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SUBACUTE KNEE PAIN IS NOT ALWAYS WHAT IT SEEMS. Steven R. Sabo, MD Sports Medicine Fellow 2011-2012 University of South Florida and Morton Plant Mease / BayCare Health System. History of Present I llness.

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Presentation Transcript
subacute knee pain is not always what it seems


Steven R. Sabo, MD

Sports Medicine Fellow 2011-2012

University of South Florida and

Morton Plant Mease / BayCare Health System

history of present i llness
History of Present Illness
  • 36 y.o. male softball player and auto mechanic c/o right knee pain, stiffness, and swelling x 3 months
  • Twisted right knee walking down stairs.
  • Posterior knee joint 6/10 pain, increases with any knee flexion.
  • No giving way, locking, or prior Hx of trauma.
r knee injury x 3 months
R knee Injury x 3 months
  • MHX/SHX: Prior left knee sprain 1 yr ago resolved. No chronic injuries or diseases.
  • Meds: None Allergies: Pen causes rash.
  • Exam: 6/10 Pain @ deep popliteal fossa,

Moderate size joint effusion without warmth

No joint line tenderness

ROM decreased (only 10 to 130 degrees)

Equivocal Thessaly test

No ligament defect noted on stress tests

differential diagnosis
Differential Diagnosis:
  • Meniscal tear with effusion
  • Baker’s cyst
  • partial ACL/PCL ligament injury with effusion
  • Osteoarthritis, loose body, Stress fracture.
  • infectious arthritis, gout or pseudogout
  • RA autoimmune arthritis, psoriatic or seronegative arthritis, amyloidosis, SLE
imaging and special studies
Imaging and Special Studies:
  • X-rays revealed mild osteoarthritis
  • CBC, ESR, CRP, RF and ANA ordered by PCM and were normal
  • Aspiration of knee = 10 ml of blood tinged “rusty” colored synovial fluid without evidence of crystals, infection, or malignant cells.
  • Stiffness and effusion recurred rapidly before the next day
  • Sports Med / Ortho ordered an MRI.
mri of right knee
MRI of Right Knee
  • Diffuse non-calcified nodular synovial thickening
  • 8.5 cm diameter Baker’s popliteal cyst
  • Chondromalacia Patella, mild diffuse
  • No ligament derangement, meniscal tear, fracture, or bone contusion.
new differential diagnosis
New Differential Diagnosis:
  • Synovial Chondromatosis
  • Chronic Hemarthrosis
  • Rheumatoid Arthritis
  • Pigmented Villonodular Synovitis
  • Benign fibroblastic tumors
surgery and pathology results
Surgery and Pathology Results:
  • Exploratory open arthrotomy with synovectomy done because of MRI findings.
  • Dark Red 16 x 12 x 6 cm large lobulated mass immediately extruded from the surgical wound as if under pressure.
  • Multiple lesions had eroded partially into the undersurface and margins of the patella.
  • Pathology: hypervascular proliferative synovium containing multinucleated giant cells, macrophages, and hemosiderin.
final diagnosis pigmented villonodular synovitis pvns
Final Diagnosis:Pigmented Villonodular Synovitis (PVNS)
  • Treatment: Synovectomy for complete removal of lesion, post-op hinged knee brace, then physical therapy.
  • Outcome: Patient had return of normal joint function. Normal ROM and strength. No recurrence of pain or effusion @ 6 months
  • PX: Diffuse PVNS recurs up to 46%, Localized PVNS recurs at 8%
tx options for recurrence
Tx options for recurrence
  • Repeat Synovectomy
  • XRT Radiation Therapy 4000 cGy
  • If enough of joint is destroyed: bone grafting or total joint replacement
  • Tumor Necrosis Factor αinhibitor (class of drugs): off label use to decrease inflammatory response for refractory PVNS, reported in Rheumatology case studies. Examples: etanercept (Enbrel), infliximab (Remicade), adalimumab (Humira).
take home messages
Take Home Messages:
  • Relatively rare (incidence 1.8 cases/ million people), usually benign intra-articular and peri-articular hyperproliferation of synovium

Cause debated: malignant transformation vs. chronic inflammatory

  • Removal of the lesion is usually curative
  • Repeat imaging is prudent since it recurs
  • Important to occasionally widen your DDX for knee pain.
special thanks
Special Thanks:

Our patient (written consent given to allow this case report)

Allen Hughes, MD

Orthopedic Specialties of Clearwater FL

Sean Bryan, MD

USF / MPM Sports Medicine Fellowship and

Family Medicine Residency Program Director

Ted Farrar, MD

USF / MPM Sports Medicine Fellowship Associate Director

Jonathan Squires, MD

Radiology Associates of Clearwater FL

Robert Schoer MD and Pathology Department

Morton Plant Mease Medical Center Clearwater FL