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Synovial Chondromatosis of the Elbow Causing a Mechanical Block to Range of Motion: a Case Report and Review of the Literature Michael J

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Synovial Chondromatosis of the Elbow Causing a Mechanical Block to Range of Motion: a Case Report and Review of the Literature Michael J (aspects of sports medicine) Synovial Chondromatosis of the Elbow Causing a Mechanical Block to Range of Motion: A Case Report and Review of the Literature Michael J. Griesser, MD, Joshua D. Harris, MD, Rickland L. Likes, DO, and Grant L. Jones, MD ABSTRACT tendon sheaths.1 Although its exact ically damage articular cartilage, We report a unique case of elbow etiology is unknown, it is thought to which may lead to degenerative synovial chondromatosis with sud- be caused by synovial metaplasia.2-4 osteoarthritis. Therefore, the stan- den onset of severe loss of elbow The resultant cartilaginous bodies dard of care consists of surgically extension and flexion range of are nourished by synovial fluid and removing loose bodies to minimize motion caused by mechanical block from deposition of chondral frag- can break free from the capsule to late joint degeneration and per- ments in the olecranon and coro- form loose bodies. In later stages of forming partial synovectomy to 19,31 noid fossae, respectively. We per- disease, the loose bodies have the prevent disease recurrence. formed successful arthroscopic sur- gical treatment of synovial chondro- matosis of the elbow. Arthroscopy “Because of...nonspecific patient reports, the examination revealed an acutely evolving synovial chondromatosis. diagnosis of synovial chondromatosis is com- Three-year follow-up indicated that arthroscopic removal of loose bod- monly delayed for several months to years.” ies and partial synovectomy can yield lasting improvement in motion without disease recurrence. potential to grow and eventually We report a unique case of calcify or even ossify.2 elbow synovial chondromatosis ynovial chondromatosis Most often affected are large with sudden onset of severe loss is an uncommon benign joints, including knee, hip, elbow, of elbow extension and flexion proliferation of hyaline and shoulder, with the knee range of motion (ROM) caused cartilaginous bodies with- accounting for most reported by mechanical block from depo- S 5-13 in the synovium of joints, bursae, or cases. Elbow joint involvement sition of chondral fragments in is relatively rare,2,6,14-27 and the the olecranon and coronoid fossae, Dr. Griesser and Dr. Harris are Resident bulk of the literature consists of respectively. We performed success- Physicians, Department of Orthopaedics, case reports. However, Mueller ful arthroscopic surgical treatment Ohio State University Medical Center, and colleagues28 reported surgi- of synovial chondromatosis of the Columbus, Ohio. cally treating 42 patients for syno- elbow. Arthroscopic examination Dr. Likes practices privately at Pueblo Bone and Joint Clinic, Pueblo, Colorado. vial chondromatosis, with 20 of revealed acutely evolving synovial Dr. Jones is Associate Professor, these cases involving the elbow. chondromatosis with the synovial Department of Orthopaedics, Ohio State Patients typically present with layer still chondroid, without artic- University Medical Center. insidious-onset pain, pain, swell- ular cartilage changes and without ing, locking or catching, and stiff- complete ossification. The patient Address correspondence to: Michael J. Griesser, MD, Department of ness. Because of these nonspe- provided written informed consent Orthopaedics, Ohio State University cific patient reports, the diagno- for print and electronic publication Medical Center, 2050 Kenny Rd, Suite sis of synovial chondromatosis is of this case report. 3300, Columbus, OH 43221 (tel, 614- commonly delayed for several 293-2663; fax, 614-293-4755; e-mail, months to years. In fact, initial CASE REPORT [email protected]). radiographs and magnetic reso- A 51-year-old, right-hand–dominant Am J Orthop. 2011;40(5):253-256. nance imaging (MRI) studies may man presented to our clinic with a Copyright Quadrant HealthCom Inc. 2011. be negative.29,30 Multiple intra- 4-year history of intermittent, activi- All rights reserved. articular loose bodies can mechan- ty-related right elbow pain and swell- www.amjorthopedics.com May 2011 253 Synovial Chondromatosis of the Elbow Examination of the right elbow (Figure 3A). On average, the loose revealed a large joint effusion with- bodies had the size, color, and con- out tenderness to palpation. The sistency of cooked rice (Figure 3B). skin was warm and dry without Numerous loose bodies remained erythema. ROM was limited to 40° intra-articularly, and these were to 100° of flexion with pain at the removed with an oscillating shaver endpoints of motion. Pronation (some loose bodies adhered to the ROM and supination ROM were synovium, and a partial synovec- preserved. There was mildly painful tomy was performed to remove crepitation with ROM, and instabil- them). On inspection and probe ity testing was negative. Gross neu- palpation, the articular surfac- rovascular examination was normal. es were completely intact, with- Radiographs showed mild osteo- out softening or any evidence of arthritic changes. Loose bodies degenerative changes. The normal were visualized anterior and pos- synovium was almost completely Figure 1. Lateral radiograph of elbow terior to the distal humerus on the replaced with a chondral layer, and shows calcifications anterior and poste- lateral radiograph (Figure 1). MRI it had hardened such that it could rior to distal humerus. Also evident are showed a large joint effusion, syno- be peeled off the joint capsule in anterior and posterior fat-pad signs. vial thickening, and loose bodies in a single layer. This was likely the the elbow joint (Figures 2A–2C). result of the acuteness of presen- ing that resolved with rest. He denied The multiple chondral fragments tation and the evolving nature of a traumatic inciting event. Eight seemed to coalesce into larger mass- the case (synovium still undergoing months before consultation at our es, and these space-occupying loose metaplasia). Of particular interest, institution, he noticed increased pain, bodies filled the olecranon and many of the cartilaginous bodies swelling, and stiffness. These symp- coronoid fossae. These larger frag- coalesced into masses to complete- toms eventually became constant. At ments blocked elbow extension and ly fill the olecranon and coronoid an outside institution, the patient had flexion, respectively. Presence of a fossae. The masses were found to been given a corticosteroid injection mechanical block with associated impinge and create a mechanical into the elbow joint, but he reported pain warranted arthroscopic elbow block to ROM. A probe was easily minimal relief. Rheumatologic and examination with complete syno- used to lift the masses from their infectious workup was negative. Just vectomy and removal of multiple fossae. The masses were friable and before his visit, he experienced an loose bodies. were excised piecemeal, without acute and significant loss of motion. Arthroscopic examination of need for an arthrotomy. There was After failure of conservative treat- the elbow was performed with the no sign of osseous integration, and ment, consisting of activity modifica- patient under regional anesthesia. loose body removal essentially rees- tion, use of nonsteroidal anti-inflam- With placement of the standard tablished the normal bony anatomy matory drugs, and physical therapy, anteromedial portal, multiple small of the distal humerus. ROM at end the patient was referred to our institu- cartilaginous loose bodies poured of procedure increased to 0° to tion for further evaluation. out of the arthroscopic cannula 130° of flexion. Figure 2. (A) T2-weighted sagittal magnetic resonance imaging (MRI) of elbow shows large joint effusion with loose bodies anterior and posterior that coalesced to form large masses in the coronoid and olecranon fossae. (B) T2-weighted coronal MRI of elbow shows effu- sion and loose bodies in coronoid fossa. (C) T2-weighted axial MRI shows elbow joint effusion with loose bodies anterior and posterior that coalesced and formed large space-occupying masses that blocked motion in the coronoid and olecranon fossae, respectively. 254 The American Journal of Orthopedics® www.amjorthopedics.com M. J. Griesser et al old karateist with a 1-year history of pain and stiffness. They treated this patient with arthroscopic loose body removal. At final follow-up, the patient had no pain or swelling, and ROM was improved. Imaging studies are an integral part of the synovial chondromato- sis workup, but are not always diag- nostic. Radiographs may be normal early in the disease, before the car- Figure 3. (A) Multiple hyaline cartilaginous loose bodies poured from arthroscopic tilaginous bodies have undergone cannula on entering elbow joint. (B) Remaining intra-articular loose bodies and those calcific changes.29 Loose bodies already removed had size, color, and consistency of cooked rice. were apparent on the lateral radio- graph of our patient’s elbow, but The synovial fluid and multi- mechanical block to ROM second- on arthroscopy it became evident ple loose body pathologic analysis ary to the coronoid and olecranon that the vast majority of them was revealed no evidence of malignancy fossae being filled with cartilagi- purely cartilaginous. MRI often or infection. The loose bodies were nous bodies.32 The first reported improves the preoperative positive all composed of benign osteocar- case32 evolved over 1 year, whereas predictive value of the diagnosis of tilaginous tissue, consistent with our case developed rather sudden- synovial chondromatosis by show- synovial chondromatosis. ly, with presentation of pain and ing
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