Rev. bras. ortop. vol.50 número5

w w w . r b o . o r g . b r

Case

report

Arthroscopic

treatment

of

synovial

osteochondromatosis

of

the

elbow.

Case

report

and

literature

review

夽

Bernardo

Barcellos

Terra

_,

_Eduardo

_Wanzenboeck

_Moraes,

_Alceuleir

_Cardoso

_de

_Souza,

José

Maria

Cavatte,

João

Carlos

de

Medeiros

Teixeira,

Anderson

De

Nadai

HospitalSantaCasadeMisericórdiadeVitória,Vitória,ES,Brazil

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Articlehistory:

Received14August2014 Accepted1September2014 Availableonline8September2015

Keywords:

Synovialchondromatosis Arthroscopy

Elbow Synovitis

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Synovialosteochondromatosisisabenignproliferativedisorderwithmetaplasiaofthe syno-vialmembranethataffectsthefibroblastsofthesynovialjoints,tendonsandbursae.In literature,therearefewdescriptionsofsynovialosteochondromatosisoftheelbow.The objectiveofthisarticlewastoreportacaseofsynovialosteochondromatosisoftheelbow inapatientaged32,basketballathlete,inwhichsurgicaltreatmentwaschosenbecauseof thepainandfunctionallimitationandstageofdiseasewithmultipleloosebodies.Patient 32,male,presentedwithpainandlimitationofmotionoftheelbow.Therangeof pas-sivemotionwas100◦_{offlexionand30}◦_{extension.Therangeofactivemotionwas40–90}◦_.

Magneticresonanceobservedmanyloosebodiesmainlyintheposteriorcompartmentin theolecranonfossaplussomechondrallesionsinthecapitellum.Thearthroscopic treat-mentwaschosenwithtwoanteriorsportals(medialandlateral)andtwoposteriorportals (standardposteriorandposterolateral)foreasingloosebodiesandosteoplastyofthe olecra-nonfossa.Thevisualanalogscalepainwas9–3anditsarcofactivemotionwas110◦_to

−20◦ offlexionandextension.OnascaleofperformancefromMayoClinicpatientswas65points preoperativelyto90postoperativelywith9monthsfollow-upandthepatientwassatisfied withthetreatmentoutcome.Arthroscopictreatmentofsynovialosteochondromatosisof theelbowisaneffectiveandsafetherapeuticmanagementwithlowmorbidityandearly returntoactivities.

©2014SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditora Ltda.Allrightsreserved.

夽

WorkperformedintheDepartmentofOrthopedicsandTraumatology,HospitalSantaCasadeMisericórdiadeVitória,Vitória,ES, Brazil.

∗ _{Correspondingauthor.}

E-mail:bernardomed@hotmail.com(B.B.Terra). http://dx.doi.org/10.1016/j.rboe.2015.08.014

Tratamento

artroscópico

da

osteocondromatose

sinovial

do

cotovelo.

Relato

de

caso

e

revisão

da

literatura

Palavras-chave:

Osteocondromatosesinovial Artroscopia

Cotovelo Sinovite

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Aosteocondromatosesinovialéumapatologiaproliferativacommetaplasiabenignada membranasinovialqueafetaosfibroblastosdasarticulac¸õessinoviais,dostendõesedas bursas.Naliteratura,existempoucasdescric¸õesdeosteocondromatosesinovialdocotovelo. Oobjetivodesteartigofoirelatarumcasodeosteocondromatosesinovialdecotoveloem umpacientede32anos,sexomasculino,atletadebasquete,noqualseoptoupelo trata-mentocirúrgicodevidoaoquadroclínicocomdorelimitac¸ãofuncionaleaoestágioda doenc¸acommúltiploscorposlivres.Pacienteapresentoudorelimitac¸ãodoarcode movi-mentodocotovelo.Oarcodemovimentopassivoerade100◦_{deflexãoe−30}◦_deextensão.

Naressonânciamagnéticaobservaram-sediversoscorposlivres,principalmenteno com-partimentoposteriornafossadoolecrano,alémdealgumaslesõescondraisnocapítulo. Optou-sepelotratamentoartroscópicocomafeituradedoisportaisanteriores(mediale lateral)edoisposteriores(posteriorpadrãoeposterolateral)pararemoc¸ãodoscorposlivres eosteoplastiadafossaolecraniana.Aescalavisualanalógicadadorfoide9para3eseuarco demovimentoativofoipara110◦_{deflexãoe−20}◦_{deextensão.Naescaladedesempenho}

daClínicaMayoopacientefoide65pontosnopré-operatóriopara90nopós-operatório comnovemesesdeseguimentoesatisfeitocomoresultado.Otratamentoartroscópico daosteocondromatosesinovialdocotovelomostra-secomumaopc¸ãoterapêuticaeficaze seguranomanejoterapêuticodessapatologia,apresentabaixamorbidadeeretornoprecoce àsatividades.

©2014SociedadeBrasileiradeOrtopediaeTraumatologia.PublicadoporElsevier EditoraLtda.Todososdireitosreservados.

Introduction

Synovialosteochondromatosisisaproliferativepathological conditionwithbenignmetaplasiaofthesynovialmembrane thataffectsthefibroblastsofthesynovialjoints,tendonsand bursas.Thefirstdescriptionintheliteratureofthis patholog-icalconditionwasinrelationtothekneejoint,byAmbrose Páréin1958,apudHoandChoueka.1

Osteochondromatosiscan affect anyjoint,but the great majorityofthecasesinvolvethe knee.Inthe upperlimbs, thejointmostaffectedistheelbow,buttheshoulder,wrist, acromioclavicularandeventheinterphalangealjointsmaybe involved.2,3_{Thefirstcaseintheelbowwasreportedby}

Hender-sonin1918,citedbyMusseyandHenderson.4_{Intheliterature,}

therearefewdescriptionsofsynovialosteochondromatosisof theelbow,mainlyconcerningsurgicalresults.5

Synovial osteochondromatosis can be classified as pri-marywhenthecartilaginoustissueoriginatesdirectlyfrom the metaplasia of the synovial tissue or the bursa; or as secondary synovial osteochondromatosis when freebodies originatedirectlyfromthehyalinecartilageandaredeposited inthejointspaceorinthetendonsheath,duetodegenerative diseases,traumaorneuropathicarthropathy.6

Synovial osteochondromatosis can be subdivided into intra-articular synovial and tenosynovial (extra-articular) types.Intra-articularosteochondromatosisismorecommon and is usually monoarticular. Tenosynovial osteochondro-matosisisextra-articularand morecommonlyinvolvesthe flexortendonsofthefingers,wristsandfeet.Histologically, theyarethesameentities,butitisimportanttodifferentiate

them, since there is a greater chance that extra-articular tenosynovialosteochondromatosismightreoccur.7,8

Theobjectiveofthispaperwastoreportonacaseof syno-vialosteochondromatosisoftheelbowina32-year-oldpatient whowasabasketballplayer,forwhomsurgicaltreatmentwas chosen because ofhisclinical condition ofpain and func-tionallimitationandthestageofthedisease,withmanyfree bodies.

Case

report

Thepatientwasa32-year-oldmanwhocametothe outpa-tientclinic3monthsbeforethesurgery,presentingpainand limitationofelbowrangeofmotionthathadbegun8months earlier.Hesaidthathehadnotfallen;hehad nothad any systemicdiseasesorprevioussurgery;andhedidnotprovide anyotherinformationofrelevancetothecase.Oninspection, itwasnotedthatoneelbowpresentedslightedema,but with-out phlogisticsigns.Hecomplainedofpainonpalpationin thefossaoftheolecranonandintheregionoftheinsertion oftheextensorsandsupinatorsoftheforearm.Thepassive rangeofmotionwasfrom40◦ _to100◦ _{offlexion.Theactive} rangeofmotionwasfrom50◦ _to90◦_{,pronationwas90}◦ _and supinationwas85◦_{.Neurologicalandvascularexaminations} showednormalfindings.

RL 90 left RL 93 left _R 2 cm

P

2 cm P

F Sc 9 F F

TSE/M SI 12

Sc 9 TSE/M SI 11

Fig.1– T2-weightedsagittalmagneticresonanceimagingshowingmanyfreebodiesinthefossaoftheolecranon.

capitellum(Figs.1–3),andtheradiologist’sdiagnostic hypoth-esiswasthatthiswasintra-articularsynovial osteochondro-matosis.Theresultsfromtheserumtestswerenegativefor rheumatologicaldiseasesorinfectiousprocesses.

Because of the severity of the case, it was decided to usearthroscopictreatment.Twoanteriorportals(medialand lateral)wereopened(for partialsynovectomy,anterior cap-sulotomy to gain extension and microperforations in the capitellum because of the osteochondral lesions) and two posterior portals (standard posterior and posterolateral) in ordertoremovethefreebodiesandperformosteoplastyon thefossaoftheolecranon becauseofthelocalosteophytes (Figs.4–7).Atthetimeofthesurgery,materialfor histopatho-logical examinationwascollected (free bodyand fragment fromthesynovialmembrane),whichsubsequentlyconfirmed thediagnosis.

Thepatient was immobilized bymeans ofcompressive bandaging.Passivemovementwasallowedduringthe imme-diate postoperativeperiod and activemovement according tothetoleranceofpain.Physiotherapeuticrehabilitationwas startedonthetenthpostoperativeday.

Inthesecondweekaftertheoperation,thepatientreturned to the outpatient clinic practically without pain and pre-sentedanactiverangeofmovementof20–100◦_{(Figs.8and9).}

Eighteenmonthsaftertheoperation,thescoreonthevisual analogscalehaddecreasedfrom9to1andthepatient’sactive rangeofmotionwasnow10–130◦_{.OntheMayoClinic} perfor-mancescale,thepatientwentfrom65pointsto90afterthe operationandhewasextremelysatisfiedwiththeresultfrom thetreatment. TheMayoClinicfunctionalscale9_takesinto

considerationfourcriteria(pain,rangeofmotion,stabilityand function)andrangesfrom10to100points.Resultantscores higherthan90areexcellent;75to89good;60to74fair;and lowerthan60poor.

Discussion

Synovialosteochondromatosisofthejointsisararecondition forwhichthedefinitionanddiagnostic criteriaareunclear. Thereisstilllittleknowledgeaboutthiscondition.10_Clinically,

thesignsandsymptomsarenonspecificandmaysuggest sev-eral pathological conditions. Inmost cases, the symptoms comprisepainand/orlossofrangeofmotion.Incapacityto performcompleteextensionisoneofthefirstsymptoms, fol-lowedinsomecasesbylockingofthejoint.Stiffnessisnota markedcharacteristic.Inourcase,thepatienthadapainful

RL 90 left RL 93 left _{RL 96 left}

2 cm P

2 cm P

2 cm P

F Sc 8 F F

TSE/M SI 12

Sc 8 TSE/M SI 11

AP 89 post

AP 85 post

AP 82 post

3 cm

R

3 cm

R

3 cm

R

F

F

F

Sc 6

TSE/M

SI 11

Sc 6

TSE/M

SI 10

Sc 6

TSE/M

SI 9

Fig.3–T2-weightedcoronalmagneticresonanceimagingshowingmanyfreebodiesinthefossaoftheolecranonandin thelateralcompartment,alongwithachondrallesioninthecapitellum.

rangeofmotion,withoutanysigns andsymptomsof com-pressionoftheulnarnerve.

MilgramandPease11_{described30casesofsynovial}

osteo-chondromatosisandidentifiedthreedistinctstages:disease withintrasynovialactivity,butwithoutthepresenceoffree bodies;transitionallesionswithsynovialactivityandfree bod-ies;and multiplefreebodies, but without synovialactivity. Ourpatientwasinstage3,sincehepresentedmultiple intra-articular free bodies. From arthroscopy, we observed only slightfociofsynovitis.

Fig.4–Intraoperativearthroscopicimageshowingfree bodiesinthefossaoftheolecranon.

Bothconservativetreatmentandsurgerycanbeusedas therapyforosteochondromatosis.Painreliefcanbeachieved through nonsurgicaltreatment. Surgicaltreatmentis advo-catedinphasesIIandIIIbythegreatmajorityofauthors.It shouldbeperformedinassociationwithsynovectomy,since theremayberecurrenceofthelesionafterremovalofthefree bodyalone.However,somestudieshavequestionedtreatment involving synovectomy.12,13 _{In the casepresentedhere, we}

chosetoperformsynovectomyoftheanteriorandposterior compartments.

Fig.6–Freebodiesremoved.

In the literature, recurrence of this disease has been reported in up to 22% of the cases.14 _{The cause is}

gener-ally attributed to incomplete removal of free bodies or to the synovial disease.Itis believed that recurrence implies thatthereisa greater chanceofmalignant transformation tochondrosarcoma,althoughthistransformationofsynovial osteochondromatosis is rare.15,16 _{The possibility of}

malig-nanttransformationneedstobeconsideredwhenperiosteal reactionandcorticalerosionareobserved.Onanalyzing his-tologicalslides,thedifferentialdiagnosestobeconsideredare periosteal chondroma, giant-cell tumor, calcifying aponeu-roticfibroma,tumoralcalcinosis,hydroxyapatitedeposition, free bodies and inflammatory arthritis. The results from histopathologicalanalysisonthefreebodyandonafragment fromthecapsuleshowedalterationscompatiblewithsynovial osteochondromatosiswithmoderatediseaseactivity.

Intheupperlimbs,thelocationmostaffectedbysynovial osteochondromatosisistheelbow,followedinsecondplace bytheshoulder.Paimetal.16_{reportedtheresultfrom}

arthro-scopictreatmentofacaseofsynovialosteochondromatosis oftheshoulder,inwhich44freebodieswereremoved.Over a1-yearfollow-up,almostcompleterecoveryoftherangeof motion,withoutpain,wasshown.Lasmaretal.17_reporteda

caseofsynovialosteochondromatosisinaknee,inwhichover an8-monthfollow-up,excellentrecoverywasobtained.These authorsdrewattentiontothedifferentialdiagnosiswith pig-mented villonodular synovitis and noted that in standard radiographicexaminations,thediagnosismightgounnoticed,

Fig.7–Arthroscopicportalsconstructed(proximal anteromedial,proximalanterolateral,standardposterior andposterolateral).

given that the freebodies mightnot becalcified. Polesello etal.18_{reportedtheresultfromarthroscopictreatmentofsix}

casesofhiposteochondromatosis,fromwhichgoodresults wereshown,withimprovementontheHarrisscaleas modi-fiedbyByrd,from54pointsbeforetheoperationto90points aftertheoperation.

Fig.8–Twoweeksaftertheoperation,with−20◦ofactive

Fig.9–Twoweeksaftertheoperation,with100◦_ofactive flexion.

Thecasereportedinthepresentstudyhasbeenfollowed upfor16monthsandsofarthepatientremainsfreefrompain andwithoutanysignsofrecurrence.

Conclusion

Arthroscopictreatment ofsynovialosteochondromatosis of theshoulderwasshowntobeaneffectiveandsafemeansof therapeuticmanagementforthispathologicalcondition,with lowmorbidityandanearlyreturntoactivities.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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