Synovial Chondromatosis 

  • Author: Christopher C Annunziata, MD; Chief Editor: Harris Gellman, MD   more...
 
Updated: Jun 10, 2010
 

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.

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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 chondromatosisArthroscopic appearance of synovial chondromatosis loose bodies in the shoulder. Sagittal T2-weighted MRI through the knee in an adSagittal 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 chondrArthroscopic image of pedunculated synovial chondromatosis in the knee.
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Epidemiology

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.

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Etiology

Synovial chondromatosis occurs as either a primary or secondary form. Although the molecular basis is still unclear, high levels of BMP-2 and BMP-4 have been isolated from diseased synovium and free bodies.[5] These growth factors may be involved in the pathologic metaplasia observed in synovial chondromatosis.

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.

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Pathophysiology

Primary synovial chondromatosis appears to occur in 3 phases, as Milgram described in 1977.[6]

  • 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. Only 4 case reports have documented malignant degeneration of synovial chondromatosis.[7, 8, 9]

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, 10]

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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.

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Indications

Patients with recurrent painful effusions, mechanical symptoms, or both due to synovial chondromatosis refractory to conservative intervention are candidates for surgical intervention.

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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, 11] In current practice, most authors agree that arthroscopic removal of loose bodies for mechanical symptoms is the best surgical strategy.

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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.

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Contributor Information and Disclosures
Author

Christopher C Annunziata, MD  Orthopedic Surgeon, Commonwealth Orthopedics and Rehabilitation; Assistant Clinical Professor, Department of Orthopedic Surgery, Georgetown University Medical Center; Team Physician, Washington Redskins; Team Physician, DC United

Christopher C Annunziata, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, Arthroscopy Association of North America, Eastern Orthopaedic Association, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Coauthor(s)

John J Christoforetti II, MD  Orthopaedic Surgeon, TriState Orthopaedics and Sports Medicine, Inc., Clinical Instructor, Department of Orthopaedics, University of Pittsburgh School of Medicine

John J Christoforetti II, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and Arthroscopy Association of North America

Disclosure: Nothing to disclose.

Evan H Argintar, MD  Resident Physician, Department of Orthopaedic Surgery, Georgetown University Hospital

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Ian D Dickey, MD, FRCSC  Adjunct Professor, Department of Chemical and Biological Engineering, University of Maine; Consulting Staff, Adult Reconstruction, Orthopedic Oncology, Department of Orthopedics, Eastern Maine Medical Center

Ian D Dickey, MD, FRCSC is a member of the following medical societies: American Academy of Orthopaedic Surgeons, British Columbia Medical Association, Canadian Medical Association, and Royal College of Physicians and Surgeons of Canada

Disclosure: Stryker Orthopaedics Consulting fee Consulting; Cadence Honoraria Speaking and teaching

Dinesh Patel, MD, FACS  Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital

Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons

Disclosure: Nothing to disclose.

Chief Editor

Harris Gellman, MD  Consulting Surgeon, Broward Hand Center; Voluntary Clinical Professor of Orthopedic Surgery and Plastic Surgery, Departments of Orthopedic Surgery and Surgery, University of Miami, Leonard M Miller School of Medicine

Harris Gellman, MD is a member of the following medical societies: American Academy of Medical Acupuncture, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Society for Surgery of the Hand, and Arkansas Medical Society

Disclosure: Nothing to disclose.

References

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Arthroscopic appearance of synovial chondromatosis loose bodies in the shoulder.
Arthroscopic shaver during attempted removal of loose bodies.
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.
Sagittal T2-weighted MRI of patient with synovial chondromatosis. Note the hypertrophic synovium and normal anterior cruciate ligament.
Sagittal T1-weighted MRI of the knee in a patient with synovial chondromatosis.
Coronal T2-weighted MRI of a patient with synovial chondromatosis demonstrates punctate areas of low intensity within the synovial fluid.
Coronal T2-weighted MRI of the knee in a patient with synovial chondromatosis.
Typical plain radiograph of the knee in a patient with synovial chondromatosis. No abnormalities are noted.
Arthroscopic image of pedunculated synovial chondromatosis in the knee.
Arthroscopic image of pedunculated synovial chondromatosis in the knee.
 
 
 
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