This retrospective study reports on four patients with intra-articular pigmented villonodular synovitis (PVNS) of the temporomandibular joint (TMJ) who were managed with arthroscopy between 2002 and 2009. There were three females and one male, with a mean age of 46 years at diagnosis. The common symptoms were trismus and pain. No pre-auricular swelling or mass was detected. Magnetic resonance imaging (MRI) and arthrography showed an anteriorly displaced disc, disc perforation, osteophyte of the condyle, or increased joint effusion. No neoplasm was suspected radiologically. Under arthroscopy, a yellow nodule and loose bodies were found in one patient, and a yellow or brown hyperplasia of the synovial membrane was noted in the other three patients. Degeneration of the articular cartilage was detected in two patients. The arthroscopic procedures used for every patient were partial synovectomy and debridement of articular surfaces with electric shaving and coblation. Arthroscopic disc repositioning was performed for the two young patients. Postoperative histological examination verified the diagnosis of PVNS of the TMJ. The average follow-up period was 57.4 months, and no recurrence was found. Arthroscopy has proved to be a useful method for the management of intra-articular PVNS of the TMJ.
Pigmented villonodular synovitis (PVNS) is an uncommon benign tumour-like proliferative lesion of undetermined origin arising from the synovial membranes of joints, bursa, and tendon sheaths, which was first described by Jaffe in 1941 . Its aetiology remains elusive. Possible aetiologies include disturbances of lipid metabolism, neoplasm, inflammation, trauma and haemorrhage . It has an annual incidence of 1.8 cases per million population . PVNS most commonly affects patients in the third or fourth decades of life. Most cases are monarticular and do not metastasize although they may be locally destructive. Although any joint may be affected, the knee is the most frequently affected site and is involved in 80% of cases . Involvement of the temporomandibular joint (TMJ) is uncommon, and less than 30 cases have been reported to the authors’ knowledge. The predominant symptoms in the TMJ are pre-auricular mass or swelling, pain, and limitation of mandibular movement. Although PVNS is a benign lesion, it can grow with an aggressive pattern, and it extends extra-articularly in most of the reported cases. Intracranial extension has also been reported in some severe case . It is often misdiagnosed as parotid tumour or disorder of the TMJ because of the low incidence and atypical presentations . The definite diagnosis is commonly given after histological examination.
Arthroscopy of the TMJ was introduced by Ohnishi in 1975, and is a clinically useful procedure in the diagnosis and treatment of various TMJ diseases. The authors reported a case of simultaneous PVNS and synovial chondromatosis of the TMJ that was successfully treated with arthroscopy in 2009 . There are no other reports of intra-articular PVNS of the TMJ managed with arthroscopy. This study is a retrospective review of four cases of intra-articular PVNS of the TMJ, diagnosed and treated with arthroscopy in the authors’ clinic (including the reported case); the findings of imaging studies and arthroscopy are summarized.
Patients and methods
A retrospective review was conducted of four patients with intra-articular PVNS who were treated with arthroscopy from April 2002 to August 2009. There were three females and one male, with a mean age of 46 years (range 21–74 years) at diagnosis. Their demographics, location, duration of symptoms before hospitalization, clinical manifestations, preoperative diagnosis, and follow-up are given in Table 1 . Between April 2002 and August 2009, approximately 28,000 patients visited the authors’ department complaining of disorders of the TMJ, of whom 1805 patients underwent arthroscopic examination of the TMJ.
|Case||Age/gender||Location||Symptoms||Duration of symptoms (months)||Preoperative diagnosis||Follow-up (months)|
|1||74/F||Left TMJ||Pain, crepitus, LMO||24||OA, disc perforation||Lost|
|2||62/F||Left TMJ||Pain, LMO||120||ID + OA, SC?||44|
|3||21/F||Left TMJ||Pain, clicking, LMO||5||ID||26|
|4||25/M||Right TMJ||LMO||4||ID, SC?||8|
The predominant complaints were trismus and pain. The maximal inter-incisal opening varied from 2.0 to 3.7 cm (average 2.6 cm). Severe tenderness was found in the left TMJ of three female patients. No pre-auricular swelling or mass was detected in any patient. The patients had no history of trauma, septic arthritis or rheumatoid arthritis.
The 74-year-old female patient received arthrography before surgery. The other three patients underwent magnetic resonance imaging (MRI) of the TMJ preoperatively. The imaging results were summarized ( Table 2 , Fig. 1 ). No neoplasm was suspected radiologically. Increased joint effusion was found in two patients and synovial chondromatosis was suspected.
|1||Contrast medium both in upper and in lower joint cavity||–|
|Flattened anterior surface of condyle|
|2||–||Increased joint effusion|
|Anteriorly displaced disc|
|Osteophyte of condyle|
|3||–||Anteriorly displaced disc|
|4||–||Increased joint effusion|
|Anteriorly displaced disc|
The patients were diagnosed with disorders of the TMJ and received at least 3 months nonsurgical treatment, including physical therapy and non-steroidal anti-inflammatory drugs. They did not respond well. Arthroscopy was performed on the superior joint cavity in all patients under local or general anaesthesia. Under arthroscopy, a widespread yellow or brown hyperplastic synovial membrane was noticed in three patients. A brown nodule and white loose bodies were noted in a young female patient. Disc rupture and degeneration of condyle cartilage was also found in the 74-year-old female. The disc was anteriorly displaced in the other three patients. Obvious degeneration of the articular cartilage was detected in the 62-year-old female. The condition of the synovial membrane, disc and cartilage was summarized for every patient ( Table 3 , Fig. 2 ). A biopsy was carried out for each patient. According to the arthroscopic presentations, a provisional diagnosis of PVNS was made during surgery. For all patients, the arthroscopic procedures were partial synovectomy and debridement of articular surfaces with electric shaving and coblation ( Table 3 ). For the young female patient, the brown nodule and loose bodies were removed successfully under arthroscopic guidance. Two young patients also received arthroscopic disc repositioning. After surgery, histological examination revealed that the yellow or brown proliferative synovium or nodule was composed predominantly of plump histiocytes with intermixed, variably distributed multinucleated giant cells, and it was heavily pigmented with haemosiderin ( Fig. 3 ). A definite diagnosis of PVNS was made. The loose bodies were histologically diagnosed as synovial chondromatosis.
|Case||Arthroscopic findings||Arthroscopic procedures|
|1||Brown and villous hyperplasia of synovium, ruptured disc, degeneration of cartilage, and bony defects in condyle||Synovectomy, debridement of articular surface|
|2||Brown and swollen synovium, disc displacement, extensive adhesions, proliferation of synovial villi||Synovectomy, debridement of articular surface|
|3||Orange nodule, loose bodies, disc displacement||Synovectomy, removal of loose bodies, disc repositioning, debridement of articular surface|
|4||Brown and swollen synovium, disc displacement||Synovectomy, disc repositioning, debridement of articular surface|