(Kiosk 2) PVNS Presenting as Meniscal Tear Leading to Ineffective Surgical Management

Case Diagnosis: A rare case of a 61 year old female presenting with left knee pain, later found to be diagnosed with Pigmented Villonodular Synovitis

Case Description or Program Description: A 61-year-old female with a history of left knee arthrofibrosis presented with worsening left knee pain and stiffness. Physical examination revealed swelling, crepitus, tenderness along the joint lines and behind the posteromedial aspect of the knee. Range of motion was limited to 0-50 degrees of flexion. McMurray’s test was positive. MRI without contrast of the knee demonstrated multifocal nodular regions within the joint capsule and filling a small popliteal cyst consistent with Pigmented villonodular synovitis (PVNS). Patient underwent medial and lateral meniscectomy twice, then left knee manipulation under anesthesia (MUA) four times with no relief.

Setting: Outpatient sports medicine clinic

Assessment/Results: Patient is scheduled for left knee arthroscopic synovectomy, followed by a course of physical therapy

Discussion (relevance): PVNS is a rare condition that causes the synovium to thicken. It is characterized by a benign, aggressive mass that can invade surrounding bone and cartilage. The local/nodular form only involves the tendons and is localized to one area, whereas the diffuse condition affects the entire joint lining. It can present as joint pain, stiffness, and even manifest with a positive McMurray’s test. Open synovectomy has been the standard of care. However, arthroscopic synovectomy has become more popular due to better wound healing and shorter recovery times. Nonetheless, many physicians may hesitate to perform surgery and would prefer other options such as MUA.

Conclusions: Due to PVNS presenting with similar symptoms to other diagnoses, such as osteoarthritis or meniscal tearing, it can be challenging to diagnose. This can lead to patients receiving unnecessary surgical interventions, such as with our patient. Therefore, further data is needed to help clinicians differentiate PVNS from other conditions to achieve faster relief and reduce treatment harm. It can also be argued that physicians should opt for synovectomy immediately instead of other less successful treatments.