Pigmented villonodular synovitis of the ankle occurring in a patient on anticoagulation therapy.

A case report is presented of a 45-year-old woman with an 18-month history of pain and swelling in her right ankle. There was no history of trauma. Routine investigations failed to elicit a diagnosis. The patient had been on warfarin anticoagulation therapy for 12 years. The onset of symptoms coincided with a period of poor control of her anticoagulation therapy and her international normalized ratio was recorded at 5 or above on three occasions. A diagnosis of pigmented villonodular synovitis (PVNS) was made on arthroscopic examination of her ankle; this was confirmed histologically. The etiology of PVNS remains controversial. Hemarthrosis has been suggested as an etiological factor. Although there are reports of PVNS in patients with hemophilia, there are no reports of PVNS occurring in patients on anticoagulation therapy. This case report supports a possible role for hemarthrosis in the etiology of PVNS.

The 'ABC' of examining foot radiographs.

INTRODUCTION: We report a simple systematic method of assessing foot radiographs that improves diagnostic accuracy and can reduce the incidence of inappropriate management of serious forefoot and midfoot injuries, particularly the Lisfranc-type injury. STUDY GROUP AND METHODS: Five recently appointed senior house officers (SHOs), with no casualty or Orthopaedic experience prior to their appointment, were shown a set of 10 foot radiographs and told the history and examination findings recorded in the casualty notes of each patient within 6 weeks of taking up their posts. They were informed that the radiographs might or might not demonstrate an abnormality. They were asked to make a diagnosis and decide on a management plan. The test was repeated after they were taught the 'ABC' method of evaluating foot radiographs. RESULTS: Diagnostic accuracy improved after SHOs were taught a systematic method of assessing foot radiographs. The proportion of correct diagnoses increased from 0.64 to 0.78 and the probability of recognising Lisfranc injuries increased from 0 to 0.6. CONCLUSIONS: The use of this simple method of assessing foot radiographs can reduce the incidence of inappropriate management of serious foot injuries by casualty SHOs, in particular the Lisfranc type injury.