Diagnosis of pigmented villonodular synovitis of knee

by Nathan Wei, MD, FACP, FACR

Nathan Wei is a nationally known board-certified rheumatologist and author of the Second Opinion Arthritis Treatment Kit. It's available exclusively at this website... not available in stores.

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Pigmented villonodular synovitis (PVNS) is a benign, locally invasive tumor of the synovium.

The most common location is the knee. It is also found in other joints including the hip, ankle, and elbow.

PVNS presents with acute attacks of pain and swelling. Patients may have mechanical symptoms such as locking. Aspirated joint fluid is bloody and dark brown in color. A biopsy is diagnostic. The differential diagnosis is inflammatory forms of arthritis such as rheumatoid arthritis.

PVNS usually presents as a bloody effusion affecting a single joint, and may exist in a nodular or a diffuse form. A diffuse mass may be present on exam. Erosions are seen on x-ray. The nodular form is less common and is not as destructive as the diffuse form of PVNS. It may cause a recurrent bloody effusion but the effusion may also be normal in appearance.

MRI is usually diagnostic or at the very least highly suggestive of the disorder. Other conditions that mimic PVNS on MRI are consider are hemophilic arthropathy, soft-tissue sarcoma, fibromatosis, synovial chondromatosis, septic arthritis, and rheumatoid arthritis.

Microscopically, PVNS has a characteristic and diagnostic picture consisting of phagocytic histiocyte-like cells, lipid-filled foam cells, and multinucleated giant cells along with hemosiderin-laden cells.

Treatment is arthroscopic synovectomy for the local nodular form. Some advocate the use of low dose radiation therapy following arthroscopic synovectomy. Open synovectomy is the recommended for patients with the active form of diffuse disease.

The recurrence rate is high and therefore extensive synovectomy is required. Total knee replacement is indicated for PVNS with joint destructive changes.

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