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 Table of Contents  
CASE REPORT
Year : 2014  |  Volume : 5  |  Issue : 1  |  Page : 64-66

Synovial chondromatosis of the hip - Management with synovectomy and partial removal of loose bodies: Case study


Department of Orthopedics, Deccan College of Medical Sciences, Hyderabad, Andhra Pradesh, India

Date of Web Publication15-Mar-2014

Correspondence Address:
Chavva Shamsunder
Department of Orthopedics, Deccan College of Medical Sciences, Kanchanbagh PO, DMRL 'X' Road, Santosh Nagar, Hyderabad - 500 058, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0975-9727.128952

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  Abstract 

Primary synovial chondromatosis is an uncommon disorder, in which involvement of the hip joint is still rare. Clinical symptoms are usually non-specific, clinical diagnosis of synovial chondromatosis of the hip may be difficult and delayed, especially before the ossifying nodules become evident. Currently, the recommended management is surgical removal of the loose bodies and synovectomy without dislocating the hip joint. We report a case of synovial chondromatosis of the hip in a 70 year old male patient, managed with an open synovectomy and removal of the loose bodies. We opine this is an easy and safe method for management of this disorder.

Keywords: Hip joint, loose bodies, open synovectomy, synovial chondromatosis


How to cite this article:
Shamsunder C, Khalid SA, Sujit Kumar VR. Synovial chondromatosis of the hip - Management with synovectomy and partial removal of loose bodies: Case study. Muller J Med Sci Res 2014;5:64-6

How to cite this URL:
Shamsunder C, Khalid SA, Sujit Kumar VR. Synovial chondromatosis of the hip - Management with synovectomy and partial removal of loose bodies: Case study. Muller J Med Sci Res [serial online] 2014 [cited 2019 Oct 16];5:64-6. Available from: http://www.mjmsr.net/text.asp?2014/5/1/64/128952


  Introduction Top


Primary synovial chondromatosis (PSC) of the hip joint is a rare clinical entity [1] and diagnosis is often delayed to a more advanced stage of the disease, when symptoms such as pain, swelling and loss of joint movement occur. Recurrence and malignant transformation of PSC has rarely been reported. [2] If left untreated, this may lead to secondary osteoarthritis due to cartilage wear. Therefore, early diagnosis and treatment are mandatory to prevent further complications. Various surgical intervention including removal of only loose bodies and an open synovectomy with removal of the loose bodies have been reported. [1] We report a case of PSC of the hip treated by open synovectomy.


  Case Report Top


This was a case report a 70-year-male patient, a three wheeler (auto rickshaw) driver by occupation, presented with chief complaint of pain in the right hip and limping since 1.5 years. He slipped while walking, fell on the road, following which the presenting complaints developed, prior to which he was apparently normal. He received conservative treatment (traction) for 4 days and then discontinued the treatment; but continued bed rest for 6 months, then continued walking with vague pain and limp, which gradually increased in intensity. Patient was diabetic and on glimepiride.


  Work-up Top


There was shortening and adduction deformity of right leg. Right greater trochanter, patella and malleoli were comparatively at higher level compared to the normal limb. Wasting of right thigh muscles was obvious and there was antalgic gait. There was tenderness at greater trochanter and lateral joint line. Gross global restriction of movements was significant.

His hemoglobin was 13 g/dL, erythrocyte sedimentation rate-5 mm (1 st h) and 10 mm (2 nd h), fasting blood sugar-104 mg/dL, serum alkaline phosphatase 118 U/L, human immunodeficiency virus-negative, hepatitis B surface antigen negative. Histological findings were inconclusive.

There was lytic lesion around head and neck of right femur. Diagnosis of synovial chondromatosis (SC) was arrived at based on the X-ray [Figure 1] and confirmed by magnetic resonance imaging [Figure 2]. Microscopic examination of soft-tissues of affected joint revealed discrete nodules of lobulated cartilaginous tissue in the synovium, characterized by cellular crowding with cytologic atypia and was confirmed hispathologically post-operatively [Figure 3].
Figure 1: Pre-operative radiography of right hip joint showing features of synovial chondromatosis

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Figure 2: Pre-operative magnetic resonance imaging of hip joint

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Figure 3: Histopathological features of isolated soft tissue

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He was administered human insulin for diabetic management. Open synovectomy with partial removal of loose bodies was performed through postero-lateral approach, under general anesthesia. Post-operative X-ray showed partial removal of loose bodies [Figure 4].
Figure 4: Post-operative X-ray showing partial removal of loose bodies

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Post-operative rehabilitation-non-weight bearing exercises were advised after 4 weeks of bed rest. Complete weight bearing exercises were started later on. Significant improvement in the movements of right hip was noted post-operatively than prior to surgery. Post-operatively, 45° at hip was noted. Pre-operatively, external rotation was completely restricted and abduction only 20° was possible which increased to 30° of external rotation and abduction of 40° respectively.


  Discussion Top


Evaluating a patient with chronic hip and groin pain still remains a diagnostic and treatment challenge. Detecting the site of abnormality is critical to trace the origin of pain in this area. Hence, detailed examination of hip joint along with adjacent structures is suggested and also rare causes that can present as pain in this area such as intra-abdominal pathology, urinary tract and gynecologic abnormalities and rheumatologic disorders, should be ruled out. [3] PSC, a rare benign condition characterized by pain, restriction of joint movement and loose bodies should be considered while diagnosing particularly in previous history of trauma/injury.

Osteocartilaginous nodules that originate from the synovium are the characteristic features of SC. [4] It is generally a monoarticular process affecting primarily the large joints; however, any synovial surface (including the extra-articular bursa) can be affected and even there has been reports of multi joint involvement. [5],[6] Secondary arthritis is usually the outcome of late diagnosis and treatment of SC.

It is commonly seen in men [7] and during third to fifth decades of life with a peak incidence in the fifth decade. Common clinical presentation is chronic joint pain and swelling with loss or limitation of joint movement and/or locking; however, there are reports of even painless cases in the literature. [8] Primary SC is of unknown cause, [4] initially thought to be due to reactive process, but recent evidence suggest it may be neoplastic. [9] Currently, the relative risk of malignant transformation is determined to be 5%. [8]

Plain radiographs are diagnostic of SC as the characteristic features of multiple (usually >5) calcified or osseous bodies within the joint or bursa can be identified in X-ray. [4] Arthroscopic studies are required in conditions where there is no calcification of fragments and in intrasynovial fragments (as X-rays do not show these). Pressure erosions and cyst formation in adjacent bone are usually seen in lax capsules (example: Hip). As these features are also seen in poly villous nodular synovitis, a plain radiograph essentially distinguishes these two clinical conditions. [7] Computer tomography imaging, ultrasound, bone scintigraphy will be of additional diagnostic aid.

Our patient had a fairly classic presentation of SC. Despite this, we did a systematic work-up considering etiologies of chronic hip and groin pain and rheumatologic factors to arrive at this diagnosis. Confounding data such as the human leukocyte antigen (HLA)-B27-positive finding could have indicated that he had a spondyloarthropathy. Because there is no correlation between SC and HLA-B27 it was determined to be an incidental finding. Definitive diagnosis was confirmed by biopsy.

Without intervention, the disease can progress, the joint can deteriorate and secondary osteoarthritis can occur in SC, [7],[8] thus, emphasizing the need of early diagnosis and treatment. Surgical interventions either open or arthroscopic removal of loose bodies with or without synovectomy is the treatment of choice [3] and found to be beneficial. [10] Arthroscopic synovectomy is a safe, effective procedure and considered as standard care as it allows faster rehabilitation but associated with higher recurrence rate due to incomplete debridement. [3] Synovectomy has shown to reduce the recurrence rate, reported to be around 0-15% which can be attributed to incomplete removal of loose bodies and synovium at the time of initial surgery. [2],[8] Open synovectomy with removal of loose bodies is though reliable procedure offering lesser rate of recurrence, complications involving femoral head can occur. [8] Yu et al. [10] have compared both arthroscopic and open synovectomy in PSC and opine that former procedure can be opted in initial stages of the disease, whereas latter if joint involvement is greater. We opted this procedure for safety as the patient was aged. Patient was offered alternative surgical option total (total hip replacement), but could not afford financially. We did not see any post-operative complications.


  Acknowledgments Top


We acknowledge the patient who agreed to publish this data. We appreciate the support of Dr. M. S. Latha who helped us in the preparation, editing of this manuscript.

 
  References Top

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.  Back to cited text no. 1
    
2.Davis RI, Hamilton A, Biggart JD. Primary synovial chondromatosis: A clinicopathologic review and assessment of malignant potential. Hum Pathol 1998;29:683-8.  Back to cited text no. 2
    
3.Coles MJ, Tara HH Jr. Synovial chondromatosis: A case study and brief review. Am J Orthop (Belle Mead NJ) 1997;26:37-40.  Back to cited text no. 3
    
4.Mora R, Soldini A, Raschellà F, Paparella F, Belluati A, Basile G. Primitive synovial chondromatosis of the hip joint. Ital J Orthop Traumatol 1992;18:231-9.  Back to cited text no. 4
    
5.Pope TL Jr, Keats TE, de Lange EE, Fechner RE, Harvey JW. Idiopathic synovial chondromatosis in two unusual sites: Inferior radioulnar joint and ischial bursa. Skeletal Radiol 1987;16:205-8.  Back to cited text no. 5
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6.Sviland L, Malcolm AJ. Synovial chondromatosis presenting as painless soft tissue mass - A report of 19 cases. Histopathology 1995;27:275-9.  Back to cited text no. 6
    
7.Monu JU, Oka M. Synovial osteochondromatosis. eMedicine. 2004. p. 1-13.  Back to cited text no. 7
    
8.Gille J, Krueger S, Aberle J, Boehm S, Ince A, Loehr JF. Synovial chondromatosis of the hip: A case report and clinicopathologic study. Acta Orthop Belg 2004;70:182-8.  Back to cited text no. 8
    
9.Sciot R, Dal Cin P, Bellemans J, Samson I, Van den Berghe H, Van Damme B. Synovial chondromatosis: Clonal chromosome changes provide further evidence for a neoplastic disorder. Virchows Arch 1998;433:189-91.  Back to cited text no. 9
    
10.Yu YH, Chan YS, Lee MS, Shih HN. Open and arthroscopic surgical management of primary synovial chondromatosis of the hip. Chang Gung Med J 2011;34:101-8.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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Case Report
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