Outcomes after Excision of Pigmented Villonodular Synovitis of the Knee

Abstract

Pigmented villonodular synovitis (PVNS) has a high but variable recurrence rate. Prior studies do not compare recurrence-free survival (RFS) for various surgical approaches or salvage surgery for relapse. We therefore determined: (1) RFS after excision; (2) RFS after salvage surgery for relapse; (3) factors associated with relapse. We retrospectively reviewed the medical records of 49 patients with previously untreated PVNS of the knee (12 localized, 37 diffuse) who were treated with synovectomy from 1991 to 2008; there were 22 males and 27 females, with mean age of 35.2 years (range, 10-73). Minimum followup was 1 year (mean, 6.2 years; range, 1-13). Twenty-one patients had a relapse. The RFS for index surgery was 75% and 53%; and for salvage surgery was 71% and 52% at 2 and 5 years respectively. The RFS was 95% for open versus 62% for arthroscopic synovectomy at 2 years, 71% and 41% at 5 years. The RFS was 91% for localized and 70% for diffuse PVNS at 2 years, 73% and 48% at 5 years. Diffuse disease (RR = 4.49) and arthroscopic synovectomy (RR = 3.30) were associated with relapse. Recurrence was frequent after synovectomy. Reexcision can salvage relapses as successfully as excision for primary disease; however, morbidity was associated with additional surgeries.

Does Combined Open and Arthroscopic Synovectomy for Diffuse PVNS of the Knee Improve Recurrence Rates?

“…Our recurrence rate is similar to that reported by Sharma and Cheng in a recent study [19]. The recurrence rate we report for our allarthroscopic group (62%) is similar to the Sharma all-arthroscopic cohort in that it is much higher than most previous reports for all-arthroscopic synovectomy, which have reported from 9% to 20% recurrence [5,14,21].…”

“…Anterior and posterior open arthrotomy and synovectomy under direct visualization have been performed with recurrence rates similar to the best reported for this condition [3,6,19]. Open techniques are especially important in the presence of extraarticular extension of disease, which cannot be accessed with an arthroscope [3,14].…”

“…Other authors have reported similar recurrence rates with allarthroscopic total synovectomy using anterior and posteromedial arthroscopy portals, 30°and 70°arthroscopic lenses, and transcondylar notch views [5,14,21]. Still others have reported similar recurrence rates combining the two techniques using a posterior open and anterior arthroscopic approach to minimize technical difficulty and take advantage of the benefits of each [19]. Although recurrence rates across these series are somewhat similar, most are case series only and do not directly compare differences in recurrence rates or complications for the various approaches to total synovectomy.…”

“…Nevertheless, historical attempts at complete surgical synovectomy have been associated with recurrence rates as high as 30% to 46% [2,7]. With meticulous modern techniques reported, recurrence rates have improved to the range of 8% to 20% [3,5,6,19,21] but local control remains a problem.…”

Arthroscopic synovectomy in pigmented villonodular synovitis of the knee: clinical series and outcome

“…The majority of patients have vague signs and symptoms so arthroscopy is both diagnostic and therapeutic. Diagnosis based on synovial fluid examination has been proposed by [13], synovectomy and arthroplasty [14], low-dose external beam radiotherapy [15] and imatinib therapy [16] etc. Synovectomy is the mainstay of the treatment.…”