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Second Metatarsophalangeal Joint Pigmented Villonodular Synovitis: A case report

Posted on September 1, 2011 | Comments Off on Second Metatarsophalangeal Joint Pigmented Villonodular Synovitis: A case report

by John A. Rialson, DPM1 , Eric J. Heit, DPM, FACFAS2 

The Foot and Ankle Online Journal 4 (9): 2

Pigmented Villonodular Synovitis (PVNS) is an uncommon condition of the foot. PVS of the foot accounts for 2% of all cases. We present the case of a 26 year-old male who was found to have pigmented villonodular synovitis of the second metatarsophalangeal joint. Although a high incidence is reported in the literature, the patient underwent surgical excision with no known reoccurrence to date. Findings from magnetic resonance imaging, surgical presentation and literature review is presented.

Key words: Pigmented villonodular synovitis, metatarsophalangeal joint, foot surgery, soft tissue mass.

Accepted: August, 2011
Published: September, 2011

ISSN 1941-6806
doi: 10.3827/faoj.2011.0409.0002

Pain to the second metatarsophalangeal joint (MTP) is a common complaint encountered in the foot and ankle surgeon’s office. While reasons for this presentation are vast, a soft tissue mass could be a cause of this pain. Proper work up of the patient that includes a thorough history and physical, basic radiographs, and advanced imaging studies can aid in an accurate diagnosis.

Pigmented villonodular synovitis (PVNS) is a fairly rare disease. The incidence of PVNS is 1.8 patients per million people. [1] Pigmented villonodular synovitis is a proliferative disorder of synovial tissue in the joint, tendon sheath, and/or bursa.

The common locations for PVNS are the knee, hip and ankle. Two percent of these lesions are in the foot. [2] Bone and joint destruction can occur with this disease which makes early, accurate diagnosis and treatment essential. Furthermore, despite appropriate management by surgical excision [3], PVNS has a high recurrence rate. In the foot and ankle, recurrence rate has been reported as 14.3%. [4]

Case Report

A 26 year-old male presented to the institution of the senior author with right foot pain that he had for a few weeks. The patient was unsure of the cause for the pain, but did remember feeling a pop to his right foot while performing yoga. He initially did not seek care as he was not in a lot of discomfort, but progressively his second MTP joint became more painful.

The patient was able to point to his second MTP joint as is primary location of pain. Upon presentation, the area was so painful that he was using a crutch to take the pressure off the area. No other forms of treatment have been attempted prior to evaluation.

Clinical evaluation of the area revealed mild edema over the dorsal aspect of the second MTP joint without erythema or warmth. There was no significant deformity or instability, and neurovascular status was intact with an otherwise benign exam. Initial diagnostic imaging consisted of anteroposterior, medial oblique, and lateral foot radiographs, which were normal. There were no obvious signs of Freiberg’s infraction. The only finding was a very mild joint abnormality with a subchondral cyst that was appreciated on the oblique view.

The initial diagnosis was capsulitis of the second MTP joint with possible osteochondral defect. Initial treatment consisted of CAM boot application and discussion of further imaging if not improving. The plan was to attempt this treatment for three weeks and reevaluate his foot with the option to obtain an magnetic resonance imaging (MRI).

The patient presented for follow up after the initial visit and stated that overall his condition felt worse. After the initial treatment, he experienced about five days of pain relief but developed increased pain since the initial relief. Once again, pain was localized to the second MTP joint. Clinically, there was a reduction of swelling to the area; however, with the decrease in swelling, a subcutaneous palpable mass was now present on the dorsal aspect of the second MTP joint. The contour of the metatarsal could also then be palpated with no obvious findings. The decision was then to obtain an MRI scan of the right foot.

The official findings of the MRI are as follows: “. . . markedly abnormal thickening and enhancement of the synovium surrounding the second metatarsophalangeal joint, with minimal associated joint fluid seen. Within the second MTP joint, there is abnormal signal within the metatarsal head with potential collapse of the cortical surface.” (Figs. 1A, 1B and 1C) The radiologist’s impression was a differential consideration to include a severe synovitis or other primary synovial abnormality such as PVNS. Also mentioned was no involvement of other joints to suggest a polyarticular arthropathy such as rheumatoid arthritis.

  

Figures 1ABC MR T1 image of the second MTP joint showing the soft tissue mass. (A)  An Axial image showing the mass to the second metatarsal. (B)  A STIR image of the soft tissue mass as well as showing the signal to the metatarsal head. (C)

With the above findings, the results of the MRI and treatment options were discussed with the patient. A surgical excision was planned and performed without complications. Intraoperatively after the incision and initial dissection, a lobular pigmented soft tissue mass, consistent with PVNS, was encountered. (Fig. 2) The soft tissue mass was dissected, removed, and sent for pathologic examination. (Fig. 3) Upon removing the mass, a cartilage defect to the second metatarsal head was appreciated. (Fig. 4) This finding was anticipated with the MRI but with carefully examination was a substantial deficit. The decision was made to fenestrate the head of the second metatarsal to promote fibrocartilage growth. (Fig. 5)

Figure 2 An intraoperative picture of the soft tissue mass consistent with PVNS.

Figure 3 The soft tissue mass removed from the second MTP joint and sent for examination. 

Figure 4 Operative finding of the cartilage defect to the head of the second metatarsal.

Figure 5 Operative photo showing the cartilage defect to the second metatarsal after fenestration.

The pathology report confirmed the diagnosis consistent with PVNS. He had an uneventful post operative course and at last exam had no tenderness with palpation. The second digit was in a plantigrade position and had good range of motion across the MTP joint. The patient is now over one year after the procedure and there has been no known reoccurrence to date.

Discussion

Soft tissue masses of the foot and ankle often present with complaints of pain and/or irritation with footwear. Pigmented villonodular synovitis, while most common in the knee, hip and ankle, can present in the foot, although they are most commonly seen in the rearfoot and ankle2. Nabeshima, et al., does describe a case report of PVNS to the first MTP joint. [9]

Carpintero, et al., [2] reported eight cases of PVNS in the foot. Five of the eight cases were reported in the rearfoot and the remaining three cases in the forefoot. The locations they reported were the talus, first cuneiform, first and fifth metatarsals, and middle phalanx. Interestingly, they also reported that there was radiographic bone involvement in six patients.

Similarly, Ghert, et al., [5] documented the rarity of PVNS in the foot and ankle with a review of six cases from 1978-1997. Of the six of their cases, two were isolated to the ankle joint. The remaining four cases involved the subtalar joint, midfoot and two cases in the metatarsal region. Lisfranc amputation was a treatment for one of the cases.

The invasive nature of PVNS is also an important aspect. This is described with bone involvement being found in seven of eight cases that Rochwerger et al. reported between 1981 and 1997. [6] Surgical treatment consisted of arthrodesis in six cases, one ankle synovectomy, and one toe amputation.

In our patient’s case, as well as in the literature, the use of MRI aids in the diagnosis of PVNS. The description of PVNS on MRI may have certain findings consistent with other synovial lesions. On T1-weighted images, the lesions will have low or intermediate signal intensity. Pigmented villonodular synovitis will also demonstrate low signal intensity with T2-weighted and gradient-echo images. The theory is that the hemosiderin in PVNS produces this low signal intensity on T2-weighted imaging. [7]

The final diagnosis of PVNS can be confirmed with pathological examination. Specimens may appear villous, nodular, or villonodular with often prominent hemosiderin deposition seen in most cases. [8] Histological findings of PVNS are hyperplastic synovium, giant cells, and mononuclear histiocytes with varying extent of hemosiderin deposition. [3,7,8]

While the literature states the PVNS is rare in the foot and of unknown etiology [2], some theories of etiology that are often debated are an inflammatory process, neoplasia, or lipid metabolism disorder. [8] The neoplastic theory is becoming more strongly supported by the discovery of cytogenetic aberrations. Mild repetitive trauma with hemorrhage into the joint also could explain the inflammatory nature and the hemosiderin of PVNS. One could speculate that this may be the origin in our patient with his yoga history.

References

1. Myers BW, Masi AT. Pigmented villonodular synovitis and tenosynovitis: a clinical epidemiologic study of 166 cases and literature review. Medicine 1980 59: 223-238.
2. Carpintero P, Gascon E, Mesa M, Mesa M, Jimenez C, Lopez U. Clinical and radiographic features of pigmented villonodular synovitis of the foot: Report of eight cases. JAPMA 2007 97: 415-419.
3. Brien EW, Sacoman DM, Mirra JM. Pigmented villonodular synovitis of the foot and ankle. Foot Ankle Int 2004 25: 908-913.
4. Sharma H, Jane MJ, Reid R. Pigmented villonodular synovitis of the foot and ankle: Forty years of experience from the Scottish Bone Tumor Registry. J Foot Ankle Surgery 2006 45: 329-336.
5. Gher MA, Scully SP, Harrelson JM. Pigmented villonodular synovitis of the foot and ankle: A review of six cases. Foot Ankle Int 1999 20: 326-330.
6. Rochwerger A, Groulier P, Curvale G, Launay F. Pigmented villonodular synovitis of the foot and ankle: A report of eight cases. Foot Ankle Int 1999 20: 587-590.
7. Llauger J, Palmer J, Monill JM, Franquet T, Bague S, Roson Nl. MR imaging of benign soft-tissue masses of the foot and ankle. Radiographics 1998 18: 1481-1498.
8. Murphy MD, Rhee JH, Lewis RB, Fanburg-Smith JC, Flemming DJ, Walker EA. Pigmented villonodular synovitis: Radiologic-pathologic correlation. Radiographics 2008 28:1493-1518.
9. Nabeshima Y, Mori H, Mitani M, Nagura I, Ozaki A, Fujii H, Doita M. Diffuse pigmented villonodular synovitis in the metatarsophalangeal joint of the Hallux: A Case Report. J Foot Ankle Surgery 2009 48: 573-576.

Address correspondence to: Swedish Podiatric Surgical Residency Program, Swedish Medical Center, 747 Broadway Seattle, WA 98122
1  Submitted while Chief Resident, Swedish Podiatric Surgical Residency Program, Swedish Medical Center, Seattle, WA
2  Attending Surgeon, Swedish Podiatric Surgical Residency Program, Virginia Mason Medical Center, Seattle, WA

© The Foot and Ankle Online Journal, 2011

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Pigmented Villonodular Synovitis of the Ankle with Extensive Bone Involvement: A Case Report

Posted on January 1, 2008 | Comments Off on Pigmented Villonodular Synovitis of the Ankle with Extensive Bone Involvement: A Case Report

by Remco J.A. van Wensen, MD1 , Michel P.J. van den Bekerom, MD2, Thomas W. Patt, MD3, Herman M. Peters, MD4, Eric Breemans, MD5

The Foot & Ankle Journal 1 (1): 1

We describe a case of a 49 year old man who presented with swelling of his left ankle for two months. After standard X-ray, ultrasound investigation, MRI and histological examination, the patient was diagnosed with pigmented villonodular synovitis and bone involvement of the ankle. A complete resection of the tumour was performed. A large bone defect after the resection was filled with cancellous bone graft. In pigmented villonodular synovitis, symptoms are often remarkably discrete for long periods. The course of the disease is slow, but progressive and destructive. This warrants awareness of this entity, early diagnosis, and aggressive management.

Key words: Pigmented villonodular synovitis, ankle, bone involvement, benign tumour, diffuse giant cell tumor.
Abbreviations: LNS: Localised Nodular Synovitis, GCT: Giant Cell Tumor, PVS: Pigmented Villonodular Synovitis, MRI: Magnetic Resonance Imaging, CT: Computer Tomography, AP: Antero-Posterior, ROM: Range of Motion

Published online: January 1, 2008

ISSN: 1941-6806/08/0101-0001
doi: 10.3827/faoj.2008.0101.0001

The first description of localized nodular synovitis (LNS), a localised tenosynovial giant cell tumor (GCT), was by Chassaignac in 1852. [1] He described lesions of this nodular form arising in relation to the flexor tendon sheath of the middle and index finger.

The term “pigmented villonodular synovitis” (PVS) was introduced by Jaffe, et al, in 1941 to denote a benign affection of the synovial membrane of joints, tendon sheaths, or bursae. [2]
In 1976 the GCT’s were further subdivided in a diffuse and localised form by Granowitz and Mankin. [3]

PVS is a diffuse GCT and has a reported incidence of 1.8 patients per million. 19 PVS develops most frequently in young adults, both men and women, but can start at any age. It presents most commonly as a monoarticular arthritis in the knee, hip or hand, but it can also occur in smaller joints, including the ankle. [2] PVS may be locally destructive and does not metastasize. [8] The insidious progression of the disease and its local extent often lead to bone lesions that require surgical intervention. [10-12]

The MRI appearance is pathognomonic due to the iron deposition in the tumour, which has a magnetic moment. [13-16] Histologically, the lesion is characterized by the presence of fibrous stroma, hemosiderin deposits and histiocytic infiltrates (foam cells or giant cells) in the synovial membrane. It may have many synovial protrusions that affect joints, bursae, and tendon sheaths. It has a typical yellow-brown appearance due to excessive deposits of hemosiderin and lipids. One characteristic finding of PVS is the ability of the hyperplastic synovium to invade the subchondral bone, producing cysts and erosions. [2-4] PVS can present as a localized or diffuse lesion. [4] A nodular, villonodular and villous variety of the disease can be distinguished. The various types are histologically identical and probably constitute different manifestations of the same process. [2,6] The tumour, although benign, can cause joint and bone destruction.

Symptoms are often remarkably discrete for long periods and the course of the disease is slow and progressive. This warrants awareness of this entity, early diagnosis, and aggressive management. The usual treatment of PVS is complete excision of the tumour. The case we describe is rare because of its extensive bone involvement.

Case Report

In March 2004 a 49 year old Italian man with complaints of swelling of his left ankle for the previous two months. He saw his general practitioner who requested an X-ray and ultrasound investigation. The ultrasound investigation revealed a well defined soft tissue-tumour which expanded from the postero-lateral tibia and fibula in the direction of the membrana interossea. It appeared as a homogeneous solid mass measuring 7 x 3 cm. (Fig. 1)

Figure 1 Preoperative ultrasound reveals a homogenous mass measuring 7 x 3 cm in diameter. The tumor is well defined.

X-ray investigation of the left ankle showed obvious bone abnormalities. An expanding osteolytic tumor in the lateral part of the tibia was observed. The soft tissues postero-lateral of the ankle was substantially enlarged. No calcifications were observed. The joint space was unaffected. (Fig. 2AB) The radiologist referred the patient to the orthopaedic department.

Figure 2AB Preoperative radiographs reveals an expanding, osteolytic tumor extending from the tibia to the fibula. No intra-articular involvement is appreciated.

In April 2004, this man, 90 kg, length of 1.78 mtr, visited our outpatient orthopaedic clinic. He had an unremarkable medical history taking no medications and working part-time as a cleaner. He was complaining of pain and noticed a gradual increase in swelling above his left ankle after a long car drive. Several weeks later this swelling appeared while walking a short distance. On physical examination there was a noticeable swelling to the supra- and retromalleolar region of the left lateral malleolus. The overlying skin and soft tissue was healthy. There was local tenderness retromalleolar at the medial and lateral ankle joint. The ankle was stable and had full range of motion. There were no neurovascular abnormalities to the left ankle and foot.

The bone scintigraphy revealed an increased activity at the distal end of the left tibia and fibula. (Fig. 3)

Figure 3 Bone scintigraphy reveals increased activity to the distal tibia and fibula.

MRI scan: Transversal assimilations in FSE T2, SE T1 and SE T1 with contrast soluble and T2 sagital assimilation with fat saturation provided a solution to our diagnostical problem. MRI revealed a solid mass with regular lobulated surroundings expanding between the fibula and the tibia with bone involvement. The maximal diameter of the lesion was 7 cm and it expanded as far as the concavity of the distal tibial plateau. The signal intensity was homogeneous low with some areas of increased intensity in all sequences. This is considered a fairly typical presentation of PVS. (Fig. 4ABCD)

Figure 4ABCD MRI scans with transversal assimilations in SE T1 (A) and SE T1 with contrast (C). Sagital assimilation in FSE T2 with fat contrast (B) and a sagital image of the 3 plane localizer (D).

The patient underwent surgery six weeks later. Through a posteromedial incision of the distal one-third of the left tibia the brown tumour was removed. We observed joint damage caused by the tumour expanding to the lateral side of the tibia as well as the medial side of the fibula. The tissue was sent for histological examination. The defect was filled with allogenous bone grafts. The wound was closed after extensive brushing and packing with Spongostan®.

Postoperatively the patient was placed in a plaster splint and began mobilization without weight bearing for six weeks.

The pathologist, after consulting the Dutch National Bone Tumours Panel, confirmed the diagnosis of pigmented villonodular synovitis.

Two days after the operation, a CT-scan was made for evaluation of the current status of the operated left ankle joint. There was some air in the transplanted bone and in the soft tissues. No complications were noted. (Fig. 5ABC) Six weeks after surgery the patient visited our outpatient clinic. He noticed slight pain on weight bearing. X-ray showed the leg in a Paris of plaster. (Fig. 6AB)

Figure 5ABC Post operative CT Scan showing some air pockets in the transplanted bone and soft tissues. (ABC)

Figure 6AB Post-operative AP and Lateral x-ray showing leg in Plaster of Paris.

Three and a half years after surgery the patient was free of pain and had virtually no complaints. On physical examination there was no swelling or instability of the ankle. He had a dorsiflexion of 15º and a plantar flexion of 35º of the ankle joint. There were no restrictions in daily or occupational activities.

Discussion

The etiology of PVS remains unclear. Rao, et al, [8] suggests a benign tumour arising from synovial fibroblasts and/or histiocytes. Another hypothesis postulates a local disorder of lipid metabolism in the synovial membrane. [17] According to other authors, PVS is an inflammatory reaction to an unidentified etiological agent. [1,5,10] Trauma and hemarthros have also been mentioned as possible causes. [3,18]

Sciot, et al, [29] studied the karyotypes of 44 specimens of 35 patients with localized (n = 19) or diffuse (n = 16) tenosynovial GCT’s. They found no difference in the distribution of karyotypic abnormalities between the localized and diffuse form except for trisomies (usually of chromosomes 5 and/or 7), which were more frequent in the diffuse type. They suggested that this variant of the disease is most likely neoplastic in nature.

In literature, the frequency of foot and ankle localisation varies between 11% and 14 %. [8,9,10,19] More recently Jones [20] and Rao [8] calculated a much lower frequency of 3% and 2.5%, respectively.

In the foot and ankle, two variants have been identified: tenosynovitis and articular synovitis. The articular synovial form most commonly involves the hindfoot and the ankle. Initial tenosynovitis is frequent more distal. [7-9] In the foot and ankle, the proximity of many tendons around the joints explains the local invasion of either the articular or the tendinous tissues.

Regarding the mode of bone involvement, there are various views. McMaster [21] theorized that it was through articular cartilage and cortex at chondro-osseus junction that the pigmented villonodular tissue extended into the bone. Chung and Janes [6] suggested that there is increased joint pressure due to synovial overgrowth which leads to small areas of osteoporosis followed by cystic degeneration of bone. Finally, with fracture of the cyst wall , an exuberant synovial membrane invades the cystic area. On the other hand, Scott [22] theorized that bone involvement occurs through the growth of villonodular tissue through the vascular foramina. The intra-osseous synovium gets its blood supply conveyed along these vascular stalks.

Roentgenograms in tumoral forms usually demonstrate slightly opaque soft tissues. Although a CT-scan is not necessary for making the diagnosis, it may reveal bone lesions which normal radiographs fail to show. MRI findings are specific and can assist in making the diagnosis. Synovial hypertrophy and deposits of ferromagnetic hemosiderin are typical of PVS. [23] Low signal intensity is noted in T1 and T2 weighted sequences with enhancement after gadolinium injection and without enhancement after gadolinium in areas of fibrosis. Also, hypo-intense areas on T1-weighted sequences and hyper-intense areas on T2-weighted sequences correspond to fluid in cystic lesions. [13,24,25]

Various treatments of PVS have been described including radiation therapy, synovectomy, marginal and radical excision. [3,4,26] In our patient the synovial tissue invaded the articular cartilage and bone. We performed a complete resection of the tumour. Because of a large bone defect after resection, a cancellous bone graft was implanted. Some authors prefer arthrodesis of the weight-bearing joint after the synovectomy and/or resection of the tumour. [27,28] We chose to preserve the ankle joint.

References

1. Chassaignac: Cancer de la gaine des tendons. Gazette des Hospitaux Civils et Militaines. 185. 1852.
2. Jaffe H, et al. Pigmented villonodular synovitis, bursitis and tenosynovitis. Arch Pathol. 31:731-765, 1941.
3. Granowitz S et al. Localized pigmented villonodular synovitis of the knee: report of five cases. J Bone Joint Surg. 49 (1): 122-128, Jan 1967.
4. Flandry F, et al. Current concepts review: pigmented villonodular synovitis. J Bone Joint Surg Am. 69 (6): 942-949,1987.
5. Granowitz S, et al. The pathogenesis and long-term end results of Pigmented villonodular Synovitis. Clin Orthop. (114): 335-351, Jan-Feb 1976.
6. Chung S et al. Diffuse pigmented villonodular synovitis of the hip joint. J Bone Joint Surg. 47: 293-303, Mar 1965.
7. Bonnel F, et al. Tumeur a cellules géantes des gaines synoviales dupied. Med Chir. 6: 72-78, 1990.
8. Rao A, et al. Pigmented villonodular synovitis: a review of 81 cases. J Bone Joint Surg Am. 66 (1): 76-94, Jan 1984.
9. Schajowics F, et al. Pigmented villonodular synovitis of the wrist with penetration into bone. J Bone Joint Surg Br. 50 (2): 312-313, May 1968.
10. Byers P, et al.The diagnosis and treatment of pigmented villonodular synovitis. J Bone
Joint Surg Br. 50B (2): 290-305, May 1968.
11. Groulier P, et al. Pigmented villonodular synovitis of joints: apropos of 16 cases. 58 (4): 259-267, Apr 1991.
12. Leemirijse T, et al. De la tumeur a cellules géantes a la synovite villonodulaire : a propos de quatre cas au niveau du pied. Med Chir Pied. 12: 72-80, 1996.
13. Jelinek J, et al. Imaging of pigmented villonodular synovitis with emphasis on MR imaging. AJR Am J Roentgenol. 152 (2): 337-342, Feb 1989.
14. Konrath G, et al. Magnetic resonance imaging in the diagnosis of localized pigmented villonodular synovitis of the ankle: a case report. Foot Ankle Int. 15 (2): 84-87, Feb 1994.
15. Kottal R, et al. Pigmented villonodular synovitis: a report of MR imaging in two cases.
Radiology. 163 (2): 551-553, May 1987.
16. Mandelbaum B, et al.The use of MRI to assist in diagnosis of pigmented illonodular synovitis of the knee joint. Clin Orthop (231): 135-139, Jun 1988.
17. Hirohata K. Light and electron microscopic studies of individual cells in pigmented
villonodular synovitis and bursitis. Kobe J Med Sci. 14 (4): 251-279. Dec 1968.
18. Young J, et al. Experimental production of pigmented villonodular synovitis in dogs. Am J Pathol. 30 (4): 799-811, Jul-Aug 1954.
19. Myers B, et al. Pigmented villonodular synovitis and tenosynovitis: a clinical epidemiologic study of 166 cases and literature review. Medicine. 59 (3): 223-238 May 1980.
20. Jones F, et al.: Fibrous xanthoma of synovium (giant cell tumor or tendon sheath pigmented nodular synovitis): a study of one hundred and eighty cases. J Bone Joint Surg. 51 (1): 76-86, Jan 1969.
21. McMaster P: Pigmented villonodular synovitis with invasion of bone. J Bone Joint Surg. 42 (7): 1170-1183, Oct 1960.
22. Scott P: Bone lesions in pigmented villonodular synovitis. J Bone Joint Surg. 50 (2): 306-311, May 1968.
23. Spritzer C, et al. Magnetic resonance imaging of pigmented villonodular synovitis: a report of two cases. Skeletal Radiol. 16 (4): 316-319, 1987.
24. Dufour M, et al. La synovite villonodulaire hemopigmentee (Hemopigmented villonodular synovitis) J Radiol. 72 (6-7): 363-373, Jun-Jul 1991.
25. Kransdorf M, et al. Soft tissue masses: diagnosis using MRI imaging. AJR. 153 (3): 541-547, Sep 1989.
26. Wu K, et al. Pigmented villonodular synovitis: a clinical analysis of twenty-four cases treated at Henry Ford Hospital. Orthopedics. 3: 751-758, 1980.
27. Rochwerger A, et al. Pigmented synovitis of the foot and ankle: A report of eight cases Foot Ankle Int. 20 (9): 587-590, Sep 1999.
28. Pandey S, et al. Pigmented villonodular synovitis with bone involvement. Arch Orthop Trauma Surg. 98 (3): 217-223. 1981.
29. Sciot R, et al. Analysis of 35 cases of localized and diffuse tenosynovial giant cell tumor: a report from the chromosomes and morphology (CHAMP) study group. Mod Pathol. 12 (6): 576-579, Jun 1999.

Address correspondence to: Eric Breemans, Gelre Hospitals, location Lukas, Department of Orthopaedic Surgery, P.O. Box 9014, 7300 DS, Apeldorn, the Netherlands. Tel:+ 31 55 5818181.
E-mail: Breemans@breemans.com 

1Registrar Orthopaedic Surgery, Sint Maartenskliniek, Woerden, the Netherlands.
2Registrar Orthopaedic Surgery, Academic Medical Center, Amsterdam, the Netherlands.
3Orthopaedic Surgeon, Sint Maartenskliniek, Woerden, the Netherlands.
4Pathologist, Gelre Hospitals, Apeldoorn, the Netherlands.
5Orthopaedic Surgeon, Gelre Hospitals, Apeldoorn, the Netherlands.

© The Foot & Ankle Journal, 2008

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