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Arthroscopic excision of synovial hemangioma of the knee
Arthroscopy: The Journal of Arthroscopic and Related Surgery 6(1)&l-67 Published by Raven Press, Ltd. 0 1990 Arthroscopy Association of North America
Case Report
Arthroscopic Excision of Synovial Hemangioma of the Knee Robert J. Meislin, M.D. and J. Serge Parisien, M.D., F.A.C.S.
Summary: A synovial hemangioma in the knee joint of a 33-year old woman was diagnosed and removed arthroscopically. F’reoperatively, this rare benign soft tissue lesion had caused recurrent swelling of the knee along with persis-
tent pain and occasional buckling. Two years after surgery, the patient has a painless range of motion with no evidence of recurrence. Key Words: KneeSynovial hemangioma-Suprapatellar plica. -
Synovial hemangioma is an uncommon lesion, most frequently found in the knee. The patients affected are usually young and often present clinically with localized pain, tenderness, and decreased range of motion. At times it can present as a spontaneous, atraumatic hemarthrosis of the involved joint. To date, no case of arthroscopic removal of synovial hemangioma of the knee has been reported. We report on this unique method of treatment for this rare benign tumor and discuss the salient features of this lesion.
There was no point tenderness over the medial and lateral joint lines. In addition, she was nontender to patellofemoral grind. Her knee was stable to valgus/ varus stress and showed no signs of instability. Results of McMurray and Apley tests were negative; her knee range of motion demonstrated flexion to 135”, extension 5”. There was no difference in leg length and no cutaneous lesions were noted. Radiographs of the knee including doublecontrast arthrograms were normal with no evidence of bony or soft-tissue abnormality. Laboratory values , which included a complete coagulation profile, were all within normal limits. Preoperatively, the clinical impression was hypertrophic suprapatellar plica. Arthroscopic exploration of the knee showed a 1 x 1 cm pedunculated nodular mass at the superomedial aspect of the patella. The synovium was noted to be hyperemic (Fig. 1). The medial and lateral menisci and anterior and posterior cruciate ligaments were all found to be normal; the articular cartilage of both femoral condyles and tibia1 plateaus was smooth. A limited synovectomy of the suprapatellar pouch was performed and the cherry-red soft nodule, resembling a vascular lesion, was then excised through a superolateral portal. It lacked the brown color and the firm consistency usually associated with localized villonodular synovitis. Microscopic
CASE REPORT A 33-year-old woman complained of knee pain of 1% years’ duration after an injury to the right knee in a car accident. She noted episodic swelling of her knee along with persistent pain and occasional buckling. On physical examination, swelling and tenderness was localized to the suprapatellar pouch. There was some quadriceps atrophy of the right thigh and no soft-tissue mass was appreciated. From the Arthroscopic Surgery Service, Hospital for Joint Diseases, Orthopaedic Institute, New York, New York, U.S.A. Address correspondence and reprint requests to Dr. J. Serge Parisien, 1070 Park Avenue, New York, NY 10128, U.S.A.
64
EXCISION
OF SYNOVIAL
FIG. 1. Artist’s rendering of the synovial hemangioma found in the suprapatellar pouch.
examination demonstrated a fragment of synovium containing a subsynovial nodule composed centrally of numerous dilated and irregular vascular spaces of varying sizes, containing red blood cells and lined by a single layer of endothelium and basement membrane (Fig. 2A and B). Peripherally, capillary-size vessels with pericyte proliferation were present and a mild focal chronic inflammatory infiltrate were noted. These features were consistent with a synovial hemangioma, mixed cavernous and capillary type. Postoperatively, the patient recovered uneventfully with no further complaints of knee tenderness or swelling. Twenty-four months after surgery the patient has a pain-free range of motion with no localized tenderness or evidence of recurrence. DISCUSSION Synovial hemangioma of the knee is a rare, benign soft-tissue tumor. Typically found in adolescents or young adults, this lesion may easily be the source of repeated spontaneous hemarthroses of the knee joint. Females are more frequently in-
HEMANGIOMA
65
OF KNEE
volved than are males (1). Although the reported cases in the literature are few, the recorded history of the lesion is long, with Bouchut first describing this entity in 1856 (2). Since that time, several authors have reviewed their experience with patients affected with synovial hemangioma. Coventry et al. found that patients with synovial hemangioma could often date their symptomatology to early childhood. Significant atrophy of the quadriceps was noted and a tender mass could often be palpated. Twenty-seven percent of the patients in their series had cutaneous hemangiomata (3). DePalma and Mauler similarly found in their series that their patients usually complained of pain and swelling in the joint. Radiographs were helpful only if a phlebolith was present (4). Arteriography is thought by several authors to be useful in delineating the size and location of the lesion and in occasionally demonstrating an arteriovenous fistula (576). Hemangiomas have been classified by Stout as either capillary, cavernous, mixed, or venous (7). Jacobs and Lee differentiated articular hemangiomas into either juxtaarticular or intraarticular (8). Synovial hemangiomas (which have also been reported in the elbow and ankle) have been further divided into circumscribed and diffuse groups (9,lO). Cavernous hemangiomas are usually diffuse whereas capillary and cavernous synovial hemangioma were found by Coventry et al. to be the most common type identified, at least in their series. Recurrence of the tumor may indeed be related to its histopathology. In the series of 11 patients with synovial hemangioma presented by Lewis et al., four patients with localized pedunculated hemangiomas had no recurrence after complete excision. In contrast, three of seven patients with diffuse hemangiomas had recurrences (11). Complete surgical excision is difficult and radiation treatment coupled with synovectomy had, in the past, been recommended by some as adjuvant therapy. Today, radiation therapy should be used only in cases in which surgical excision is not feasible (12). The case presented points out the challenge in preoperatively diagnosing a synovial hemangioma. The internal derangement of her knee was thought to be secondary to a hypertrophic suprapatellar plica. Plicas often become symptomatic after trauma, and although hemangiomas often arise spontaneously with no history of previous trauma, Moon, in his view of 137 cases, found that 35% of the entire series had a probable significant trauArthroscopy,
Vol. 6, No. 1, 1990
FIG. 2. A low-power photomicrograph of the hemangioma (A) removed from the suprapatellar pouch showing the mixed cavernous and capillary qualities of the tumor (hematoxylin and eosin; x 180); a higher-power photomicrograph of the hemangioma (B) (hematoxylin and eosin; x418).
EXCISION
OF SYNOVIAL
matic involvement to the knee before symptomatology (13). The patient presented in this article related a history of trauma before her complaints of recurrent knee swelling and painful arc of motion. Traumatic and nontraumatic effusions can be secondary to pigmented villonodular synovitis, loose bodies, meniscal tears, osteochondral fractures, discoid meniscus, malignant tumors, xanthoma, coagulopathies, hemophilia, inflammatory arthritides, and hemangioma. With arthroscopy, the lesion was identified and arthroscopically excised. A limited synovectomy of the suprapatellar pouch was also performed. To date there have been reports of arthroscopic diagnosis of synovial hemangioma of the knee (14,15). All cases reported, however, have ended up undergoing arthrotomy. If the tumor is intraarticular and of manageable size, operative arthroscopy should be considered in the surgeon’s armamentarium of treatment. Acknowledgement: We thank Mr. Hugh Nachamie for the artistic representation of the lesion seen in Fig. 1.
HEMANGIOMA
OF KNEE
2. Halborg A, Hansen H, Sneppen HO. Hemangioma of the knee joint. Acta Orthop Scnnd 1968;39:2m16. 3. Coventry MB, Harrison EG Jr, Martin JF. Benign synovial tumors of the knee: a diagnostic problem. J Bone Join? Surg [Am] 1966;48: 1350-8. 4. DePalma AF, Mauler GG. Hemangioma of synovial membrane. Clin Orthop 1964;32:93-9. 5. Forrest J, Staple TW. Synovial hemangioma of the knee. Demonstration by arthrography and arteriography. Am J Roentgenol 1971;112:5124. 6. Seimon LP, Hekmat F. Case report: synovial hemangioma of the knee. J Pediatr Orthop 1986;6:356-9. 7. Stout AP. Tumors of the soft tissues. In: Atlas of tumor pathology section II. Washington D.C.: Armed Forces Institute of Pathology, 1953:47. 8. Jacobs JE, Lee FW. Hemangioma of the knee joint. J Bone Joint Surg [Am] 1949;31:831-6.
9. Bennet GE, Cobey MC. Hemangioma of joints: report of live cases. Arch Surg 1939;38:487-500. 10. Larsen IJ, Landry RM. Hemangioma of the synovial membrane. J Bone Joint Surg [Am] 1%9;51:121&2. 11. Lewis RC Jr, Coventry MB, Soule EH. Hemangioma of the synovial membrane. JBone Joint Surg [Am] 1959;41:264-71. 12. Linson MA, Posner IP. Synovial hemangioma as a cause of recurrent knee effusions. J Am Med Assoc 1979;242:2214-5. 13. Moon NF. Synovial hemangioma of the knee joint. A review of previously reported cases and inclusion of two new cases. C/in Orthop 1973;90: 183-90.
14. Boe S. Synovial hemangioma of the knee joint: a case report.
REFERENCES 1. Hunt AH. Cavernous haemangioma of the knee joint: report of a case. J Bone Joint Surg [Br] 1951;33:106-7.
Arthroscopy
1986;2: 178-80.
15. Koch RA, Jackson DW. Juxtaarticular hemangioma of the knee associated with a medial synovial plica. A case report. Am J Sports Med 1981;9:265-7.
Arthroscopy, Vol. 6. No. 1, 1990
Case Report
Arthroscopic Excision of Synovial Hemangioma of the Knee Robert J. Meislin, M.D. and J. Serge Parisien, M.D., F.A.C.S.
Summary: A synovial hemangioma in the knee joint of a 33-year old woman was diagnosed and removed arthroscopically. F’reoperatively, this rare benign soft tissue lesion had caused recurrent swelling of the knee along with persis-
tent pain and occasional buckling. Two years after surgery, the patient has a painless range of motion with no evidence of recurrence. Key Words: KneeSynovial hemangioma-Suprapatellar plica. -
Synovial hemangioma is an uncommon lesion, most frequently found in the knee. The patients affected are usually young and often present clinically with localized pain, tenderness, and decreased range of motion. At times it can present as a spontaneous, atraumatic hemarthrosis of the involved joint. To date, no case of arthroscopic removal of synovial hemangioma of the knee has been reported. We report on this unique method of treatment for this rare benign tumor and discuss the salient features of this lesion.
There was no point tenderness over the medial and lateral joint lines. In addition, she was nontender to patellofemoral grind. Her knee was stable to valgus/ varus stress and showed no signs of instability. Results of McMurray and Apley tests were negative; her knee range of motion demonstrated flexion to 135”, extension 5”. There was no difference in leg length and no cutaneous lesions were noted. Radiographs of the knee including doublecontrast arthrograms were normal with no evidence of bony or soft-tissue abnormality. Laboratory values , which included a complete coagulation profile, were all within normal limits. Preoperatively, the clinical impression was hypertrophic suprapatellar plica. Arthroscopic exploration of the knee showed a 1 x 1 cm pedunculated nodular mass at the superomedial aspect of the patella. The synovium was noted to be hyperemic (Fig. 1). The medial and lateral menisci and anterior and posterior cruciate ligaments were all found to be normal; the articular cartilage of both femoral condyles and tibia1 plateaus was smooth. A limited synovectomy of the suprapatellar pouch was performed and the cherry-red soft nodule, resembling a vascular lesion, was then excised through a superolateral portal. It lacked the brown color and the firm consistency usually associated with localized villonodular synovitis. Microscopic
CASE REPORT A 33-year-old woman complained of knee pain of 1% years’ duration after an injury to the right knee in a car accident. She noted episodic swelling of her knee along with persistent pain and occasional buckling. On physical examination, swelling and tenderness was localized to the suprapatellar pouch. There was some quadriceps atrophy of the right thigh and no soft-tissue mass was appreciated. From the Arthroscopic Surgery Service, Hospital for Joint Diseases, Orthopaedic Institute, New York, New York, U.S.A. Address correspondence and reprint requests to Dr. J. Serge Parisien, 1070 Park Avenue, New York, NY 10128, U.S.A.
64
EXCISION
OF SYNOVIAL
FIG. 1. Artist’s rendering of the synovial hemangioma found in the suprapatellar pouch.
examination demonstrated a fragment of synovium containing a subsynovial nodule composed centrally of numerous dilated and irregular vascular spaces of varying sizes, containing red blood cells and lined by a single layer of endothelium and basement membrane (Fig. 2A and B). Peripherally, capillary-size vessels with pericyte proliferation were present and a mild focal chronic inflammatory infiltrate were noted. These features were consistent with a synovial hemangioma, mixed cavernous and capillary type. Postoperatively, the patient recovered uneventfully with no further complaints of knee tenderness or swelling. Twenty-four months after surgery the patient has a pain-free range of motion with no localized tenderness or evidence of recurrence. DISCUSSION Synovial hemangioma of the knee is a rare, benign soft-tissue tumor. Typically found in adolescents or young adults, this lesion may easily be the source of repeated spontaneous hemarthroses of the knee joint. Females are more frequently in-
HEMANGIOMA
65
OF KNEE
volved than are males (1). Although the reported cases in the literature are few, the recorded history of the lesion is long, with Bouchut first describing this entity in 1856 (2). Since that time, several authors have reviewed their experience with patients affected with synovial hemangioma. Coventry et al. found that patients with synovial hemangioma could often date their symptomatology to early childhood. Significant atrophy of the quadriceps was noted and a tender mass could often be palpated. Twenty-seven percent of the patients in their series had cutaneous hemangiomata (3). DePalma and Mauler similarly found in their series that their patients usually complained of pain and swelling in the joint. Radiographs were helpful only if a phlebolith was present (4). Arteriography is thought by several authors to be useful in delineating the size and location of the lesion and in occasionally demonstrating an arteriovenous fistula (576). Hemangiomas have been classified by Stout as either capillary, cavernous, mixed, or venous (7). Jacobs and Lee differentiated articular hemangiomas into either juxtaarticular or intraarticular (8). Synovial hemangiomas (which have also been reported in the elbow and ankle) have been further divided into circumscribed and diffuse groups (9,lO). Cavernous hemangiomas are usually diffuse whereas capillary and cavernous synovial hemangioma were found by Coventry et al. to be the most common type identified, at least in their series. Recurrence of the tumor may indeed be related to its histopathology. In the series of 11 patients with synovial hemangioma presented by Lewis et al., four patients with localized pedunculated hemangiomas had no recurrence after complete excision. In contrast, three of seven patients with diffuse hemangiomas had recurrences (11). Complete surgical excision is difficult and radiation treatment coupled with synovectomy had, in the past, been recommended by some as adjuvant therapy. Today, radiation therapy should be used only in cases in which surgical excision is not feasible (12). The case presented points out the challenge in preoperatively diagnosing a synovial hemangioma. The internal derangement of her knee was thought to be secondary to a hypertrophic suprapatellar plica. Plicas often become symptomatic after trauma, and although hemangiomas often arise spontaneously with no history of previous trauma, Moon, in his view of 137 cases, found that 35% of the entire series had a probable significant trauArthroscopy,
Vol. 6, No. 1, 1990
FIG. 2. A low-power photomicrograph of the hemangioma (A) removed from the suprapatellar pouch showing the mixed cavernous and capillary qualities of the tumor (hematoxylin and eosin; x 180); a higher-power photomicrograph of the hemangioma (B) (hematoxylin and eosin; x418).
EXCISION
OF SYNOVIAL
matic involvement to the knee before symptomatology (13). The patient presented in this article related a history of trauma before her complaints of recurrent knee swelling and painful arc of motion. Traumatic and nontraumatic effusions can be secondary to pigmented villonodular synovitis, loose bodies, meniscal tears, osteochondral fractures, discoid meniscus, malignant tumors, xanthoma, coagulopathies, hemophilia, inflammatory arthritides, and hemangioma. With arthroscopy, the lesion was identified and arthroscopically excised. A limited synovectomy of the suprapatellar pouch was also performed. To date there have been reports of arthroscopic diagnosis of synovial hemangioma of the knee (14,15). All cases reported, however, have ended up undergoing arthrotomy. If the tumor is intraarticular and of manageable size, operative arthroscopy should be considered in the surgeon’s armamentarium of treatment. Acknowledgement: We thank Mr. Hugh Nachamie for the artistic representation of the lesion seen in Fig. 1.
HEMANGIOMA
OF KNEE
2. Halborg A, Hansen H, Sneppen HO. Hemangioma of the knee joint. Acta Orthop Scnnd 1968;39:2m16. 3. Coventry MB, Harrison EG Jr, Martin JF. Benign synovial tumors of the knee: a diagnostic problem. J Bone Join? Surg [Am] 1966;48: 1350-8. 4. DePalma AF, Mauler GG. Hemangioma of synovial membrane. Clin Orthop 1964;32:93-9. 5. Forrest J, Staple TW. Synovial hemangioma of the knee. Demonstration by arthrography and arteriography. Am J Roentgenol 1971;112:5124. 6. Seimon LP, Hekmat F. Case report: synovial hemangioma of the knee. J Pediatr Orthop 1986;6:356-9. 7. Stout AP. Tumors of the soft tissues. In: Atlas of tumor pathology section II. Washington D.C.: Armed Forces Institute of Pathology, 1953:47. 8. Jacobs JE, Lee FW. Hemangioma of the knee joint. J Bone Joint Surg [Am] 1949;31:831-6.
9. Bennet GE, Cobey MC. Hemangioma of joints: report of live cases. Arch Surg 1939;38:487-500. 10. Larsen IJ, Landry RM. Hemangioma of the synovial membrane. J Bone Joint Surg [Am] 1%9;51:121&2. 11. Lewis RC Jr, Coventry MB, Soule EH. Hemangioma of the synovial membrane. JBone Joint Surg [Am] 1959;41:264-71. 12. Linson MA, Posner IP. Synovial hemangioma as a cause of recurrent knee effusions. J Am Med Assoc 1979;242:2214-5. 13. Moon NF. Synovial hemangioma of the knee joint. A review of previously reported cases and inclusion of two new cases. C/in Orthop 1973;90: 183-90.
14. Boe S. Synovial hemangioma of the knee joint: a case report.
REFERENCES 1. Hunt AH. Cavernous haemangioma of the knee joint: report of a case. J Bone Joint Surg [Br] 1951;33:106-7.
Arthroscopy
1986;2: 178-80.
15. Koch RA, Jackson DW. Juxtaarticular hemangioma of the knee associated with a medial synovial plica. A case report. Am J Sports Med 1981;9:265-7.
Arthroscopy, Vol. 6. No. 1, 1990