Pigmented Villonodular Synovitis

Ovid: 5-Minute Orthopaedic Consult

Editors: Frassica, Frank J.; Sponseller, Paul D.; Wilckens, John H.
Title: 5-Minute Orthopaedic Consult, 2nd Edition
> Table of Contents > Pigmented Villonodular Synovitis

Pigmented Villonodular Synovitis
Dennis E. Kramer MD
Frank J. Frassica MD
  • PVNS is an uncommon lesion characterized by diffuse proliferation of the synovium to form yellow-brown villous projections.
  • The knee is the most commonly affected joint, followed by the hip and shoulders (1).
  • Lesions almost always are unilateral.
  • Synonyms: Giant cell tumor of the tendon sheaths and joints; Hemorrhagic villous synovitis
  • Usually found in young to middle-aged adults
  • No definite gender correlation; may have slight female predominance (2)
Risk Factors
PVNS may have a slight association with recurrent hemarthrosis, but it has not been established definitively.
No known correlation exists.
  • The cause is unknown.
  • Studies in animals have produced similar
    lesions in response to recurrent hemarthroses, but lesions resolve when
    the inciting stimulus is removed (3).
  • In humans, slow progression of PVNS is the rule.
Associated Conditions
None are known.
Signs and Symptoms
  • Insidious onset
  • Slow progression
  • Recurrent nontraumatic effusions
  • Symptoms:
    • Pain
    • Swelling
    • Limitation of ROM
  • Joint possibly warm to the touch
  • Mild to moderate effusion
  • Tender mass occasionally palpated (especially in the suprapatellar pouch of the knee)
Physical Exam
  • Perform a complete examination of the knee, looking for the following:
    • Ligamentous and meniscal status
    • Possible effusion
    • Warmth at the joint
    • Pain
    • Swelling
    • Tender mass
  • Determine the ROM of the affected joint.
  • Assess for muscle atrophy.
  • With shoulder, ankle, and hip
    involvement, no physical findings or only subtle findings may be
    present, such as muscle atrophy or decreased ROM.
Joint aspiration reveals reddish brown fluid.
  • Radiography:
    • Early findings:
      • Frequently no abnormalities
      • Subtle erosions or periosteal reaction in nonweightbearing regions
    • Late findings:
      • Erosive lesions on both sides of the joint
      • Possible diffuse joint space narrowing seen in late cases
  • MRI:
    • Increasingly helpful in establishing the diagnosis and directing treatment
    • Areas of extremely low signal are seen in the synovial lining on both T1- and T2-weighted images (“signal dropout”) (4).
    • Characteristically, joint effusion and irregularity of the synovial lining are seen.
Pathological Findings
  • Lesions may be large and diffuse or more discrete.
  • Grossly, PVNS is characterized by villous projections or matted nodules stained with hemosiderin.
  • Microscopically, elongated villi or nodules contain inflammatory infiltrates, foamy histiocytes, and hemosiderin deposits.
Differential Diagnosis
  • Inflammatory arthritis
  • Traumatic effusions
  • Infection
  • Synovial sarcoma
  • Hemosiderosis
  • Hemochromatosis
General Measures
  • PVNS is a benign lesion.
    • The potential for malignant degeneration has been reported but is extremely rare (5).
  • In diffuse lesions:
    • It is almost impossible to remove the entire lesion without injuring important ligaments and capsular structure.
    • Therefore, the recurrence rate is high.
  • In severe or recurrent cases, radiotherapy has been effective (6,7).
  • Make appropriate referrals to establish the diagnosis and consider treatment options.
  • Treat patients symptomatically with:
    • Immobilization
    • Splinting
    • NSAIDs
    • Analgesics
Special Therapy
  • External beam irradiation is commonly used for recurrent PVNS (6, 7).
  • Radiation synovectomy with an intra-articular injection of radioactive isotope also has been used (8).
  • Analgesics


  • Arthroscopic synovectomy through multiple portals is the 1st line of treatment for diffuse PVNS.
    • An open posterior synovectomy may be necessary with extensive posterior extra-articular extension (2,10).
  • Some surgeons prefer both open anterior and posterior synovectomies for diffuse PVNS (8).
  • Localized, nodular PVNS responds well to simple excision (open or arthroscopic) (11).
Patients are followed every 6–12 months with MRI scans and physical examination (8).
The prognosis is good.
  • Recurrence is common.
  • Articular damage and bone loss may occur in long-standing disease.
  • Joint replacement may be necessary.
Patient Monitoring
  • MRI is effective in detecting early local recurrences (8).
  • Patients with asymptomatic local recurrences are treated with observation.
1. Dorwart
RH, Genant HK, Johnston WH, et al. Pigmented villonodular synovitis of
synovial joints: clinical, pathologic, and radiologic features. AJR Am J Roentgenol 1984;143: 877–885.
2. Ogilvie-Harris
DJ, McLean J, Zarnett ME. Pigmented villonodular synovitis of the knee.
The results of total arthroscopic synovectomy, partial, arthroscopic
synovectomy, and arthroscopic local excision. J Bone Joint Surg 1992;74A:119–123.
3. Granowitz SP, D’Antonio J, Mankin HL. The pathogenesis and long-term end results of pigmented villonodular synovitis. Clin Orthop Relat Res 1976;114:335–351.
4. Goldman AB, Dicarlo EF. Pigmented villonodular synovitis. Diagnosis and differential diagnosis. Radiol Clin North Am 1988;26:1327–1347.
5. Bertoni
F, Unni KK, Beabout JW, et al. Malignant giant cell tumor of the tendon
sheaths and joints (malignant pigmented villonodular synovitis). Am J Surg Pathol 1997;21:153–163.
6. O’Sullivan
B, Cummings B, Catton C, et al. Outcome following radiation treatment
for high-risk pigmented villonodular synovitis. Int J Radiat Oncol Biol Phys 1995;32:777–786.
7. Rodriguez
Blanco CE, Leon HO, Guthrie TB. Combined partial arthroscopic
synovectomy and radiation therapy for diffuse pigmented villonodular
synovitis of the knee. Arthroscopy 2001;17:527–531.
8. Chin
KR, Barr SJ, Winalski C, et al. Treatment of advanced primary and
recurrent diffuse pigmented villonodular synovitis of the knee. J Bone Joint Surg 2002;84A:2192–2202.
9. de Ponti A, Sansone V, da Gama Malcher M. Result of arthroscopic treatment of pigmented villonodular synovitis of the knee. Arthroscopy 2003;19:602–607.
10. Zvijac JE, Lau AC, Hechtman KS, et al. Arthroscopic treatment of pigmented villonodular synovitis of the knee. Arthroscopy 1999;15: 613–617.
11. Lee BI, Yoo JE, Lee SH, et al. Localized pigmented villonodular synovitis of the knee: arthroscopic treatment. Arthroscopy 1998;14:764–768.
Additional Reading
Cotten A, Flipo RM, Chastanet P, et al. PVNS of the hip: review of radiographic features in 58 patients. Skeletal Radiol 1995;24:1–6.
Granowitz SP, D’Antonio J, Mankin HL. The pathogenesis and long-term end results of PVNS. Clin Orthop Relat Res 1976;114:335–351.
Spjut HJ, Dorfman HD, Fechner RE, et al. Lesions of synovial origin. In: Tumors of Bone and Cartilage. Washington, DC: Armed Forces Institute of Pathology, 1971:391–410.
215.3 Benign neoplasm, knee
Patient Teaching
Even with appropriate care, the recurrence rate is high, especially in diffuse PVNS (2,8).
After surgery, ROM exercises are important to prevent contractures.
Q: Is irradiation effective in controlling recurrent disease?
A: External beam irradiation, when combined with repeat surgery, can be very effective.

Q: How do patients know if they have PVNS in 1 of their joints?
A: Patients most commonly present with severe joint pain and palpable swelling in superficial joints.

Q: When do patients with PVNS need a joint replacement?
Joint replacement surgery is needed when the joint surfaces have been
destroyed or the bone involvement is so severe that curettage and
grafting is not feasible.

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