Review Question - QID 4482

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Pigmented Villonodular Synovitis Studies Arthrocentesis QID: 4482 (OBQ12.122)

QID 4482 (Type "4482" in App Search)

A 38-year-old male presents with right knee pain that is progressively worsening over the past 5 months. He is unable to perform his occupation as a construction worker and had to stop playing tennis. He denies constitutional symptoms. The patient had an effusion that was drained by his primary care provider 2 months ago and he took a picture of it on his cell phone to show you (Figure A). On examination there is an effusion in the knee and there is tenderness along the parapatellar region. He has full knee extension and flexion, but open chain knee extension exacerbates his pain. His Lachman examination demonstrates 3 mm of anterior translation with an endpoint noted. A radiograph is shown in Figure B and MRI images are shown in Figure C and D. What is the next most appropriate step in management?

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Neoadjuvant chemotherapy, surgical resection, adjuvant chemotherapy

209/5504

Neoadjuvant external beam radiation, wide surgical resection, and adjuvant chemotherapy

190/5504

Arthroscopic or open resection of the lesion

87%

4768/5504

Observation with serial radiographs and physical therapy for lower leg and core strengthening

140/5504

Arthroscopic or open plica removal and lateral retinacular release

149/5504

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The clinical and radiographic presentation is most consistent with a diagnosis of pigmented villonodular synovitis (PVNS).

PVNS is a benign condition which can predispose patients to early arthritis. Biopsy specimens often show nodular pattern of giant cells, diffuse proliferation of mononuclear cells of synovial- or histiocytic-type, and hemosiderin. Treatment for symptomatic PVNS includes synovectomy. Often this can be accomplished arthroscopically in the anterior portion of the knee with localized PVNS, but the synovial nodules in the posterior knee often require a formal posterior arthrotomy to completely remove and decrease recurrence rates.

Damron et al. present a level 5 review article discussing how musculoskeletal tumors may originally mimic a traumatic condition. Physicians can misdiagnosis trauma or athletic injury and inappropriately render invasive treatment that leads to a delay in diagnosis or an inappropriate invasive procedures that results in extension of the tumor.

Figure A demonstrates a bloody aspirate which can be seen with PVNS. Figure B shows an opacity that is obscuring the normal Hoffa's fat pad. Figures C and D are sagittal MRI sequences demonstrating a localized intermediate-signal intensity soft-tissue mass in the anterior compartment with prominent diffuse enhancement. Illustration A shows an arthroscopic image that demonstrates brownish villonodular fronds floating in the joint consistent with PVNS. Illustration B demonstrates a PVNS specimen resected through an arthrotomy that reveals the brownish appearance caused by hemosiderin.

Incorrect Answers:
Answer 1: Neoadjuvant chemotherapy, surgical resection, adjuvant chemotherapy can be used to treat osteosarcomas.
Answer 2: Neoadjuvant external beam radiation, wide surgical resection, and adjuvant chemotherapy is not indicated in PVNS.
Answer 4: Observation with serial radiographs can be implemented for enchondromas or osteochondromas and lower leg/core strengthening is indicated for patellofemoral pain syndrome.
Answer 5: There is no clinical evidence that the patients symptoms would improve with plica excision or lateral retinacular release as this is not the appropriate treatment for PVNS.

ILLUSTRATIONS: