A Rare Cause of Recurrent Pain in Athletes: Synovial Hemangioma

Abstract

Background:

Synovial hemangioma is a rare neoplastic lesion, which can result in recurrent hemarthrosis and pain. It can affect any joint, tendon, or bursa, withal those around the knee. The intra-articular lesion is more prevalent and is more frequently diagnosed in female children or young adults.

Indications:

Surgery is indicated when patients present with recurrent painful hemarthrosis that affect daily living and functionality.

Technique Description:

Diagnostic knee arthroscopy, initially without tourniquet inflation, was performed to detect and study the extent of the lesion. Afterwards, the tourniquet was inflated to proceed with the surgical excision. Medial parapatellar approach was performed, and limits of the hemangioma were identified. Wide resection was performed taking care to not damage the medial meniscus and medial condyle cartilage. Neoplastic lesion was sent to pathology analysis. The tourniquet was deflated and hemostasis checked because these lesions can present extensive bleeding.

Results:

Localized, well-circumscribed, and encapsulated lesions have been reported to usually present low recurrence rate when completely excised.

Discussion/Conclusion:

It is a rare disease, and around 200 cases have been reported; therefore, conclusions about treatment and outcomes rely mostly on case series and case reports. Early diagnosis and treatment are paramount to prevent degenerative changes secondary to recurrent hemarthrosis.

Patient Consent Disclosure Statement:

The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Graphical Abstract

This is a visual representation of the abstract.

Video Transcript

Here we present a rare case of synovial hemangioma of the knee.

Our author's conflict of interest can be seen here in this slide.

Synovial hemangioma was first described in 1856 and, only around 200 cases have been reported so far in the literature. ¹ The lesion is a rare benign neoplastic lesion, which can result in recurrent painful hemarthrosis and quadriceps muscle atrophy. ⁶ It is more frequently diagnosed in children or young adults, with a slight female predominance.^4,7 Since it is a rare condition, it usually is misdiagnosed as an internal derangement of the knee, like a meniscus tear, leading to a delay in the diagnosis and treatment sometimes for years.^1,7 Initial reports describe the use of different imaging modalities with most cases (78%) being diagnosed only after surgery. ³ However, in the early 2000s, that reality changed with magnetic resonance imaging (MRI) making possible a high percentage of preoperative diagnose, becoming the noninvasive “gold standard” to diagnose the lesion.^2,3 Arthroscopy is the invasive “gold standard” to detect this condition. ⁵ However, there is still no consensus about the treatment modality, and wide surgical resection seems appropriate due to high recurrence rate.^5,7

Our patient is a 16-year-old female, with no previous medical history, who was referred to our practice due to a recurrent painful joint effusion affecting the left knee for months, associated with volleyball practice. The episodes of effusion were compromising the patient's capability of engaging into sports activity.

At physical examination, the patient presented well-aligned knees, normal gait pattern, with full range of motion, no joint effusion, and quadriceps atrophy. Palpation of the medial retinaculum and duck walk test were both painful.

Radiographs showed no changes to the knee joint. However, magnetic resonance imaging with contrast presented a lesion compatible with intra-articular hemangioma. The first image, on the left, is a T1 sagittal reconstruction, showing the lesion with isointense signal (lower than the fat signal, but higher than the muscle signal), and the image from the right is a T2 sagittal, and the yellow arrow shows the lesion with hypersignal and involvement of the infrapatellar fat pad. Here, in this sagittal T2 image, the classic serpentine appearance can be seen showing high signal and close relationship with the anterior horn of the medial meniscus. On the right image, it is possible to see the close relation to the medial retinaculum pointed by the yellow arrow. The presented images are gadolinium contrast enhanced. This contrast is important to best diagnose this lesion. Before being referred to our service, this patient was previously submitted to two MRIs without contrast and no diagnosis was performed. Considering the patient's history and findings of physical examination and imaging studies, an arthroscopy was indicated.

Patient was submitted to diagnostic arthroscopy using anterolateral portal. Initially, the procedure was without tourniquet inflation, permitting the vascular lesion to be filled with blood, which allows adequate detection and study of the disease extent. Routine articular inventory was performed. An isolated sessile, port wine, and lobulated lesion was localized in the anteromedial aspect of the knee at the synovial wall, just above the medial meniscus.

This is the arthroscopic photo showing the purple lobulated lesion, which is classically described as a cluster of grapes.

Due to sessile appearance, it was proceeded to open excision. Tourniquet was inflated, and a medial parapatellar approach was performed. The limits of the tumor were identified, and the lesion resected with margins. Tourniquet was deflated and hemostasis checked before suture because these lesions can present extensive bleeding.

Here you can see the excised lesion with infrapatellar fat attached on the left, and the final appearance after closing the wounds on the right.

Full range of motion and weight-bearing as tolerated were allowed at postoperative day 1. Physical therapy initiated as soon as possible to maintain range of motion and start strengthening. At 6 weeks, patient was allowed to initiate sports.

Now, with 6 months follow-up, our patient is well, with no complaints. She has returned to sports, and no recurrence has been detected so far. In these photos, you can see the patient with full range of motion.

It is a rare disease, and around 200 cases have been reported; therefore, conclusions about treatment and outcomes rely mostly on case series and case reports. Early diagnosis and treatment are paramount to prevent degenerative changes secondary to recurrent hemarthrosis, therefore optimizing outcomes.^5,7 Localized, well-circumscribed, and encapsulated lesions seems to have lower recurrence rate when completely excised; however, high recurrence rate is widely reported in the literature for this disease; therefore, patient and family should be educated.^4,5

This article published in 1973 by Moon is the biggest case review study on synovial hemangiomas to our knowledge. He reviewed 137 cases reported on the literature and summarized all treatments performed, including radiotherapy, total and partial synovectomy, total or partial mass excision, and injections. It is important to note that complete lesion excision and absence of recurrence do not translate functional recovery. On the other hand, residual lesion also does not mean unfavorable outcome. In Moon's review, 72% recovered functionally despite of the 4% recurrence rate and additional 5% of residual lesion. In his analysis, the treatment of choice should be total excision of the tumor. ⁴

These are our references.

And thank you for watching our video about a rare cause of recurrent pain in athletes, the synovial hemangioma.