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Author Topic: Can My Weird Complex Thickened Synovial Tissue Heal/Absorb On Its Own?  (Read 596 times)

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Offline MasterForte

  • MICROgeek (<20 posts)
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This is going to be a long read so I apologize for that, but I really need some help.

Details:
Age - 25
Height - 5"8
Weight - 144 lbs
Gender - Male
Medications - Aleve 1000mg
Smoking Status - Non-smoker
Previous and current medical issues - Just this left knee issue
Duration and Location of complaint - Left knee, 1.5 years

I was an extremely athletic individual before this happened. February of last year I started feeling pains when I was pushing myself on the exercise bike. I continued pushing through it and when it got real bad I did an extreme leg weightlifting session which had my muscles in pain for days thinking it could help. After that, my knee/leg blew up with fluid and stayed that way since. Like a foolish idiot, I didn't get treatment right away. It wasn't until 9 months later that I had surgery on the knee.

Pre-surgery MRI of the knee:

EXAM: MRI right knee.
COMPARISON: MRI left femur same day, MRI left femur 10/10/2017, plain radiographs 10/03/2017.
HISTORY: Knee pain.
TECHNIQUE: Axial PDFS, Cor PD, Cor PDFS, Sag PD, and Sag T2FS sequences performed.

FINDINGS: There is a large joint effusion. Complex thickened irregular synovial tissue is noted particular the suprapatellar recess. Fluid dissects along the lateral and posterior margin of the distal femoral metadiaphysis. Sub-centimeter lymph nodes are present in the popliteal fossa. Skin thickening and reticulation of subcutaneous fatty tissues is fairly prominent at the lateral margin of the distal thigh with mild myositis involving the short head biceps muscle belly posterolaterally. Complex synovial fluid dissects proximally were into the thigh please refer to MRI dictation of the left femur performed same day. Subtle low signal is noted along at least a portion of the synovial lining likely related to hemorrhagic deposition/hemosiderin. There is mild heterogeneity of the marrow involving the distal femur proximal tibia and fibula suggesting osteopenia which may be related to disuse. Hyperemia related osteopenia could present in a similar fashion. Despite the large joint effusion there is no evidence of focal osseous erosion. The cartilage is well maintained.

Ligaments: Anterior cruciate ligament fibers demonstrate no acute pathology.Posterior cruciate ligament fibers demonstrate no acute pathology.
Superficial and deep MCL fibers intact.Lateral collateral ligament complex including the popliteal tendon intact. Meniscus: Medial meniscus is unremarkable.
Lateral meniscus is unremarkable.
Cartilage: No high-grade chondromalacia present.
Extensor mechanism: Quadriceps and patellar tendons intact.
Complex synovial fluid dissects into the pre femoral fat pad.

IMPRESSION: 1. Complex dissecting synovial fluid collection extending from the suprapatellar recess about the distal femoral metadiaphysis into the popliteal fossa and dissecting proximally into the thigh. There is complexity to the collection with internal septations and proteinaceous debris. Skin thickening and reticulation of subcutaneous fatty tissues present. There is osteopenia at the joint. Constellation of findings raises suspicion of indolent infection such as TB. There is relatively well-preserved cartilage. No definitive erosion. Subtle low signal along the portions of the capsular tissue suggests hemosiderin deposition associated with the aspirated hemorrhage. Although PVNS is not entirely excluded, it is considered less likely given the aggressive dissecting fluid which is more typically seen in the setting of infection.

Pre-surgery MRI of the femur:

EXAM: MRI left thigh without and with contrast
COMPARISON: None.
HISTORY: Left thigh pain
TECHNIQUE: Long axis T1, PDFS and STIR, axial T1, axial T2, axial T1 fat sat pre and postcontrast, long axis T1FS post contrasted images performed prior to and following intravenous administration 7mL Gadavist.

FINDINGS: Osseous structures: There is no fracture nor concerning marrow lesion present.
Soft tissues: Extensive inflammatory changes present at the knee with a complex septated fluid dissecting proximally to the mid diaphyseal level of the thigh reference coronal image 20. This extends 18 cm proximal to the knee joint at the lateral margin at the junction of the anterior and posterior compartments along the deep fascia. This communicates with the popliteal fossa roughly 9 cm proximal to the joint reference axial image 22. Thickening of the wall and internal septations are present throughout the collection with adjacent subcutaneous edematous changes and skin thickening. The crescentic collection in the popliteal fossa and at the distal diaphyseal/metadiaphyseal level demonstrates peripheral enhancement on axial postcontrast image 21. The transverse diameter of the collection posterior to the femur measures 4.3 cm. The focus extending to the subcutaneous fatty tissues extends 3.9 cm AP with an average depth of approximately 1.5 cm transverse. The peripheral enhancing a dissecting fluid demonstrates a slightly irregular and thickened wall. Sub-centimeter lymph nodes are present in the popliteal fossa. The collection appears to communicate with the knee joint with the irregular and moderately thickened septations noted at the suprapatellar recess. The suprapatellar recess collection is also thickened and irregular with internal septations present. The patient as the parotid the working clinical diagnosis of PVNS. This could result in blood-tinged joint fluid, however the degree of dissection and irregularity of the process as well as subcutaneous edematous change is somewhat atypical. MRI findings are concerning for an indolent infection such as TB arthrosis. I do not clearly identify a focal nodular low signal region nor bony erosive change on this examination.
Neurovascular: Vasculatures patent. Sub-centimeter popliteal lymph nodes present.

IMPRESSION: 1. Marked irregular inflammatory dissecting peripheral enhancing fluid extends from the knee cephalad 18 cm dissecting through the deep fascia into the subcutaneous fatty tissues with adjacent edematous change in the subcutaneous fat and dermis at the junction of the anterior and posterior compartment laterally. This insinuating dissecting process raises concern for indolent infection such as tuberculous arthrosis which can demonstrate significant fistulous communication. Gonnococcal infection should be considered as well. Large joint effusions related to intra-articular pathology typically demonstrate a more organized geographic distribution with thin septations and wall enhancement. Certainly, I cannot exclude PVNS, however indolent infection must be excluded based on these imaging findings.

So the doctors were thinking infection. I was taken to the operating room around mid-November and had an arthroscopic synovectomy performed. The abnormal tissue growth was biopsied and showed absolutely no growth. The way this tissue was described to me was that it looked like a pimple and when it was squeezed, orange pus-like fluid came out. After the surgery my OS put me on bactrim and I started running fevers and had elevated liver enzymes. The infectious disease team at the hospital ran all sorts of tests on me and everything came back negative. Once I was off the bactrim, oddly that stopped so it turned out I was allergic to bactrim. However, they did do another MRI about a month later.

1-month post-op MRI of the knee:

MRI of the left knee without with contrast
Comparison: X-ray. MRI from 11/09/2017
Technique: Coronal STIR and T1, axial T2, T1, PD fat sat, T1 fat sat pre and postcontrast with a dose 7 mL Gadavist. Coronal T1 fat sat postcontrast also performed.
History: Inflammatory process previously identified.

Findings:
Bony structures: Mild rather diffuse edema is seen in the proximal tibia and distal femur most consistent with disuse osteopenia. No other bony findings are identified.
There remains a large effusion in the joint. There is some peripheral synovial enhancement but no nodularity is seen. No low signal is seen to suggest PVNS. There is surrounding edema with enhancement extending into the vastus medialis and lateralis. This consistent with mild myositis. The supra patellar effusion extends about center and centimeters proximal to the knee joint. There is edema posterior to the knee and also a small additional locule of fluid extending laterally from the posterior joint. The extensive multiloculated appearance seen in this region on the prior study has improved.

IMPRESSION: 1. There remains a large effusion with some surrounding enhancement and myositis. No nodularity or low signal is seen to suggest nodular or pigmented villonodular synovitis. Overall this is most likely represent some form of infection. Additional loculated pocket of fluid is seen posteriorly but the complex multiloculated appearance seen previously is somewhat improved. The effusion extends least 10 cm proximal to the knee joint. Proximal to this is not visible on this knee exam. 2. Disuse osteopenia

Infectious disease doctors told me that things look the same on the MRI, maybe a little bit better. 5 months post-op, another doctor told me that the moderate amount of fluid on my knee is possibly permanent. However, I am now 8-months post-op and quite a lot has changed for the better. My left knee actually resembles my good one in shape, BUT there is still noticeable swelling around it especially on the sides and extending above the kneecap. That being said, my knee was never drained post-op except once right after when I started running fevers. I did try to go back to my OS to have it drained about 2 weeks ago, but he told me there really isn't enough fluid in there for him to drain it, so that's a good thing right? He did give me a cortisone shot (didn't help), and put me on medrol for a week (slowly helped out but once I stopped it the knee stopped getting better). I am now on Aleve to keep targetting the inflammation.

So my question basically is, is it possible that complex septated synovial tissue can go back to normal on it's own? My knee has obviously gotten much better so I'm hoping so, but I figured you guys would have a better idea of how this works in the body. I have full range of motion, can do a full squat but very awkwardly and with some pain and I do feel the fluid in there.

On a side note, can the fluid on my knee also cause knee crepitus? It only happens when I'm laying down and move my leg or when I tense my leg muscles and then move it.

Thank you for reading this and thank you for any help you can offer!! I do plan on trying to make another appointment with my OS and seeing if we can do another MRI just to see what's going on and why there is still some excess fluid still there after 8 months and why it's so slow to go away or change much, but my mind is going crazy. It's been a long-time and I've been so hopeless and depressed over it. Thanks again for any input!!