Diffuse Pigmented Villonodular Synovitis Around the Ankle

Unusual presentation of talonavicular joint pigmented villonodular synovitis: a case report

BACKGROUND

Pigmented villonodular synovitis is a rare yet locally invasive disorder impacting synovial tissues. This case report delineates the atypical manifestation of pigmented villonodular synovitis in the talonavicular joint, detailing its diagnostic complexity and successful management.

CASE PRESENTATION

A 56-year-old Iranian patient with a 4-year history of chronic ankle pain, initially diagnosed with degenerative joint disease post-trauma based on imaging, underwent talonavicular fusion surgery. An unexpected pigmented villonodular synovitis mass was encountered during the procedure. Subsequent interventions encompassed tumor resection, talonavicular joint fusion, and allograft bone grafting. Despite the initial intervention, persistent pain and nonunion necessitated a secondary procedure, involving joint surface curettage and autograft bone grafting. At the 12-month follow-up, the patient remained pain-free without tumor recurrence.

CONCLUSION

This case report highlights the significance of considering pigmented villonodular synovitis as a crucial differential diagnosis in chronic ankle pain, even when there is evidence of degenerative joint disease and a history of trauma. Magnetic resonance imaging serves a crucial role in accurate diagnosis. Treatment necessitates precise tumor removal, appropriate bone grafting techniques and secure fixation.

LEVEL OF EVIDENCE

IV.

Combined Arthroscopic and Endoscopic Synovectomy for Diffuse Pigmented Villonodular Synovitis (PVNS) of the Ankle

The current treatment of choice for diffuse-type pigmented villonodular synovitis (PVNS) is surgical excision. Complete synovectomy is necessary because of the local aggressiveness of the disease, with a significant recurrence rate and a minor chance of malignant transformation. The recurrence rate is even greater in those cases with extra-articular extension. Arthroscopic and endoscopic synovectomy have the advantage of avoidance of extensive soft-tissue dissection, which is associated with open synovectomy. The purpose of this Technical Note is to describe the details of combined arthroscopic and endoscopic synovectomy as treatment for diffuse PVNS of the ankle. By a combination of different arthroscopic and endoscopic approaches of the ankle region, a complete synovectomy of both intra-articular and extra-articular components of diffuse-type PVNS is feasible.

Anterior Capsule Reconstruction in the Setting of PVNS

BACKGROUND

Pigmented villonodular synovitis (PVNS) is a benign proliferative disease affecting tendon sheaths and synovial tissue. Pigmented villonodular synovitis in the foot and ankle has a high rate of recurrence, which can be destructive if incompletely removed. This case series analyzes functional outcomes after PVNS operative resection with an anterior ankle capsular reconstruction, using a novel technique.

METHODS

Three patients with PVNS underwent surgery between 2010 and 2020. The operative technique involved a posterior, midline approach for PVNS resection of the affected ankle joint, followed by a standard anterior approach for capsular excision. Subsequent anterior capsular reconstruction was performed with a regenerative tissue matrix and a bioresorbable anchoring system. Preoperative and postoperative range of motion for the ankle and subtalar joints, visual analog scale (VAS) for pain, and return to daily activities was assessed along with appropriate radiographs and magnetic resonance imaging (MRI) imaging.

RESULTS

All 3 surgeries had a mean follow-up period of 52.3 (range, 4-123) months and resulted in successful recovery as assessed by the VAS and self-reported activity. Preoperative ankle dorsiflexion and plantarflexion along with subtalar inversion and eversion range of motion were all normal. Postoperative ankle motion and subtalar motion were not statistically different. No complications or recurrence of PVNS was observed.

CONCLUSION

Further investigation is warranted to better understand the clinical outcomes of this technique designed to successfully eliminate PVNS recurrence.

LEVEL OF EVIDENCE

IV- Retrospective case series.

Treatment, recurrence rates and follow-up of Tenosynovial Giant Cell Tumor (TGCT) of the foot and ankle-A systematic review and meta-analysis

Background

The tenosynovial giant cell tumor (TGCT) is a usually benign lesion which arises from the synovium. It affects joints, tendon sheaths and bursae. The clinical course is often unpredictable, and local recurrences frequently occur. The aim of this study was to describe different treatment options, surgical complications, and to develop a follow-up regime based on a systematic literature review and meta-analysis of foot and ankle lesions.

Methods and results

1284 studies published between 01/1966 and 06/2021 were identified. 25 met the inclusion criteria, with a total of 382 patients. Of these, 212 patients had a diffuse (dTGCT) and 170 a localized (lTGCT) TGCT. Patients with a dTGCT had a mean age of 36.6±8.2 years, and 55% were female. The overall complication rate was 24% in dTGCT, irrespective of the therapeutic procedure; the mean follow-up was 37.9±27.4 months with a recurrence rate of 21%, and recurrences occurred between 3 and 144 months, the vast majority (86%) within the first 5 years following intervention. Patients with a lTGCT had a mean age of 31.2±5.7 years, and 53% were female. Complications occurred in 12%. The mean follow-up was 51.1±24.6 months, the recurrence rate was 7%, and recurrence occurred between 1 and 244 months after intervention.

Conclusion

Diffuse TGCTs of the foot and ankle region have a remarkable recurrence rate irrespective of therapeutic procedures, and most lesions reoccurred within 5, with more than half of these in the first 2 years. The lTGCTs are well treatable lesions, with a low recurrence and a moderate complication rate. Based on these findings, we propose a follow-up regime for the dTGCT including a clinical survey and MR imaging 3 months after surgical intervention (baseline), followed by twice-yearly intervals for the first 2 years, yearly intervals up to the fifth year, and further individual follow-up due to the fact that recurrences can even occur for years later. For the lTGCT a clinical survey and MRT is proposed after 3–6 months after intervention (baseline), followed by annual clinical examination for 3 years, and in case of symptoms MR-imaging. Larger prospective multi-center studies are necessary to confirm these results and recommendations.