Introduction
History of the Procedure
The pain, swelling, and mechanical symptoms of synovial chondromatosis and its generation of loose bodies have historically been treated with surgery. Since the mid 1950s, the technical strategy has included open arthrotomy with removal of loose bodies and synovectomy. Controversy exists regarding the utility of synovectomy. Some authors prefer simple loose-body removal and limited excision of involved synovium only. The recent evolution of arthroscopic techniques offers a relatively noninvasive strategy for select cases.
Problem
Synovial chondromatosis is a rare condition in which foci of cartilage develop in the synovial membrane of joints, bursae, or tendon sheaths as a result of metaplasia of the subsynovial connective tissue. These ectopic foci of cartilage can result in painful joint effusions and, on the generation of loose bodies, mechanical symptoms.1,2,3,4,5
Arthroscopic appearance of synovial chondromatosis loose bodies in the shoulder.
Sagittal T2-weighted MRI through the knee in an adult with synovial chondromatosis demonstrates abnormal signal intensity in the suprapatellar pouch. Also note hypertrophic synovium in the intercondylar notch region and a normal posterior cruciate ligament.
Arthroscopic image of pedunculated synovial chondromatosis in the knee.
Recent studies
Ackerman et al performed a retrospective analysis of 11 patients treated with total hip arthroplasty (7 patients) or total knee arthroplasty (4 patients) for severe arthritis associated with synovial chondromatosis. In all patients, pain and functional scores showed significant improvement. Knee range of motion was found to improve in all patients, but synovial chondromatosis did recur in one knee. Synovial chondromatosis also recurred in one hip.6
Galat et al followed 8 patients with synovial chondromatosis of the foot and ankle, 2 of whom had midfoot involvement and 6 ankle involvement. Ankle synovectomy with loose body removal was performed in 4 patients, who were were pain-free at last follow-up (average, 9.5 y). One patient underwent excision and midfoot arthrodesis for severe midfoot destruction. Below-the-knee amputations were ultimately required in 3 patients (for multiple recurrences in one case and for malignant transformation to low-grade chondrosarcoma in 2 cases).7
Boyer and Dorfmann reported on the outcome of 111 patients who underwent arthroscopic treatment for primary synovial chondromatosis of the hip, with a mean follow-up of 78.6 months (range, 12-196 months). In 23 patients, more than one arthroscopy was necessary, and open surgery was ultimately required in 42 patients. Of the 69 patients treated with arthroscopy alone, no further treatment was required in 51, and additional arthroscopies were necessary in 18. Excellent or good outcome was reported in 56.7% of the total 111 patients, and 22 patients required total hip replacement.8
Frequency
The exact prevalence is unknown, but the disorder is rare worldwide. Most reported series indicate a male-to-female ratio of 2:1. In addition, most cases are reported in middle-aged individuals; only a few case reports have described the condition occurring in children.
Etiology
Synovial chondromatosis occurs as either a primary or secondary form.
Primary synovial chondromatosis
This form is described as the presence of ectopic cartilage in synovial tissue and as loose bodies in the joint cavity with or without calcification (osteochondromatosis) and without an identifiable joint pathology. Whether this represents synovial metaplasia or a true neoplasia is unclear. The true etiology remains unknown, but most authorities favor the metaplastic theory.
Secondary synovial chondromatosis
The secondary form is synovial chondromatosis in the setting of preexistent osteoarthritis, rheumatoid arthritis, osteonecrosis, osteochondritis dissecans, neuropathic osteoarthropathy, tuberculosis, or osteochondral fractures. Free chondral or osteochondral fragments formed by underlying disease implant into the synovium and induce metaplastic cartilage around them.
Pathophysiology
Primary synovial chondromatosis appears to occur in 3 phases, as Milgram described in 1977.9
- Phase 1 - Active intrasynovial disease without loose bodies
- Phase 2 - Transitional lesions with osteochondral nodules in the synovial membrane and osteochondral bodies lying free in the joint cavity
- Phase 3 - Multiple free osteochondral bodies with quiescent intrasynovial disease
Synovial chondromatosis is considered a benign process associated with an extremely low risk of malignancy. Case reports have described the coexistence of chondrosarcoma and synovial chondromatosis, sparking debate as to whether the chondromatosis is a cause or the result of chondrosarcoma. One case report documented malignant degeneration of synovial chondromatosis.10
Involvement is typically monoarticular, with the large joints being most frequently affected. The knee joint is involved in 60-70% of cases; the shoulder, elbow, and hip are the next most frequently involved joints. Reports have described involvement of multiple other joints and locations, including the temporomandibular joint, spinal facet joints, the acromioclavicular joint, wrist joint, ankle joint, biceps tendon sheath, and extra-articular locations.1,2,3,11
Presentation
The typical history of a patient with primary synovial chondromatosis of the knee is a middle-aged man with monoarticular pain, swelling, and stiffness with or without mechanical symptoms in the knee. No history of acute trauma is usually reported, but the patient may have a distant history of knee injury. No systemic signs of infection or illness are apparent.
With regard to the physical examination, no obvious deformity is likely on inspection. The joint may be enlarged compared with the uninvolved side. No overlying skin changes are observed.
On palpation, a large effusion can be felt, and the joint has a spongy sensation. Variably present are palpable loose bodies in synovial recesses, tenderness along the medial or lateral joint line, and decreased patellar mobility. Range of motion is typically decreased, with a 10-15° loss in flexion and extension. Pain varies with movement. With regard to special testing, results of a ligamentous examination (eg, Lachman test, drawer test) are normal. No specific maneuver is described.
Indications
Patients with recurrent painful effusions, mechanical symptoms, or both due to synovial chondromatosis refractory to conservative intervention are candidates for surgical intervention.
Relevant Anatomy
Synovium lines the interior surface of diarthrodial joints and is composed of vessel-rich fronds lined by synoviocytes. Ectopic cartilage bodies in the synovium and loose in the joint must be removed. The need for total synovectomy, including removal of normal areas of synovium, is questionable. Total synovectomy can lead to clonally significant stiffness after surgery, with reported rates of up to 43% when the procedure is performed by means of open arthrotomy.
Dorfmann et al and Coolican and Dandy reported low recurrence rates after arthroscopic treatment of the knee and no postoperative stiffness with simple excision of loose bodies.1,4,12 In current practice, most authors agree that arthroscopic removal of loose bodies for mechanical symptoms is the best surgical strategy.
Contraindications
Contraindications to arthroscopic surgery for synovial chondromatosis are few. Only joints amenable to arthroscopy (eg, knee, shoulder, wrist, elbow) are considered. When large loose bodies are abundant, some authors have favored open excision, citing technical difficulty with the arthroscopic approach. Patients must be deemed appropriate candidates for surgery from a medical perspective. Finally, regional or general anesthesia may be used depending on the patient's health and on the preference of the treating surgeon and the anesthesiologist.
More on Synovial Chondromatosis |
 Overview: Synovial Chondromatosis |
| Workup: Synovial Chondromatosis |
| Treatment: Synovial Chondromatosis |
| Follow-up: Synovial Chondromatosis |
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| References |
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References
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Keywords
synovial chondrometaplasia, articular chondromatosis, osteochondromatosis, chondrocalcinosis articularis, tenosynovial chondrometaplasia, joint chondromata, diffuse endochondromatosis
