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| CASE REPORT |
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| Year : 2016 | Volume
: 36
| Issue : 3 | Page : 120-122 |
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Arthroscopic management of synovial chondromatosis of the hip
Kuan-Hsiang Hsieh, Ru-Yu Pan, Pei-Hung Shen, Zheng-Yi Huang
Department of Orthopaedic Surgery, Tri-Service General Hospital, Taipei, Taiwan, Republic of China
| Date of Submission | 24-Dec-2015 |
| Date of Decision | 28-Jan-2016 |
| Date of Acceptance | 02-May-2016 |
| Date of Web Publication | 1-Jul-2016 |
Correspondence Address:
Dr. Ru-Yu Pan
Department of Orthopaedic Surgery, Tri-Service General Hospital, 325 Cheng-Kung Road, Section 2, Taipei 114, Taiwan
Republic of China
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/1011-4564.185216
We present a female patient without any underlying disease. Progressive pain, and locking sensation of the right hip with limited range of motion were told and synovial chondromatosis (SC) of right hip was diagnosed. Radiographies revealed characteristic finding of SC including multiple calcified loose bodies within the right hip joint. Removal of cartilaginous fragments as well as nearly total synovectomy was performed arthroscopically on the right hip. Short-term postoperative follow-up of our patient revealed improved hip function and resolution of all symptoms. Keywords: Hip joint, synovial chondromatosis, surgery, arthroscopic
How to cite this article:
Hsieh KH, Pan RY, Shen PH, Huang ZY. Arthroscopic management of synovial chondromatosis of the hip. J Med Sci 2016;36:120-2 |
| Introduction | |  |
Synovial chondromatosis (SC) is a disease commonly affecting large joints including knee, hip, and shoulder. Although the condition has been described as a benign neoplasm of the synovium, its progressive dissemination into the articular structures will result in joint destruction. The etiology of SC is not clearly known yet; nevertheless, metaplasia of synovial lining tissue into chondrocytes has been explained as a probable cause.[1],[2] It usually affects a single joint in which the most common site is the knee and is twice as frequent in men as in women. It is commonly seen during the third to fifth decades of life presenting with aggravating joint pain, swelling, crepitus, and limited range of motion (ROM). Moreover, palpable swelling and effusion may be the only clinical finding.
| Case Report | | |
A 37-year-old female had experienced progressively worse pain around the right hip joint for 2 years. She consulted an orthopedic clinic and was treated with nonsteroidal anti-inflammatory drugs, but this did not relieve the pain.
Preoperative radiographs showed a lot of calcified loose bodies around right hip [Figure 1]. Magnetic resonance imaging showed proliferation of the synovium within the joint space without obvious invasion to the acetabulum [Figure 2]. Under the impression of SC, the patient underwent arthroscopic debridement and partial resection of hypertrophic synovium and removal of loose bodies in the right hip [Figure 3]. | Figure 1: (a and b) Preoperative radiographs showed a lot of calcified loose bodies around right hip
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 | Figure 2: (a and b) Magnetic resonance imaging showed proliferation of the synovium within the joint space without obvious invasion to the acetabulum
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 | Figure 3: (a and b) Multiple loose bodies and cartilage destruction were found under scope
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In the hip arthroscopic surgery, the patient was placed in the supine position on the fracture table under general anesthesia. Traction of the involved limb at 25° adduction was performed under fluoroscopic assistance. A blunt trocar was placed into the hip joint after a sequential dilatation of the tract. An arthroscope with a protecting sheath was inserted, and the hip joint was examined. All visible loose bodies were removed [Figure 4], the synovium was examined for the abnormal area, and these were excised arthroscopically. The appearances of the bodies and the synovium were recorded. All specimens obtained from the surgeries were examined by experienced pathologists [Figure 5]. | Figure 5: (a) Lobulated chondroid tissue (×40) (b) mature chondrocytes with bland nuclei and myxochondroid stroma (×200)
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Early active assistive ROM was started following the surgery. She gained a range of 0–100° on the right hip. Symptoms resolved significantly, and the patient was able to walk without any difficulty. She was kept follow-up at our hospital for 2 years [Figure 6].
| Discussion | | |
SC or osteochondromatosis (when ossification is present), also called Reichel's syndrome, was first described by Reichel in 1900.[3] The etiology of this disorder is still unclear. Many theories such as reactivation of residual embryonal cells, traumatic initiation, or benign neoplastic disease have been advocated.[4] The generally accepted pathogenesis of the submesothelial foci of cartilaginous bodies is that they are formed by metaplasia of pluripotential cells in the synovial membrane.[5] These nodules can ossify by endochondral bone formation and attach to the synovium by a thin vascular pedicle. They may break free and become loose bodies in the joint space.
Primary SC should be differentiated from cartilaginous loose bodies that are secondary to other joint diseases such as degenerative arthritis.[6] Loose bodies in secondary SC showed uniform chondrocytes and annular calcification surrounding the core tissue.
Three phases have been described for this disease.[7] In the first active phase, the disease is limited to the synovium without loose body formation; in the second transitional phase, there are both loose bodies and intrasynovial lesions; and in the third quiescent phase, there are only free loose bodies without the active intrasynovial process. The disease is most commonly seen in the third to fifth decades, and there is a predominance of men to women in a ratio of about 2:1.[4] The most common joint involved is the knee, but the elbow, hip, shoulder, ankle, temporomandibular joints, and other small joints have also been described. Extra-articular involvement (bursa or tendon sheath) is extremely rare.
With advances in arthroscopic surgeries, an arthroscopic operation of the hip joint with SC can be a reliable procedure. However, to most surgeons, hip arthroscopy may be a technically difficult procedure to perform because of the deep-seated location, relatively limited hip joint space, and few indications or infrequent opportunities to perform this procedure. To overcome these problems, we used traditional approaches to the hip joint and introduced the arthroscopic instruments through a small anterior capsulotomy incision without hip dislocation. This provides an easy and safe method for arthroscopic access to the hip joint. The procedure also decreases the complications of hip arthroscopy such as neurovascular trauma during traction or portal placement, and iatrogenic damage to the articular cartilage and acetabular labrum when introducing instruments.[8]
| Conclusion | | |
An arthroscopy-assisted synovectomy with removal of the loose bodies has the following advantages over a traditional hip arthrotomy surgery. It is performed without dislocation of the hip, which can prevent the complication of osteonecrosis of the femoral head. Under a magnification of the video system, a synovectomy can be done properly with arthroscopic instruments. In spite of the limited follow-up period of one case, we believe that this method may provide the benefits of both arthroscopic and open procedures and may minimize complications for proper management of this disorder.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | 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;26:555-60.  |
| 2. | Milgram JW. Synovial osteochondromatosis: A histopathological study of thirty cases. J Bone Joint Surg Am 1977;59:792-801. [ PUBMED] |
| 3. | Knoeller SM. Synovial osteochondromatosis of the hip joint. Etiology, diagnostic investigation and therapy. Acta Orthop Belg 2001;67:201-10. |
| 4. | Ginai AZ. Case report 607: Synovial (osteo) chondromatosis of left hip joint and ileopsoas bursa. Skeletal Radiol 1990;19:227-31. |
| 5. | Hardacker J, Mindell ER. Synovial chondromatosis with secondary subluxation of the hip. A case report. J Bone Joint Surg Am 1991;73:1405-7. |
| 6. | Saotome K, Tamai K, Koguchi Y, Sakai H, Yamaguchi T. Growth potential of loose bodies: An immunohistochemical examination of primary and secondary synovial osteochondromatosis. J Orthop Res 1999;17:73-9. |
| 7. | Milgram JW. Synovial osteochondromatosis in association with Legg-Calvé-Perthes disease. Clin Orthop Relat Res 1979;145:179-82. [ PUBMED] |
| 8. | Sekiya JK, Wojtys EM, Loder RT, Hensinger RN. Hip arthroscopy using a limited anterior exposure: An alternative approach for arthroscopic access. Arthroscopy 2000;16:16-20. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
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