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


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

In This Article

Surgical Technique

Adequate preoperative imaging is vital for surgical planning. CT scan may be a helpful addition to plain radiographs if there is extensive bony involvement. MRI can aid in determining the extent of disease and in surgical planning. PVNS is known to extend outside of the joint capsule to affect tendons and soft tissues (Figure 1).[2] In this scenario arthroscopy as an adjunct to an open procedure would be appropriate.

Figure 1.

Preoperative MRI of a patient with diffuse pigmented villonodular synovitis evident. The first image (A) demonstrates tibiotalar as well as extensive soft-tissue involvement deep to the Achilles tendon while the second (B) reveals additional subtalar involvement.

In contrast to the knee joint, the entire ankle is more easily accessible through an arthroscopic approach. A bump is placed under the operative hip. If desired, a tourniquet can be placed on the operative thigh. Alternatively, we use the Esmarch bandage as a tourniquet after exsanguination. The thigh is placed into a well-leg holder with the hip flexed to 45–60 degrees. A sterile distraction device is assembled and applied after preparing and draping. Standard anteromedial and anterolateral portals are established, and diagnostic arthroscopy is performed. An example from our institution can be seen in Figure 2. If needed for localized variants, and for all diffuse variants, we use an accessory posterolateral portal. Similarly, subtalar arthroscopy affords excellent visualization of the joint and may facilitate complete synovectomy as an adjunct to open surgery. We use a combination of arthroscopic shaver and radiofrequency ablation to remove all pathologic synovium and to minimize bleeding. We start with a 21-point examination of the ankle as described by Ferkel[20] and proceed with systematic debridement of the joint anteriorly, centrally, and then posteriorly. Overdistraction can reduce the anterior capsular volume, making anterior synovectomy more challenging. Intraoperative adjustment of the amount of distraction may be necessary when working in the front or back of the ankle. All involved synovium is excised and any bleeding is controlled with radiofrequency ablation/cauterization. The tourniquet is let down prior to removal of the arthroscope.

Figure 2.

Intraoperative findings in a patient with diffuse pigmented villonodular synovitis of the ankle and subtalar joint show (A) diffuse involvement of the ankle synovium as well as (B) some focal areas of disease.

Subtalar arthroscopy is performed if PVNS is seen on preoperative MRI or if PVNS tissue is observed in the lateral gutter involving the subtalar joint. Midlateral, anterolateral, and posterolateral portals are used to access the subtalar joint. The posterior facet, middle facet, cervical ligament, and interosseous ligament can be visualized and debrided as necessary. Additionally, extraarticular extension can be noted and may impact the open portion of surgical excision. When open excision is performed for extraarticular disease, incisions should be designed to reach affected anatomical areas. An extensile approach posterior to the medial malleolus is used to protect the posterior tibial neurovascular bundle.

Postoperatively, a well-padded splint is applied, and the ankle is immobilized for a minimum of 2 wk. At the 2-week postoperative visit, sutures are removed and patients begin weight bearing in a cast boot. Partial to full weight bearing is allowed in the boot over the course of 4 wk. The patient is allowed to return to full activities as tolerated at 6 wk. Compression stockings are routinely recommended once surgical incisions are healed and until swelling resolves. Yearly follow-up is required to monitor for recurrence with repeat MRI performed if symptoms return.

A common complication is recurrence of the disease, and the rate is believed to be minimized with complete excision of diseased synovium. As such, adequate preoperative imaging to determine the extent of disease followed by careful debridement of all affected tissues is mandatory. Other complications include prolonged wound drainage, bleeding, iatrogenic cartilage injury, and hemarthrosis. Postoperative wound drainage can be minimized by a watertight closure and splint immobilization. Iatrogenic cartilage injury can be minimized by proper portal placement and adequate distraction. To minimize the risk of hemarthrosis, deflate the tourniquet after synovectomy and ensure hemostasis is obtained.