Pigmented villonodular synovitis of knee diagnosis

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 slow growing, benign, locally invasive synovial tumor.

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

PVNS presents with acute episododes of pain and swelling. Patients may have mechanical symptoms (locking and catching). When synovial fluid is aspirated from the joint, it is hemorrhagic and dark brown. A biopsy is diagnostic. The differential diagnosis is primarily to separate PVNS from rheumatoid arthritis.

PVNS usually presents as a monoarticular hemarthrosis, 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 recurrent hemarthrosis and the aspirate may be of normal color.

MRI is can be diagnostic. The most characteristic feature of PVNS on MRI is the presence of intraarticular nodular masses of low signal intensity on T1, T2-weighted, and proton-density-weighted images.

Treatment is usually arthroscopic synovectomy. This is indicated for the nodular form or for the inactive form of diffuse disease. Some authors advocate the use of low dose radiation therapy following arthroscopic synovectomy. The combination therapy has been effective in reducing symptoms of pain and edema, and in improving overall function of patients. Open synovectomy is the treatment of choice for patients with the active form of diffuse disease.

The recurrence rate is relatively high and therefore both anterior and posterior open synovectomy is required. Total knee replacement is indicated for PVNS with joint destructive changes.

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