It’s not what it looks like: challenges in diagnosis of synovial lesions of the knee joint

Abstract

BackgroundWith the advent of MRI (Magnetic Resonance Imaging), Synovial lesions around knee are being more and more easily detected. Synovial lesions of knee present with boggy swelling, effusion, pain, and restriction of motion. Differential diagnoses of such lesions include pigmented villonodular synovitis, synovial lipoma, synovial chondromatosis, rheumatoid arthritis, synovial hemangioma, amyloid arthropathy, xanthomata and lipoma arborescens. CT and MRI often help in diagnosis of such lesions. MRI of Lipoma Arborescens has been regarded to have characteristic diagnostic appearance – it includes a synovial mass with frond-like architecture and fat signal intensity on all pulse sequences. Sometimes Lipoma Arborescens can present in conjunction with inflammatory arthritis. Synovectomy is often curative for such conditions.FindingsWe report two cases where lesions diagnosed as Lipoma Arborescens on MRI subsequently revealed to be chronic inflammatory synovitis, characterized by absence of fat infiltration in histopathological examination – refuting the original diagnosis. There was infiltration of lymphocytes and neutrophils in the synovium, suggestive of chronic inflammatory arthritis. Both of these patients required management from rheumatologist, and had relief of symptoms after use of methotrexate and hydroxychloroquine. We also report a third case, where a loose body appearing as chondral fragment on arthroscopy was subsequently diagnosed as an organized hematoma on histopathological examination.ConclusionDiagnostic pitfalls after MRI of the knee is not uncommon. For example - normal variant of meniscomeniscal ligaments have been reported as meniscal tears; motion artifacts have been falsely reported as meniscal injuries; and meniscofemoral ligament can appear as free osteochondral fragment. In most of these cases, a routine arthroscopy is enough to clear the confusion. However, as evident in the three cases described here - in some synovial lesions of knee joint, even after MRI and arthroscopic examination, histopathological confirmation may still be prudent. In spite of availability of advanced imaging technologies and high definition arthroscopy equipment, an arthroscopy surgeon still must not forget the value of histopathological examination in establishing the true nature of synovial lesions of the knee joint.

Knee Arthroscopy for the Treatment of Lipoma Arborescens

“…Furthermore, degenerative changes were seen in 87% of the patients, whereas meniscal tears and synovial cysts were found in 72% and 38%, respectively. Histopathological examination is the ultimate diagnostic method to confirm lipoma arborescens 24 .…”

An Alterna2ve Diagnosis and Treatment Perspec2ve for Lipoma Arborescens and Literature Review

“…[2][3][4]6,7 Yine tanıda daha çok MRG kullanılmaktadır. 1,[4][5][6][7][8] Tedavide de cerrahi yöntemler konservatif yaklaşımların önüne geçmektedir. 1,3,5,7,9 Bu çalışmada, hastaların sadece dizlerde kısıtlılıkla da gelebileceğinin, tanıda invaziv olmayan, kolay, tekrarlanabilir, radyasyon içermeyen ve ucuz bir yöntem olan ultrasonografinin kullanabileceğinin ve konservatif tedavi yaklaşımlarından da izokinetik egzersizlerin akılda tutulması gerektiğinin hatırlatılması amaçlanmıştır.…”

The efficiency of MRI scan for the evaluation of ligament tear in Synovial Joints

“…For the detection of synovial lesions and in follow-up procedures, US (joint high-frequency ultrasonography), conventional radiography, and MRI (magnetic resonance imaging) are commonly used (Naganna et al, 2017;Turan et al, 2017). Magnetic resonance imaging (MRI) is often performed before arthroscopic procedures, and the findings of the MRI decide the management plans (Dash et al, 2016). With a sensitivity range of 87 to 94 percent, MRI is considered the most noninvasive technique for the detection of an ACL tear in the knee joint (Delin et al, 2016).…”