Synovial Chondromatosis

Introduction

A proliferative disease of the synovium
- associated with cartilage metaplasia
- results in multiple intra-articular loose bodies
- ranges from synovial tissue to firm nodules of cartilage
Epidemiology
- demographics
  - usually affects young adults 30-50 years of age
  - 2:1 male to female ratio
- location
  - knee is most common location
Genetics
- occasional chromosome 6 abnormalities have been found

Presentation

Symptoms
- slow progression of symptoms
- pain and swelling
  - pain worse with activity
- mechanical symptoms including stiffness
- can occur in the bursa overlying an osteochondroma
Physical exam
- decreased range of motion
- can have warmth, erythema, or tenderness

Imaging

Radiographs
- recommended views
  - standard AP/lateral of affected joint
- findings
  - variable depending on stage of disease
  - may show stippled calcification
MRI
- initially cartilage nodules are only visible on MRI
- lobular appearance
- in later stage, signal drop out consistent with calcification

Studies

Histology
- discrete hyaline cartilage nodules in various stages of calcification and ossification
- chondrocytes
  - mild atypia
  - binucleate cells
  - occasional mitoses

Treatment

Nonoperative
- observation
  - indications
    - mild symptoms not affecting range of motion
Operative
- open or arthroscopic synovectomy and loose body resection
  - indications
    - severe symptoms affecting range of motion
  - outcomes
    - treatment is symptomatic but may help prevent degenerative joint changes

TAG

(OBQ07.57) What is the preferred treatment of painful synovial chondromatosis of the hip in a young adult as seen in the radiograph in Figure A? Topic

Review Topic

FIGURES: A

1. Conventional total hip arthroplasty
2. Total hip resurfacing with synovectomy
3. Arthroscopic removal of loose bodies
4. Femoral CAM lesion osteoplasty
5. 600cGy radiation once to affected hip joint

PREFERRED RESPONSE ▶

DISCUSSION: Synovial chondromatosis of the hip when symptomatic is treated by removal of the loose bodies with synovectomy, chondroplasty, and labral debridement as needed. Synovial chondromatosis is a painful synovial proliferative disorder that is associated with cartilage metaplasia that results in multiple intra-articular loose bodies. It most often occurs in young adults who present with pain, stiffness, and swelling. Radiographs usually show fine, stippled, intra-articular calcifications, as we see here, characteristic of partially calcified cartilage granules. In a young adult with preserved joint space an arthroplasty is not recommended.

A case series by Marchie et al of 29 patients with synovial chondromatosis treated by hip arthroscopy found benefit especially in cases with early grade cartilage changes.

Illustration A demonstrates arthroscopic evaluation and removal of loose bodies associated with synovial chondromatosis.

Illustrations: A

REFERENCES:

1. Dorfman HD, Czerniak B: Bone Tumors. St Louis, MO, Mosby, 1998, pp 1041–78

2. Marchie A, Panuncialman I, McCarthy JC. Efficacy of hip arthroscopy in the management of synovial chondromatosis. Am J Sports Med. 2011 Jul;39 Suppl:126S-31S. PMID:21709042 (Link to Abstract)

Question Authors:

Charles Jobin MD, Michael Hughes MD,

Please Rate Educational Value!

3.0

Average 3.0 of 10 Ratings

TAG

(OBQ04.197) A 47-year-old man presents with right groin pain. Hip radiograph, CT, arthroscopy, and histology slide are shown in Figures A through D. Which of the following statements is true regarding this condition? Topic

Review Topic

FIGURES: A

1. This is a benign metaplastic process which requires wide excision due to the risk of malignant transformation
2. This is a benign metaplastic process which requires symptomatic treatment
3. This is a benign neoplastic process which requires marginal excision
4. This is a benign neoplastic process which requires intralesional excision and adjuvant chemotherapy
5. This is a malignant neoplastic process which requires hip disarticulation and coverage

PREFERRED RESPONSE ▶

DISCUSSION: The history, images, and histology slide are all consistent with synovial chondromatosis, a benign metaplastic process which requires symptomatic treatment only. Metaplasia, in contrast to neoplasia, is a process where one cellular phenotype transforms into another cellular phenotype, each non-cancerous. Two examples are the synovial transformation to chondroid tissue in synovial chondromatosis and Barrett's esophagus where normal squamous epithelium is replaced with metaplastic columnar epithelium. While synovial chondromatosis has a low risk of malignant transformation, Barrett's metaplasia has a high risk of malignant transformation and therefore requires more aggressive treatment. Gilbert and Shpitzer each report on their case series of synovial chondromatosis treated with synovectomy and loose body removal showing good long term results.

REFERENCES:

1. Diseases of the synovial membrane, in McCarthy EF, Frassica FJ (eds): Pathology of Bone and Joint Disorders. Philadelphia PA. WB Saunders, 1998, pp 307-310

2. Gilbert SR, Lachiewicz PF. Primary synovial osteochondromatosis of the hip: report of two cases with long-term follow-up after synovectomy and a review of the literature. Am J Orthop (Belle Mead NJ). 1997 Aug;26(8):555-60. Review. PMID:9267556 (Link to Abstract)

3. Shpitzer T, Ganel A, Engelberg S. Surgery for synovial chondromatosis. 26 cases followed up for 6 years. Acta Orthop Scand. 1990 Dec;61(6):567-9. PMID:2281768 (Link to Abstract)

Question Authors:

Patrick O'Donnell MD/PhD,

Please Rate Educational Value!

4.0

Average 4.0 of 7 Ratings

Level of Evidence 4 (Case Series)

Marchie A, Panuncialman I, McCarthy JC. Efficacy of hip arthroscopy in the management of synovial chondromatosis. Am J Sports Med. 2011 Jul;39 Suppl:126S-31S. PMID:21709042 (Link to Abstract)
Gilbert SR, Lachiewicz PF. Primary synovial osteochondromatosis of the hip: report of two cases with long-term follow-up after synovectomy and a review of the literature. Am J Orthop (Belle Mead NJ). 1997 Aug;26(8):555-60. Review. PMID:9267556 (Link to Abstract)
Shpitzer T, Ganel A, Engelberg S. Surgery for synovial chondromatosis. 26 cases followed up for 6 years. Acta Orthop Scand. 1990 Dec;61(6):567-9. PMID:2281768 (Link to Abstract)

Textbooks

Review of Orthopaedics, 6th Edition, Mark D. Miller MD, Stephen R. Thompson MBBS MEd FRCSC, Jennifer Hart MPAS PA-C ATC, an imprint of Elsevier, Philadelphia, Copyright 2012
AAOS Comprehensive Orthopaedic Review, Jay R. Leiberman. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2009
Orthopaedic Knowledge Update 10, John M Flyn. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2011
Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009
Orthopaedic In-training Examination (OITE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Self-Assessment Examination (SAE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Dorfman HD, Czerniak B: Bone Tumors. St Louis, MO, Mosby, 1998, pp 1041–78
Diseases of the synovial membrane, in McCarthy EF, Frassica FJ (eds): Pathology of Bone and Joint Disorders. Philadelphia PA. WB Saunders, 1998, pp 307-310

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