Outcomes of arthroscopic management for pigmented villonodular synovitis of the hip

Arthroscopic Management of Pigmented Villonodular Synovitis of the Hip: A Systematic Review

Background/Objectives: Pigmented villonodular synovitis (PVNS) is a benign proliferation of synovial tissue that can cause joint damage. The hip, although less commonly affected than the knee, presents a challenging diagnosis and treatment, with magnetic resonance imaging (MRI) as the gold standard for detection. Surgical excision, arthroscopic or open, is the main treatment approach, but there is no consensus on the best strategy for the hip. The aim of this systematic review is to evaluate the clinical outcomes, complications, and revision rates associated with arthroscopic hip surgery for PVNS. Methods: A systematic review was performed following the PRISMA guidelines. Relevant studies were identified by searching four databases: PubMed, Scopus, Embase, and Medline. Selected articles were evaluated according to the criteria of levels of evidence (LoE). For retrospective studies, the Coleman Methodology Score (mCMS) was used. This systematic review was registered with the International Prospective Register of Systematic Reviews. Results: Six studies satisfied the criteria; these involved 77 patients (48% male, 52% female) with a mean age of 26.4 years and a mean follow-up of 54.3 months. MRI and biopsy confirmed the diagnoses, and arthroscopic synovectomy was the primary treatment. Success rates ranged from 80% to 100%, with a recurrence rate of 7.8%, 1.3% requiring revision surgery, and eight (10.4%) patients in three studies reporting conversion to THA. Complications included mild effusions and residual synovitis. All patients who underwent a subsequent total hip arthroplasty were affected by advanced osteoarthritis. Conclusions: Our systematic review reveals that the use of hip arthroscopy in diagnosing and treating PVNS has shown satisfactory results without increasing the risk of recurrence or complications and can return patients to their former activity levels, provided their preoperative osteochondral status is good and there is early management of PVNS of the hip joint.

Arthroscopic Excision of Pigmented Villonodular Synovitis of the Trochanteric Bursa

Trochanteric bursitis is a common disorder affecting middle-aged adults and usually presents with lateral-based hip pain and swelling. It usually responds to conservative measures, including adductor stretching, abductor strengthening, and select injections of corticosteroid or platelet-rich plasma. For refractory cases, excision, open or arthroscopic, is usually recommended. We observed a 55-year-old woman who had lateral hip pain and longstanding swelling consistent with refractory trochanteric bursitis. Her persistent symptoms, coupled with atypical findings on imaging, prompted an arthroscopic evaluation. Arthroscopic examination of the peritrochanteric space revealed a fulminant bursal inflammation that pierced through the iliotibial band. The bursal inflammation was excised arthroscopically and biopsy of the tissue revealed a diagnosis of pigmented villonodular synovitis (PVNS). The patient had an uneventful recovery and had a full resolution of symptoms with no recurrence noted at 3-year follow-up. This is the first reported case of arthroscopic excision of PVNS of the trochanteric bursa. Given that it may mimic trochanteric bursitis, it is important for clinicians to be aware of the possibility of this progressive condition for appropriate clinical intervention. [Orthopedics. 2023;46(6):e381-e383.].

Best clinical management of tenosynovial giant cell tumour (TGCT): A consensus paper from the community of experts

Tenosynovial giant cell tumour (TGCT) is a rare, locally aggressive, mesenchymal tumor arising from the joints, bursa and tendon sheaths. TGCT comprises a nodular- and a diffuse-type, with the former exhibiting mostly indolent course and the latter a locally aggressive behavior. Although usually not life-threatening, TGCT may cause chronic pain and adversely impact function and quality of life (QoL). CSFR1 inhibitors are effective with benefit on symptoms and QoL but are not available in most countries. The degree of uncertainty in selecting the most appropriate therapy and the lack of guidelines on the clinical management of TGCT make the adoption of new treatments inconsistent across the world, with suboptimal outcomes for patients. A global consensus meeting was organized in June 2022, involving experts from several disciplines and patient representatives from SPAGN to define the best evidence-based practice for the optimal approach to TGCT and generate the recommendations presented herein.

Intra-labral pigmented villonodular synovitis: a rare case in two adult patients

This article discusses two rare cases of intra-labral pigmented villonodular synovitis (PVNS) of the hip. The hip joint represents the second most common location of pigmented villonodular synovitis, second to the knee [1]. The majority of hip PVNS cases either diffusely involve the synovium or are focal lesions within the joint. The lesions and synovium show foci of low signal intensity related to hemosiderin deposition, a finding that differentiates PVNS from other causes of synovial proliferation. Our case report presents two rare manifestations of PVNS lesions localized within the hip labrum. This presentation could easily be mistaken for a cyst by imaging modality. Despite the rarity of this condition, we highlight the importance of questioning the possibility of intra-labral PVNS, when patients have persistent hip pain not responding to therapy and atypical imaging findings. Highlighting this rare presentation is crucial for establishing the correct diagnosis, guiding treatment, and obtaining the best clinical outcome.

Lateral T-Capsulotomy with Hip Arthroscopy for Access and Excision of Posterior Intra-Articular Mass

There is a lack of literature regarding arthroscopic access to the posterior peripheral compartment of the hip. Compared with open surgery, arthroscopy offers less-invasive treatment for intra-articular mass excision. Arthroscopic hip mass excision has focused on selective resection of lesions in the central compartment and anterior peripheral compartment due to difficult and previously undescribed posterior access. We introduce a technique for arthroscopic excision of a posterior intra-articular hip mass consistent with pigmented villonodular synovitis, also known as tenosynovial giant cell tumor, using a modified T-capsulotomy based on the lateral aspect of the hip capsule. This modified capsulotomy allows for more posterior and lateral access to the central and peripheral compartments while minimizing violation of the iliofemoral ligament.

Open or Arthroscopic Synovectomy Is the Preferred Management Option in Pigmented Villonodular Synovitis of the Hip Joint Without Evidence of Degeneration: A Systematic Review of 20 Studies

Purpose

To provide an up-to-date systematic review on the treatment options for pigmented villonodular synovitis (PVNS) of the hip and provide a grade of recommendation using standardized systems.

Methods

A systematic search of PubMed, Embase, Web of Science, and The Cochrane Library from the date of inception of each database through December 4, 2021, was performed. Studies that described the outcomes of treatment of hip PVNS were identified. These outcomes were discussed and synthesized by three reviewers, and a grade of recommendation was assigned.

Results

Twenty studies were identified. Seven studies described arthroscopic synovectomy, eight studies described open synovectomy, nine studies described arthroplasty, and one study described osmic acid synoviorthesis. Synovectomy, either open or arthroscopic, had similar rates of disease recurrence. Hip arthroplasty had low rates of disease recurrence compared to synovectomy; however, it was associated with significant risk of aseptic loosening in the longer term.

Conclusion

Synovectomy, either open or arthroscopic based on surgeon preference, is favored in the treatment of hip PVNS if there is no evidence of joint space narrowing. Arthroplasty should be considered in cases with joint space narrowing or recurrence following joint preservation therapy. There is insufficient evidence to support synoviorthesis either as monotherapy or adjuvant therapy.

Level of Evidence

IV, systematic review of Level III and IV studies.