DR.MOHAMMED IRFAN SHEIKHalmost 6 years ago

Results of Total Knee Arthroplasty in Patients with Pigmented Villonodular Synovitis-Reporting Three Cases

A 61-year-old woman was referred to our clinic because of right knee pain and swelling. She had a history of painful swelling of the knee for about 8 years and was treated by open debridement for 7 years and aspiration and corticosteroid injection 6 years before admission in another center. At presentation, the right knee had obvious swelling with large all-around palpable mass with 0 - 100 ranges of motion (ROM). She had no history of trauma, rheumatoid or hematologic disorder and diabetes mellitus. In AP/lateral X-rays grade 3 osteoarthritis, according to Kellgren and Lawrence, radiographic grading system (5) and huge soft tissue mass shadow in suprapatellar pouch and posterior popliteal area was seen (Figures 1a and 1b). An MRI showed the extent of the mass and was in favor of PVNS (Figure 1c). Because of weak tibialis posterior (TP), pulse angiography was performed, which confirmed TP occlusion and mass blood perfusion from genicular branches (Figure 1d). Arthroscopic biopsy confirmed the diagnosis of PVNS. Surgery was done in 2 stages. In the first stage, 3 months after the biopsy, in prone position and lazy S popliteal incision the posterior mass excised. One month later, in supine position, with standard anterior midline incision, anterior mass excised and posterior stabilized total knee arthroplasty (TKA) with LPS prosthesis (Zimmer Biomet, Warsaw, Indiana, USA) was performed. At the 10 year follow-up she is painless without recurrence of disease and the prosthesis is stable (Figures 1e and 1f). According to the knee injury and osteoarthritis outcome score (KOOS) (6) the functional result is excellent. A 63-year-old man who had a diffuse form of PVNS and history of 2 time open right knee arthrotomy and synovectomy with 3 incisions in posterior, medial, and anterior surface of the knee in 2002 and 2003 in another center. The ultrasound showed 2 40 × 26 and 45 × 30 millimeters masses in popliteal space of knee. MRI confirmed the masses (Figure 2a). On admission he had grade 3 osteoarthritis, according to Kellgren and Lawrence radiographic grading system (Figure 2b). ROM was 60 degrees with 20 degrees flexion contracture. Due to the severe disabling pain, total knee replacement with LCCK prosthesis (Zimmer Biomet, Warsaw, Indiana, USA) was performed. At the time of TKA 2 masses and synovium were excised. One year after TKA he has no pain or swelling. ROM is 110 degrees without flexion contracture. Prosthesis is well fixed (Figure 2c). According to knee injury and osteoarthritis outcome score (KOOS) the functional result is excellent. An 80-year-old man with history of a car to pedestrian accident 8 years before referring to our clinic without history of fracture or soft tissue injury of his left knee. His main complaint was his left knee pain and swelling. ROM was 90 degrees with 10 degrees flexion contracture. In the X-ray, grade 3 osteoarthritis, according to Kellgren and Lawrence radiographic grading system, and diffuse soft tissue mass was seen (Figures 3a and 3b). The MRI revealed characteristic findings of diffuse PVNS. Arthroscopic biopsy was performed and confirmed the diagnosis. Two months later, with anterior standard medial parapatellar approach, total synovectomy and rotating hinged TKA (Zimmer Biomet, Warsaw, Indiana, USA) was performed. One-week after the operation, the patient returned to the operating room, the hematoma was evacuated and hemovac drain inserted then discharged without complication 1 week later. Ten weeks after TKA, the patient suffered simple falling down and quadriceps femoris tendon ruptured (Figure 3c). Direct repair of quadriceps femoris tendon and augmentation with no 5 non-absorbable suture performed. At the last visit, 9 months after index operation, the patient had 30-degree extension lag with 0 - 110 passive ROM. Prosthesis is stable without recurrence of disease (Figures 3d and 3e). According to knee injury and osteoarthritis outcome score (KOOS) Functional result is fair.