Synovial Chondromatosis Treatment & Management

Nonsteroidal anti-inflammatory drugs can be used along with transcutaneous therapies (eg, ultrasound, thermal therapies) for reduction of inflammation. Patients with primarily mechanical symptoms do not benefit significantly from nonoperative therapy. One case report demonstrated radiotherapy as a successful modality when used for synovial chondromatosis of the knee refractory to several previous surgical interventions^[13] .

Treatment includes arthroscopic examination and excision of loose bodies, with limited synovectomy of involved synovium only.

Patients who have a history and have physical, plain radiographic, and MRI findings that are consistent with a diagnosis of synovial chondromatosis requiring surgical intervention are referred for a preoperative medical evaluation and clearance for surgery.

Frank discussion of the risks of arthroscopic surgery should address rates of infection (< 1%), thromboembolic disease (1-3%), iatrogenic neurovascular injury ( < 1%), complications related to anesthesia, and recurrence of symptoms that require further surgery (0-20%).

Consent is obtained for surgical intervention on an elective basis.

Arthroscopic treatment of synovial chondromatosis of the knee

After general anesthesia is induced, the affected limb is correctly identified and examined with the patient under anesthesia. If multiple loose bodies are present, limited passive range of motion or crepitus may be present. Examination of ligamentous stability typically yields normal findings.

The procedure proceeds as follows:

1. Apply a nonsterile thigh tourniquet.
2. Surgically prepare the affected leg to the level of the tourniquet.
Standard arthroscopic portals are established in the medial suprapatellar and medial and lateral parapatellar locations.
• When access to the posterior compartment of the knee is required, a posteromedial portal should be established.
• The surgeon should be comfortable with establishing this portal, and he or she must be aware of the increased potential for damage to the saphenous nerve superficially and to the popliteal artery and tibial nerve posteriorly.
A 30° arthroscope is inserted through the lateral parapatellar portal, and diagnostic arthroscopy is performed. When the arthroscope is introduced, abundant round cartilaginous bodies are typically present, both free in the joint and embedded in the synovial lining.
• In primary synovial chondromatosis, the articular surfaces are typically normal.
• In secondary synovial chondromatosis, chondromalacia or osteochondral defects reflective of underlying disease may be present.
3. Arthroscopic graspers are used to remove all free loose bodies.
4. Large or pedunculated lesions embedded in the synovium are excised by using arthroscopic graspers and shavers. A large outflow cannula can be helpful for extracting loose cartilaginous pieces.
5. All specimens are sent to a pathologist for histologic evaluation.
6. Arthroscopic instruments are withdrawn, and portals are closed with monofilament nonabsorbable sutures.
7. A sterile dressing is applied, and the knee is placed in an immobilizer.
8. The patient is transferred to the recovery room for observation and recovery from anesthesia.

The patient is discharged from the surgical suite with narcotic pain medication, enteric-coated aspirin for deep venous thrombosis prophylaxis, and a nonsteroidal anti-inflammatory drug. Pathology results are carefully followed up. Immediate, full weight bearing is permitted in a knee immobilizer, with instructions to elevate and apply ice to the knee for the first 3-7 days.

The patient is seen for a follow-up visit 3-7 days after surgery for evaluation of surgical wounds. Sutures are removed and sterile bandages (eg, Steri-Strips) are applied.

Physical therapy for full active, active-assisted, and passive range of motion begins. When full range of motion is achieved (at a goal of 3 wk after surgery), the therapist is instructed to focus on quadriceps strengthening. Full return to activity can be anticipated by 6-8 weeks after surgery.

The most common complications include stiffness and recurrence of mechanical symptoms due to loose-body generation. In most series, rates of recurrent symptoms that required repeat arthroscopic surgery were < 20%. With aggressive postoperative rehabilitation, use of the arthroscopic approach typically helps prevent stiffness.

In current practice, most authors agree that arthroscopic removal of loose bodies for mechanical symptoms is the best surgical treatment. This strategy minimizes postoperative stiffness associated with open procedures and successfully accomplishes synovectomy and loose body removal. Now, longer follow-up has validated the success generated from early arthroscopic reports.

Dorfmann et al demonstrated that arthroscopic loose-body excision was successful in 25 (78%) of 32 knees.^[14] Most failures were simple recurrences requiring repeat arthroscopic surgery. Four of 24 patients with prolonged functional impairment had substantial tibiofemoral arthritis at the initial time of treatment. At 2-year follow-up, Samson et al treated 11 of 13 patients with arthroscopic treatment. Of this group, 6 good and 6 very good outcomes were achieved, with only 2 patients requiring arthroscopic reoperation.^[15]

Synovial chondromatosis may lead to articular damage and subsequent development of osteoarthritis. Ackerman et al retrospectively examined the outcome of joint arthroplasty applied in the setting of severe osteoarthritis in patients with synovial chondromatosis. With average follow-up of 10.8 years, all patients reported improvements in pain, range of motion (knees only), and functional scores. One of 7 hips and 1 of 4 knees demonstrated radiographic reoccurrence.^[16]

Evidence supporting arthroscopic treatment now is supported in other joints. Urbach et al evaluated arthroscopic treatment of synovial chondromatosis found in the shoulder. With follow-up between 4-9 years, 5 patients demonstrated very good clinical results. Of note, 2 patients were found to develop asymptomatic progression of disease.^[17] At mean follow-up of 5.3 years, Lunn et al retrospectively evaluated 15 individuals treated by shoulder arthroscopic synovectomy, loose body removal, and selective bicep tenodesis for primary and secondary synovial chondromatosis. Here, 9 patients demonstrated bicipital groove loose bodies, and, of this subgroup, 7 patients underwent open bicipital debridement and tenodesis. Disease reoccurrence occurred in only 2 patients at an average of 7.5 years.^[18]

Less arthroscopic success has been demonstrated in the ankle. In 2008, Galat et al reviewed 8 patients, average age of 37 years, who presented with ankle (6) or midfoot (2) synovial chondromatosis. In half of these patients, open synovectomy led to pain-free function without disease reoccurrence. Unfortunately, 3 patients ultimately underwent below-knee amputation for reoccurrence (1) or low-grade malignant transformation.^[9] A single case report of successful arthroscopic treatment of synovial chondromatosis of the ankle joint has been reported.^[19]

Synovial chondromatosis of the hip is uncommon. In 2006, Schoeniger et al reviewed 8 patients with monoarticular synovial chondromatosis of the hip who had joint debridement and a modified total synovectomy performed through a surgical hip dislocation with a trochanteric flip osteotomy. With average follow-up of 6.5 years, 2 patients had symptomatic progression necessitating joint replacement. The remaining 6 patients demonstrated no disease reoccurrence, progression of osteoarthritis, and continued pain relief.^[20] In 2008, Boyer and Dorfmann reviewed 120 patients who underwent arthroscopic management for primary synovial chondromatosis of the hip. With average follow-up of 78.6 months, of 111 patients, 37.8% required further open surgery and 20.7% required additional arthroscopic surgery. Of this original population, 56.7% reported excellent or good outcome, but 19.8% eventually underwent hip joint replacement.^[21]

Given the results of these studies, arthroscopic management for synovial chondromatosis is appropriate for disease isolated to the knee and possibly the shoulder. For reasons that remain unclear, this success has yet to be evaluated and/or confirmed to ankle and hip pathology. Regardless, outcomes for patients with severe, symptomatic arthritis and secondary synovial chondromatosis seem to generate less predictable results.

Controversies surrounding the diagnosis and treatment of synovial chondromatosis are few. Fukuhara et al identified elevated levels of chondrocalcin in the synovial fluid of patients with synovial chondromatosis.^[22] They suggest that this finding may assist in diagnosing the disease, though the utility of this test does not justify its expense at this point. Open synovectomy and loose-body excision remain acceptable treatments. Sufficient evidence supports arthroscopic removal of loose bodies with limited synovectomy as first-line surgical therapy.