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THE
DIAGNOSIS
PIGMENTED
P. D.
H. A.
the
Middlesex
The
clinical
that
and
Hospital,
many
benign
has
amputations
condition,
the
have
and
the
past
been
mistakes
still
ENGLAND
National
Orthopaedic
pigmented
villonodular
difficult
for
what
be made
Hospital
London
posed
performed
may
Royal
between
often
P. H. NEWMAN,
LOWY,
LONDON,
of Orthopaedics,
distinction
in
M.
THOMSON,
and
Institute
pathological
synovioma
A. D.
OF
SYNOVITIS
0. W. DEACON,
and
SIsoNs
and
malignant
TREATMENT
VILLONODULAR
R. E. COTTON,
BYERS,
From
AND
problems
is now
by those
synovitis
: there
considered
who
are
and
is no
to be an
unfamiliar
with
doubt
entirely
the
two
conditions.
The
purpose
of the
synovitis
and
in which
histological
present
to present
report
information
material
is to review
with
and
regard
detailed
the
literature
to a series
clinical
information
HISTORICAL
of the
sheaths
nodule
in the
knee.
pigmented
cases
were
villonodular
studied
personally,
available.
REVIEW
The first account
of what we now know
as pigmented
Chassaignac
(1852) who described
lesions
of the nodular
tendon
on
of eighty
middle
and index fingers.
Both considered
the lesions
villonodular
form arising
synovitis
in relation
was that of
to the flexor
Simon
(1865)
described
a large pedunculated
to be sarcomata.
Moser
(1909)
reported
the
first example
of the diffuse
type
of lesion : the ankle
was affected
and
the patient
was
free of recurrence
seven
years
after
synovectomy.
Dowd
(1912),
who described
a diffuse
synovial
lesion
of the knee, was the first to question
the malignant
nature
of this type of
lesion.
In
the
giant-cell
early
the nomenclature
is often
1897),
villous
arthritis
(Dowd
literature
tumour
(Targett
confusing,
1912),
the
benign
terms
xanthoma
or
synovioma
(Stewart
1948) and myeloxanthoma
(Dor
1898) being used.
These names
suggested
a neoplastic
although
Dor had first suggested
that the nodular
lesion
was inflammatory.
More
Wright
(1951)
has maintained
that the lesions
in question
are benign
synoviomas.
In 1941 Jaffe, Lichtenstein
paper,
based
on clinical
Their
tendon
sheaths
that
part
of
and
the nodular
of the same
the
In
of
1954
been
pigmented
led
process.
The
to
and
conclude
Hudacek
suggested,
however,
that
by
that
synovitis,
course,
the
of the
condition.
similar,
and
as well
as the
condition
They
suggested
was
histological
not
observed
that
a
they
were
appearance
tumour,
but
an
agent.
produced
synovitis
account
histologically
benign
to an unknown
villonodular
definitive
were
villonodular
synovitis.
cases involving
joints,
changes
repeated
these
but
more
which
injection
changes
are
closely
they
of
not
regarded
blood
really
resemble
into
as
similar
the
knees
comparable
those
to those
of
with
seen
in
dogs.
those
of
haemophilia
1967).
Fisk
290
Young
the
lesions
them
villonodular
(Hoagland
trauma
disease
Sutro introduced
the term pigmented
pathological
experience
with twenty
still
is
diffuse
response
pigmented
It has
bursae,
and
lesions,
inflammatory
and
and
origin,
recently
(1952)
to
attributed
synovial
fringes,
the
changes
with
of pigmented
consequent
villonodular
hydrarthrosis.
synovitis
This
THE
JOURNAL
was
to
repeated
thought
OF BONE
AND
minor
to set
JOINT
up
SURGERY
a
THE
DIAGNOSIS
self-perpetuating
and Copeland
but
the
anatomical
of
Wilson
cholesterol
Most
sites
lipoid
levels
this
of the
and
now
been
patients.
The
an
hips,
true
nature
inflammatory
Pigmented
and
the
villonodular
1956),
women.
anterior
and
synovitis
published
McCormack
and
knee,
a pedunculated
where
Granowitz
and
Gazale
1959).
More
recent
of the
disease
Mankin
lesions
than
multiple
Nodular
joint
involvement,
The
diffuse
where
In both
and
two
1951).
diffuse
and
years
often
elapse
before
pain
is not
usually
severe,
and Wilson
1939,
common
in cases
and
a bloodstained
may
be slightly
Atmore
of long
(Jaffe
is often
1958,
form
adults
occur
to
(Atmore,
equal
the
Lewis
(1947),
Breimer
and
attention
to radiological
changes
present.
unknown.
Dahlin
numbers
has
lesions
disease
process
seeks
been
notably
but
lesions
The
described
advice
be a definite
Thejoint
is usually
the
(Jaffe
1958,
of
the
disease
example
is
of
(Greenfield
on record
is usually
medical
occasionally
joints,
recorded.
documented
are
and
of men
and involve
1955 ; Phalen,
locking
knee,
all been
one well
affected,
patient
larger
and
affects
have
only
nodular
it can
in the
instability
usually
were
the
the
Larmon
to have
in dispute.
is still
(Chassaignac
slowly
progressive,
(Jaffe
1958,
symptom
et a!. 1956).
Swelling
is nearly
always
present.
Joint
duration.
In the diffuse
form there
is diffuse
synovial
effusion
raised
nodular
blood
appear
still
agent
Santo
raised
is therefore
etiological
young
rise
form
knees
the
untenable.
de
found
do not
approximately
also
give
of multiple
or three
Although
the
affects
and shoulder
diffuse
form
both
cases
who
process
the
include
lesions
may
and Wallace
I 950), but several
1852, Galloway
et a!. 1940).
(1940),
view
including
investigators
but
this
authors,
of the fingers
are the most numerous
the dorsum
(Sherry
and Anderson
nodule
1967).
make
several
FEATURES
of cases
hip, ankle,
subtalar
joint,
elbow,
wrist
characteristically
monarticular
: in the
ankles)
by
Ghormley
usually
series
In the nodular
form,
aspect
more
frequently
knees,
process,
291
SYNOVITIS
villonodular
synovitis.
Geschickter
from osteoclasts
in sesamoid
bones,
and
CLINICAL
Ghormley
VILLONODULAR
postulated
Broders
of their
favour
PIGMENTED
(fingers,
has
observation.
writers
lesions
Galloway,
in some
OF
led ultimately
to pigmented
that the lesions
originate
metabolism
(1939)
confirmed
TREATMENT
process
which
(1949)
suggested
A disorder
and
AND
Wright
(de
Santo
stiffness
thickening,
not tender,
but
and
most
(1962)
have
drawn
seen
in the
fingers
is
its temperature
1965).
Freiberger
in adjacent
(1958)
bone.
and Smith
These
are
and hip: typical
lesions
show cystic erosions
on either
side
sclerosis,
and with no loss of joint
space
or demineralisation
may also be lobular
swelling
of the soft tissues.
Pugh
often
of the joint without
of surrounding
calcification
bone,
and
or
there
TREATMENT
All authorities
agree that the nodular
lesions
should
be treated
by local excision,
despite
a high rate of recurrence,
which
ranges
from
16 per cent (Galloway
et a!. 1940) to 48 per cent
(Wright
1951).
In the diffuse
form
extensive
synovectomy
is advocated
by most
writers
(Shafer
and Larmon
1951, Atmore
used arthroplasty
with encouraging
The high recurrence
rate after
ci a!. 1956).
results.
synovectomy
combination
with synovectomy
(Shafer
alone (Greenfield
and Wallace
1950).
lesions
will regress
after radiotherapy,
that joint
stiffness
might
be precipitated
is effective
term
VOL.
or justified.
results
50 B,
can
NO.
be
2, MAY
Furthermore,
obtained
1968
even
when
In the
has
hip,
led to the
Chung
use
and
Janes
(1965)
of radiotherapy,
either
have
in
and Larmon
1951, Friedman
and
Schwartz
1957)
or
There
is no doubt
that both synovial
and intraosseous
but McMaster
(1960)
and Atmore
et a!. (1956)
feared
and were not convinced
that this form of treatment
Chung
and Janes
(1965)
showed
that satisfactory
longthe
disease
has
not
been
completely
eradicated.
292
P. D. BYERS,
R. E. COTTON,
0.
W. DEACON,
M. LOWY,
PRESENT
The
records
of the
over a period
of miscellaneous
Royal
National
of approximately
joint
disease
The
histological
Orthopaedic
Each
of
sections
us approached
the
Hospital
thirty
years
were searched,
were found.
Cases
in which
were
diagnosis
and
by
benign
non-specific
four
information,
villonodular
of pigmented
the
A. D. THOMSON
Middlesex
and more
the following
synovitis,
xanthoma,
examined
and in the absence
ofclinical
agreed
diagnosis
of pigmented
H. A. SISSONS,
SERIES
made
were
reviewed
: pigmented
villonodular
synovioma,
giant-cell
tumour
of tendon
sheath,
synovitis
and haemarthrosis.
independently
details.
An
P. H. NEWMAN,
of
us
synovioma,
synovitis,
who
and then
synovitis
Hospital
than
200
diagnosis
are
examples
had been
malignant
traumatic
pathologists,
first
as a group
with the clinical
was reached
in 126 cases.
villonodular
synovitis
independently,
on
the basis
of the information
in the literature
and his own experience.
Lack
of agreement
was expected
but was, in fact, rarely
encountered.
When
there
was disagreement,
opinion
was between
pigmented
villonodular
synovitis
and non-specific
synovitis
in eleven
cases,
and
between
pigmented
villonodular
synovitis
and a malignant
tumour
in eight cases.
The eleven
cases
were
regarded
eight cases
be malignant
as uncertain
in which
and
substantiated
this
and
malignancy
five to be
were
not
included
in the
was initially
suspected,
pigmented
villonodular
final
group
three
were
synovitis.
of cases
agreed
on
Follow-up
: of the
discussion
information
to
view.
TABLE
DISTRIBUTION
OF LESIONS
I
IN PIGMENTED
V1LLONODULAR
Number
SYNovms
of cases
Site
Diffuse
Nodular
Knee
.
24
13
37
Fingers
.
-
26
26
7
7
Foot
In
eighty
information
of
was
were examined
was obtained
from
the
time
Ankle
.
5
Hip.
.
2
Wrist
.
Shoulder
.
126
the
available,
All
cases
lesions
5
2
I
histologically
and
the
personally
by one
by correspondence.
diagnosed
present
report
cases
detailed
is based
on
of us, and in the remaining
The follow-up
period
varied
this
clinical
group.
and
follow-up
Seventy
patients
ten the necessary
information
from three to thirty-five
years
of treatment.
DISTRIBUTION
bursal
Total
in the present
were encountered.
series
The
OF
showed
either
distribution
LESIONS
joint
or
of lesions
tendon
sheath
involvement:
is shown
in Table
I. Lesions
no
of
the knees
and fingers
occurred
most
commonly
(46 per cent and 33 per cent of all cases),
while
feet, ankles,
hips,
wrists
and shoulders
were affected
with decreasing
frequency.
In
only one patient,
with involvement
of both ankles,
was more than one joint
affected.
In the
fingers,
lesions
were mostly
on the palmar
aspect
of the distal
or intermediate
phalanx:
they
did not always
interphalangeal
have
joint.
origin
from
the
tendon
sheath
and
sometimes
THE
JOURNAL
appeared
OF
BONE
related
AND
JOINT
to the
SURGERY
THE
DIAGNOSIS
AND
TREATMENT
OF PIGMENTED
AGE
The
most
condition
frequent
and
is chiefly
age
below
that
patients
were
at
The
age.
men
one
of young
presentation
and
was
youngest
or those
fourth
was
293
SYNOVITIS
SEX
persons
in the
patient
forty-seven
AND
VILLONODULAR
in early
decade,
eleven
with
and
the
middle
an
oldest
life
even
(Fig.
1).
distribution
sixty-eight.
The
above
Thirty-three
women.
25
NUMBER
OF
20
PATIENTS
5
I0
Q.JQ
11-20
21-30
31-40
41-50
AGE
IN
61-70
70&ovgr
YEARS
FIG.
Age at onset
51-60
1
of pigmented
villonodular
synovitis.
SYMPTOMS
Swelling,
related
the
which
Pain
patients.
to the
larger
The
and
one
the
on
interval
clinical
swelling.
between
presenting
was
usually
stiffness
(eleven
locking
occurred
symptoms
resulted
nerve
the
presentation
frequent
but
and
patient
ulnar
most
Joint
Instability
In
pressure
the
thirty-three,
in
size of the
form.
from
present
swellings.
nodular
by far
was
was
at the
onset
ranged
patients)
only
was
its severity
was
in
knee
was
seen
not
in seventy
necessarily
usually
associated
lesions,
usually
with
of the
________________
wrist.
I
of symptoms
from
symptom,
mild:
one
month
to fifteen
years,
with an average
of two and a half
years.
In forty-seven
patients
the interval
exceeded
one year.
A history
of trauma
was
obtained
in
eighteen
patients.
PHYSICAL
In
the
partly
diffuse
from
synovial
form
from
swollen
joint
joint
synovitis and
diagnostic
point.
involved
slightly
movement
warm,
was
with
marked
presented
fossa,
as
The
Knee
localised
swellings
initially
regarded
bursitis.
VOL.
50 B,
NO.
2.
MAY
was
joints
1968
lesions
as
in
of
a helpful
were
tender.
Limitation
the long-standing
swelling.
from
fluid
is suggestive
villonodular
but
not
seen
in
swollen,
was
and partly
of bloodstained
Aspiration
a chronically
pigmented
the
thickening
synovial
effusion.
SIGNS
often
of
cases
occasionally
the
popliteal
semimembranosus
FIG. 2
Radiograph
showing
invasion
of femur
and
pelvis in case of pigmented
villonodular
synovitis of hip.
294
P. 1).
0.
R. E. COTTON,
BYERS,
W.
DEACON,
M. LOWY,
In
nodular
sometimes
the
H. A. SISSONS,
P. H. NEWMAN,
lesions
an
cases
the
of
effusion,
and
was
palpable.
a mass
A. D. THOMSON
knee
in
there
In
a progression
diffuse
In
most
cases
abnormality
15 per cent,
bone
shows
was
the
Erosions
local
periods
excision
of four
and
the
year’s
the pelvis
(Fig.
correct
diagnosis;
of phalanges
was
and
of the
performed
seven
Figure 4-Antero-posterior
the nodular
type of lesion.
hand
and
years
has
3).
the
and
the
invasive
and lateral
radiographs
Figure
5-Radiograph
in
a
man
of
no
shown
sign
of
together
in Figures
stiffness
confirm
the
synovioma
Figure
2
in a case
of
of the
nine
4 and
with
one
of the
hip.
radiological
and
hind-
performed.
tissue
was
histologically.
with
villonodular
forty-seven
and
In
of
sometimes
pigmented
was
synovial
confirmed
this,
treatment.
of
Subsequent
re-examination
patient
is alive
and well
are
radiological
appearance
pain
appeared
to
of malignant
quarter
amputation
tion
pigmented
diagnosis
revealed
radical
very
history
Biopsy
diagnosis
foot
to the
swelling.
evidence
interpretation,
proven
synovitis,
the femur
established
appearances
no
was
shown:
histological
subsequently
invade
sections
had
FINDINGS
there
led to unnecessarily
Same case as Figure
2. Appearance
of lesion
in
hindquarter
amputation
specimen,
showing
pigmented
tissue involving
the head and neck of the
femur and the acetabulum,
as well as the soft tissue
adjacent
to the hip joint,
injury
nodular
apart
from soft-tissue
however,
unmistakable
involvement
uncertain
3
cases
form.
RADIOLOGICAL
FIG.
the
from
of
many
a diagnosis
of loose body or meniscus
been made
before
operation.
ln several
knee
lesions
the
suggested
was
two-thirds
years
At operafound
to
histological
later.
5.
ln each
case
Follow-up
for
recurrence.
showing
invasion
of the proximal
phalanx
of a finger
showing
invasion
of the proximal
phalanx
of toe in nodular
type of lesion.
fHE
JOURNAL
OF BONE
AND
JOINT
SURGERY
in
THE
DIAGNOSIS
AND
TREATMENT
OF PIGMENTED
1-IAEMATOLOGICAL
Estimation
test
always
of
haemoglobin,
rheumatoid
for
were
rate,
carried
out
white
in all
cell
count
patients.
and
Normal
the
results
Rose
Waaler
were
almost
obtained.
PATHOLOGICAL
The
common
nodular
pathological
proliferation
lipid.
and
295
SYNOVITIS
iNVESTIGATiONS
sedimentation
arthritis
VILLONODULAR
The
features
of synovial
gross
of the
tissues,
appearance
FINDINGS
and
is variable
lesion
of
(Figs.
FIG.
Diffuse
group
cases
studied
due
to the
pigmentation
of the knee joint
6 to
8).
consisted
of villous
presence
A given
or
of haemosiderin
lesion
may
show
a
6
showing
darkly
pigmented
tissue.
FIG.
Figure
7-Another
diffuse
7
lesion
nodular
8
FIG.
of knee joint showing
villous and nodular
lesion from the tendon
sheath of a finger.
structures.
Figure
8-A
predominantly
villous
or nodular
appearance,
or both may be seen.
Extensive
areas of synovial
membrane
may be covered
with fine or coarse
villi which are usually
a brownish
red colour.
The synovial
tissues
may be diffusely
thickened
and sessile
or pedunculated
nodules,
up to
several
long,
centimetres
detectable
yellow
is enough
to
histological
be
colour
recognised
sections
In
occasional
bones,
and
produces,
cases
this may
it
must
are
50
D
B,
NO.
2, MAY
be
by
examined.
present.
brown.
the
naked
The
The
In the
eye,
tissue
degree
vast
but
can
of
pigmentation
majority
in
a few
be
soft
ranges
of cases
the
from
amount
cases
it can
be
and
fleshy,
solid,
found
a barely
of pigment
only
when
or even
hard.
gross
examination
shows
extension
of pigmented
tissue
into adjacent
sometimes
be extensive
(Fig. 3). Despite
the alarm
that such a finding
be emphasised
that
it is not, with
this type of lesion,
an indication
of
malignancy.
VOL.
may
to ckirk
1968
296
P. D. BYERS,
On
consists
microscopic
examination
of
a
stroma
plasma
villous
Cellular
the fleshy tissue
coarse
and form
Firmer
the form
(Fig.
11).
the
and
reticulin
with
M. LOWY,
abnormal
few
P. H. NEWMAN,
tissue
collagen
fibres
fibroblasts
relatively
coarse
lesion
DEACON,
histiocytes,
contain
of
W.
reticulin
cells,
lesions
Network
cells.
0.
of
lymphocytes,
The
R. E. COTTON,
and
reticulin
little
stromal
small
<205.)
tissue.
lesions,
usually
nodular,
thickness
increases
have
a more
large
(Haematoxylin
In such
surround
collagenous
which
separate
in amount,
the
of
and
eosin,
lesions
small
including
cells,
this
are
is also
collections
and
synovitis
cells,
giant
fibres,
and
A. D. THOMSON
villonodular
a variety
multinucleated
of the softer
nodules
(Figs.
9 and 10).
an open network
(Fig. 9): they usually
of strands
of varying
As the stromal
tissue
pigmented
which
or collagen
fibres
surrounding
(Reticulin
stain,
relatively
in
in
H. A. SISSONS,
of
<
found.
true
of
cells.
205.)
the reticulin
fibres are
groups
of two or three
stroma,
usually
present
in
smaller
or larger
groups
of cells
strands
coalesce
to form large sheets
THE
JOURNAL
OF
BONE
AND
JOiNT
SURGERY
THE
DIAGNOSIS
of collagen
dotted
sometimes
shows
(Fig.
12).
The
and
structure
basic
with
small
hyaline
tissue
their
disease
AND
TREATMENT
spaces.
change
may
and
be highly
appearance
does
OF PIGMENTED
Some
lesions
some
areas
vascular
not
VILLONODULAR
are
highly
may
(Figs.
be
14 and
suggest
that
collagenous:
mistaken
15),
the
for
but
297
SYNOVITIS
the
vasoformative
fibrous
osteoid
vessels
or
have
activity
tissue
cartilage
a normal
is part
of
the
process.
FIG.
More
prominent
stromal
tissue, with groups
(Haematoxylin
#{149}
11
of cells, spaces and
and eosin,
x 205.)
multinucleated
giant
cells.
#{149}#{149}
:
.
;
-
-
:‘
V
Highly
The
the
collagenous
great
features
majority
of
larger,
and their
or lipid, appear
the
tissue:
VOL.
50 B,
material
resembling
giant cells are present.
of cells
plasma
cells,
mononuclear
and
others
resemble
exact nature
is less easily specified.
to be histiocytes
(Figs.
16 and 17).
it is tempting
NO.
are
while
FIG.
12
osteoid
tissue
(Haematoxylin
2, MAY
1968
to
regard
them
as
synovial
or cartilage.
and eosin,
Scattered
x 130.)
multinucleated
are
or
in shape.
Some
The
majority
small
Some,
Others
round
oval
lymphocytes.
containing
haemosiderin
appear
to be related
in nature,
but
this
point
have
are
pigment
to spaces
in
needs
to
be
298
P. D. flYERS,
examined
in
R. E. COTTON,
detail.
more
villonodular
synovitis.
to be ramifications
of synovial
villi.
tissue
of another
mononuclear
cells
mononuclear
contrasts
This
type
or
form
a
strikingly
type
of space
that
found
that
stromal
the
that
may
they
H. A. SISSONS,
in
are
fact,
to originate
more
cells,
lying
do
not
free
pseudo-epithelial
of the
present
appear
coalescence
cells
are
of the
lined
the
The
contain
central
mucin:
structures
“
proportion
sonic
others
in the
produce
pigmented
others
by the
to the
tissue:
areas:
in
while
in the
solid
A. D. THOMSON
present
vascular,
(Figs.
14 and 15) produced
show the closest
relationship
cavity.
by
same
lining
their
appearance
thus
of a malignant
synovioma.
series and is consequently
histological
feature
of pigmented
villonodular
synovitis.
in question
are formed
by the proliferation
of entrapped
represent
a process
of synovial
differentiation.
Alternatively,
be a consequence
to which
are,
others
the
and
in a high
characteristic
spaces
appear
of
of the”
or that
they
component
They
giant
structures
cells,
synovial
cavity
which
layer,
was
tissue
P. 1-1. NEWMAN,
artefacts;
those
with
It
it is possible
of
multinucleated
as a rather
is possible
11).
(Fig.
M. LOWY,
simply
continuous
to be regarded
surface
variety
are
resembling
cells,
rarely
A
Some
of the main synovial
The spaces,
however,
are
cells
0. W. DEACON,
reference
of the
has
already
progressive
been
condensation
made.
The
p
‘b
of their
fibrous
synovial
*-;
;:
1
;
of the
question
‘.
0
‘.
j#{149}
,.
..
I
I
,
*
FIG.
Highly
cellular
tissue
with
multinucleated
13
giant
(Haematoxylin
nature
must
that
and
consequently
synovial
cells,
be left
like
other
undecided
types
of
are
present
cells
and
and
strands
eosin,
at present:
mesothelial
of collagenous
material.
205.)
in this
cell,
context
are
it must
notoriously
be emphasised
difficult
to
define
identify.
Multinucleated
giant
cells
in all lesions
and
are
a conspicuous
histological
feature
in about
throughout
the
lesions
the giant
half of them
(Figs.
11, 12, 13 and
16).
In most
the nuclei
are distributed
cell, although
occasionally
they are located
peripherally.
In the cellular
cells often
appear
as clusters
of nuclei
with only an indistinct
cytoplasmic
border
separating
collagenous
the
them
from the adjacent
stromal
giant
cells are more
characteristically
size
of
Giant
the
cells
cells
may
is
occur
Spindle-celled
although
this
type
the
variable,
and
in areas
fibroblastic
formation
of
the
the
number
devoid
of
tissue
was
collagenous
cells
of
nuclei
haemosiderin
not
(Fig. 13).
surrounded
may
be
pigment
conspicuous
stroma
When
the
by spaces
as
or
in
many
as
is more
II).
The
fifty
or
more.
lipid.
lesions
presumably
stroma
(Fig.
of
results
the
from
present
the
series,
activity
of cell.
TilE
JOURNAL
OF
BONE
AND
JoINT
SURGERY
of
THE DIAGNOSIS
the
degree
be disturbingly
Although
synovitis
gained
may
during
the
hyperchromatism
The
AND
synovial
areas
cells
OF PIGMENTED
of
cellularity
high,
and
of the
abnormal
of the
Villous
of
examination
and
appearance
TREATMENT
some
series
mitosis
characteristic
in fact,
always
was,
areas
occasional
present
VILLONODULAR
of
tissue
cells
may
of cases
was
that
of
a benign
pigmented
be
villonodular
present,
the
the nuclear
of a malignant
that
iIG.
14
strands
of vascular
cellular
pigmentation.
(Haematoxylin
lesion showing
of haemosiderin
in
mitotic
299
SYNOVITIS
experience
pleomorphism,
tumour
were
never
seen.
condition.
tissue.
and
The
eosin,
dark
:<
patches
are
55.)
15
FIG.
A more solid villous lesion, showing
spaces which appear
to be ramifications
of the joint
space.
An area of palely staining
lipid-containing
macrophages
is present.
(Haematoxylin
and eosin,
x 55.)
The
14 and
the
lesions
be
scattered
substances
16)
50 B,
responsible
lipid
studied
quite
concentrated
VOL.
and
focally.
NO.
2, MAY
for
(Figs.
contained
diffusely
The
1968
the
15 and
at
least
throughout
lipid
material
pigmentation
17);
the
microscopic
the
of the
quantity
tissue,
is always
of
tissue
these
amounts
but
within
of
it
is
are
varies
each
more
macrophages;
haemosiderin
greatly,
of
them.
usual
the
(Figs.
although
for
all
They
them
haemosiderin
may
to
be
is
300
P. 1). BYERS,
nearly
always
were
present
F. COTTON,
0.
W.
DEACON,
M. LOWY,
in mononuclear
cells, although
cells.
In one of the cases
in multinucleated
the
R.
in regional
pigmented
lymph
synovial
;
nodes,
P.11.
a few
studied,
the
gross
NEWMAN,
II.
granules
may
large amounts
appearance
A. SISSONS,
A.
D.
THOMSON
be found
extracellularly
or
of haemosiderin
pigment
wrongly
suggesting
metastasis
of
lesion.
“7$
;,
p
:
16
(haemosiderin)
FIG.
Collections
of iron-containing
pigment
reaction
.
are
for haemosiderin,
present
in many
cells.
(Perls’
820.)
4’..
:
-
‘I
I
I
#{149}
p.
#{149} -
ii
.5.
.
4
4
I
‘$
‘‘
I
I
,.-.,
vA. __5
#{149} /
p
of palely
.#{149}4.’%.
#{149},.‘#{149}
4
#{149}
#{149}‘P.
-\
..v
.
.,
4_
#{149} #{149}..
staining
1’
-
a
4
‘
.:
‘
17
FIG.
Collections
ai4,
1#{149}
#{149}4
#{149}:4p,#{149} ,#{149},
,f_
dIp.I,p.4p_
‘;1,I
-.
. ,
4;
4
‘:;
‘,
#{149}
-
5#{149}$
.
:bt((;’
-.
‘P
#{149}.
#{149}#{248}#{149}
S
,
.
.5
I
S
It,
#{149}
-.
I
lipid-containing
macrophages.
(Haematoxylin
and
eosin,
205.)
The
extended
cells,
histological
structure
of the lesions
to bone was not different
from that
multinucleated
giant
cells
and
fibrous
DIFFERENTIAL
true
Conditions
tumours
to be considered
include
occurring
in the neighbourhood
of pigmented
villonodular
of other
cases,
the same
stroma
HISTOLOGICAL
other
being
found
(Fig.
synovitis
combination
which
had
of round
18).
DIAGNOSIS
types
of synovitis
of joints
and tendon
THE
JOURNAL
and synovial
sheaths.
OF
BONE
reaction,
AND
JOINT
and
SURGERY
THE
DIAGNOSIS
The synovitis
group
iron-containing
pigment
synovitis
such
lesions
do
seen
in the
shoulder
as
not
knee
have
TREATMENT
OF
may
may
be a cause
be present.
of confusion,
But other
conspicuous
have
joint
been
after
lipid
cuff
in other
types
frequently
(Soeur
tears
VILLONODULAR
particularly
features
accumulations
This
appearance.
injuries
rotator
is
PIGMENTED
and
nodular
meniscus
synovitis
to show any
accumulation
or
with
reported
Rheumatoid
cells
giant
a villous
in association
findings
AND
(Cotton
in traumatic
pigmented
of
type
1949);
it has
and
Rideout
also
was
Tissue
within
clear;
four
an
invaded
of the
patients
in
but
appearance,
the
The characteristic
the more
varied
present
amputation
on the
it became
however,
supposition
clear that,
two groups
could
be made.
the histological
characteristics
sometimes
referred
showed
to
as
unquestionably
of
and
nodular
involve
to
they
are
appearance
of the
50 B,
NO.
latter
type of pigmented
(Jaffe ci a!. 1941,
2, MAY
1968
tissues,
distinguished
They
from
type
lack
synovial
tissues
the
fail
change
cell types
is a prominent
of pigmented
synovitis
confusion
and malignant
had occurred
in fact,
been
treated
giant
cells
and
villonodular
synovitis
they never metastasised,
including
a predominantly
structures
synovitis.
in
similar
by major
stromal
were malignant.
On review
of the material,
effective
histological
distinction
between
the
adjacent
have
which
the
In
bone.
spindle-celled
other
are
pigmentation
of lesion.
the internal
aspect
of a joint,
or take
The term benign
synovioma
has, in the
to as the nodular
and his colleagues
VOL.
extension
had,
cells,
multinucleated
and eosin,
x 205.)
the lesions
experience,
“pseudo-epithelial”
villonodular
series
The lesions
of pigmented
of a malignant
tumour;
synovioma
neoplastic;
characteristic
pigmented
local
malignant
showing
round
(Haematoxylin
that
with
described
essentially
18
FIG.
bone
tissue.
been
1964);
of haemarthrosis.
villous
appreciable
degree
of pigmentation.
of lymphocytes
and plasma
cells;
years
cases when
villonodular
are rarely
present,
and the
of reaction
is commonly
villonodular
synoVitis
are not seen.
The question
of distinguishing
between
pigmented
villonodular
synovioma
was the starting
point
for the present
investigation.
That
in past
301
SYNOVITIS
soft-tissue
quite
contrast,
structure
tumours
different
and
It is of interest
the
that
from
the
characteristic
they
lesions
which
by the
origin
from preformed
synovial
past, been used to describe
what
villonodular
Jaffe 1958)
never
showed
although
they
rarely,
tissue.
is now
is
presence
spaces
of
villous
if ever,
referred
synovitis
(Stewart
1948, Wright
1951).
Jaffe
have argued
at length
against
the neoplastic
302
p.
D.
nature
BYERS,
of this
in keeping
the
R. E. COTTON,
type
with
of lesion,
the
possibility
then
and
presents
DEACON,
M. LOWY,
the findings
or
“
between
little
lequirement
condition
in the
benign
and
P.
H.
group
nature
“
and
H. NEWMAN,
present
reactive
“
forms,
or of examples
for adopting
the term
The fundamental
be aware
of the
to
W.
inflammatory
“
of confusion
any intermediate
additional
reasons
is
0.
a diagnosis
experience
A. D.
appear
Furthermore,
and
the
in the benign
synovitis.
of pigmented
of it; reaching
THOMSON
to us to be
condition.
synoviomas,
of malignant
change
pigmented
villonodular
in making
to have
of cases
of the
malignant
A. SISSONS,
absence
of
condition,
villonodular
the correct
are
synovitis
diagnosis
problem.
TREATMENT
Finger
lesions-Except
in one
case,
lesions
Although
digital
nerves
were sometimes
There
was, however,
a recurrence
rate
some
cases,
to excise
the
without
a tourniquet.
In
one case primary
amputation
of the fingers
damaged,
of 27 per
were
initially
treated
by local
patients
were relieved
cent.
This is attributable
nodule
in the out-patient
two patients,
fingers
were
of a finger was carried
excision.
of their symptoms.
to an attempt,
in
department
under
local
anaesthesia
or
amputated
for repeated
recurrences
; in
out for a mistaken
diagnosis
of synovial
sarcoma.
TABLE
RESULTS
OF OPERATION
Synovectomy
Excision
Arthrodesis
lesions-This
relieved
of their
undetected
The
was
actually
and
became
appreciable
in order
change
to regain
Improved
sm5s
after
the
Worse
some
No change
since
operation
2
6
4
3
6
3
4
0
I
3
1
0
.
.
0
3
0
0
of lesions
fell into
two
categories-diffuse
and
nodular-and
with regard
to the results
of treatment.
In the nodular
form,
(Table
II).
Six of the thirteen
patients
were completely
difference
results
and
only
There
did not
and
were
more
poor.
painful.
treatment.
range
four
were
not
improved,
possibly
because
were only two definite
recurrences.
respond
so well to surgery.
In most
the results
stiffer
OF THE KNEE
.
symptoms
at operation.
diffuse
lesions
performed
Complete
relief of
SYNOVITIS
.
group
these showed
a marked
excision
gave satisfactory
VILLONODULAR
symptoms
.
only
II
PIGMENTED
of tumour
Biopsy
Knee
FOR
Two
of movement
in five patients;
in no case did
deformity
sometimes
remained.
Only
two
The
patients
rest
patients
had
before
and
Biopsy
was
the
joints-Two
original
biopsy
below-knee
specimens
amputations
had
been
were
reported
performed
as showing
THE
for
foot
malignant
JOURNAL
no
synovectomy
only
operation
attributable
was performed
synovectomy
and radiotherapy.
Two above-knee
amputations
were performed
in cases where
histological
diagnosis
of malignant
tumour
(synovial
sarcoma
and fibrosarcoma)
made.
Both patients
were free of recurrence
at subsequent
examination.
Other
knees
although
the residual
followed
by a course
of
radiotherapy;
later examination
showed
a satisfactory
result.
The recurrence
rate after synovectomy
was 46 per cent and is probably
the difficulty
of performing
a complete
synovectomy
in this joint.
Arthrodesis
in three patients,
in two as a primary
procedure
and in one for recurrence
following
the
the
or reported
after
this procedure
biopsy
was
lesions
synovectomy
in three
symptoms
a quadricepsplasty
operation.
follow
patients
an extensive
cured
residual
required
deterioration
In one of the
were
offurther
lesions
an erroneous
had been
in cases
synovioma.
OF BONE
to
AND
where
In a third
JOINT
SURGERY
THE
case
a histological
The
patient,
showed
DIAGNOSIS
of
evidence
by
of
recurrence.
involvement.
been
The
left
with
thirty
a stiff,
years
painful
no doubt
that
The
suspects
that
have
been
caused
by
of
the
order
of
the
excision
none
foot
of
and
ankle
as in other
bone
lesions
were
patients
responded
parts
of the
A second
was again
and later
regressed,
biopsy.
these
body,
patient
with
accompanied
performed
developed
but the
and
a femoral
patient
has
both
Two
bone
joint
thus
course
of irradiation,
some
as long as
any firm conclusions,
although
there is
soft-tissue
lesions
to regress.
On the other
to
allow
and
and
patients
increasing
were
a full
small
impotence
it.
developed
curettage
given
too
causes
the
of radiotherapy
lesions
same
he became
impotent,
the lesions
have
were
are
radiotherapy
one
results
nine
of the
following
follow-up
303
hip.
patients
numbers
hand,
synovectomy
and
Subsequently
Radiologically,
eight
ago.
other
made
At
SYNOVITIS
hip has already
been discussed.
Pain was a marked
feature
and
Synovectomy
Radiotherapy-Only
was
amputation.
; the recurrence
rate was
made
worse
by surgery.
followed
by radiotherapy.
neck fracture
which
united.
VILLONODULAR
synoVioma
refused
One patient
with a lesion
of the
lesion
is also of special
interest.
bone
OF PIGMENTED
malignant
nineteen,
of
well to local excison
but no patient
was
a hip
TREATMENT
diagnosis
a girl
any
AND
fracture
with
stiffness
satisfactory
in
knee
the
patient
lesions
; one
eventually
in only
two
with
treated
the
by
required
hip
lesion
may
radiotherapy
after
an arthrodesis.
The
cases.
DISCUSSION
Pigmented
in
the
villonodular
records
these
had
benign
recorded,
of the
been
essentials
the
to those
condition
finger
to
was
death
to make
this
of most
other
young
condition,
only
126
of approximately
and
from
reports
confirm
affecting
rare
a period
tumours,
all cases
and
similar
chronic
or
malignant
in almost
at operation,
painless,
joint
for
during
of this condition.
No
are there any authenticated
It is possible
in all
is a relatively
hospitals
mistaken
nature
nor
appearances
synovitis
two
it is therefore
pigmented
of lymphatic
the
diagnosis
by
histological
writers
adults.
cases
thirty
being
years.
important
basis
of the
examination.
in that
macroscopic
Our
of the
series
the
has been
spread.
findings
it is a monarticular,
In 80 per cent
of
to stress
villonodular
synovitis
or haematogenous
on the
found
Some
are
relatively
either
the
knee
affected.
The typical
nodule
on the finger
usually
presents
little diagnostic
difficulty,
although
radiological
evidence
of bone invasion
may mislead
the unwary
into diagnosing
a malignant
lesion.
Recurrence
may further
alarm
both the surgeon
and the pathologist,
but, provided
the
natural
history
of the condition
is borne
in mind,
it should
not be difficult
to reach the correct
diagnosis.
Treatment
of the finger lesions
presen’s
little difficulty,
although
it must be stressed
that
excision
general
should
anaesthesia
always
and
be performed
with
a tourniquet.
recurrence
rate is simply
due
Nodular
lesions
in the
great
Although
care
we
to incomplete
excision.
knee
are usually
readily
and
have
difficulty,
the
differential
diagnosis
tuberculosis,
rheumatoid
arthritis
and
involvement
and normal
sedimentation
of a bloodstained
effusion.
This latter
erythrocyte
sedimentation
bone involvement,
but
pigmented
appearance
even
VOL.
before
50
B,
rate.
2,
MAY
material
Malignant
1968
has
between
synovioma
been
examined.
we
and
conditions,
feel
that
removed;
using
the
high
adequate
remain
undetected.
Sometimes
body
or torn cartilage,
and its
the diffuse
form
which
causes
pigmented
malignant
synovioma.
rate excludes
rheumatoid
finding
is also unusual
the intra-articular
origin
should
make
a diagnosis
histological
NO.
resting
proper
proof
diagnosed
exposure
should
be used to ensure
that no additional
lesions
a pedunculated
nodule
gives the clinical
picture
of a loose
true
nature
only becomes
apparent
at arthrotomy.
It is
most
under
no
may
of the lesion
of pigmented
villonodular
synovitis,
The characteristic
monarticular
arthritis,
as does the aspiration
in tuberculosis,
as is the normal
be suspected
in the
presence
and the typical
reddish-brown
villonodular
synovitis
possible
of
304
P. D. BYERS,
In
all
R. F. COTTON,
cases
interpretation
in
which
discussed
surgeon
and
have discussed
is limited
should
amputation
with
not
of
Further
evidence
leads to recurrence
Only
its
P. H. NEWMAN,
is considered,
pathologist
to
seek
lesions
the
H. A. SISSONS,
a biopsy
; errors
a second
of
are
less
must
be
likely
to
A. D. THOMSON
performed
occur
and
when
of pigmented
villonodular
whose
experience
of this
its
both
the
synovitis
and
type of lesion
opinion.
knee
by
extensive
synovectomy
has
proved
to
be
cases unsatisfactory.
There
is a risk of aggravating
the patient’s
of a complete
cure are only about
1 7 per cent.
The fact that biopsy
by remission
suggests
that
the condition
may
be self-limiting.
synovitis,
synovial
if the
should
reluctant
M. LOWY,
in favour
of this view is that synovectomy,
although
necessarily
incomplete,
in less than 50 per cent of cases.
We therefore
suggest
that in this form
villonodular
extensive
but the
the
hesitate
diffuse
unpredictable
and in some
symptoms
and the chances
alone
was often
followed
a limited
DEACON,
pathologist
are aware
of the possibility
the problem
together.
A pathologist
Treatment
pigmented
0. W.
resection,
patient’s
once
no
symptoms
the
diagnosis
further
become
has
surgery
serious
synovectomy
be considered
; it may
possibility
of subsequent
arthrodesis
be
been
carried
established
out
or disabling-and
by
as
an
this
then have to be carried
or hinge
arthroplasty
initial
rarely
out
must
a biopsy
of
or
by
procedure.
occurs-should
as a calculated
risk,
be borne
in mind
it fail.
Radiotherapy
may also be used, particularly
in older patients
; we are, however,
to recommend
its use for a benign
condition
in a young
patient,
not only because
of
possible
carcinogenic
effect,
but
also
because
of
the
considerable
risk
of
producing
disabling
stiffness
of the joint.
At other sites, such as the wrist or the ankle,
synovectomy,
if performed
with care, offers
a good
chance
of success.
The hip presents
a special
problem,
as treatment
may be required
for disabling
symptoms
at a relatively
early stage in the development
of the lesion.
In these
cases,
particularly
achieved
when
by more
bone
radical
involvement
surgery
such
has
occurred,
as arthrodesis
the best
or total
functional
results
replacement
are probably
arthroplasty.
SUMMARY
1 The literature
on pigmented
villonodular
synovitis
has been
reviewed
and a series
eighty
additional
cases is reported.
2. The condition
usually
presents
either as a nodule
in a finger or knee, or as a diffuse lesion
a knee.
The lesions,
although
benign,
sometimes
erode
or invade
the tissue of adjacent
bones.
3. Distinction
from
malignant
synovioma
can
be made
on the basis
of the macroscopic
of
.
appearance
appearance:
4. Treatment
of the lesion
at operation
(relationship
to joints
pigmentation),
and by histological
examination.
of the nodular
form by excision
is satisfactory
diffuse
lesions
of the knee gives poor results.
5. The
etiology
of pigmented
villonodular
self-limiting
process,
possibly
inflammatory
synovitis
in nature.
or tendon
but
sheaths:
extensive
is unknown,
but
in
villonodular
synovectomy
it
appears
for
to
be
a
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