Rev. bras. ortop. vol.49 número1

r e v b r a s o r t o p . 2014;49(1):74–77

w w w . r b o . o r g . b r

Case

Report

Lipoma

arborescens

of

the

knee:

a

case

report

夽

,

夽夽

Daniel

Rodrigo

Klein

Servic¸odeOrtopediaeTraumatologia,HospitalArquidiocesanoCônsulCarlosRenaux,Brusque,SC,Brazil

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Articlehistory:

Received2December2012 Accepted22March2013

Keywords:

Knee

Lipomaarborescens Synovialmembrane

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Casereportofafemalepatientof26yearswhocomplainedofpainandrecurrentepisodes ofjointswellinginhisleftkneeabout10yearsago.Afteranamnesis,physical examina-tionandradiographicimagingandmagneticresonancewerediagnosedwitharborescent lipomaoftheknee,andthepatientunderwentarthroscopictreatmentforresectionofthe lesion.Postoperativelythepatientwasreferredtophysicaltherapyrehabilitationwithgood evolution.

©2014SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditora Ltda.Allrightsreserved.

Lipoma

arborescente

de

joelho:

relato

de

caso

Palavras-chave:

Joelho

Lipomaarborescente Membranasinovial

r

e

s

u

m

o

Relatodecasodeumpacientedosexofemininode26anosqueapresentavaqueixasde doreseventuaise episódiosrecorrentesdederramearticularno joelhoesquerdohavia aproximadamente10anos.Apósanamnese,examefísico,examesradiográficoseexames deimagemporressonânciamagnéticafoifirmadoodiagnósticodelipomaarborescente dejoelho.Apacientefoisubmetidaatratamentoartroscópicopararessecc¸ãodalesão.No pós-operatóriofoiencaminhadaparareabilitac¸ãofisioterápica,comboaevoluc¸ão.

©2014SociedadeBrasileiradeOrtopediaeTraumatologia.PublicadoporElsevierEditora Ltda.Todososdireitosreservados.

Introduction

Arborescentlipomaisararebenignintra-articularlesion char-acterizedbydiffusereplacementofsynovialtissuebymature adipocytes,causingavillouslipomatousproliferationofthe sinovialmembrane.1

Typically,this isamonoarticular condition. Theknee is themostcommonlyaffectedjoint.Thehighestincidenceof

夽

Pleasecitethisarticleas:KleinDR.Lipomaarborescentedejoelho:relatodecaso.RevBrasOrtop.2014;49:74–77.

夽夽

StudyconductedatOrthopedyandTraumatologyService,HospitalArquidiocesanoCônsulCarlosRenaux,Brusque,SC,Brazil. E-mail:[email protected]

presentation occurs inthe fourthand fifthdecades oflife, withnopredilectionforgender.2_{Thetypicalclinical}

presenta-tionconsistsofrepetitioneffusions,oftenwithlargevolume, accompaniedbyadiffuseandintermittentpain.Intheknee theconditioncommonlyaffectsthesuprapatellarpouch,with asoftconsistencyonpalpation.Weshouldsuspectthe diag-nosisinapatientwhoseclinicalhistoryisoffrequentjoint effusions,occasionalpainandincreasedvolumeinthe supra-patellaraspect.Radiographicstudiesmaybenormalorshow

2255-4971/$–seefrontmatter©2014SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditoraLtda.Allrightsreserved.

rev bras ortop.2014;49(1):74–77

75

Fig.1–Increasedvolumeintheleftknee.

nonspecificchanges, suchas increasedsoft tissue or even degenerativechanges.2_{Magneticresonanceimaging(MRI)is}

theprimarydiagnostictest.Theimageofamassofsynovial villousarchitecture,withisointensitywithsubcutaneousfat, isconsideredbysomeauthorsaspathognomonicfor arbores-cent lipoma,which enablesthe establishmentofdiagnosis evenbeforethe resultsofthe anatomopathological exami-nation.Therecommendedtreatmentisopenorarthroscopic synovectomy,withveryrarecasesofrecurrenceofpatology.3

Case

report

Female,26 years old.Thepatientreportedthat, since ado-lescence, had episodes of swelling and occasional pain in theleftkneewithoutanytriggeringtraumaticevent.Denied ahistoryofgivingwayorlockingofthe joint,havingseen several doctors; sometimes, she underwent arthrocentesis withoutdiagnosis.Hersymptomswerereasonablywell con-trolledwithphysicaltherapytomaintainmusclecontroland rangeofmotion.Onphysicalexamination,shehadbilateral genuvalgus, withswellinginthe leftknee (Fig.1).Shealso presentedapalpablemassofsoftandpainlessconsistency inthelateralaspect,andapositivekeysigninferring mod-eratejoint effusion,rangeofmotionwithaudiblecrackling inflexion-extension arcand pain withcompression ofthe patellofemoraljoint. Themaneuversin search ofligament andmeniscallesionswere negative,withnoother relevant signsor symptoms. Thepatienthad nofamily orpersonal historyworthyofnote.Plainradiographsofthekneeshowed reducedmedialjointspace,subchondralsclerosis,and reac-tionalosteophytes(Fig.2).

MRI demonstrated a large joint effusion, thickening of synovial membranes with enhancement after contrast mediumwithfinger-like aspectandlipomatous contenton the lateral aspect of the joint, besides degenerative chon-dralcompartmentalchangesanddegenerationinthebodyof themedialmeniscus(Fig.3).Afterevaluationofthe physi-calexaminationandlaboratorytests,thepatientunderwent videoarthroscopywithuseofanterior-inferiorand anterior-superiorportalstoresectthelesion andtoobtain material foranatomopathologicalexamination,withconfirmationof

Fig.2–RadiographsoftheleftkneeinAP(A)andlateral viewsshowingdegenerativechanges(B).

thediagnosisoflipomaarborescens.Besidescompartmental degenerativelesions,thearthroscopicexaminationrevealed synovitisofpedunculatedappearanceandareddish,diffuse color,withpredominanceinthelateralgutter(Fig.4).

Adrainsuctionwasappliedfor24h,collectingavolumeof approximately350mLofblood.Thepatientwasdischarged without complaintsthe next day after the procedure. The physicaltherapywasinitiatedimmediately afterdischarge, aimingtomaintaintherangeofmotionandmusclecontrol, andthepatientwasallowedtosupporttheweightastolerated. Thirtydaysaftersurgery,thepatientwasallowedtoreturn toherusualactivities. Inherlatestrevision(approximately threemonthspostoperatively),thepatientwasasymptomatic withminimaljointeffusion. Inthefirstyear,the follow-up willbesemiannual;subsequently,thepatientwillbeannually accompaniedfortwoyears.

Discussion

76

Fig.3–Magneticresonanceimaginginsagittal(A),coronal (B)andaxial(C)slices,depictingthevillousandlipomatous appearanceofthesynovialmembrane.

prominentvilloustransformation.4 _{Itsetiology isunknown,}

althoughinsomecasesthisproblemisassociatedwithcertain conditions,suchasdegenerativejointdisease,diabetes melli-tus,rheumatoid arthritis,andpsoriaticarthritis,suggesting the possibility of a reaction process.1 _{Popliteal cysts were}

notedinapproximately20%ofreportedcases.4_Althoughthe

knee is the most commonly affected joint, there are also reportsofinvolvementinthe wrist,4,5 _elbow,4,6 _shoulder,4,7

ankle,4,8 _{and hip.}4,9 _{The differential diagnosis of}

arbores-cent lipoma of the knee includes pigmented villonodular synovitis,intra-articularlipomaoftheknee,synovial chondro-matosis,synovialhemangioma,andrheumatoidarthritis.1,4

Itsinsidiousclinicalcourse,supplementedbytestssuchas radiographyandmainlyMRI,virtuallyconfirmsthediagnosis. A synovialmass of villousarchitecture depicting isointen-sity with subcutaneous fat (hyperintense on T1, which is abolishedinthesequenceswithfatsaturation)canbeseen on MRI. There is no contrast uptakeby the lesion,which

Fig.4–Intraoperativemacroscopicappearanceofthe lesion(AandB):diffusevillousprojectionswithreddish color,locatedpredominantlyinthelateralgutter.

excludesotherinflammatoryorneoplasticprocessesofthe synovia.However,someintra-articulardiffusionofthe con-trastintothejointfluid,withinsinuationbetweenthesinovial lipomatous villous projections, can be seen, giving rise to smallareasofuptake.1_{Nowadays,withthemorewidespread}

use of MRI, it has become more easier to diagnose this pathology.

Theopenorarthroscopicsynovectomyisconsidered cura-tivebymostauthors.Althoughtherearefewpublishedcases of arthroscopic synovectomy, these showed good progress during a follow-up period ofup to two years,2 _{with lower}

morbiditywhencomparedtocaseswhereopenconventional treatmentwasdone.1_{Wefoundnomajortechnicaldifficulties}

forthearthroscopicprocedure,perhapsbecausethespecific localizationofthepathologyintheanterioraspectoftheknee. The use ofthe anterior- superioraccessory portals greatly facilitatedtheprocedure,withlittleincreaseinmorbidityfor thepatient.Adrainsuctionshouldbeappliedforaperiodof approximately24hafterthesurgery,inviewofthebleeding thatoccursaftertheprocedure.

rev bras ortop.2014;49(1):74–77

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Conflicts

of

interest

Theauthordeclaresnoconflictsofinterest.

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3.SumathiS,KhanDM,AnnamV,MrinaliniVR.Secondary unilateralmonoarticularlipomaarborescensoftheknee.A casereportwithreviewofliterature.IntJBiolMedRes. 2012;3(1):1456–8.

4.KloenP,KeelSB,ChandlerHP,GeigerRH,ZarinsB,Rosenberg AE.Lipomaarborescensoftheknee.JBoneJointSurgBr. 1998;80(2):298–301.

5.GaedeEA.Einfallvonsynovitischronicavillosageneralisata. ArchOrthopUnfallchir.1961;53:315–9.

6.LevadouxM,GadeaJ,FlandrinP,CarlosE,AswadR,PanuelM. Lipomaarborescensoftheelbow:acasereport.JHandSurg Am.2000;25(3):580–4.

7.LaorrA,PeterfyCG,TirmanPF,RabassaAE.Lipoma arborescensoftheshoulder:magneticresonanceimaging findings.CanAssocRadiolJ.1995;46(4):311–3.

8.NapolitanoA.Lipomaarborescensofthesynovialfluid; clinicalcontributiontoacaselocatedatthesynoviaofthe wrist.ProgMed(Napoli).1957;13(4):

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