It's not what it looks like: challenges in diagnosis of synovial lesions of the knee joint.

Kumar Kaushik Dash,Amyn Rajani,Piyush Vishwas Gavai,Roshan Wade

doi:10.1186/s40634-016-0039-3

Abstract

BackgroundWith the advent of MRI (Magnetic Resonance Imaging), Synovial lesions around knee are being more and more easily detected. Synovial lesions of knee present with boggy swelling, effusion, pain, and restriction of motion. Differential diagnoses of such lesions include pigmented villonodular synovitis, synovial lipoma, synovial chondromatosis, rheumatoid arthritis, synovial hemangioma, amyloid arthropathy, xanthomata and lipoma arborescens. CT and MRI often help in diagnosis of such lesions. MRI of Lipoma Arborescens has been regarded to have characteristic diagnostic appearance – it includes a synovial mass with frond-like architecture and fat signal intensity on all pulse sequences. Sometimes Lipoma Arborescens can present in conjunction with inflammatory arthritis. Synovectomy is often curative for such conditions.FindingsWe report two cases where lesions diagnosed as Lipoma Arborescens on MRI subsequently revealed to be chronic inflammatory synovitis, characterized by absence of fat infiltration in histopathological examination – refuting the original diagnosis. There was infiltration of lymphocytes and neutrophils in the synovium, suggestive of chronic inflammatory arthritis. Both of these patients required management from rheumatologist, and had relief of symptoms after use of methotrexate and hydroxychloroquine. We also report a third case, where a loose body appearing as chondral fragment on arthroscopy was subsequently diagnosed as an organized hematoma on histopathological examination.ConclusionDiagnostic pitfalls after MRI of the knee is not uncommon. For example - normal variant of meniscomeniscal ligaments have been reported as meniscal tears; motion artifacts have been falsely reported as meniscal injuries; and meniscofemoral ligament can appear as free osteochondral fragment. In most of these cases, a routine arthroscopy is enough to clear the confusion. However, as evident in the three cases described here - in some synovial lesions of knee joint, even after MRI and arthroscopic examination, histopathological confirmation may still be prudent. In spite of availability of advanced imaging technologies and high definition arthroscopy equipment, an arthroscopy surgeon still must not forget the value of histopathological examination in establishing the true nature of synovial lesions of the knee joint.

Highlights

Tools and technologies available for diagnosis and management of orthopaedic conditions have come a long way in last few decades
We describe a case series comprising of two cases diagnosed as Lipoma Arborescens and one case diagnosed as Nodular Synovitis; where histopathology refuted the original diagnosis and changed the plan of management
Most of the published literature agrees that the characteristic Magnetic Resonance Imaging (MRI) appearance is pathognomonic and synovectomy is most often curative (Liddle et al 2012). We show in this case series that not all cases, which appear as Lipoma Arborescens on MRI, have fat infiltration in synovial tissue - negating the radiological diagnosis

Summary

Introduction

Tools and technologies available for diagnosis and management of orthopaedic conditions have come a long way in last few decades. As evident in the three cases described here - in some synovial lesions of knee joint, even after MRI and arthroscopic examination, histopathological confirmation may still be prudent. Kloen et al have described 6 such cases, with characteristic MRI picture, arthroscopic appearance and histopathological confirmation (Kloen et al 1998) (Fig. 1). MRI report concluded Lipoma Arborescens of the synovium of knee joint with characteristic synovial growth pattern; and associated moderate synovial joint effusion extending in to suprapatellar bursa.

Results

Conclusion