A Case of Synovial Hemangioma of the Knee - Knee Surgery ...

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Key Words: Knee, Synovial hemangioma, Arthroscopic excision. Synovial .... calized pigmented villonodular synovitis that also shows low signal on MRI and ...
Case Report

J Korean Knee Soc, Vol. 23, No. 2, June 2011

A Case of Synovial Hemangioma of the Knee Sung-Il Shin, M.D., Jung-Woo Kang, M.D. and Joo-Hyun Ahn, M.D. Department of Orthopedic Surgery, Kangdong Sacred Heart Hospital, Hallym University School of Medicine, Seoul, Korea

We report an unusual case of a 17-years-old male with complaints of pain and swelling of the left knee for the last 3 years with limitation of movement. He presented with spontaneous hemarthrosis of the knee joint. Magnetic resonance imaging revealed an intra articular mass. Arthroscopic excision was performed and the histology was characteristic of synovial hemangioma. After 1 year, the patient was completely asymptomatic and showed no signs of recurrence. Key Words: Knee, Synovial hemangioma, Arthroscopic excision

Synovial hemangioma is a benign tumor in a joint

ago. He neither experienced any special trauma nor had

rarely occurring in children or young adults, charac-

drug use or special diseases. Before the visit, for 3

terized by local pain, tenderness, soft tissue swelling,

years, he got swelling occurred and went down 6 times

movement restrictions and hemarthrosis occurring with-

totally when he had walked for a long time but didn’t

2)

out trauma . Due to its nonspecific symptoms, it is dif-

receive any special treatment.

ficult to diagnose, and thus treatment is delayed easily.

Physical examination findings showed a swelling in

The authors excised a case of synovial hemangioma oc-

his left knee joint and infrolateral patella tenderness

curring in the knee joint through an arthroscopic oper-

and a movable mass was palpated directly under the

ation, obtained satisfactory results through follow-up, so

patella. The range of knee joint movement was limited

make a report along with a literary review.

o o approximately from 0 to 120 , he complained pain o when flexed more than 120 . Hemarthrosis was observed

in the joint aspiration. In simple radiographs, there was

CASE REPORT

no special finding observed (Figs. 1-3), and no abnorA male patient aged 17 came to the hospital with

mal finding in laboratory tests including one for defect

pain and swelling of left knee joint as his chief com-

in the coagulation of blood. In an magnetic resonance

plaint which had slowly progressed since about 3 years

imaging (MRI), between directly under the patella and outer thigh, there was a swelling with a diameter of about 30 mm, and in a T1-weighted image, similar to or

Received: March 9, 2011 Revised: April 12, 2011 Accepted: May 7, 2011

slightly higher signal intensity than muscle appeared while in T2-weighted image, high signal intensity was

Corresponding author: Sung-Il Shin, M.D. Department of Orthopedic Surgery, Kangdong Sacred Heart Hospital Hallym University School of Medicine, 445 Gil-dong, Gangdong-gu, Seoul 134-701, Korea TEL: 82-2-2224-2230, FAX: 82-2-489-4391 E-mail: [email protected]

shown. Overall, irregular shape appeared as lobation (Figs. 4, 5). For the removal of lesions and the biopsy, surgical treatment was performed. Through the operation, we 123

124

Fig. 1. Anteroposterior radiograph. No significant bony abnormality.

대한슬관절학회지:제 23 권 제 2 호 2011 Volume 23, Number 2, June 2011

Fig. 3. Merchant view. No significant bony abnormality.

Fig. 2. Lateral radiograph. No significant bony abnormality.

Fig. 4. T1-weighted sagittal MR image shows mass, have the signal intensity similar to muscle.

checked whether there was any abnormality in the joint

chial spots on the surface and reddish color overall due

including meniscus using arthroscope under general an-

to the extended blood vessel. In the biopsy, a lot of

esthesia, and in a arthroscopic finding through ante-

blood vessels with a variety of size in the synovial tissue

romedial portal, a mass was attached to the infrapatella

could be observed which could be diagnosed of synovial

fat pad (Figs. 6, 7). After insertion of a probe, they

hemangioma (Figs. 8, 9).

were detached from the base and they were relatively

As a result of 1 year follow-up after the operation,

easily separated and a complete excision was performed

there were no knee joint pain & tenderness and a nor-

including partial synovial capsule.

mal range of knee joint movement, was shown after 3

The excised tissue was sized about 30 mm, with pete-

months. The patient was satisfied and there was no

125

Sung-Il Shin, et al:A Case of Synovial Hemangioma of the Knee

Fig. 5. T2-weighted sagittal MR image shows heterogenous high signal intensity mass including low signal intensity septa within the lesion.

Fig. 7. Arthroscopic view shows removal of synovial hemangioma.

Fig. 8. Microscopic finding shows several proliferation of vascular channel with synovial lining (H&E stain, ×40). Fig. 6. Arthroscopic view of synovial hemangioma.

sion arising from any structure lined by synovium including the intra-articular region, bursal spaces and ten-

proof of relapse.

3) don sheaths .

DISCUSSION

3) Devaney et al. classified hemangioma into capillary,

cavernous, mixed and venous; and out of all, cavernous Synovial hemangiomas are rare causes of recurrent,

hemangioma occurs most frequently (50%), followed by

non-specific joint complaints and take place most often

capillary hemangioma (25%), mixed hemangioma (20%),

in the knee joint. Till now, fewer than 200 cases have

and venous hemangioma (5%). In 1939, Bennet and

been reported in the world published reports. By defi-

1) Cobey classified hemangioma morphologically into dif-

nition, a synovial hemangioma is a benign vascular le-

fuse hemangioma and circumscribed hemangioma based

대한슬관절학회지:제 23 권 제 2 호 2011 Volume 23, Number 2, June 2011

126

T2-weighted image, the boundary is clearer, with medium to high signal. MRI is not beneficial to all types of ailment in the knee joint, but it is useful when there is a mass on the joint or intermittent exudation from non-trauma; it helps distinguish the boundary in the joint as well as the condition of the joint. In the case study in this paper, we were able to identify the boundary of the mass by using MRI before operation, but on the T2-weighted image it showed low signal. This type of condition should be carefully distinguished from localized pigmented villonodular synovitis that also shows Fig. 9. Microscopic finding shows thin walled vascular space of varying sizes lined with a single layer of endothelial cells (H&E stain, ×100).

low signal on MRI and T1/T2-weighted image. Paley 7) and Jackson argued that arthroscopy is the best way to

diagnose hemangioma in the knee joint and the final di8) agnosis is made only on histopathology .

on the 29 cases that had been reported. Diffuse he-

The origin of synovial hemangiomas continues to be

mangioma is mostly cavernous, with intermittent pain

an enigma. Whether they merely represent late stages of

and swelling: circumscribed hemangioma is capillary,

post-traumatic lesion of are they true neoplastic vascular

and most of them are pedunculated. The case in this

proliferations; is not yet clear.

study can be considered to be diffuse hemangioma,

Management of a case of synovial hemangioma de-

which easily separates from surrounding synovial; histo-

pends on the anatomical distribution of the lesion.

logically, it can be seen as capillary hemangioma.

Management of synovial hemangioma include open ex-

Synovial hemangiomas mostly present as a non-trau-

cision, arthroscopic excision, embolization, and arthro9)

reported a success

matic joint swelling combined with recurrent hemor-

scopic excision by laser. Schechter

rhagic effusions in early childhood. Like this case re-

6) in using radioactive therapy after wide excision. Moon ,

ported, the symptoms usually persist for several years

however, considered excision by operation as the best

before the time of diagnosis. In most cases, a spongy

way to treat the localized hemangioma and didn’t rec-

compressible mass can be palpated over the joint, which

ommend radioactive therapy for cases that can be surgi-

4)

decreases in size with elevation of the extremity . 6)

5)

cally treated. Meislin and Parisien

reported that they

According to Moon , 75% of the symptoms are found

had diagnosed synovial hemangioma by using arthro-

in children under the age of 16; patient’s average age

scopy and successfully removed it by arthroscopic

is 10.9 for girls and 12.5 for boys.

excision. Arthroscopic excision is carried out, if the le-

In regular radioactive examination, it may look like

sion is pedunculated and well-circumscribed. Diffuse le-

tumor-related phlebolithe, but it is not very useful in

sions are difficult to excise arthroscopically. For such

10)

diagnosing the exact condition. Shapiro and Fanton

cases, open wide excision is recommended. In Korea,

stated the significance of adopting MRI in diagnosing

such case has not been reported yet, and the use of ar-

the hemangioma in the joint. In case of synovial he-

throscopy is limited in diffuse hemangioma. When syno-

mangioma, the boundary is not clear on T1-weighted

vial hemangioma in knee joint is local and easily re-

image, showing the same intensity in the muscle and

moved, arthroscopic excision is recommendable.

high signal in the area with low blood flow; on

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Sung-Il Shin, et al:A Case of Synovial Hemangioma of the Knee

CONFLICT OF INTEREST No potential conflict of interest relevant to this article was reported.

5.

6.

REFERENCES 7. 1. Bennet GE, Cobey MC: Hemangioma of joints: report of five cases. Arch Surg, 38; 487-500: 1939. 2. Boe S: Synovial hemangioma of the knee joint--a case report. Arthroscopy, 2; 178-180: 1986. 3. Devaney K, Vinh TN, Sweet DE: Synovial hemangioma: a report of 20 cases with differential diagnostic considerations. Hum Pathol, 24; 737-745: 1993. 4. Enzinger FM, Weiss SW: Benign tumors and tumorlike lesions of blood vessels. In: Enzinger FM, Weiss WS ed. Soft tissue tumors. 2nd ed. St Louis, Mosby;

8.

9. 10.

489-453: 1988. Meislin RJ, Parisien JS: Arthroscopic excision of synovial hemangioma of the knee. Arthroscopy, 6; 64-67: 1990. Moon NF: Synovial hemangioma of the knee joint. A review of previously reported cases and inclusion of two new cases. Clin Orthop Relat Res, (90); 183-190: 1973. Paley D, Jackson RW: Synovial haemangioma of the knee joint: diagnosis by arthroscopy. Arthroscopy, 2; 174-177: 1986. Rogalski R, Hensinger R, Loder R: Vascular abnormalities of the extremities: clinical findings and management. J Pediatr Orthop, 13; 9-14: 1993. Schechter DC: Intra-articular hemangioma of the knee. Am Surg, 27; 638-641: 1961. Shapiro GS, Fanton GS: Intraarticular hemangioma of the knee. Arthroscopy, 9; 464-466: 1993.

슬관절에 발생한 활액막 혈관종 한림대학교 의과대학 강동성심병원 정형외과

신성일ㆍ강정우ㆍ안주현 17세 남자환자의 좌측 슬관절에, 관절부종과 운동제한을 동반한 활액막 혈관종의 증례를 보고한다. 환자 는 자발적 혈관절증이 발생하였고, MRI에서 관절내 종괴가 발견되었다. 슬관절경적 절제술 및 생검을 시행하였고, 조직학적 검사상 활액막 혈관종으로 판명되었다. 환자의 증상은 완전 호전되었고, 1년간 재발의 징후는 나타나지 않고 있다. 색인 단어: 슬관절, 활액막 혈관종, 관절경적 절제술