Open anterior synovectomy for diffuse pigmented villonodular synovitis of the knee surgical technique
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Pigmented villonodular synovitis (PVNS) is a rare, benign locally aggressive disorder of the synovium of joints, bursae and tendon sheaths and has three main subtypes. The World Health Organisation classifies intra-articular diffuse PVNS as ‘diffuse-type giant cell tumour’ (Dt-GCT), differentiating it from the localised intra-articular form of PVNS and from GCTTS (giant cell tumours of tendon sheaths) commonly encountered in fingers and toes. The histological appearances are similar across all three PVNS sub-types (https://www.sciencedirect.com/science/article/pii/S1877132712000991).
The pathoaetiology of PVNS has been linked to inflammatory, vascular and traumatic causes but chromosomal abnormalities, autonomous growth, bone invasion and the rare malignant transformation of PVNS suggest a neoplastic cause (https://online.boneandjoint.org.uk/doi/epub/10.1302/0301-620X.95B3.30192).
Typically patients are between the age of 20 and 50 years, although many examples have been reported involving infants, children and adolescents (https://online.boneandjoint.org.uk/doi/epub/10.1302/0301-620X.95B3.30192). As the diffuse-type insidiously infiltrates the synovial cavity lining leading to eventual osseous erosions and sub- chondral cysts, patients present with insidious swelling and/or pain which has been present for months or years.
The mainstay of treatment for diffuse PVNS remains radical surgical excision. The recurrence rate of diffuse PVNS of knee after attempted arthroscopic resection is very high, therefore open surgery is preferred as the recurrence rate is reported to be less than 30% after two years. (https://europepmc.org/article/PMC/2758986)
Readers will also find it useful to read Jonathan Stevensons complimentary technique Excision of synovial chondromatosis using a posterior approach to the knee
Author: Jonathan Stevenson FRCS (Tr & Orth)
Institution: Royal Orthopaedic Hospital, Birmingham, UK.
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