Offering surgical insights, this author presents a rare case of a peri-ligamentous granuloma engulfing the anterior talofibular ligament in a 26-year-old patient.
Giant cell tumors can occur in the bone and on tendon sheaths. They are generally benign tumors. As of this writing, there are four documented cases in which giant cell tumor is associated with a ligament.1-4 Although there are case studies of giant cell tumor of the talus and of the ankle, to our knowledge, there are no cases associated with the anterior talofibular ligament.5-8
A giant cell tumor of the tendon sheath is a peritendinous lesion that is made up of cells derived from the synovial tissue. It is generally benign and often associated with a history of trauma.9 Fibrous histiocytoma of synovium, pigmented nodular synovitis, localized nodular tenosynovitis, benign synovioma, fibrous xanthoma of the synovium and pigmented villonodular bursitis are all synonymous names of the giant cell tumor of the tendon sheath.10,11
A Closer Look At The Preoperative Findings
A 26-year-old Hispanic man presented with pain in his right ankle. The patient sustained a motor vehicle accident three months prior to presentation. He was being treated for lower back, shoulder and knee injuries at a private clinic.
Upon examination of the right ankle, there was swelling on the dorsolateral aspect around the anterior talofibular ligament. There was pain with plantarflexion and dorsiflexion of the ankle. The radiographic image of the patient’s right ankle failed to reveal a fracture or dislocation.
Magnetic resonance imaging (MRI) revealed scarring of the anterior talofibular and calcaneofibular ligaments with a periligamentous granuloma engulfing the anterior talofibular ligament and tibiotalar arthritic formation. The patient had utilized physical therapy for three months without any significant improvement.
I explained to the patient that he was a candidate for an arthroscopic procedure for removal of the granuloma formation. I described a reconstruction of the anterior talofibular ligament and calcaneofibular ligament. The patient consented to the procedure after an explanation of all the associated risks, benefits and alternatives.
Pertinent Insights On The Surgical Technique
The patient was on the operating table in a supine position. After administration of regional anesthesia with IV sedation, we prepped and draped the patient in the usual sterile manner. The senior author performed a stab incision medial to the tibialis anterior tendon. I inserted a 4.0 mm scope in the medial portal and made the lateral portal with a transillumination technique.
Immediate observation revealed a significant hypertrophied synovium. A full radius shaver allowed for increased visualization and provided for the debridement of the hypertrophied synovium of the anterior ankle mortise. The lateral ankle gutter was blocked with a large lesion. The ligament was partially visible and attenuated, and the lesion was attached to the ligament.
After further evidence of an osteochondral lesion and more hypertrophied synovium, I decided to open the ankle to remove the lesion due to the size of lesion. I performed a 4 cm lateral curvilinear incision. After sharp and blunt dissection with careful retraction a large granuloma lesion was adhered to the anterior talofibular ligament. The anterior talofibular ligament was significantly scarred and partially torn.
I sent a 3 cm x 1 cm granuloma to pathology. I repaired the ligament before closing the ankle. The granuloma specimen was irregular, firm and had a yellow-orange lobular presentation. Histopathology confirmed the diagnosis of a giant cell tumor of the tendon sheath.
During nine months of postoperative follow-up, the patient showed no complications of the right ankle. Almost one year after the surgery, the patient presented with pain in the right ankle again and with tenderness over the anterior talofibular ligament. I ordered a new MRI. However, the patient did not go for study and was lost in follow-up.
What The Literature Reveals About Giant Cell Tumors
A giant cell tumor is a fairly common bone tumor that accounts for about 5 percent of all the primary bone tumors. It is a benign tumor that has a high chance of recurrence. The recurrence may be due to an initial incomplete excision of the tumor. The giant cell tumor occurs most commonly in the fingers, occurring less in the ankle.5 According to one study, there was no recurrence after the surgery and no cases of malignancy in the 15 cases that were available for long-term follow-up.5 The clinical picture may present as an insidious onset of pain with a history of trauma, which one may misdiagnose as an ankle sprain.
Although there is one documented case involving arthroscopic resection of an extra-articular tenosynovial giant cell tumor from the ankle, we chose to open up the ankle to remove the granuloma.6 This also allowed us to repair the ligament. There are articles on giant cell tumor of the tendon sheath in the ankle but to our knowledge, no giant cell tumor of the tendon sheath has been associated with anterior talofibular ligament.5-7
Dr. Yager is a Fellow of the American College of Foot and Ankle Surgeons. He is in private practice at the New York Foot and Ankle Institute.
Dr. Lee is a third-year resident at the Mount Sinai Hospital Podiatric Residency Program in New York City.
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