Pigmented villonodular synovitis (PVNS) is a rare benign disease of the synovium of joints and tendon sheaths, which may be locally aggressive. We present 18 patients with diffuse-type PVNS of the foot and ankle followed for a mean of 5.1 years (2 to 11.8). There were seven men and 11 women, with a mean age of 42 years (18 to 73). A total of 13 patients underwent open or arthroscopic synovectomy, without post-operative radiotherapy. One had surgery at the referring unit before presentation with residual tibiotalar PVNS. The four patients who were managed non-operatively remain symptomatically controlled and under clinical and radiological surveillance. At final follow-up the mean Musculoskeletal Tumour Society score was 93.8% (95% confidence interval (CI) 85 to 100), the mean Toronto Extremity Salvage Score was 92 (95% CI 82 to 100) and the mean American Academy of Orthopaedic Surgeons foot and ankle score was 89 (95% CI 79 to 100). The lesion in the patient with residual PVNS resolved radiologically without further intervention six years after surgery. Targeted synovectomy without adjuvant radiotherapy can result in excellent outcomes, without recurrence. Asymptomatic patients can be successfully managed non-operatively. This is the first series to report clinical outcome scores for patients with diffuse-type PVNS of the foot and ankle. Cite this article: Bone Joint J 2013;95-B:384–90

Pigmented villonodular synovitis (PVNS) is a rare benign neoplastic proliferation of synovial tissue which is typically localised and usually responds well to surgery and/or radiotherapy. We present a case of unusually aggressive of PVNS of the hip in a 73-year-old woman

1. The literature on pigmented villonodular synovitis has been reviewed and a series of eighty additional cases is reported. 2. The condition usually presents either as a nodule in a finger or knee, or as a diffuse lesion in a knee. The lesions, although benign, sometimes erode or invade the tissue of adjacent bones. 3. Distinction from malignant synovioma can be made on the basis of the macroscopic appearance of the lesion at operation (relationship to joints or tendon sheaths: villonodular appearance: pigmentation), and by histological examination. 4. Treatment of the nodular form by excision is satisfactory but extensive synovectomy for diffuse lesions of the knee gives poor results. 5. The etiology of pigmented villonodular synovitis is unknown, but it appears to be a self-limiting process, possibly inflammatory in nature

Pigmented villonodular synovitis (PVNS) is a rare proliferative process of the synovium which most commonly affects the knee and occurs in either a localised (LPVNS) or a diffuse form (DPVNS). The effect of different methods of surgical synovectomy and adjuvant radiotherapy on the rate of recurrence is unclear. We conducted a systematic review and identified 35 observational studies in English which reported the use of surgical synovectomy to treat PVNS of the knee. A meta-analysis included 630 patients, 137 (21.8%) of whom had a recurrence after synovectomy. For patients with DPVNS, low-quality evidence found that the rate of recurrence was reduced by both open synovectomy (odds ration (OR) = 0.47; 95% CI 0.25 to 0.90; p = 0.024) and combined open and arthroscopic synovectomy (OR = 0.19, 95% CI = 0.06 to 0.58; p = 0.003) compared with arthroscopic surgery. Very low-quality evidence found that the rate of recurrence of DPVNS was reduced by peri-operative radiotherapy (OR = 0.31, 95% CI 0.14 to 0.70; p = 0.01). Very low-quality evidence suggested that the rate of recurrence of LPVNS was not related to the surgical approach. . This meta-analysis suggests that open synovectomy or synovectomy combined with peri-operative radiotherapy for DPVNS is associated with a reduced rate of recurrence. Large long-term prospective multicentre observational studies, with a focus on both rate of recurrence and function, are required to confirm these findings. Cite this article: Bone Joint J 2015;97-B:550–7

Introduction: Pigmented villonodular synovitis is an uncommon, benign, proliferative, neoplastic process of the synovial membrane presumed to be of histiocytic origin and is likely to cause diagnostic dilemma. We present 4 cases with varied presentations in the form of increasing groin pain, inguinal mass, co-existing osteoarthritis which were subsequently confirmed to have PVNS. Methods and results: Clinical records and imaging modalities of 4 patients with histologically confirmed Pigmented villonodular synovitis of the hip, accrued from Scottish Bone Tumour Registry between 1969 and 2000 were reviewed. Discussion: PVNS of the hip is an important differential diagnosis when osteoarthritis is associated with atypical clinical picture or lytic lesions. Although it remains confined to the joint, soft tissue masses extending beyond the capsule in to retroperitoneum or anterior and posterior aspects of hip have been reported as shown here. Radiographs in early stages are normal or include a concentric joint space narrowing. MR is an important non-invasive modality for surgical planning and to define the size and extent of the lesion, recurrence, delineating between synovial proliferations and periarticular or intra-abdominal organs. The role of arthroscopy, both diagnostic and therapeutic, is rapidly emerging, although, it has its own limitations. A carefully performed total excision often prevents recurrence as can be seen in this series

1. Five cases of pigmented villonodular synovitis with associated lesions within bone are recorded, two in the hip, two in the knee and one in the elbow. 2. The mode of formation of these intraosseous lesions is explained and methods of treatment are discussed

Torsion and subsequent ischaemia is a well-recognised cause of symptoms and morbidity in general surgery. We present three cases of solitary pigmented villonodular tumours of the knee which were found to have undergone torsion. We believe these to be the first intra-articular tumours in which torsion has been reported

A case of unusually extensive pigmented villonodular synovitis of the wrist with involvement of bone, particularly of the distal end of the radius, is reported. The clinical and radiographic evidence suggested a diagnosis of primary bone tumour, possibly a giant-cell tumour with sarcomatous transformation

1. Synovitis was induced in the hip joints of fifty-six rabbits by the intra-articular injection of surgical talc. The opposite hip joint and eleven suitable"sham" operations served as controls. 2. The results in the hips injected with talc were as follows. Widening of the medial joint space and sometimes acetabular changes were seen; enlargement of the femoral head and neck in two planes was found, with, in most cases, flattening of the superior aspect of the head; there was thickening of the joint cartilage and sometimes deformity of the capital epiphysis; thickening of the cartilage was the main cause of the coxa magna, cervix magna and ischium magnum. 3. The embryology, micro-anatomy and development of the hip joint is reviewed and attention is drawn to the configuration of the layers of germinal cartilage cells. The effect of an induced synovitis in producing hyperplasia of the joint cartilage, incongruity of the articulating surfaces and subsequent subluxation is discussed

Fourteen cases of pigmented villonodular synovitis (PVNS) of the foot and ankle (between January 1957 and December 1999) accrued from Scottish bone tumor registry are presented with an average follow-up of 4.6 years aimed to analyse the clinical, radiological and histopathological features in order to investigate the clinical behaviour of PVNS in the foot and ankle, and to determine the factors influencing recurrence. The mean age was 26.4 years (range, 8 to 52 years). There were eight females and six males. The mean delay in presentation was 10.3 months. The anatomical sites were foot phalanges (n=2), tarso-metatarsal area (n=3) and hindfoot (n=9). Hindfoot cases comprised of 6 extra-articular soft tissue swelling around the ankle, two affecting the ankle joint and one involving the subtalar joint. There were eight (57.1%) cases presented with painless lump, five (35.7%) patients with painful lumps and one case with a lump associated with toe deformity. The clinical suspicion were ganglion, gout, soft tissue swelling (? tumour) and exostosis. Peri-articular tissue invasion and cortical infiltration was found in one third on plain films. CT scan showed multiple lytic lesions and MRI scan findings were consistent with extensive low signal soft tissue hypertrophy and bone erosion, two of which were suspected with synovial sarcoma. Excision of the lump was done in 4 cases with a complete recovery. Foot phalangeal PVNS were treated with toe amputation through metatarsophalangeal joint and no cases had recurrence of the lesion. There were two recurrences affecting the ankle and the subtalar joint. Recurrent ankle PVNS was treated with re-exploration, open synovectomy, curettage of talar cyst and autogenous bone grafting. The second recurrent case involving subtalar joint was treated with re-excision and curettage. Both recurred cases were primarily treated with intralesional excision for their diffuse variety. There were no recurrences in the nodular variety. Complete recovery was achieved in 85.7% case (12/14). A high index of suspicion for PVNS should be observed for cases presenting with a painless or painful mass in the foot and ankle region. Complete recovery can be achieved in the majority by complete excision. Toe amputation may be considered for foot phalangeal PVNS

After knee replacement, therapy resistant, chronic synovitis is common and leads to effusion and pain.

A cohort of 55 patients with 57 knee replacements and chronic synovitis underwent radiosynoviorthesis. In summary, 101 joints were treated using 182±9 MBq of 90Y-citrate. The number of radiosynoviorthesis ranged from 1 to 4 (53%, 21%, 23%, and 4%). Every patient received a 99mTc-MDP scintigraphy before and three months after every radiosynoviorthesis. Follow-up ranged from 5.7 to 86.7 months. For qualitative analysis, an four steps scoring was used (0 = no response or worsening, 1 = slight, 2 = good, 3 = excellent response). For quantification, the uptake was determined within the 99mTc-MDP scintigraphy soft tissue phase before and after therapy.

At the end of long-term follow-up 27% of patients have an excellent, 24% good, 30% slight and 20% no response. The duration of response was 7.5±8.3 months (maximum 27 months). In repeated treatment, the effect after the first therapy was lesser than in patients who received a single treatment in total. However, three months after the last radiosynoviorthesis, patients with repeated treatment showed a similar effectiveness than single treated patients. At the end of long-term follow-up, patients with repeated radiosynoviorthesis had a higher effectiveness at similar duration response. In the 99mTc-MDP scan 65% of patients showed a reduction of uptake. When comparing subjective and objective response 78% of patients showed a concordance in both, symptoms and scintigraphy. Pilot histological analysis revealed that the synovitis is triggered by small plastic particles.

Radiosynoviorthesis is effective in patients with knee replacement and chronic synovitis. It shows good subjective and objective response rates and long response duration. Repeated treatment leads to a stronger long-time response. The chronic synovitis is caused by plastic particles, which result from the abrasion of the polymeric inlay of endoprothesis.

Introduction:. Pigmented Villonodular Synovitis (PVNS) is a rare inflammatory disorder of the synovium, bursa and tendon sheath. The objective of this study was to evaluate the long-term outcomes and morbidity associated with operative management of PVNS of the hand. Methods:. Histological databases were retrospectively interrogated. All patients between 2003–2008 with confirmed PVNS of the hand were included in the study. Results:. 15 patients were identified with PVNS of the hand. 10/15 (67%) patients had growths over the digits and 4/15 (26%) involved the thumb with two of these involving the IPJ. 6/10 (60%) of cases with digital involvement arose from a joint (4 PIPJ & 2 MCPJ). Nodular growth was the most common cause for referral. Average length of symptoms prior to presentation was 2.4 years (6 months–5 years). 6/15(40%) of cases had pre-operative MR scans with 100% radiological and histological correlation. Marginal excision was the operative intervention of choice. There was no evidence of bony destruction in any cases. 4/15(26.7%) patients developed a temporary neurapraxia. 4/15 (26.7%) had recurrence at 5 years of which 3/10 had amputations p=0.008. One amputation was due to digital artery injury, two due to recurrence. All patients reported stiffness post-operatively. No functional deficit was recorded. Conclusions:. MR imaging is useful in radiological confirmation of PVNS and is both sensitive and specific making routine biopsy unnecessary. PVNS joint destruction appears rare in such patients although excision carries a high morbidity and risk of recurrence. Those with recurrence are significantly more likely to undergo amputation

Synovitis in the subacromial bursa (SAB) and the gle-nohumeral joint (GHJ) is often seen in rotator cuff diseases. In order to clarify its significance, following studies were conducted. The mRNA expression levels of IL-1B, sIL-1ra and icIL-1ra and the amount of substance P in the SAB synovium were correlated with the degree of shoulder pain. The cytokine-mRNAs in the GHJ synovium expressed more significantly in full-thickness tears (perforating tears) than in non-perforating tears. Biochemical markers (MMP-1, MMP-3) in the GHJ fluid were significantly higher in massive cuff tears than in smaller tears. These findings suggest the possibility that SAB and GHJ synovitis in rotator cuff diseases are associated with shoulder pain and the development of glenohumeral arthropathy, respectively

Pigmented villonodular synovitis is a monoarticular proliferative process most commonly involving the synovium of the knee joint. There is considerable debate with regards to diagnosis and effective treatment. We present our experience of managing PVNS of the knee joint over a 12 year period. Twenty-eight patients were reviewed. MRI was used to establish recurrence in symptomatic patients rather than routine screening and to identify posterior disease prior to surgery. Eight patients had localised disease and were all treated with open synovectomy and excision of the lesion, with no evidence of recurrence. Twenty patients had diffuse disease, eight treated arthroscopically and twelve with open total synovectomy. Nineteen patients (95%) had recurrence on MRI, however, only five (25%) had evidence of clinical recurrence. There were no significant complications following arthroscopic synovectomy. Open synovectomy, in contrast, was associated with three wound infections and two thrombo-embolisms. Three patients had Complex regional pain syndrome. We believe diffuse disease should be treated with arthroscopic synovectomy which is associated with minimal morbidity and can be repeated to maintain disease control. Radiotherapy is helpful in very aggressive cases. TKR was used when there was associated articular erosion

Purpose: Pigmented Villonodular Synovitis (PVNS) is an uncommon presentation characterised by hyperplastic synovium, bloody effusions and bone erosions. Incompletely resected localised and diffuse lesions have a high recurrence rate. The management of recurrent lesions depends on the expertise of the surgeon and severity of the lesion. The imaging characteristics of PVNS and experience of British knee surgeons in managing these lesions is presented in our study. Methods: A postal questionnaire was sent to 100 knee surgeons of the British Association of Surgeons of the Knee (BASK) with questions relating to their experience in managing localised and recurrent PVNS. The options included either arthroscopic or open synovectomy with or without radiotherapy, radical excision or referral. Results: 74 responses were included in the study. 73 out of the total cohort of 74 surgeons (98.7%) had seen less than 5 presentations in their career. Localised lesions were treated primarily by arthroscopic synovectomy [N=58(78.4%)] or open synovectomy [N=12(16.2%)] with radiotherapy being utilised in 4 lesions (5.4%). For local recurrence the management was arthroscopic [N=26(35.1%)] and open [N= 19(25.7%)] synovectomy. Radiotherapy was used in 18 (24.3%) of patients with localised recurrence and 8 (10.8%) of were referred to specialist units. Infiltrating lesions were treated with open synovectomy and radiotherapy [N=22(29.7%)] and 20 cases [27.02%] were referred to specialist units. Imaging of PVNS and Conclusions: The role of imaging is invaluable in early diagnosis and treatment due to limited experience in managing such presentations. Routine radiography and Computerised Axial Tomography (CT scan) often demonstrate non-marginal pressure erosions with sclerotic margins as well as nodular soft tissue masses. Sonography shows non-specific focal or nodular synovial thickening with increased flow on colour doppler. Magnetic Resonance imaging characteristics of PVNS are nodular, synovial masses which are low signal on T1-weighted and T2-weighted imaging

The opposable thumb is one of the defining characteristics of human anatomy and is involved in most activities of daily life. Lack of optimal thumb motion results in pain, weakness, and decrease in quality of life. First carpometacarpal (CMC1) osteoarthritis (OA) is one of the most common sites of OA. Current clinical diagnosis and monitoring of CMC1 OA disease are primarily aided by X-ray radiography; however, many studies have reported discrepancies between radiographic evidence of CMC1 OA and patient-related outcomes of pain and disability. Radiographs lack soft-tissue contrast and are insufficient for the detection of early characteristics of OA such as synovitis, which play a key role in CMC OA disease progression. Magnetic resonance imaging (MRI) and two-dimensional ultrasound (2D-US) are alternative options that are excellent for imaging soft tissue pathology. However, MRI has high operating costs and long wait-times, while 2D-US is highly operator dependent and provides 2D images of 3D anatomical structures. Three-dimensional ultrasound imaging may be an option to address the clinical need for a rapid and safe point of care imaging device. The purpose of this research project is to validate the use of mechanically translated 3D-US in CMC OA patients to assess the measurement capabilities of the device in a clinically diverse population in comparison to MRI.

Four CMC1-OA patients were scanned using the 3D-US device, which was attached to a Canon Aplio i700 US machine with a 14L5 linear transducer with a 10MHz operating frequency and 58mm. Complimentary MR images were acquired using a 3.0 T MRI system and LT 3D coronal photon dense cube fat suppression sequence was used. The volume of the synovium was segmented from both 3D-US and MR images by two raters and the measured volumes were compared to find volume percent differences. Paired sample t-test were used to determine any statistically significant differences between the volumetric measurements observed by the raters and in the measurements found using MRI vs. 3D-US. Interclass Correlation Coefficients were used to determine inter- and intra-rater reliability.

The mean volume percent difference observed between the two raters for the 3D-US and MRI acquired synovial volumes was 1.77% and 4.76%, respectively. The smallest percent difference in volume found between raters was 0.91% and was from an MR image. A paired sample t-test demonstrated that there was no significant difference between the volumetric values observed between MRI and 3D-US. ICC values of 0.99 and 0.98 for 3D-US and MRI respectively, indicate that there was excellent inter-rater reliability between the two raters.

A novel application of a 3D-US acquisition device was evaluated using a CMC OA patient population to determine its clinical feasibility and measurement capabilities in comparison to MRI. As this device is compatible with any commercially available ultrasound machine, it increases its accessibility and ease of use, while proving a method for overcoming some of the limitations associated with radiography, MRI, and 2DUS. 3DUS has the potential to provide clinicians with a tool to quantitatively measure and monitor OA progression at the patient's bedside.

Background: The surgical treatment of extensive diffuse Pigmented Villonodular Synovitis (PVNS) of large joints alone, is unsatisfactory, with high rates of local recurrence. Postsynovectomy adjuvant treatment with external beam radiation therapy or intraarticular injection of Yttrium90 (Y90) yielded better results. Aims: Experience with 10 cases treated with debulking surgery followed by intraarticular injection of Y90 is reported. Methods: Between January 1989 and June 1998, 10 patients (8 males and 2 females aged 15049 years) with extensive diffuse PVNS were treated. In 6 patients the knee joint, in 3 patients the ankle joint, and in 1 patient the hip joint were involved. The 10 patients underwent 15 operations, 1 patient had 3 surgical procedures, and 3 patients underwent 2 surgeries (interval between re-operations for local recurrence were 2–4 years). All patients had an intraarticular injection of 15–25 mCi of Y90, 6–8 weeks after the last surgery. Results: Follow up time was 2.5–12 years (mean 6 years). All patients were followed by repeated computerized tomography (CT) scans, magnetic resonance imaging (MRI), plain X-ray films and bone scans semi-annually. In 9 patients no evidence of disease and no progression of bone or articular destruction have been noted. In 1 patient stabilization of disease was achieved with no further evidence of bony or articular damage. No complications were noticed after surgery, nor after the intraarticular Y90 injection. Conclusions: A combination of debulking surgery with intraarticular injection of Y90 for extensive diffuse PVNS of major joints is a reliable way of treatment with good results

Introduction: Diffused pigmented villonodular synovitis (PVNS) is a locally aggressive lesion for which surgery provides only marginal resection. An adjuvant treatment modality is therefore required to prevent local tumor recurrence. The authors describe their experience with intra-articular injection of Yttrium. 90. (Y. 90. ), a radioisotope, as an adjuvant for tumor resection. Materials and Methods: Between 1989 and 2002, 20 patients with diffuse PVNS were treated with post-operative, intraarticular injection of Y. 90. There were 15 male and 5 female patients who ranged in age from 13 to 67 years (mean, 35 years). Anatomic locations of the affected joints included: knee – 15, ankle – 4, hip – 1. Tumor resection was initially done in all patients: 13 patients required open arthrotomy, the remaining 7 underwent arthroscopic tumor resection. Ten patients were referred for treatment after having operation for a local tumor recurrence: 6 patients had one, 2 had two, 1 had three, and the remaining one had five local recurrences. Six to eight weeks after surgery, intraarticular injection of 15–25 mCi of Y. 90. was done. These procedures were conducted in the operating room under local anesthesia and fluoroscopic guidance. All patients were followed for a minimum of two years (range, 25–168 months; mean, 65 months). Results: Following Y. 90. injection, all patients reported mild pain around the affected joint. This pain was well controlled with the use of NSAID’s and typically resolved within a few days or weeks. Three patients had superficial skin inflammation and associated blisters around the site of injection, probably the result of Y. 90. effect on the soft-tissues. All were treated conservatively with complete resolution of their symptoms. All patients gained their pre-injection range-of-motion within 4–6 weeks. At the most recent follow-up, five patients had transient post-radiation skin changes (discoloration of the skin and dry and scaly skin) and local recurrence occurred in only one patient (5%) with PVNS around the knee; additional Y. 90. injections were unsuccessful and he eventually underwent knee arthrodesis. Conclusion: Y. 90. injection is a reliable adjuvant for surgery in the management of diffused PVNS. Local tumor control and good function, associated with only mild morbidity are achieved in the majority of the patients

Abstract