An atypical synovial chondromatosis of knee - A rare case report

M. Jyothiprasanth; CR Jithin; Akhil K. Thomas; P. Sarang; Anita Vincent

doi:10.1016/j.jorep.2023.100164

View/Download PDF

Buy Reprints

PDF

Translate this page into:

Case Report

2023

:2;

100164

doi:

10.1016/j.jorep.2023.100164

An atypical synovial chondromatosis of knee - A rare case report

M. Jyothiprasanth^a, CR Jithin^a,, Akhil K. Thomas^a, P. Sarang^a, Anita Vincent^b

a Department of Orthopedics, Baby Memorial Hospital, Kannur, Kerala, India

b St James Hospital Chalakudy, India

∗Corresponding author: CR Jithin. drjithincradhakrishnan@gmail.com

Received: 2022-12-22, Accepted: 2023-4-10, Published: 2023-4-17

The Author(s)

Disclaimer:
This article was originally published by Reed Elsevier India Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.

Abstract

Synovial chondromatosis is a rare pathology of the synovial sheath of large joints, which had its peak incidence between the third and fifth decade of life. It can arise from synovial sheaths or bursae around the joints. The literature has also documented their unusual presentations in smaller joints and their incidence in the young populations. It is a documentation of a rare pathology affecting synovial membrane: a metaplastic growth from the synovium forming a mass fixed to the adjacent cartilage, which necessitated open excision, synovectomy, and debridement for eradication.

A female patient in her fifth decade complains of left knee pain with effusion and movement restriction for four years. Diagnostic evaluation done in detail with imaging modalities and histopathologically. She underwent arthrotomy and synovectomy, and a large irregular cartilaginous mass was removed. Post Operative histopathological examination concluded the pathology as synovial chondromatosis.

The metaplastic growth arising from synovium forming a solid mass diagnosed as synovial chondromatosis with fixity to joint margins was an atypical feature. Early diagnosis and complete removal of involved synovium were suggested for reliable recovery.

Keywords

Synovial chondromatosis

Solid mass

Loose body

Show Related Articles from PubMed

1 Introduction

Synovial chondromatosis is an uncommon pathology mainly involving synovium of joints, also arising from tendon sheaths and joint bursae. Pathologically it is the synovial metaplasia where the synovial elements turn into cartilage, forming loose bodies inside the joint.¹^,² It is primarily known to affect large joints of the lower extremity, such as the knee, ankle, and hip and upper extremity joints such as the wrist and shoulder joint.³ Small joint involvement of the hand, foot, DRUJ of the wrist and tibiofibular joints were also documented^4–7 along with bursal involvement in literature.^8–10 Typically it is a pathology of the third and fifth decades; its childhood incidence was also documented.¹¹^,¹² This case of synovial chondromatosis was presented as a solid intraarticular mass originating from marginal synovium which was rarely reported in the literature.

2 Case report

A female patient presented in her fifth decade with chronic knee pain associated with swelling and left knee movement restriction (Fig. 1). Symptoms were insidious in onset, four years of duration, and progressive in nature. Recently there was no loss of weight, appetite, evening rise of temperature, or trauma to the affected joint and no relevant past medical or surgical history. Clinical examination revealed an attitude of 15–20° knee flexion and comparable quadriceps wasting with the contralateral limb. Diffused swelling of the knee with popliteal fossa fullness was noticed on inspection. There was no local rise of temperature while diffuse tenderness all around the knee, which was moreover medial side of the anterior joint line. Globular bony hard, slightly movable swelling around 12 × 14 × 4cm in axial transverse and anteroposterior planes respectively palpated over the upper and anterior aspect of the knee which was extending to both lateral and medial aspects beneath the patellar tendon. Her flexion deformity ranges between 15-90°. Instability tests including the varus-valgus stress test were negative and there were no neurovascular deficits. MRI evaluation showed fluid collection, synovial growth and a large calcific body anterior to the femoral condyle. (Fig. 2). Fine Needle aspiration cytology was performed and reported papillary hyperplasia of the synovium. An open surgical procedure was preferred considering clinical and MRI evaluation findings (Fig. 3) inside the knee joint. The knee joint was exposed by an anterior mid-line incision and deepened along the medial patellar retinaculum. A 14 × 10 × 4 cm growth was taken out located below the patellar tendon and lateral retinaculum. Irregular nodular outgrowths (Fig. 4) along the swelling margins were excised from anterior to posterior with extensive synovectomy of all compartments. Post-operative histopathological examination of the synovium and the loose bodies done twice at two different centers and established the diagnosis of synovial chondromatosis with papillary hyperplasia of the synovium (Fig. 5). The knee rehabilitation protocol was explained to the patient. Regular follow-ups were done at one, three and six months. She had a painless range of movement of 0–130° of flexion at three months. No clinical and radiological evidence were found suggestive of disease recurrence at the sixth-month follow-up after the surgical procedure.

Left knee in 15–20° flexion with comparable quadriceps wasting and generalized swelling of the knee.

T2 weighted MRI images showing effusion, synovial hypertrophy and a large calcific body in front of the femoral condyle.

Extensive involvement with a large loose body around knee.

Histo-pathological examination, conclusive of synovial chondromatosis with papillary hyperplasia of the synovium.

3 Discussion

Synovial chondromatosis is a metaplasia of native synovial tissue in which cartilaginous body formation within the synovium of affected joints. Characteristic features of three phased disease spectrum range between metaplasia, synovitis and loose body formation.² The most common presentation of this condition was swelling, pain and restriction of affected joint movements.⁹ Male preponderance of synovial chondromatosis is two times that in females.¹⁴ Unilateral involvement is most common and bilateral involvement has also been reported.⁷^,¹⁰^,¹⁵ MRI is the preferred investigation since it has a high soft tissue delineation profile.¹⁶ Reported knee joint involvement was mainly intraarticular, while extraarticular or a combination of both were also documented in literature.⁹^,¹⁸ The pathological extent of the metaplasia lies within the range of solely cruciate ligament involvement to destruction of the affected knee joint.^18–20 Cartilaginous nodules of synovial metaplasia were usually seen in and around the synovium, which occasionally forms loose bodies following joint movements.⁷^,⁹^,¹¹^,¹³^,^15–18 Contrary to it this patient had several small nodules with nearby cartilage fixity. Allard et al. commented about presence of aberrant tissues at the synovial cartilage junction in joints which were immunohistochemically comparable to the native synovial tissue.²¹ Available surgical options for these conditions were either open or arthroscopic procedures.³^,¹³ Total synovectomy is superior to isolated procedures like loose body removal.¹³ Total knee replacement is another alternative if present with osteoarthritis.⁹^,²² Complications of this condition include secondary osteoarthritis, malignant transformation and recurrence.¹³^,²²^,²³ Differential diagnosis of synovial chondromatosis has the possibilities such as Pigmented villonodular synovitis, synovial hemangioma, and lipoma arborescent.²⁴

4 Conclusion

Funding/sponsorship

This research did not receive any specific grant from the public, commercial or not-for-profit funding agencies.

Informed consent (patient/guardian)

Detailed written informed consent was obtained for the publication of data, images and treatment-related documents with out any objection.

Institutional ethical committee approval

Not applicable.

Authors contribution

All authors equally contributed in Conceptualization, Data curation, Format analysis, Investigation, Methodology, Writing – review & editing.

References

Jeffreys T.E., . Synovial chondromatosis. J Bone Joint Surg. 1967;3:530-534.
[Google Scholar]
Miligram J.W., . Synovialosteochondromatosis. J Bone JointSurg. 1977;59-A:792.
[Google Scholar]
Yu G.V., Zema R.L., Johnson R.W.S., . Synovial Osteochondromatosis. A case report and review of the literature. J Am Podiatr Med Assoc Journal. 2002;92:247-254.
[Google Scholar]
Von Schroeder H.P., Axelrod T.S., . Synovial osteochondromatosis of the distal radio-ulnar joint. J Hand Surg. 1996 Feb;21(1):30-32.
[Google Scholar]
Batheja N.O., Wang B.Y., Springfield D., et al . Fine-needle aspiration diagnosis of synovial chondromatosis of the tibiofibular joint. Ann Diagn Pathol. 2000 Apr;4(2):77-80.
[Google Scholar]
Bryan A.W., Dean-Yar T., Christina M.W., . Metacarpophalangeal joint synovial osteochondromatosis: a case report. Iowa Orthop J. 2008;28:91-93.
[Google Scholar]
Taglialavoro G., Moro S., Stecco C., Pennelli N., . Bilateral synovial chondromatosis of the first metatarsophalangeal joint: a case report. Reumatismo. 2003 Oct-Dec;55(4):263-266.
[Google Scholar]
Boya H., Pinar H., Ozcan O., . Synovial osteochondromatosis of the suprapatellar bursa with an imperforate suprapatellar plica. Arthroscopy. 2002 Apr;18(4):E17.
[Google Scholar]
Paraschau S., Anastasopoulos H., Flegas P., Karanikolas A., . Synovial chondromatosis: a case report of 9 patients. EEXOT. 2008;59(3):165-169.
[Google Scholar]
Kawasaki T., Imanaka T., Matsusue Y., . Synovial osteochondromatosis in bilateral subacromial bursae. Rheumatol. 2003;13:367-370.
[Google Scholar]
Carey R.P., . Synovial chondromatosis of the knee in childhood. A report of two cases. J Bone Joint Surg. 1983 Aug;65(4):444-447.
[Google Scholar]
Kistler W., . Synovial chondromatosis of the knee joint: a rarity during childhood. Eur J Pediatr Surg. 1991 Aug;1(4):237-239.
[Google Scholar]
Ogilvie-Harris D.J., Saleh K., . Generalized synovial chondromatosis of the knee: a comparison of removal of the loose bodies alone with arthroscopic synovectomy. Arthroscopy. 1994 Apr;10(2):166-170.
[Google Scholar]
Valmassy R., Ferguson H., . Synovial Osteochondromatosis: a brief review. J Am Podiatr Med Assoc. 1992;82:427-431.
[Google Scholar]
Heather S., Paula S., Andrew B., Tania P., . A case report of bilateral synovial chondromatosis of the ankle. Chiropr Osteopathy. 2007;15:18.
[Google Scholar]
Frick M.A., Wenger D.E., Adkins M., . MR imaging of synovial disorders of the knee: an update. Radiol ClinNorthAm. 2007 Nov;45(6):1017-1031.
[Google Scholar]
Amin M.U., Qureshi P.S., Ghaffar A., Shafique M., . Primary synovial osteochondromatosis of the surapatellar pouch of knee: correlation of imaging features with surgical findings. J. Radiol. Case Rep.. 2010 Aug;4(8):7-14.
[Google Scholar]
Mackenzie H., Gulati V., Tross S., . A rare case of a swollen knee due to disseminated synovial chondromatosis: a case report. J Med Case Rep. 2010;4:113.
[Google Scholar]
Majima T., Kamishima T., Susuda K., . Synovial chondromatosis originating from the synovium of the anterior cruciate ligament: a case report. Sports Med Arthrosc Rehabil Ther Technol. 2009;1:6.
[Google Scholar]
Pengatteeri Y.H., Park S.E., Lee H.K., Lee Y.S., Gopinathan P., Han C.W., . Synovial chondromatosis of the posterior cruciate ligament managed by a posterior-posterior triangulationtechnique. Knee Surg Sports Traumatol Arthrosc. 2007 Sep;15(9):1121-1124.
[Google Scholar]
Allard S.A., Bayliss M.T., Maini R.N., . The synovium-cartilage junction of the normal human knee. Implications for joint destruction and repair. Arthritis Rheum. 1990 Aug;33(8):1170-1179.
[Google Scholar]
Ackerman D., Lett P., Galat D.D., Parvizi J., Stuart M.J., . Results of total hip and total knee arthroplasties in patients with synovial chondromatosis. J Arthroplasty. 2008;23(3):395-400.
[Google Scholar]
Peter H., Neil A., Justin C., Ali F., William H., . Malignant transformation in synovial chondromatosis of the knee? The Knee. 2001 oct;8(3):239-242.
[Google Scholar]
Adelani M.A., Wupperman R.M., Holt G.E., . Benign synovial disorders. J Am Acad Orthop Surg. 2008 May;16(5):268-275.
[Google Scholar]