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Arthroscopic treatment of tumor-like lesions of the knee joint
Case Report
Arthroscopic Treatment of Tumor-Like Lesions of the Knee Joint: Localized Pigmented Villonodular Synovitis and Ganglion Cyst of the Anterior Cruciate Ligament Dietrich S. Hammer, M.D., Michael Dienst, M.D., and Dieter M. Kohn, M.D.
Abstract: We present the arthroscopic treatment of a case of localized pigmented villonodular synovitis that led to increasing restriction of knee flexion and the case of a ganglion cyst within the anterior cruciate ligament causing unspecific pain. Both pathologies could be resected arthroscopically with complete relief of symptoms and no recurrence. In cases with unspecific clinical signs and intra-articular masses shown on magnetic resonance imaging, arthroscopy is the next therapeutic step. Localized tumor-like lesions can often be excised without recurrence in the same session. Key Words: Tumor-like lesion—Pigmented villonodular synovitis—Anterior cruciate ligament—Ganglion cyst—Arthroscopic treatment.
P
rimary tumors of the knee joint are rare. Tumorlike lesions occur more often. We describe the cases of 2 patients in whom we treated such lesions arthroscopically. The first patient had localized pigmented villonodular synovitis (PVNS), the second had an intra-articular ganglion attached to the anterior cruciate ligament (ACL). PVNS is a rare proliferative condition affecting the synovial membrane of joints, bursae and tendon sheaths (the incidence of articular location is 1.8 cases per million population per year). The etiology of PVNS is still uncertain. Recurrent hematoma, chronic inflammation, and trauma have been considered to be the cause. The lesion prefers the joints of the lower extremity, especially the knee, and it is nearly almost always monoarticular. It presents in 2 forms: local and
diffuse, the latter occurring more often. PVNS can act as a locally aggressive lesion that invades surrounding soft tissue and bone.1-3 Ganglion cysts within the ACL are unusual findings. Whereas periarticular cystic lesions, such as popliteal cysts (Baker’s cyst), and intra-articular cystic lesions, such as synovial pseudocysts of the posterior cruciate ligament and meniscal cysts, are fairly common (meniscal cysts are found in 3% of patients who undergo meniscus surgery), there are only few reports of ganglion cysts within the cruciate ligaments. The etiology is unclear. According to 1 theory, the ganglion cyst represents a mucinous degeneration of connective tissue.4 Other explanations are herniation of synovial tissue through a defect in the joint capsule or tendon sheath and proliferation of omnipotent mesenchymal cells.5,6
From the Orthopaedic University Hospital, Homburg/Saar, Germany. Address correspondence and reprint requests to Dietrich S. Hammer, M.D., Orthopaedic University Hospital, D-66424 Homburg/Saar, Germany. E-mail: [email protected] © 2001 by the Arthroscopy Association of North America 0749-8063/01/1703-2548$35.00/0 doi:10.1053/jars.2001.22368
CASE REPORTS
320
Case 1 A 36-year-old woman with no history of knee problems reported lateral knee pain after a twisting injury to her right knee. Magnetic resonance imaging (MRI)
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 17, No 3 (March), 2001: pp 320 –323
LOCALIZED PVNS AND GANGLION CYST was arranged by the consulted physician and it showed a large intra-articular effusion and an intraarticular soft tissue mass within the dorsal intercondylar fossa measuring 3 ⫻ 2 ⫻ 2 cm (Fig 1). When she came to our outpatient clinic 1 week later, the discomfort in her right knee had almost completely disappeared. On examination, the right knee was free of inflammation with no effusion but a discreet pain on pressure at the lateral joint line. Typical meniscal signs were negative and the ligaments were stable. The flexion was restricted with extension/flexion 10°/ 0°/120°. The arthroscopic procedure revealed intact menisci and no ligamentous lesion. A cavity in the dorsal part of the intercondylar fossa above the insertion of the posterior cruciate ligament could be detected. It was filled with a brownish pedunculated soft-tissue mass which was resected along with the surrounding synovial membrane (Fig 2). The histologic examination confirmed the diagnosis of PVNS. The patient recovered well after this procedure. At last follow-up 1 year postoperatively, she was asymptomatic with unrestricted range of movement of her right knee. The control MRI showed no signs of local recurrence.
321
Case 2 A 39-year-old woman underwent arthroscopy of her left knee because of discomfort after a twisting injury. Resection of the posterior horn of the medial meniscus due to a longitudinal tear was performed, which made her completely asymptomatic. Three years afterward, she complained of gradually increasing discomfort in her left knee laterally and dorsally while weight bearing. On examination, the knee presented with no signs of inflammation or effusion, stable ligaments, and unrestricted range of movement. Palpation of the dorsomedial joint line was painful. No specific meniscal signs could be elicited. An MRI, performed to lighten the anamnestic and clinical discrepancy, revealed a 1.5 ⫻ 1.5 ⫻ 2 cm mass in the intercondylar fossa in the vicinity of the insertion of the ACL with low signal intensity on T1-weighted MRIs and increased signal intensity on T2-weighted MRIs (Fig 3). The lateral meniscus showed no pathology. Arthroscopy showed a 1-cm longitudinal tear of the posterior horn of the lateral meniscus. The meniscus was resected partially. The ACL bulged in the femoral attachment area. Splitting the ligament with a probe led to release of viscous material from a ganglion (Fig 4). A frozensection biopsy examination of the ganglion wall was unsuspicious of a malignancy. Thus, resection of the ganglion out of the fibers of the ACL was completed. No other intra-articular pathology was detected. The postoperative course was without complications. At the 1-year follow-up, the patient was still asymptomatic. DISCUSSION
FIGURE 1. Unenhanced T1-weighted SE sequence (TR/TE ⫽ 465/14, No. ACQ 2, slice thickness 4.5 mm) in sagittal orientation of the right knee shows a mass located in the intercondylar fossa and posterior joint cavity between the origin of the ACL and the insertion of the posterior cruciate ligament. The mass is well delineated, measuring 3 ⫻ 2 cm and of relatively homogeneous signal intensity (SI) comparable to the SI of muscle.
Both patients described above presented with unspecific clinical signs on examination. MRI revealed intra-articular masses in each case. Despite 2 different underlying pathologies, arthroscopy was the next diagnostic and, finally, the therapeutic step. The prognosis of PVNS depends crucially on the presenting form: localized or diffuse. The localized form in the knee joint can be cured definitely in almost all cases by arthroscopic local excision.7-9 In our first case, the localized PVNS was pedunculated, which is the usual presentation. We achieved a good result after arthroscopic local excision with full restoration of range of movement and no recurrence at the 1-year follow-up. The treatment of the diffuse form of PVNS is more controversial and uncertain. Reports of radiation synovectomy with yttrium-90 were promising but long-
322
D. S. HAMMER ET AL.
FIGURE 2. Intraoperative arthroscopic view (anterolateral portal, 70° lens, right knee) of the brownish pedunculated PVNS localized in the dorsal intercondylar fossa.
term results are missing.10,11 In cases with diffuse spread of PVNS, synovectomy by means of an open arthrotomy is widely accepted. However the median recurrence rate in literature is about 40%.1-3,12 Sometimes ganglion cysts within the cruciate liga-
FIGURE 3. Unenhanced T2-weighted TSE sequence (TR/TE ⫽ 200/ 15, No. Acq. 4, slice thickness 4.0 mm) with fat suppression in sagittal orientation of the left knee suggesting a cystic structure located in the intercondylar fossa and posterior joint cavity close to the midportion and femoral origin of the ACL. The mass seems to consist of a small wall and septations of low signal intensity (SI) filled with high SI areas suggesting fluid collection.
FIGURE 4. Arthroscopic view (central portal, 30° lens, left knee) of the femoral attachment of the ACL bulged by a ganglion cyst (arrows).
ments can be difficult to detect with arthroscopy. In cases with atypical knee pain, preoperative MRI is recommended in order not to overlook pathologies hidden to the arthroscopic view. In our second case, the bulged femoral origin of the ACL could barely be missed on arthroscopy, but this does not apply to all lesions.13 In literature, arthroscopic resection of the ganglion cyst with preservation of the ligament is reported to be the most frequently performed treatment. Recurrence has not been reported.6,14,15 Total resection of the ACL was necessary in 1 case with complete mucoid cystic degeneration.16 Other methods included arthroscopic needle aspiration17 or computed tomography– guided aspiration18 with good results. In our second case, with a tear of the posterior horn of the lateral meniscus at the same time, it is debatable how much the ganglion cyst of the ACL contributed to the patient’s symptoms. Nevertheless the patient recovered completely after arthroscopy. Arthroscopy allows for a more accurate diagnosis in tumor-like lesions of the knee joint with MRI as the preceding tool. It is possible to discover small lesions or additional pathology that are not shown by MRI. Biopsy specimens can be taken and definite treatment can often be performed in cases with localized lesions. If recurrence is suspected, a second arthroscopy and re-evaluation can be combined with treatment. Cases with diffuse spread of tumor-like lesions may need arthrotomy.
LOCALIZED PVNS AND GANGLION CYST REFERENCES 1. Ogilvie-Harris DJ, McLean J, Zarnett ME. Pigmented villonodular synovitis of the knee. J Bone and Joint Surg Am 1992;74:119-123. 2. Rader CP, Barthel T, Hendrich C, Eulert J. The pigmented villonodular synovitis of the knee joint. Zentralbl Chir 1995; 120:564-570. 3. Eisold S, Fritz T, Buhl K, Leutloff U, Meeder PJ. Pigmented villonodular synovitis: Case reports and review of literature. Chirurg 1998;69:284-290. 4. Liu SH, Osti L, Mirzayan BS. Ganglion cysts of the anterior cruciate ligament: a case report and review of the literature. Arthroscopy 1994;10:110-112. 5. Schmitz MC, Schaefer B, Bruns J. A ganglion of the anterior horn of the medial meniscus invading the infrapatellar fat pad. Knee Surg Sports Traumatol Arthrosc 1996;4:97-99. 6. Bellellini A, De Luca F, Maresca G, Nardis P. Synovial cyst of the cruciate ligament. Findings with magnetic resonance in 8 symptomatic cases. Radiol Med Torino 1996;92:346-350. 7. Van Meter CD, Rowdon GA. Localized pigmented villonodular synovitis presenting as a locked lateral meniscal bucket handle tear: A case report and review of the literature. Arthroscopy 1994;10:309-312. 8. Lee BI, Yoo JE, Lee SH, Min KD. Localised pigmented villonodular synovitis of the knee: Arthroscopic treatment. Arthroscopy 1998;14:764-768. 9. Williams AM, Myers PT. Localised pigmented villonodular synovitis: A rare cause of locking of the knee. Arthroscopy 1997;13:515-516.
323
10. Wiss DA. Recurrent villonodular synovitis of the knee: Successful treatment with yttrium 90. Clin Orthop 1982;169:139144. 11. Franssen MJAM, Boerbooms AMT, Karthaus RP, Buijs WCAM, Van de Putte LBA. Treatment of pigmented villonodular synovitis of the knee with yttrium-90 silicate: Prospective evaluations by arthroscopy, histology and 99mTc pertechnetate uptake measurements. Ann Rheum Dis 1989;48: 1007-1013. 12. Beguin J, Locker B, Vielpeau C, Souquieres G. Pigmented villonodular synovitis of the knee: Results from 13 cases. Arthroscopy 1989;5:62-64. 13. Horvath LZ, Aebersold P, Bodoky A. Ganglion cysts arising from the cruciate ligaments of the knee: Case report and literature review. Arthroskopie 1997;10:211-213. 14. Roeser WM, Tsai E. Ganglion cysts of the anterior cruciate ligament. Arthroscopy 1994;10:574-575. 15. Nakagawa Y, Matsusue Y, Nakamura T. Ganglia of the posterior cruciate ligament. A report of three cases and a review of the literature. Bull Hosp Jt Dis 1998;57:165-168. 16. Kumar A, Bickerstaff DR, Grimwood JS, Suvarna SK. Mucoid cystic degeneration of the cruciate ligament. J Bone Joint Surg Br 1999;81:304-305. 17. Kang CN, Lee SB, Kim SW. Symptomatic ganglion cyst within the substance of the anterior cruciate ligamant. Arthroscopy 1995;11:612-615. 18. Campagnolo DI, Davis BA, Blacksin MF. Computed tomography– guided aspiration of a ganglion cyst of the anterior cruciate ligamant: A case report. Arch Phys Med Rehabil 1996;77:732-733.
Arthroscopic Treatment of Tumor-Like Lesions of the Knee Joint: Localized Pigmented Villonodular Synovitis and Ganglion Cyst of the Anterior Cruciate Ligament Dietrich S. Hammer, M.D., Michael Dienst, M.D., and Dieter M. Kohn, M.D.
Abstract: We present the arthroscopic treatment of a case of localized pigmented villonodular synovitis that led to increasing restriction of knee flexion and the case of a ganglion cyst within the anterior cruciate ligament causing unspecific pain. Both pathologies could be resected arthroscopically with complete relief of symptoms and no recurrence. In cases with unspecific clinical signs and intra-articular masses shown on magnetic resonance imaging, arthroscopy is the next therapeutic step. Localized tumor-like lesions can often be excised without recurrence in the same session. Key Words: Tumor-like lesion—Pigmented villonodular synovitis—Anterior cruciate ligament—Ganglion cyst—Arthroscopic treatment.
P
rimary tumors of the knee joint are rare. Tumorlike lesions occur more often. We describe the cases of 2 patients in whom we treated such lesions arthroscopically. The first patient had localized pigmented villonodular synovitis (PVNS), the second had an intra-articular ganglion attached to the anterior cruciate ligament (ACL). PVNS is a rare proliferative condition affecting the synovial membrane of joints, bursae and tendon sheaths (the incidence of articular location is 1.8 cases per million population per year). The etiology of PVNS is still uncertain. Recurrent hematoma, chronic inflammation, and trauma have been considered to be the cause. The lesion prefers the joints of the lower extremity, especially the knee, and it is nearly almost always monoarticular. It presents in 2 forms: local and
diffuse, the latter occurring more often. PVNS can act as a locally aggressive lesion that invades surrounding soft tissue and bone.1-3 Ganglion cysts within the ACL are unusual findings. Whereas periarticular cystic lesions, such as popliteal cysts (Baker’s cyst), and intra-articular cystic lesions, such as synovial pseudocysts of the posterior cruciate ligament and meniscal cysts, are fairly common (meniscal cysts are found in 3% of patients who undergo meniscus surgery), there are only few reports of ganglion cysts within the cruciate ligaments. The etiology is unclear. According to 1 theory, the ganglion cyst represents a mucinous degeneration of connective tissue.4 Other explanations are herniation of synovial tissue through a defect in the joint capsule or tendon sheath and proliferation of omnipotent mesenchymal cells.5,6
From the Orthopaedic University Hospital, Homburg/Saar, Germany. Address correspondence and reprint requests to Dietrich S. Hammer, M.D., Orthopaedic University Hospital, D-66424 Homburg/Saar, Germany. E-mail: [email protected] © 2001 by the Arthroscopy Association of North America 0749-8063/01/1703-2548$35.00/0 doi:10.1053/jars.2001.22368
CASE REPORTS
320
Case 1 A 36-year-old woman with no history of knee problems reported lateral knee pain after a twisting injury to her right knee. Magnetic resonance imaging (MRI)
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 17, No 3 (March), 2001: pp 320 –323
LOCALIZED PVNS AND GANGLION CYST was arranged by the consulted physician and it showed a large intra-articular effusion and an intraarticular soft tissue mass within the dorsal intercondylar fossa measuring 3 ⫻ 2 ⫻ 2 cm (Fig 1). When she came to our outpatient clinic 1 week later, the discomfort in her right knee had almost completely disappeared. On examination, the right knee was free of inflammation with no effusion but a discreet pain on pressure at the lateral joint line. Typical meniscal signs were negative and the ligaments were stable. The flexion was restricted with extension/flexion 10°/ 0°/120°. The arthroscopic procedure revealed intact menisci and no ligamentous lesion. A cavity in the dorsal part of the intercondylar fossa above the insertion of the posterior cruciate ligament could be detected. It was filled with a brownish pedunculated soft-tissue mass which was resected along with the surrounding synovial membrane (Fig 2). The histologic examination confirmed the diagnosis of PVNS. The patient recovered well after this procedure. At last follow-up 1 year postoperatively, she was asymptomatic with unrestricted range of movement of her right knee. The control MRI showed no signs of local recurrence.
321
Case 2 A 39-year-old woman underwent arthroscopy of her left knee because of discomfort after a twisting injury. Resection of the posterior horn of the medial meniscus due to a longitudinal tear was performed, which made her completely asymptomatic. Three years afterward, she complained of gradually increasing discomfort in her left knee laterally and dorsally while weight bearing. On examination, the knee presented with no signs of inflammation or effusion, stable ligaments, and unrestricted range of movement. Palpation of the dorsomedial joint line was painful. No specific meniscal signs could be elicited. An MRI, performed to lighten the anamnestic and clinical discrepancy, revealed a 1.5 ⫻ 1.5 ⫻ 2 cm mass in the intercondylar fossa in the vicinity of the insertion of the ACL with low signal intensity on T1-weighted MRIs and increased signal intensity on T2-weighted MRIs (Fig 3). The lateral meniscus showed no pathology. Arthroscopy showed a 1-cm longitudinal tear of the posterior horn of the lateral meniscus. The meniscus was resected partially. The ACL bulged in the femoral attachment area. Splitting the ligament with a probe led to release of viscous material from a ganglion (Fig 4). A frozensection biopsy examination of the ganglion wall was unsuspicious of a malignancy. Thus, resection of the ganglion out of the fibers of the ACL was completed. No other intra-articular pathology was detected. The postoperative course was without complications. At the 1-year follow-up, the patient was still asymptomatic. DISCUSSION
FIGURE 1. Unenhanced T1-weighted SE sequence (TR/TE ⫽ 465/14, No. ACQ 2, slice thickness 4.5 mm) in sagittal orientation of the right knee shows a mass located in the intercondylar fossa and posterior joint cavity between the origin of the ACL and the insertion of the posterior cruciate ligament. The mass is well delineated, measuring 3 ⫻ 2 cm and of relatively homogeneous signal intensity (SI) comparable to the SI of muscle.
Both patients described above presented with unspecific clinical signs on examination. MRI revealed intra-articular masses in each case. Despite 2 different underlying pathologies, arthroscopy was the next diagnostic and, finally, the therapeutic step. The prognosis of PVNS depends crucially on the presenting form: localized or diffuse. The localized form in the knee joint can be cured definitely in almost all cases by arthroscopic local excision.7-9 In our first case, the localized PVNS was pedunculated, which is the usual presentation. We achieved a good result after arthroscopic local excision with full restoration of range of movement and no recurrence at the 1-year follow-up. The treatment of the diffuse form of PVNS is more controversial and uncertain. Reports of radiation synovectomy with yttrium-90 were promising but long-
322
D. S. HAMMER ET AL.
FIGURE 2. Intraoperative arthroscopic view (anterolateral portal, 70° lens, right knee) of the brownish pedunculated PVNS localized in the dorsal intercondylar fossa.
term results are missing.10,11 In cases with diffuse spread of PVNS, synovectomy by means of an open arthrotomy is widely accepted. However the median recurrence rate in literature is about 40%.1-3,12 Sometimes ganglion cysts within the cruciate liga-
FIGURE 3. Unenhanced T2-weighted TSE sequence (TR/TE ⫽ 200/ 15, No. Acq. 4, slice thickness 4.0 mm) with fat suppression in sagittal orientation of the left knee suggesting a cystic structure located in the intercondylar fossa and posterior joint cavity close to the midportion and femoral origin of the ACL. The mass seems to consist of a small wall and septations of low signal intensity (SI) filled with high SI areas suggesting fluid collection.
FIGURE 4. Arthroscopic view (central portal, 30° lens, left knee) of the femoral attachment of the ACL bulged by a ganglion cyst (arrows).
ments can be difficult to detect with arthroscopy. In cases with atypical knee pain, preoperative MRI is recommended in order not to overlook pathologies hidden to the arthroscopic view. In our second case, the bulged femoral origin of the ACL could barely be missed on arthroscopy, but this does not apply to all lesions.13 In literature, arthroscopic resection of the ganglion cyst with preservation of the ligament is reported to be the most frequently performed treatment. Recurrence has not been reported.6,14,15 Total resection of the ACL was necessary in 1 case with complete mucoid cystic degeneration.16 Other methods included arthroscopic needle aspiration17 or computed tomography– guided aspiration18 with good results. In our second case, with a tear of the posterior horn of the lateral meniscus at the same time, it is debatable how much the ganglion cyst of the ACL contributed to the patient’s symptoms. Nevertheless the patient recovered completely after arthroscopy. Arthroscopy allows for a more accurate diagnosis in tumor-like lesions of the knee joint with MRI as the preceding tool. It is possible to discover small lesions or additional pathology that are not shown by MRI. Biopsy specimens can be taken and definite treatment can often be performed in cases with localized lesions. If recurrence is suspected, a second arthroscopy and re-evaluation can be combined with treatment. Cases with diffuse spread of tumor-like lesions may need arthrotomy.
LOCALIZED PVNS AND GANGLION CYST REFERENCES 1. Ogilvie-Harris DJ, McLean J, Zarnett ME. Pigmented villonodular synovitis of the knee. J Bone and Joint Surg Am 1992;74:119-123. 2. Rader CP, Barthel T, Hendrich C, Eulert J. The pigmented villonodular synovitis of the knee joint. Zentralbl Chir 1995; 120:564-570. 3. Eisold S, Fritz T, Buhl K, Leutloff U, Meeder PJ. Pigmented villonodular synovitis: Case reports and review of literature. Chirurg 1998;69:284-290. 4. Liu SH, Osti L, Mirzayan BS. Ganglion cysts of the anterior cruciate ligament: a case report and review of the literature. Arthroscopy 1994;10:110-112. 5. Schmitz MC, Schaefer B, Bruns J. A ganglion of the anterior horn of the medial meniscus invading the infrapatellar fat pad. Knee Surg Sports Traumatol Arthrosc 1996;4:97-99. 6. Bellellini A, De Luca F, Maresca G, Nardis P. Synovial cyst of the cruciate ligament. Findings with magnetic resonance in 8 symptomatic cases. Radiol Med Torino 1996;92:346-350. 7. Van Meter CD, Rowdon GA. Localized pigmented villonodular synovitis presenting as a locked lateral meniscal bucket handle tear: A case report and review of the literature. Arthroscopy 1994;10:309-312. 8. Lee BI, Yoo JE, Lee SH, Min KD. Localised pigmented villonodular synovitis of the knee: Arthroscopic treatment. Arthroscopy 1998;14:764-768. 9. Williams AM, Myers PT. Localised pigmented villonodular synovitis: A rare cause of locking of the knee. Arthroscopy 1997;13:515-516.
323
10. Wiss DA. Recurrent villonodular synovitis of the knee: Successful treatment with yttrium 90. Clin Orthop 1982;169:139144. 11. Franssen MJAM, Boerbooms AMT, Karthaus RP, Buijs WCAM, Van de Putte LBA. Treatment of pigmented villonodular synovitis of the knee with yttrium-90 silicate: Prospective evaluations by arthroscopy, histology and 99mTc pertechnetate uptake measurements. Ann Rheum Dis 1989;48: 1007-1013. 12. Beguin J, Locker B, Vielpeau C, Souquieres G. Pigmented villonodular synovitis of the knee: Results from 13 cases. Arthroscopy 1989;5:62-64. 13. Horvath LZ, Aebersold P, Bodoky A. Ganglion cysts arising from the cruciate ligaments of the knee: Case report and literature review. Arthroskopie 1997;10:211-213. 14. Roeser WM, Tsai E. Ganglion cysts of the anterior cruciate ligament. Arthroscopy 1994;10:574-575. 15. Nakagawa Y, Matsusue Y, Nakamura T. Ganglia of the posterior cruciate ligament. A report of three cases and a review of the literature. Bull Hosp Jt Dis 1998;57:165-168. 16. Kumar A, Bickerstaff DR, Grimwood JS, Suvarna SK. Mucoid cystic degeneration of the cruciate ligament. J Bone Joint Surg Br 1999;81:304-305. 17. Kang CN, Lee SB, Kim SW. Symptomatic ganglion cyst within the substance of the anterior cruciate ligamant. Arthroscopy 1995;11:612-615. 18. Campagnolo DI, Davis BA, Blacksin MF. Computed tomography– guided aspiration of a ganglion cyst of the anterior cruciate ligamant: A case report. Arch Phys Med Rehabil 1996;77:732-733.