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Year |
2001 |
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Question Number |
131. |
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Category |
Select |
Question
A 23-year-old woman has had chronic swelling in the ankle for the past year with no injury. Plain radiographs are normal. At ankle arthroscopy, the articular surfaces appear normal. The synovial tissue is inflamed and friable; a biopsy specimen of the synovium is shown in Figure 39. What is the most likely diagnosis?
1- Tuberculosis
2- Synovial cell sarcoma
3- Pigmented villonodular synovitis
4- Rheumatoid arthritis
5- Chrondrocalcinosis
Figures
Answer (click for answer)
Preferred Answer: 3
The history is that of a young person with a chronic 1 year history of swelling. The biopsy shows a multinucleated giant cell.
VNS shows exuberant proliferation of villi and nodules. The synovium is rust colored or brown because of hemosiderin deposits. Patients have pain; swelling and rust colored or blood effusion. Histologic features include pigmented synovial histiocytes, foam cells (lipid laden histiocytes) and multinucleated giant cells. Treatment is surgical excision of the synovium.
It has been most commonly described in the knee and hip, with most series reporting <5% occurrence in the foot and ankle. The first reference presents six patients with pigmented villonodular synovitis of the foot and ankle that were treated. Four of the patients had not been previously diagnosed, and two patients presented with recurrent disease. All six were women. Two patients’ disease presented isolated to the ankle joint. The other four involved more than one joint: subtalar joint and midfoot in two, and the metatarsal region in two. The histology of the primary and recurrent lesions did not differ. The recurrent lesions were more diffuse and locally destructive. Surgical management ranged from simple excision to synovectomy to Lis franc amputation.
The second reference reviewed the cases of eighty-one patients with pigmented villonodular synovitis and giant-cell tumor of the tendon sheath. The average duration of symptoms prior to consulting a physician was twenty-seven months. The lesion was slow-growing, was located in one joint or tendon sheath, and usually was asymptomatic in a finger or thumb but painful in a knee or toe. Twenty-nine per cent of the finger or thumb lesions and 21 per cent of the knee lesions that were followed recurred. Approximately 70 per cent of the radiographs showed abnormalities that ranged from soft-tissue swelling to bone erosion. Six lesions were incidental findings during arthrotomy for some other lesion. The histological characteristics of the solitary nodular, multiple nodular, and diffuse lesions suggested that they have a common histogenesis that is characterized by proliferation of fibroblastic or histiocytic mesenchymal cells, or both, beneath the synovial or tenosynovial lining cells, and by collagen production. Foam cells and iron deposits appear to be secondary changes and are usually seen in the periphery of the expanding nodules. The centrifugal growth pattern and the distinct differences between the lesional tissue and the adjacent hyperplastic synovial tissue suggest that pigmented villonodular synovitis is a true neoplastic process.
Reference: Ghert M, Scully SP, Harrelson JM: Pigmented villonodular synovitis of the foot and ankle: A review of six cases. Foot Ankle Int 1999;20:236-330.
Rao AS, Vigorita VJ: Pigmented villonodular synovitis (giant cell tumor of the tendon sheath and synovial membrane): A review of eighty-one cases, JBJS Am 1984;66:76-94.