. Open surgical synovectomy causes stiffness and pain and has a long recovery time, mainly after procedures involving the knee joint. However, the relapse rates of both approaches are reported to be relatively high, ranging between 8% and 46%.
The common presenting patients complains in this study were tolerable knee pain and swelling with or without one or more of the followings: limp, instability, locking or catching sensation. Twelve patients who had a diagnosis of DPVNS of the knee were followed for an average of 3years (range,1.5 to 4.5 years) after complete arthroscopic synovectomy. In the present study majority, 66.7% of the participants were males, (with male to female ratio2:1), Keyhani S et al stated that male to female ratio was 2.5:1 [18]. Which is supports our findings, in contrast, HoudekMT, et al study which reported 58% were females and42% were males [18]. Mollon B et al study also reportedthe predominant of females (80%) [17], this variation may due to the small sample size included in the study.
16.7% of our study participants were in their 30 years old and the same percentage were children (9,11 years), with age range from 9-63 years old (average age 29 years) similar findings obtained by Gouin F et al, reported average age of 33 years [19], and De Visser et al revealed mean age was 32 (range 12–72) years [20].
Regarding the LYSHOLM score and IKCDS: all patients scoring better after the operation, the mean LYSHOLM score was improved from 54.9 preoperatively to77.9 postoperatively which is significant. Keyhani S et al revealed both Lysholm score and IKDC scores were significantly improved in all study participants [18].
In this study, recurrence was reported in one patient (8.3%) of the study participants, while a higher recurrence percentage reported by Mollon B et al study was 13 % of patientsexperienced symptomatic diseaserecurrence [17]. While Keyhani S et al reported no cases of clinical recurrence, infection, joint stiffness, or neurovascular lesionswere observed [18]. In the study of Kotwal et al., it was noted that the factors contributing to the risk of recurrence were incomplete excision, mitotic activity and bone involvement [21].
The final common pathway of DPVNS of the knee leads to total joint destruction, which eventually leads to the need for joint replacement. This should be avoided,if possible, especially in these young and healthy patients.
The results of this study proved that: Arthroscopic synovectomy is ideal for treating DPVNS with good clinical and functional outcomeand low recurrence rate.It hasthe advantages of minimal complications, minimal invasion and fast post-operative recovery.All abnormal synovialtissue must be eradicated, therebyremoving the risk of further jointdestruction and recurrence. Although DPVNS is a rare conditionin pediatric patients,it should be considered in differential diagnosis of any arthritis in children.
Recommendations:
The study recommends that: To considerusing arthroscopic synovectomy as good option for treatment of diffuse pigmented villonodulor synovitis of the knee. To emphasize that early diagnosis and well done arthroscopic synovectomy gives good clinical outcome with low recurrence rate. Further researches with large samples comparing arthroscopic synovectomy with other modalities of treatment required.
Compliance with ethical standards
Acknowledgments: Department of orthopedic HagelsfiHospital who contributed by any mean to the success of this study.
Conflict of interest:
None to declare Statement of informed consent
Approval of this study was obtained from our institutional review board
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