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Arthroscopic treatment of synovial osteochondromatosis of the elbow. Case report and literature review
ARTICLE IN PRESS
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Case report
1
Arthroscopic treatment of synovial osteochondromatosis of the elbow. Case report and literature review夽
2
3
4
6
Bernardo Barcellos Terra ∗ , Eduardo Wanzenboeck Moraes, Alceuleir Cardoso de Souza, José Maria Cavatte, João Carlos de Medeiros Teixeira, Anderson De Nadai
7
Hospital Santa Casa de Misericórdia de Vitória, Vitória, ES, Brazil
5
Q1
8
9
a r t i c l e
i n f o
a b s t r a c t
10 11
Article history:
Synovial osteochondromatosis is a benign proliferative disorder with metaplasia of the syn-
12
Received 14 August 2014
ovial membrane that affects the fibroblasts of the synovial joints, tendons and bursae. In
13
Accepted 1 September 2014
literature, there are few descriptions of synovial osteochondromatosis of the elbow. The
14
Available online xxx
objective of this article was to report a case of synovial osteochondromatosis of the elbow in a patient aged 32, basketball athlete, in which surgical treatment was chosen because of
15
the pain and functional limitation and stage of disease with multiple loose bodies. Patient
16
Keywords:
17
Synovial chondromatosis
32, male, presented with pain and limitation of motion of the elbow. The range of passive
18
Arthroscopy
motion was 100◦ of flexion and 30◦ extension. The range of active motion was 40–90◦ . Mag-
19
Elbow
netic resonance observed many loose bodies mainly in the posterior compartment in the
20Q2
Synovitis
olecranon fossa plus some chondral lesions in the capitellum. The arthroscopic treatment was chosen with two anteriors portals (medial and lateral) and two posterior portals (standard posterior and posterolateral) for easing loose bodies and osteoplasty of the olecranon fossa. The visual analog scale pain was 9–3 and its arc of active motion was 110◦ to −20◦ of flexion and extension. On a scale of performance from Mayo Clinic patients was 65 points preoperatively to 90 postoperatively with 9 months follow-up and the patient was satisfied with the treatment outcome. Arthroscopic treatment of synovial osteochondromatosis of the elbow is an effective and safe therapeutic management with low morbidity and early return to activities. © 2014 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda. All rights reserved.
夽 Work performed in the Department of Orthopedics and Traumatology, Hospital Santa Casa de Misericórdia de Vitória, Vitória, ES, Brazil. ∗ Corresponding author. E-mail: [email protected] (B.B. Terra). http://dx.doi.org/10.1016/j.rboe.2015.08.014 2255-4971/© 2014 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda. All rights reserved.
Please cite this article in press as: Terra BB, et al. Arthroscopic treatment of synovial osteochondromatosis of the elbow. Case report and literature RBOE 926 1–6 review. Rev Bras Ortop. 2015. http://dx.doi.org/10.1016/j.rboe.2015.08.014
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Tratamento artroscópico da osteocondromatose sinovial do cotovelo. Relato de caso e revisão da literatura r e s u m o
21 22 23
Palavras-chave:
A osteocondromatose sinovial é uma patologia proliferativa com metaplasia benigna da
24
Osteocondromatose sinovial
membrana sinovial que afeta os fibroblastos das articulac¸ões sinoviais, dos tendões e das
25
Artroscopia
bursas. Na literatura, existem poucas descric¸ões de osteocondromatose sinovial do cotovelo.
26
Cotovelo
O objetivo deste artigo foi relatar um caso de osteocondromatose sinovial de cotovelo em
27
Sinovite
um paciente de 32 anos, sexo masculino, atleta de basquete, no qual se optou pelo tratamento cirúrgico devido ao quadro clínico com dor e limitac¸ão funcional e ao estágio da
28 29
doenc¸a com múltiplos corpos livres. Paciente apresentou dor e limitac¸ão do arco de movi-
30
mento do cotovelo. O arco de movimento passivo era de 100◦ de flexão e −30◦ de extensão.
31
Na ressonância magnética observaram-se diversos corpos livres, principalmente no com-
32
partimento posterior na fossa do olecrano, além de algumas lesões condrais no capítulo.
33
Optou-se pelo tratamento artroscópico com a feitura de dois portais anteriores (medial e
34
lateral) e dois posteriores (posterior padrão e posterolateral) para remoc¸ão dos corpos livres
35
e osteoplastia da fossa olecraniana. A escala visual analógica da dor foi de 9 para 3 e seu arco
36
de movimento ativo foi para 110◦ de flexão e −20◦ de extensão. Na escala de desempenho
37
da Clínica Mayo o paciente foi de 65 pontos no pré-operatório para 90 no pós-operatório
38
com nove meses de seguimento e satisfeito com o resultado. O tratamento artroscópico
39
da osteocondromatose sinovial do cotovelo mostra-se com uma opc¸ão terapêutica eficaz e
40
segura no manejo terapêutico dessa patologia, apresenta baixa morbidade e retorno precoce
41 42
às atividades. © 2014 Sociedade Brasileira de Ortopedia e Traumatologia. Publicado por Elsevier
43
Editora Ltda. Todos os direitos reservados.
44
Introduction Synovial osteochondromatosis is a proliferative pathological 46 condition with benign metaplasia of the synovial membrane 47 that affects the fibroblasts of the synovial joints, tendons and 48 Q3 bursas. The first description in the literature of this patholog49 ical condition was in relation to the knee joint, by Ambrose 50 Paré in 1558, cited by Ho and Choueka.1 51 Osteochondromatosis can affect any joint, but the great 52 majority of the cases involve the knee. In the upper limbs, 53 the joint most affected is the elbow, but the shoulder, wrist, 54 acromioclavicular and even the interphalangeal joints may be 55 involved.2,3 The first case in the elbow was reported by Hender56 son in 1918, cited by Mussey and Henderson.4 In the literature, 57 there are few descriptions of synovial osteochondromatosis of 58 the elbow, mainly concerning surgical results.5 59 Synovial osteochondromatosis can be classified as pri60 mary when the cartilaginous tissue originates directly from 61 the metaplasia of the synovial tissue or the bursa; or as 62 secondary synovial osteochondromatosis when free bodies 63 originate directly from the hyaline cartilage and are deposited 64 in the joint space or in the tendon sheath, due to degenerative 65 diseases, trauma or neuropathic arthropathy.6 66 Synovial osteochondromatosis can be subdivided into 67 intra-articular synovial and tenosynovial (extra-articular) 68 types. Intra-articular osteochondromatosis is more common 69 and is usually monoarticular. Tenosynovial osteochondro70 matosis is extra-articular and more commonly involves the 71 flexor tendons of the fingers, wrists and feet. Histologically, 72 they are the same entities, but it is important to differentiate 45
them, since there is a greater chance that extra-articular tenosynovial osteochondromatosis might reoccur.7,8 The objective of this paper was to report on a case of synovial osteochondromatosis of the elbow in a 32-year-old patient who was a basketball player, for whom surgical treatment was chosen because of his clinical condition of pain and functional limitation and the stage of the disease, with many free bodies.
73 74 75 76 77 78 79 80
Case report The patient was a 32-year-old man who came to the outpatient clinic 3 months before the surgery, presenting pain and limitation of elbow range of motion that had begun 8 months earlier. He said that he had not fallen; he had not had any systemic diseases or previous surgery; and he did not provide any other information of relevance to the case. On inspection, it was noted that one elbow presented slight edema, but without phlogistic signs. He complained of pain on palpation in the fossa of the olecranon and in the region of the insertion of the extensors and supinators of the forearm. The passive range of motion was from 40◦ to 100◦ of flexion. The active range of motion was from 50◦ to 90◦ , pronation was 90◦ and supination was 85◦ . Neurological and vascular examinations showed normal findings. Complementary imaging examinations and serum tests (regarding infection and rheumatology) were performed. Magnetic resonance imaging showed a variety of free bodies, especially in the posterior compartment of the fossa of the olecranon, along with some chondral lesions in the
Please cite this article in press as: Terra BB, et al. Arthroscopic treatment of synovial osteochondromatosis of the elbow. Case report and literature RBOE 926 1–6 review. Rev Bras Ortop. 2015. http://dx.doi.org/10.1016/j.rboe.2015.08.014
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Sc 9 TSE/M SI 12
F
Sc 9 TSE/M SI 11
F
P
F
P
2 cm
2 cm
RL 90 left
RL 93 left
R
Fig. 1 – T2-weighted sagittal magnetic resonance imaging showing many free bodies in the fossa of the olecranon.
100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123
capitellum (Figs. 1–3), and the radiologist’s diagnostic hypothesis was that this was intra-articular synovial osteochondromatosis. The results from the serum tests were negative for rheumatological diseases or infectious processes. Because of the severity of the case, it was decided to use arthroscopic treatment. Two anterior portals (medial and lateral) were opened (for partial synovectomy, anterior capsulotomy to gain extension and microperforations in the capitellum because of the osteochondral lesions) and two posterior portals (standard posterior and posterolateral) in order to remove the free bodies and perform osteoplasty on the fossa of the olecranon because of the local osteophytes (Figs. 4–7). At the time of the surgery, material for histopathological examination was collected (free body and fragment from the synovial membrane), which subsequently confirmed the diagnosis. The patient was immobilized by means of compressive bandaging. Passive movement was allowed during the immediate postoperative period and active movement according to the tolerance of pain. Physiotherapeutic rehabilitation was started on the tenth postoperative day. In the second week after the operation, the patient returned to the outpatient clinic practically without pain and presented an active range of movement of 20–100◦ (Figs. 8 and 9).
Sc 8 TSE/M SI 12
F
P 2 cm
RL 90 left
Eighteen months after the operation, the score on the visual analog scale had decreased from 9 to 1 and the patient’s active range of motion was now 10–130◦ . On the Mayo Clinic performance scale, the patient went from 65 points to 90 after the operation and he was extremely satisfied with the result from the treatment. The Mayo Clinic functional scale9 takes into consideration four criteria (pain, range of motion, stability and function) and ranges from 10 to 100 points. Resultant scores higher than 90 are excellent; 75 to 89 good; 60 to 74 fair; and lower than 60 poor.
124 125 126 127 128 129 130 131 132 133
Discussion Synovial osteochondromatosis of the joints is a rare condition for which the definition and diagnostic criteria are unclear. There is still little knowledge about this condition.10 Clinically, the signs and symptoms are nonspecific and may suggest several pathological conditions. In most cases, the symptoms comprise pain and/or loss of range of motion. Incapacity to perform complete extension is one of the first symptoms, followed in some cases by locking of the joint. Stiffness is not a marked characteristic. In our case, the patient had a painful
Sc 8 TSE/M SI 11
F
P 2 cm
RL 93 left
F
P 2 cm
RL 96 left
Fig. 2 – T1-weighted sagittal magnetic resonance imaging showing many free bodies in the fossa of the olecranon. Please cite this article in press as: Terra BB, et al. Arthroscopic treatment of synovial osteochondromatosis of the elbow. Case report and literature RBOE 926 1–6 review. Rev Bras Ortop. 2015. http://dx.doi.org/10.1016/j.rboe.2015.08.014
134 135 136 137 138 139 140 141 142
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r e v b r a s o r t o p . 2 0 1 5;x x x(x x):xxx–xxx
Sc 6 TSE/M SI 11
Sc 6 TSE/M SI 10
F
Sc 6 TSE/M SI 9
F
F
R
R
R
3 cm
3 cm
3 cm
AP 89 post
AP 85 post
AP 82 post
Fig. 3 – T2-weighted coronal magnetic resonance imaging showing many free bodies in the fossa of the olecranon and in the lateral compartment, along with a chondral lesion in the capitellum.
143 144 145 146 147 148 149 150 151 152
range of motion, without any signs and symptoms of compression of the ulnar nerve. Milgram and Pease11 described 30 cases of synovial osteochondromatosis and identified three distinct stages: disease with intrasynovial activity, but without the presence of free bodies; transitional lesions with synovial activity and free bodies; and multiple free bodies, but without synovial activity. Our patient was in stage 3, since he presented multiple intraarticular free bodies. From arthroscopy, we observed only slight foci of synovitis.
Both conservative treatment and surgery can be used as therapy for osteochondromatosis. Pain relief can be achieved through nonsurgical treatment. Surgical treatment is advocated in phases II and III by the great majority of authors. It should be performed in association with synovectomy, since there may be recurrence of the lesion after removal of the free body alone. However, some studies have questioned treatment involving synovectomy.12,13 In the case presented here, we chose to perform synovectomy of the anterior and posterior compartments.
Fig. 4 – Intraoperative arthroscopic image showing free bodies in the fossa of the olecranon.
Fig. 5 – Intraoperative arthroscopic image showing free bodies in the fossa of the olecranon and one of them being removed with the aid of grasping arthroscopic tweezers.
Please cite this article in press as: Terra BB, et al. Arthroscopic treatment of synovial osteochondromatosis of the elbow. Case report and literature RBOE 926 1–6 review. Rev Bras Ortop. 2015. http://dx.doi.org/10.1016/j.rboe.2015.08.014
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Fig. 6 – Free bodies removed.
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In the literature, recurrence of this disease has been reported in up to 22% of the cases.14 The cause is generally attributed to incomplete removal of free bodies or to the synovial disease. It is believed that recurrence implies that there is a greater chance of malignant transformation to chondrosarcoma, although this transformation of synovial osteochondromatosis is rare.15,16 The possibility of malignant transformation needs to be considered when periosteal reaction and cortical erosion are observed. On analyzing histological slides, the differential diagnoses to be considered are periosteal chondroma, giant-cell tumor, calcifying aponeurotic fibroma, tumoral calcinosis, hydroxyapatite deposition, free bodies and inflammatory arthritis. The results from histopathological analysis on the free body and on a fragment from the capsule showed alterations compatible with synovial osteochondromatosis with moderate disease activity. In the upper limbs, the location most affected by synovial osteochondromatosis is the elbow, followed in second place by the shoulder. Paim et al.16 reported the result from arthroscopic treatment of a case of synovial osteochondromatosis of the shoulder, in which 44 free bodies were removed. Over a 1-year follow-up, almost complete recovery of the range of motion, without pain, was shown. Lasmar et al.17 reported a case of synovial osteochondromatosis in a knee, in which over an 8-month follow-up, excellent recovery was obtained. These authors drew attention to the differential diagnosis with pigmented villonodular synovitis and noted that in standard radiographic examinations, the diagnosis might go unnoticed,
5
Fig. 7 – Arthroscopic portals constructed (proximal anteromedial, proximal anterolateral, standard posterior and posterolateral).
given that the free bodies might not be calcified. Polesello et al.18 reported the result from arthroscopic treatment of six cases of hip osteochondromatosis, from which good results were shown, with improvement on the Harris scale as modified by Byrd, from 54 points before the operation to 90 points after the operation.
Fig. 8 – Two weeks after the operation, with −20◦ of active extension.
Please cite this article in press as: Terra BB, et al. Arthroscopic treatment of synovial osteochondromatosis of the elbow. Case report and literature RBOE 926 1–6 review. Rev Bras Ortop. 2015. http://dx.doi.org/10.1016/j.rboe.2015.08.014
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Fig. 9 – Two weeks after the operation, with 100◦ of active flexion.
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The case reported in the present study has been followed up for 16 months and so far the patient remains free from pain and without any signs of recurrence.
Conclusion 200 201 202 203
Arthroscopic treatment of synovial osteochondromatosis of the shoulder was shown to be an effective and safe means of therapeutic management for this pathological condition, with low morbidity and an early return to activities.
Conflicts of interest 204
The authors declare no conflicts of interest.
205
references 206
207 208 209 210
1. Ho YY, Choueka J. Synovial chondromatosis of the upper extremity. J Hand Surg. 2013;38(4):804–10. 2. Bui-Mansfield LT, Rohini D, Bagg M. Tenosynovial chondromatosis of the ring finger. AJR Am J Roentgenol. 2005;184(4):1223–4.
3. Gallia GL, Weiss N, Campbell JN, McCarthy EF, Tufaro AP, Gokaslan ZL. Vertebral synovial chondromatosis. Report of two cases and review of the literature. J Neurosurg Spine. 2004;1(2):211–8. 4. Mussey RD Jr, Henderson MS. Osteochondromatosis. J Bone Joint Surg Am. 1949;31(3):619–27. 5. Matsumoto K, Hukuda S, Fujita M, Kakimoto A, Tachibana S. Cubital bursitis caused by localized synovial chondromatosis of the elbow. A case report. J Bone Joint Surg Am. 1996;78(2):275–7. 6. Ozcelik IB, Kuvat SV, Mersa B, Pilanci O. Synovial chondromatosis of the metacarpophalangeal joint of the ring finger. Acta Orthop Traumatol Turc. 2010;44(4):337–9. 7. Milgram JW, Addison RG. Synovial osteochondromatosis of the knee. Chondromatous recurrence with possible chondrosarcomatous degeneration. J Bone Joint Surg Am. 1976;58(2):264–6. 8. Milgram JW. Synovial osteochondromatosis: a histopathological study of thirty cases. J Bone Joint Surg Am. 1977;59(6):792–801. 9. Morrey BF, An KN, Chao EY. Functional evaluation of the elbow. In: Morrey BF, editor. The elbow and its disorders. 2nd ed. Philadelphia: WB Saunders; 1993. p. 95. 10. Kamineni S, O’Driscoll SW, Morrey BF. Synovial osteochondromatosis of the elbow. J Bone Joint Surg Br. 2002;84(7):961–6. 11. Milgram JW, Pease CN. Synovial osteochondromatosis in a young child. A case report. J Bone Joint Surg Am. 1980;62(6):1021–3. 12. Shpitzer T, Ganel A, Engelberg S. Surgery for synovial chondromatosis. 26 cases followed up for 6 years. Acta Orthop Scand. 1990;61(6):567–9. 13. Ranalletta M, Bongiovanni S, Calvo JM, Gallucci G, Maignon G. Arthroscopic treatment of synovial chondromatosis of the shoulder: report of three patients. J Shoulder Elbow Surg. 2009;18(3):e4–8. 14. Maurice H, Crone M, Watt I. Synovial chondromatosis. J Bone Joint Surg Br. 1988;70(5):807–11. 15. Davis RI, Hamilton A, Biggart JD. Primary synovial chondromatosis: a clinicopathologic review and assessment of malignant potential. Hum Pathol. 1998;29(7):683–8. 16. Paim AE, Ferreira DC, Paim A, Almeida RM. Tratamento artroscópico da osteocondromatose sinovial do ombro: relato de caso. Rev Bras Ortop. 2008;43(4):146–9. 17. Lasmar NP, Vieira RB, Rosa JO, Lasmar RCP, Scarpa AC. Osteocondromatose sinovial. Rev Bras Ortop. 2010;45(5):490–2. 18. Polesello GC, Ono NK, Honda EK, Guimarães RP, Ricioli Junior W, Schroeder e Souza BG, et al. Tratamento artroscópico da osteocondromatose sinovial do quadril. Rev Bras Ortop. 2009;44(4):1.
Please cite this article in press as: Terra BB, et al. Arthroscopic treatment of synovial osteochondromatosis of the elbow. Case report and literature RBOE 926 1–6 review. Rev Bras Ortop. 2015. http://dx.doi.org/10.1016/j.rboe.2015.08.014
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RBOE 926 1–6
r e v b r a s o r t o p . 2 0 1 5;x x x(x x):xxx–xxx
www.rbo.org.br
Case report
1
Arthroscopic treatment of synovial osteochondromatosis of the elbow. Case report and literature review夽
2
3
4
6
Bernardo Barcellos Terra ∗ , Eduardo Wanzenboeck Moraes, Alceuleir Cardoso de Souza, José Maria Cavatte, João Carlos de Medeiros Teixeira, Anderson De Nadai
7
Hospital Santa Casa de Misericórdia de Vitória, Vitória, ES, Brazil
5
Q1
8
9
a r t i c l e
i n f o
a b s t r a c t
10 11
Article history:
Synovial osteochondromatosis is a benign proliferative disorder with metaplasia of the syn-
12
Received 14 August 2014
ovial membrane that affects the fibroblasts of the synovial joints, tendons and bursae. In
13
Accepted 1 September 2014
literature, there are few descriptions of synovial osteochondromatosis of the elbow. The
14
Available online xxx
objective of this article was to report a case of synovial osteochondromatosis of the elbow in a patient aged 32, basketball athlete, in which surgical treatment was chosen because of
15
the pain and functional limitation and stage of disease with multiple loose bodies. Patient
16
Keywords:
17
Synovial chondromatosis
32, male, presented with pain and limitation of motion of the elbow. The range of passive
18
Arthroscopy
motion was 100◦ of flexion and 30◦ extension. The range of active motion was 40–90◦ . Mag-
19
Elbow
netic resonance observed many loose bodies mainly in the posterior compartment in the
20Q2
Synovitis
olecranon fossa plus some chondral lesions in the capitellum. The arthroscopic treatment was chosen with two anteriors portals (medial and lateral) and two posterior portals (standard posterior and posterolateral) for easing loose bodies and osteoplasty of the olecranon fossa. The visual analog scale pain was 9–3 and its arc of active motion was 110◦ to −20◦ of flexion and extension. On a scale of performance from Mayo Clinic patients was 65 points preoperatively to 90 postoperatively with 9 months follow-up and the patient was satisfied with the treatment outcome. Arthroscopic treatment of synovial osteochondromatosis of the elbow is an effective and safe therapeutic management with low morbidity and early return to activities. © 2014 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda. All rights reserved.
夽 Work performed in the Department of Orthopedics and Traumatology, Hospital Santa Casa de Misericórdia de Vitória, Vitória, ES, Brazil. ∗ Corresponding author. E-mail: [email protected] (B.B. Terra). http://dx.doi.org/10.1016/j.rboe.2015.08.014 2255-4971/© 2014 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda. All rights reserved.
Please cite this article in press as: Terra BB, et al. Arthroscopic treatment of synovial osteochondromatosis of the elbow. Case report and literature RBOE 926 1–6 review. Rev Bras Ortop. 2015. http://dx.doi.org/10.1016/j.rboe.2015.08.014
RBOE 926 1–6
2
ARTICLE IN PRESS r e v b r a s o r t o p . 2 0 1 5;x x x(x x):xxx–xxx
Tratamento artroscópico da osteocondromatose sinovial do cotovelo. Relato de caso e revisão da literatura r e s u m o
21 22 23
Palavras-chave:
A osteocondromatose sinovial é uma patologia proliferativa com metaplasia benigna da
24
Osteocondromatose sinovial
membrana sinovial que afeta os fibroblastos das articulac¸ões sinoviais, dos tendões e das
25
Artroscopia
bursas. Na literatura, existem poucas descric¸ões de osteocondromatose sinovial do cotovelo.
26
Cotovelo
O objetivo deste artigo foi relatar um caso de osteocondromatose sinovial de cotovelo em
27
Sinovite
um paciente de 32 anos, sexo masculino, atleta de basquete, no qual se optou pelo tratamento cirúrgico devido ao quadro clínico com dor e limitac¸ão funcional e ao estágio da
28 29
doenc¸a com múltiplos corpos livres. Paciente apresentou dor e limitac¸ão do arco de movi-
30
mento do cotovelo. O arco de movimento passivo era de 100◦ de flexão e −30◦ de extensão.
31
Na ressonância magnética observaram-se diversos corpos livres, principalmente no com-
32
partimento posterior na fossa do olecrano, além de algumas lesões condrais no capítulo.
33
Optou-se pelo tratamento artroscópico com a feitura de dois portais anteriores (medial e
34
lateral) e dois posteriores (posterior padrão e posterolateral) para remoc¸ão dos corpos livres
35
e osteoplastia da fossa olecraniana. A escala visual analógica da dor foi de 9 para 3 e seu arco
36
de movimento ativo foi para 110◦ de flexão e −20◦ de extensão. Na escala de desempenho
37
da Clínica Mayo o paciente foi de 65 pontos no pré-operatório para 90 no pós-operatório
38
com nove meses de seguimento e satisfeito com o resultado. O tratamento artroscópico
39
da osteocondromatose sinovial do cotovelo mostra-se com uma opc¸ão terapêutica eficaz e
40
segura no manejo terapêutico dessa patologia, apresenta baixa morbidade e retorno precoce
41 42
às atividades. © 2014 Sociedade Brasileira de Ortopedia e Traumatologia. Publicado por Elsevier
43
Editora Ltda. Todos os direitos reservados.
44
Introduction Synovial osteochondromatosis is a proliferative pathological 46 condition with benign metaplasia of the synovial membrane 47 that affects the fibroblasts of the synovial joints, tendons and 48 Q3 bursas. The first description in the literature of this patholog49 ical condition was in relation to the knee joint, by Ambrose 50 Paré in 1558, cited by Ho and Choueka.1 51 Osteochondromatosis can affect any joint, but the great 52 majority of the cases involve the knee. In the upper limbs, 53 the joint most affected is the elbow, but the shoulder, wrist, 54 acromioclavicular and even the interphalangeal joints may be 55 involved.2,3 The first case in the elbow was reported by Hender56 son in 1918, cited by Mussey and Henderson.4 In the literature, 57 there are few descriptions of synovial osteochondromatosis of 58 the elbow, mainly concerning surgical results.5 59 Synovial osteochondromatosis can be classified as pri60 mary when the cartilaginous tissue originates directly from 61 the metaplasia of the synovial tissue or the bursa; or as 62 secondary synovial osteochondromatosis when free bodies 63 originate directly from the hyaline cartilage and are deposited 64 in the joint space or in the tendon sheath, due to degenerative 65 diseases, trauma or neuropathic arthropathy.6 66 Synovial osteochondromatosis can be subdivided into 67 intra-articular synovial and tenosynovial (extra-articular) 68 types. Intra-articular osteochondromatosis is more common 69 and is usually monoarticular. Tenosynovial osteochondro70 matosis is extra-articular and more commonly involves the 71 flexor tendons of the fingers, wrists and feet. Histologically, 72 they are the same entities, but it is important to differentiate 45
them, since there is a greater chance that extra-articular tenosynovial osteochondromatosis might reoccur.7,8 The objective of this paper was to report on a case of synovial osteochondromatosis of the elbow in a 32-year-old patient who was a basketball player, for whom surgical treatment was chosen because of his clinical condition of pain and functional limitation and the stage of the disease, with many free bodies.
73 74 75 76 77 78 79 80
Case report The patient was a 32-year-old man who came to the outpatient clinic 3 months before the surgery, presenting pain and limitation of elbow range of motion that had begun 8 months earlier. He said that he had not fallen; he had not had any systemic diseases or previous surgery; and he did not provide any other information of relevance to the case. On inspection, it was noted that one elbow presented slight edema, but without phlogistic signs. He complained of pain on palpation in the fossa of the olecranon and in the region of the insertion of the extensors and supinators of the forearm. The passive range of motion was from 40◦ to 100◦ of flexion. The active range of motion was from 50◦ to 90◦ , pronation was 90◦ and supination was 85◦ . Neurological and vascular examinations showed normal findings. Complementary imaging examinations and serum tests (regarding infection and rheumatology) were performed. Magnetic resonance imaging showed a variety of free bodies, especially in the posterior compartment of the fossa of the olecranon, along with some chondral lesions in the
Please cite this article in press as: Terra BB, et al. Arthroscopic treatment of synovial osteochondromatosis of the elbow. Case report and literature RBOE 926 1–6 review. Rev Bras Ortop. 2015. http://dx.doi.org/10.1016/j.rboe.2015.08.014
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Fig. 1 – T2-weighted sagittal magnetic resonance imaging showing many free bodies in the fossa of the olecranon.
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capitellum (Figs. 1–3), and the radiologist’s diagnostic hypothesis was that this was intra-articular synovial osteochondromatosis. The results from the serum tests were negative for rheumatological diseases or infectious processes. Because of the severity of the case, it was decided to use arthroscopic treatment. Two anterior portals (medial and lateral) were opened (for partial synovectomy, anterior capsulotomy to gain extension and microperforations in the capitellum because of the osteochondral lesions) and two posterior portals (standard posterior and posterolateral) in order to remove the free bodies and perform osteoplasty on the fossa of the olecranon because of the local osteophytes (Figs. 4–7). At the time of the surgery, material for histopathological examination was collected (free body and fragment from the synovial membrane), which subsequently confirmed the diagnosis. The patient was immobilized by means of compressive bandaging. Passive movement was allowed during the immediate postoperative period and active movement according to the tolerance of pain. Physiotherapeutic rehabilitation was started on the tenth postoperative day. In the second week after the operation, the patient returned to the outpatient clinic practically without pain and presented an active range of movement of 20–100◦ (Figs. 8 and 9).
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Eighteen months after the operation, the score on the visual analog scale had decreased from 9 to 1 and the patient’s active range of motion was now 10–130◦ . On the Mayo Clinic performance scale, the patient went from 65 points to 90 after the operation and he was extremely satisfied with the result from the treatment. The Mayo Clinic functional scale9 takes into consideration four criteria (pain, range of motion, stability and function) and ranges from 10 to 100 points. Resultant scores higher than 90 are excellent; 75 to 89 good; 60 to 74 fair; and lower than 60 poor.
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Discussion Synovial osteochondromatosis of the joints is a rare condition for which the definition and diagnostic criteria are unclear. There is still little knowledge about this condition.10 Clinically, the signs and symptoms are nonspecific and may suggest several pathological conditions. In most cases, the symptoms comprise pain and/or loss of range of motion. Incapacity to perform complete extension is one of the first symptoms, followed in some cases by locking of the joint. Stiffness is not a marked characteristic. In our case, the patient had a painful
Sc 8 TSE/M SI 11
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P 2 cm
RL 93 left
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P 2 cm
RL 96 left
Fig. 2 – T1-weighted sagittal magnetic resonance imaging showing many free bodies in the fossa of the olecranon. Please cite this article in press as: Terra BB, et al. Arthroscopic treatment of synovial osteochondromatosis of the elbow. Case report and literature RBOE 926 1–6 review. Rev Bras Ortop. 2015. http://dx.doi.org/10.1016/j.rboe.2015.08.014
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Fig. 3 – T2-weighted coronal magnetic resonance imaging showing many free bodies in the fossa of the olecranon and in the lateral compartment, along with a chondral lesion in the capitellum.
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range of motion, without any signs and symptoms of compression of the ulnar nerve. Milgram and Pease11 described 30 cases of synovial osteochondromatosis and identified three distinct stages: disease with intrasynovial activity, but without the presence of free bodies; transitional lesions with synovial activity and free bodies; and multiple free bodies, but without synovial activity. Our patient was in stage 3, since he presented multiple intraarticular free bodies. From arthroscopy, we observed only slight foci of synovitis.
Both conservative treatment and surgery can be used as therapy for osteochondromatosis. Pain relief can be achieved through nonsurgical treatment. Surgical treatment is advocated in phases II and III by the great majority of authors. It should be performed in association with synovectomy, since there may be recurrence of the lesion after removal of the free body alone. However, some studies have questioned treatment involving synovectomy.12,13 In the case presented here, we chose to perform synovectomy of the anterior and posterior compartments.
Fig. 4 – Intraoperative arthroscopic image showing free bodies in the fossa of the olecranon.
Fig. 5 – Intraoperative arthroscopic image showing free bodies in the fossa of the olecranon and one of them being removed with the aid of grasping arthroscopic tweezers.
Please cite this article in press as: Terra BB, et al. Arthroscopic treatment of synovial osteochondromatosis of the elbow. Case report and literature RBOE 926 1–6 review. Rev Bras Ortop. 2015. http://dx.doi.org/10.1016/j.rboe.2015.08.014
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Fig. 6 – Free bodies removed.
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In the literature, recurrence of this disease has been reported in up to 22% of the cases.14 The cause is generally attributed to incomplete removal of free bodies or to the synovial disease. It is believed that recurrence implies that there is a greater chance of malignant transformation to chondrosarcoma, although this transformation of synovial osteochondromatosis is rare.15,16 The possibility of malignant transformation needs to be considered when periosteal reaction and cortical erosion are observed. On analyzing histological slides, the differential diagnoses to be considered are periosteal chondroma, giant-cell tumor, calcifying aponeurotic fibroma, tumoral calcinosis, hydroxyapatite deposition, free bodies and inflammatory arthritis. The results from histopathological analysis on the free body and on a fragment from the capsule showed alterations compatible with synovial osteochondromatosis with moderate disease activity. In the upper limbs, the location most affected by synovial osteochondromatosis is the elbow, followed in second place by the shoulder. Paim et al.16 reported the result from arthroscopic treatment of a case of synovial osteochondromatosis of the shoulder, in which 44 free bodies were removed. Over a 1-year follow-up, almost complete recovery of the range of motion, without pain, was shown. Lasmar et al.17 reported a case of synovial osteochondromatosis in a knee, in which over an 8-month follow-up, excellent recovery was obtained. These authors drew attention to the differential diagnosis with pigmented villonodular synovitis and noted that in standard radiographic examinations, the diagnosis might go unnoticed,
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Fig. 7 – Arthroscopic portals constructed (proximal anteromedial, proximal anterolateral, standard posterior and posterolateral).
given that the free bodies might not be calcified. Polesello et al.18 reported the result from arthroscopic treatment of six cases of hip osteochondromatosis, from which good results were shown, with improvement on the Harris scale as modified by Byrd, from 54 points before the operation to 90 points after the operation.
Fig. 8 – Two weeks after the operation, with −20◦ of active extension.
Please cite this article in press as: Terra BB, et al. Arthroscopic treatment of synovial osteochondromatosis of the elbow. Case report and literature RBOE 926 1–6 review. Rev Bras Ortop. 2015. http://dx.doi.org/10.1016/j.rboe.2015.08.014
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Fig. 9 – Two weeks after the operation, with 100◦ of active flexion.
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The case reported in the present study has been followed up for 16 months and so far the patient remains free from pain and without any signs of recurrence.
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Arthroscopic treatment of synovial osteochondromatosis of the shoulder was shown to be an effective and safe means of therapeutic management for this pathological condition, with low morbidity and an early return to activities.
Conflicts of interest 204
The authors declare no conflicts of interest.
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references 206
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Please cite this article in press as: Terra BB, et al. Arthroscopic treatment of synovial osteochondromatosis of the elbow. Case report and literature RBOE 926 1–6 review. Rev Bras Ortop. 2015. http://dx.doi.org/10.1016/j.rboe.2015.08.014
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