Arthroscopy in the Treatment of Pigmented Villonodular Synovitis of the Ankle and Subtalar Joints

A Technique Guide and Case Series

Kyle R. Sweeney, MD; Harris S. Slone, MD; Sameh A. Labib, MD

Disclosures

Curr Orthop Pract. 2017;28(5):499-502. 

In This Article

Abstract and Introduction

Abstract

Pigmented villonodular synovitis is a proliferative synovial-based inflammatory process that can lead to joint destruction and debilitating pain. Surgical excision is the "gold standard" for treatment of pigmented villonodular synovitis. Given the limited soft tissues surrounding the ankle in conjunction with the ability of arthroscopy to easily access the entire joint, arthroscopic management of ankle pigmented villonodular synovitis allows for successful treatment while minimizing the surgical complications of an open approach. The preoperative planning and surgical technique are described in detail. Additionally, three patients with pigmented villonodular synovitis in the tibiotalar and subtalar joints who were successfully treated with arthroscopically assisted synovectomy are reported.Three patients with pigmented villonodular synovitis in the tibiotalar and subtalar joints underwent arthroscopically assisted synovectomy without adjuvant radiotherapy. With a mean age of 37.7 yr (range 23–52) and mean follow-up of 83 wk (range 19–184), there was no evidence of recurrence. Mean Short Form-12 scores for physical and mental component summaries were, respectively, 49.05±4.76 and 54.57±4.55. The mean Foot and Ankle Disability Index (FDAI) score for the patients was 88.13±9.6. These results suggest good to excellent results. Arthroscopically assisted synovectomy in patients with pigmented villonodular synovitis of the ankle and hindfoot is an effective treatment option, providing adequate visualization for complete excision while minimizing soft-tissue complications related to larger surgical exposures.

Introduction

Pigmented villonodular synovitis (PVNS) is a proliferative synovial based inflammatory process that can lead to joint destruction and debilitating pain.[1] Two main types of PVNS exist, diffuse PVNS (DPVNS) and localized PVNS (LPVNS). LPVNS also is often referred to as nodular PVNS. DPVNS is generally associated with worse outcomes and higher recurrence rates. Surgical excision remains the "gold standard" for treatment of PVNS.[1] Radiotherapy and oral medications are used as adjunctive therapies or as primary treatment when complete surgical excision is not possible.

Most of the literature regarding surgical treatment for PVNS has focused on the knee because it is the most common location for the disease.[1–3] Arthroscopic, open, and combined open/arthroscopic synovectomies have all been described.[2–6] Reports of recurrence after surgical excision are highly variable, with rates up to 65%.[3,4,7] Incomplete excision of pathologic tissue is thought to be associated with higher recurrence rates after surgery.[7,8] Isolated arthroscopic treatment of DPVNS in the knee may result in higher recurrence rates compared to arthroscopic synovectomy combined with open excision[3] or open excision alone.[2,7] High recurrence rates with arthroscopic-only treatment have largely been attributed to difficulty with complete synovectomy of the posterior compartment of the knee. Recently, reports of multidirectional arthroscopic synovectomy have shown promise with regard to low recurrence rates, and improved knee function postoperatively.[4]

There is far less literature regarding treatment of PVNS in the ankle and hindfoot as compared to the knee, and all but one study in the available literature are case reports or small case series.[2,9–18] Fewer studies discuss arthroscopic treatment or combined surgical approaches for the treatment of either LPVNS[5,19] or DPVNS.[10,13] With the limited soft tissues surrounding the ankle as compared to the knee and the ability of arthroscopy to easily access the entire joint, arthroscopic management of ankle PVNS allows for successful treatment while minimizing surgical complications. To our knowledge no published technique guide exists describing arthroscopically assisted treatment of DPVNS in the ankle or subtalar joint. Institutional review board approval was obtained, and consent to use of data was obtained from each of the patients.

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