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Recurrent synovial chondromatosis of the knee after radical synovectomy and arthrodesis


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We describe a case of highly refractory synovial chondromatosis, which recurred despite four arthroscopic synovectomies, a chemical synovectomy, two open synovectomies and an arthrodesis. A review of the literature revealed one similar case. Both presented with marked joint stiffness suggesting a poor prognosis. Although arthrodesis may relieve short-term symptoms it does not prevent further recurrence of disease.
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VOL. 88-B, No. 5, MAY 2006 673
Recurrent synovial chondromatosis of the
knee after radical synovectomy and
J. S. Church,
W. H. Breidahl,
G. C. Janes
From Perth
Orthopaedic and
Sports Medicine
Centre, Perth,
Western Australia
J. S. Church, BSc, FRCS(Tr &
Orth), Orthopaedic Fellow
17 Inman Road, London SW18
3BB, UK.
W. H. Breidahl, MRCP,
FRANZCR, Radiologist
Perth Radiology Clinic, 127
Hamersley Road, Subiaco 6008,
Western Australia, Australia.
G. C. Janes, FRACS(Orth),
Orthopaedic Surgeon
Perth Orthopaedic & Sports
Medicine Centre, 31 Outram
Street, West Perth 6005,
Western Australia, Australia.
Correspondence should be sent
to Mr J. S. Church; e-mail:
©2006 British Editorial Society
of Bone and Joint Surgery
17579 $2.00
J Bone Joint Surg [Br]
Received 22 December 2005;
Accepted 18 January 2006
We describe a case of highly refractory synovial chondromatosis, which recurred despite
four arthroscopic synovectomies, a chemical synovectomy, two open synovectomies and
an arthrodesis. A review of the literature revealed one similar case. Both presented with
marked joint stiffness suggesting a poor prognosis. Although arthrodesis may relieve
short-term symptoms it does not prevent further recurrence of disease.
Case report
In January 1996, a 24-year-old female teacher
and national-standard hockey player was seen
with a three-month history of progressive loss
of movement and locking of the right knee. On
examination, she had a diffusely swollen joint
with a fixed-flexion deformity of 45˚ and flex-
ion to 90˚. She underwent an arthroscopy at
her local hospital during which multiple chon-
dromata were removed. Histology of these
chondromata revealed variably sized nodules
of hyaline cartilage, some which which were
undergoing dystrophic calcification. Synovial
chondromatosis was diagnosed. Following
arthroscopy and two subsequent injections of
cortisone, the patient’s range of movement
improved and she was able to return to playing
hockey. However, within three months, her
symptoms returned with associated pain and
swelling. This persisted despite an attempted
chemical synovectomy with a course of yttrium
injections and two further arthroscopic debride-
ments. By November 1997, she had a fixed-
flexion deformity of 40˚ with flexion to only
50˚. An MRI scan revealed extensive synovial
fibrosis with a loose body, 4 cm x 4 cm, in the
posterior compartment of the knee (Fig. 1).
She was referred to the regional tertiary cen-
tre, where it was decided to perform an open
synovectomy and removal of loose bodies. His-
tology, following the procedure, confirmed the
diagnosis of recurrent synovial chondroma-
tosis. Following this, however, her pain and
reduced movement persisted and, in April
1998, she underwent a radical open synovec-
tomy. This included the removal of both the
menisci and cruciates, which improved her
pain with a range of movement from 10˚ to
Fig. 1
Sagittal proton density image through the
intercondylar region of the right knee. A
large, low-signal-intensity mass lies poste-
rior to the anterior cruciate ligament (arrow).
100˚ of flexion. Unfortunately, the improvement was brief.
Over the following year she underwent a further arthro-
scopic debridement, daily continuous passive movement
and correction of the fixed-flexion deformity with a circular
frame. Despite this, she continued to experience constant
pain in the knee and a limited range of movement from 0˚
to 10˚ of flexion. An MRI scan showed significant intra-
articular fibrosis but no evidence of recurrence (Fig. 2).
In April 2001, arthrodesis of the knee was successfully
undertaken using a circular frame. The pain resolved and
she was able to return to an active lifestyle, which included
participating in triathlons. In April 2005, however, she pre-
sented with a nine-month history of progressive night pain,
which had not responded to anti-inflammatory medication.
A further MRI scan revealed a solid fusion, but with multi-
ple foci of nodular synovial proliferation in the medial and
lateral gutters, intercondylar notch and along the popliteus
tendon, consistent with a diagnosis of recurrent synovial
chondromatosis (Fig. 3).
Synovial chondromatosis is a rare, benign condition charac-
terised by cartilaginous metaplasia of the intimal layer of
the synovial membrane of joints, tendons and bursae. Jaffe
described the condition in 1958,
and the knee is the most
commonly affected joint.
The early literature focused on
the primary management of this condition. Murphy et al
described 32 patients treated at the Mayo clinic with open
removal of loose bodies and affected synovium. There was
only one recurrence. Jeffreys
reviewed 17 cases treated sur-
gically, with no recurrences. His paper concluded that
removal of the loose bodies alone was preferable to syn-
ovectomy, because there was less post-operative stiffness
Fig. 2
Sagittal proton density image through the intercondylar region of the
right knee. There is extensive fibrosis in the intercondylar region and the
fat pad. Patella baja has developed.
Fig. 3a
Fig. 3b
MRI scans performed in April 2005, demonstrating, a) sagittal T2-
weighted fat-suppressed image after arthrodesis. The recurrent synovial
chondromatosis appears as an area of relatively high signal intensity pos-
teriorly (arrow) and, b) coronal T2-weighted fat-suppressed image dem-
onstrating no residual joint space.
VOL. 88-B, No. 5, MAY 2006
and complete synovectomy was ‘impracticable’. In 1989,
Coolican and Dandy
reported that arthroscopic removal
of loose bodies and the affected synovium achieved better
results than open procedures, and in the same year Dorf-
mann et al
concluded that arthroscopic removal of the
loose bodies alone gave satisfactory results. This was dis-
puted by Ogilvie-Harris and Saleh
in 1994, who found a
significant difference between the rates of recurrence after
arthroscopic removal of the loose bodies and arthroscopic
synovectomy. All recurrences were subsequently treated
successfully with an arthroscopic synovectomy.
One can, therefore, conclude that recurrence of synovial
chondromatosis is rare, particularly after synovectomy. The
majority of the reported recurrences have responded well to
a repeat procedure. We could only find one report of a
highly refractory synovial chondromatosis similar to our
case. This was the one failure reported by Coolican and
in which the patient presented with a range of
movement from 45˚ to 90˚ of flexion. After three arthro-
scopic synovectomies and removal of loose bodies, an
arthrotomy and an open synovectomy, the patient still com-
plained of severe pain and stiffness. A manipulation under
anaesthetic was performed which resulted in a fracture of
the femur. When this had united, the patient was left with
20˚ of movement in the knee and an arthrodesis was
offered. No further information was available as to the
eventual outcome of this patient.
The primary complaint in both our case and that of
Coolican and Dandy
was of significant stiffness, both hav-
ing a range of movement from 45˚ to 90˚ of flexion at pre-
sentation. Synovial chondromatosis most commonly pre-
sents with pain and swelling in the affected joint.
Stiffness was reported as a secondary symptom in only two
of eight patients of Jeffreys,
all of whom complained pri-
marily of pain and swelling, and loss of extension was
noted in five of 18 knees by Coolican and Dandy.
In their
case of recurrence and in ours, the stiffness was severe and
was the primary complaint, suggesting a poor prognosis.
The stiffness in our case could be caused by a thickened,
metaplastic synovium coupled with the presence of multiple
loose bodies within the knee.
Arthrodesis has previously been reported to be a success-
ful salvage procedure for recurrent synovial chondromato-
sis. Harvey and Negrine
carried out an arthrodesis of the
distal interphalangeal joint of the middle finger and reported
no recurrence after three years. Hocking and Negrine
sequently described the successful outcomes of two arthro-
deses performed for synovial chondromatosis of the
subtalar joint at five years. To the best of our knowledge,
ours is the first outcome report of arthrodesis for refractory
synovial chondromatosis of the knee and is the first re-
ported case of recurrence in any joint after arthrodesis. Al-
though the arthrodesis initially provided significant pain
relief and functional improvement, it did not prevent recur-
rence of the synovial chondromatosis.
No benefits in any form have been received or will be received from a commer-
cial party related directly or indirectly to the subject of this article.
1. Coolican MR, Dandy DJ.
Arthroscopic management of synovial chondromatosis of
the knee: findings and results in 18 cases.
J Bone Joint Surg [Br]
2. Murphy FP, Dahlin DC, Sullivan CR.
Articular synovial chondromatosis.
J Bone
Joint Surg [Am]
3. Jeffreys TE.
Synovial chondromatosis.
J Bone Joint Surg [Br]
4. Hocking R, Negrine J.
Primary synovial chondromatosis of the subtalar joint affect-
ing two brothers.
Foot Ankle Int
5. Dorfmann H, De Bie B, Bonvarlet JP, Boyer T.
Arthroscopic treatment of synovial
chondromatosis of the knee.
6. Ogilvie-Harris DJ, Saleh K.
Generalized synovial chondromatosis of the knee: a
comparison of removal of the loose bodies alone with arthroscopic synovectomy.
7. Harvey FJ, Negrine J.
Synovial chondromatosis in the distal interphalangeal joint.
J Hand Surg [Am]
... Complete excision of the lesion is the standard treatment for synovial chondromatosis, however arthrodesis seems to be the definitive treatment for recurrent synovial chondromatosis [14]. One case report showed a similar treatment strategy where after removal of all loose bodies, a subtalar arthrodesis was done. ...
... 14 Owing to difficulty in accessing the posterior compartment arthroscopically, open approaches have traditionally been used to excise loose bodies of the posterior compartment. 15,16 For arthroscopic treatment of posterior disease, the use of accessory posterior portals and a trans-septal technique has been described to provide adequate surgical access while protecting the popliteal neurovascular bundle. 6 Release of the posterior capsule and knee flexion greater than 90 are required to protect the vessels. ...
Full-text available
Synovial chondromatosis is a benign metaplastic disease of the synovial joints, characterized by the development of cartilaginous nodules in the synovium. Treatment generally includes open or arthroscopic loose body removal combined with a synovectomy. An all-arthroscopic approach has been described to minimize complications and reduce morbidity while providing adequate control of local disease. The purpose of this Technical Note is to describe our techniques and technical pearls that allow for adequate excision of disease while minimizing complications and disease recurrence. The combination of patient positioning, the establishment of multiple arthroscopic portals to ensure optimal visualization and freedom of instruments, the use of a leg holder, and the use of a variety of surgical instruments to facilitate loose body removal and synovectomy is critical to optimize clinical outcomes and minimize complications. Although technically demanding, our described technique can help facilitate extensive loose body removal and complete synovectomy.
... The definitive treatment for recurrences remains arthrodesis. Despite this, Church et al. have reported an isolated case where recurrence despite arthrodesis is still possible [16]. ...
Full-text available
Primary synovial chondromatosis, or Reichel's syndrome, is a rare benign tumour arising from the synovial lining of a joint. We present the case of a 25-year-old male with Reichel's syndrome of the ankle, with subsequent recurrence following open retrieval of loose bodies. The initial presentation was of lateral malleolus discomfort which limited moderately strenuous exercise. Clinical examination showed a mild effusion and pain on extremes of movement. Imaging confirmed the presence of multiple loose bodies within the anterior and anterolateral recesses of the ankle. Open removal of 27 loose bodies from the joint was performed, with good postoperative recovery. He represented with pain 9 months later, with imaging of the ankle showing reaccumulation of loose bodies to a lesser extent. A trial of conservative management was opted for. Reichel's syndrome confined to the ankle is an exceedingly rare diagnosis, with few cases reported in the literature. This case saw the recurrence of the disease in a short time period despite successful surgery in the first instance. Management options to treat recurrence include repeat retrieval of foreign bodies, synovectomy, radiotherapy, or arthrodesis. While the prognosis is favourable, a low risk of malignant potential warrants adequate patient follow-up.
... Surgical excision is the treatment of choice which includes excision of the nodule or an excision with extensive synovectomy although neither of these techniques has been shown to succeed in preventing recurrence. [18] ...
Full-text available
The infrapatellar fat pad (IFP) is an intracapsular structure with critical importance both mechanically and endocrinologically. Its dysfunction must be considered while clinically investigating the symptoms arising from the knee joint. Infrapatellar fat pad may be subject to trauma, impingement, inflammation or tumoral formations. Although tumors arising within or adjacent to IFP are not extremely rare, the literature can only provide limited information about them. This article aims to briefly review the current literature on tumors and tumor-like lesions of the IFP and surrounding tissues; focusing on diagnosis and treatment management.
... 11 No obstante, se han publicado reportes que informan recidivas luego de la sinovectomía artroscópica inicial, la sinovectomía química, la sinovectomía abierta e incluso posartrodesis de rodilla. 12 No hallamos comunicaciones sobre la recidiva tras la resección amplia en el tobillo o el pie. ...
Full-text available
La condromatosis sinovial es una lesión poco frecuente caracterizada por la metaplasia cartilaginosa de la membrana sinovial de pequeñas y grandes articulaciones. Se suelen observar múltiples nódulos cartilaginosos y un grado variable de destrucción articular. Las manifestaciones clínicas son variables y dependen de la localización y el estadio de la enfermedad. Nuestra paciente concurrió con una tumoración en la planta del pie a nivel de la raíz del segundo y tercer dedo, de meses de evolución. Luego de los estudios por imágenes correspondientes y evidenciar la extensión dorsal de la lesión, se decidió realizar la resección en bloque a través de doble abordaje; el análisis anatomopatológico informó condromatosis sinovial. La ausencia de extensión intrarticular fue constatada en la cirugía. Este caso representa una manifestación poco frecuente de la patología no solo por su localización, sino también por su ubicación extrarticular. Según nuestra búsqueda bibliográfica, no se han publicado reportes de casos con condromatosis sinovial extrarticular avanzada (grado 3) en el antepié y creemos que debería ser considerada dentro de las lesiones tumorales de aspecto cartilaginoso en esta localización.
... The localization of primary SC in the knee joint is mostly the anterior compartment (2,16). A limited number of patients with posterior compartment localization have also been reported (17)(18)(19). In our study, contrary to primary SC, patients with secondary SC showed mostly posterior compartment involvement regardless of the number of the loose bodies. ...
Full-text available
Aim: To investigate the relationship of cartilage loss in tibiofemoral and patellofemoral joints with the number, size and location of loose bodies in secondary synovial chondromatosis (SC). Methods: Eighty-eight patients with secondary SC were evaluated retrospectively. The size and location of loose bodies were evaluated by both X-ray and magnetic resonance imaging. The relationship between cartilage lesions and the number, location and size of loose bodies were assessed by Chi-square test and Fisher’s exact test. Results: When the relationship between the presence of loose body and cartilage damage was evaluated, it was observed that 83% of subjects (n=74) had cartilage loss at the tibiofemoral joint, 75% (n=66) on the medial and 9% (n=8) of patients had on the lateral side. It was determined that when the number of loose bodies was ≤5, the mean diameter was 7.3 mm (2-21 mm). It was 12.7 mm (2-30 mm) when the number was >5. The most frequently affected locations were the posterior compartment of the posterior cruciate ligament and the superior compartment of the popliteal fossa, regardless of the degree of cartilage loss. Conclusion: We concluded that the higher the cartilage damage, the higher the number and size of loose bodies. We assume that our study provides insight into further investigations to study new classification system for secondary SC in the knee joint.
Synovial chondromatosis of the finger is a rare metaplasia affecting either the finger joint or the tendon sheath. It is a benign extraosseus cartilage tumor that often occurs in numbers and is not solitary in nature. This accumulation of masses within the finger can lead the patient to seek medical care. Symptoms are often painful and functionally disabling. Although rare, synovial chondromatosis must be considered in the differential diagnosis for patients with multiple lesions or masses within the hand and finger. Patient workup involves advanced imaging, including magnetic resonance imaging, ultra-sonography, and computerized tomography. However, the results of these studies may be inconclusive. Conservative management can be discussed with the patient but has proven to be ineffective. Surgical excision is the recommended first-line treatment. Whether the surgery is arthroscopic or open, with or without synovectomy, is at the surgeon's discretion. Mass recurrence after surgery is an unfortunate complication, and subsequent treatment strategies are undefined. Recurrence may not occur at the same anatomical site. This condition can be intra-articular (within the figure joint) or extra-articular (within the tendon sheath or bursa). Revision surgery in the form of open excision with synovectomy is the mainstay of treatment. There have been only a few case reports of synovial chondromatosis involving the finger. This case series and up-to-date review of the literature presents a discussion of current surgical care. [Orthopedics. 2021;44(x):xx-xx.].
Synovial chondromatosis is a rare benign condition which develops in the synovial tissue of a joint, bursa or tenosynovial sheath. It is characterised by formation of cartilaginous nodules which may enlarge and grow into larger masses. Although radiological imaging contributes to a differential diagnosis, a final diagnosis can only be established with histological examination. Meticulous examination of the lesions is essential in ruling out sarcomatous change. We present a review of the literature and report two cases of synovial chondromatosis of the knee joints diagnosed over a ten-year period in the orthopaedic unit of a tertiary hospital serving mainly an urban- and peri-urban population sample.
The synovium of the knee is the most extensive and complex in the body. The most common primary synovial disorders are pigmented villonodular synovitis, synovial chondromatosis, synovial hemangioma, and lipoma arborescens. Magnetic resonance imaging provides excellent soft tissue contrast with multi-planar capabilities by noninvasive means to effectively evaluate the synovium. This case-based chapter reviews the diagnostic approach of the most common primary synovial disorders and presents arthroscopic treatment strategies in management of these challenging diseases.
Synovial chondromatosis is a rare disease in which multiple, metaplastic, cartilaginous masses form in the synovial membrane. These may calcify or ossify. The affection is monarticular and most commonly involves the knee. Although the clinical features are usually completely non-specific, the roentgenogram often provides important diagnostic information. Other entities that produce intraarticular and intrasynovial osteocartilaginous masses should not be included with synovial chondromatosis. In the present series of thirty-two cases, synovectomy proved to be a good form of treatment. Although cellular activity within foci in twenty-three of these thirty-two cases suggested the possibility of chondrosarcoma, the course was not clinically malignant in any of the cases.
A case of synovial chondromatosis of the distal interphalangeal joint of the long finger with an 8-year follow-up is presented. The lesion recurred 4 years after simple synovectomy, requiring a second operation with arthrodesis.
Between 1971 and 1987, arthroscopy was performed in 39 patients with synovial chondromatosis of the knee; 29 of these patients (32 knees) were followed an average of 3.5 years. A good result was obtained in 78% of the cases. Removal of loose bodies was the only treatment in 31 of the 32 knees. A synovectomy was performed in one case. No synovectomies were performed secondarily. Only three patients required a second arthroscopic procedure. The essential prognostic factor for a good functional result is the condition of the femorotibial cartilage. We concluded that simple arthroscopic removal of cartilaginous bodies without synovectomy is the treatment of choice for synovial chondromatosis of the knee.
We report the results of arthroscopic removal of loose bodies and abnormal synovium from 18 knees with primary synovial chondromatosis. After a mean of three years, six months (range one to 10 years), 14 knees were either symptom-free or had only minor symptoms. Three of these had required two arthroscopic operations. Three patients were improved but not cured and there was one failure. The results were better than the published results of open operation for this condition. Three patterns of macroscopic appearances were noted: four knees had large lesions covered by normal synovium, 10 had small fragments of cartilage lying in or on the synovium and four had only free fragments of cartilage in the joint cavity but none in, on, or under, the synovium. These three appearances may represent three different disease processes.
1. Nineteen patients with articular synovial chondromatosis are reviewed. 2. The etiology, diagnosis and management of the condition are discussed. 3. It is concluded that extensive synovectomy is not justified; simple removal of loose bodies is the treatment of choice.
Thirteen patients with generalized synovial chondromatosis of the knee were treated by either removal of the loose bodies alone (n = 5) or arthroscopic synovectomy (n = 8). The average follow-up was 38 months (range 23-61). There were three recurrences in the loose body removal group, which were subsequently treated by arthroscopic synovectomy. Statistical analysis of the results shows a significant improvement in pain, synovitis and effusion, range of movement, and function after either treatment. The group treated by arthroscopic synovectomy had significantly lower recurrence rates (p = 0.02). We recommend arthroscopic synovectomy for patients with generalized synovial chondromatosis. However, if loose bodies alone are removed, a recurrence can be successfully treated by an arthroscopic synovectomy.
Primary synovial chondromatosis is a rare benign condition characterized by the formation of multiple cartilaginous nodules in the synovium of joints and on occasions tendon sheaths or bursae. A case of primary synovial chondromatosis affecting the subtalar joint is reported. The patient's brother developed the same condition affecting the same joint 2 years later. The proposed etiologies are discussed including the presence of the proto-oncogene C-erb B-2.