Received September 5, 2014; Accepted November 14, 2014
Chondromatosis of the Hip Treated with Surgical Dislocation : A Case Report
Emiri Kishimoto, Tohgo Nonaka, Fumiaki Nishisaka, Kanji Fukuda, Masao Akagi
Department of Rehabilitation Medicine, Kinki University Faculty of Medicine Department of Orthopaedic Surgery, Kinki University Faculty of Medicine
Osakasayama, Osaka 589-8511, Japan
Abstract
We report a case of chondromatosis of the hip joint treated with surgical dislocation. A 41- year-old man had right hip pain with moderate limitation of the range of motion. Plain radio- graphs showed no abnormal findings in the hip.
M agnetic resonance imaging (M RI) showed the presence of multiple intra-articular osteochon- dral bodies. Complete removal of the loose bodies and synovectomy were performed through
surgical dislocation. One year after the opera- tion, the patient had fully recovered and retur- ned to his previous employment. M RI revealed complete removal of the loose bodies and no evidence of avascular necrosis. We considered that surgical dislocation is a useful approach for chondromatosis of the hip joint.
Key words:chondromatosis, surgical disloca- tion of the hip, M RI
Introduction
Synovial chondromatosis is an uncommon, monoarticular disease mainly affecting large joints. This disease is an infrequently diagnosed benign disorder of the synovium whereby meta- plastic transformation takes place to form osteo- chondral bodies in the synovial cavity.
Although it can occur in any synovial joint,the knee is the most commonly affected ; involve- ment of the hip joint is relatively rare. Since the clinical symptoms of primary synovial osteo- chondromatosis of the hip are insidious and nonspecific,it is difficult to detect this condition during its early stages on the basis of radiogra- phically evident osseous bodies. Although metaplastic changes of the synovium have been reported to be nonaggressive, mechanical dam- age to the articular cartilage with multiple loose intra-articular bodies can lead to degenerative osteoarthritis of the hip. Therefore, surgical removal of these bodies from the hip is generally accepted as the optimal treatment.
Herein, we present a case of synovial chon- dromatosis of the hip treated with surgical dis- location. The patient was informed that data concerning the case would be submitted for publication, and he provided consent.
Case report
A 41-year-old man complained of intermittent right groin pain for two years. No previous history of trauma was noted. He had consulted many hospitals,but no diagnosis had been given.
On examination, atrophy of the right thigh muscle was noted. The range of motion of the right hip was limited on flexion,abduction,and rotation, as determined based on the results of the flexion-abduction/ external rotation-exten- sion test. There was no length discrepancy.
Plain radiographs showed no abnormal findings associated with the right hip. However, mag- netic resonance imaging (MRI) revealed the presence of multiple intra-articular osteochon- dral bodies (Fig.1).
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We performed complete debridment and synovectomy with hip dislocation, as described by Ganz et al. The patient was placed in the lateral position. Using a lateral approach with trochanteric osteotomy and flip,the capsule was exposed anteriorly and z-shaped capsulotomy was performed. Then, the hip was dislocated, while preserving the integrity of the external rotator muscles. We observed multiple adherent and free chondromas on or around the femoral neck. Extensive saucerization of the femoral neck was also noted. We carried out complete debridment and synovectomy (Fig.2). His- tological study of the loose bodies showed char- acteristic findings of synovial osteochon- dromatosis. Clustered chondrocytes were obser- ved in hyaline cartilage tissue surrounded by the synovial membrane. Calcification was identified beneath the synovium. According to the Mil- gram criteria for staging synovial osteochon- dromatosis, this case was phase 3,i.e.,there were
intra-articular chondral fragments without active synovial-based disease(Fig.3). We used the pin- sleeve system (AI Medic, Tokyo, Japan) for reattachment of the great trochanter. For the first 3 weeks postoperatively,partial weight-bear- ing with 5 kg and no active hip abduction were recommended to facilitate healing of the osteotomized trochanter. The postoperative course was uneventful, and the patient returned to his previous employment after 10 weeks.
Groin pain was not noted at the 2-year follow-up examination. Postoperative radiography showed total resection of the free bodies and complete healing of the greater trochanter. There were no findings of avascular necrosis of the femoral head (Fig.4).
Discussion
Synovial chondromatosis is a rare and benign proliferative disorder of the synovial lining,and
Fig.2 Intraoperative photographs of open arthrotomy. a:
Many intra-articular chondral bodies (arrows in a) can be seen around the dislocated femoral head (Fe), with subsequent resection of a component containing synovium. b : Extensive erosion of the femoral neck can be noted ( ). c: Photograph showing the de- brided fragments.
Fig.4 Postoperative images. A. Plain anteroposterior radiograph of the pelvis showing complete resection of the free bodies and secure fixation of the greater trochanter,as well as a lateral view(B). C.Coronary T2-weighted fat-suppressed (TR : 1355 /TE : 80)also reveals no findings of avascular necrosis of the femor- al head.
Fig.3 Photomicrograph (original magnification,×40; H- E stain) showing the synovial proliferation with subsynovial cartilaginous nodule formation ( ).
Fig.1 Preoperative images. A.Plain anteroposterior radio- graph of the pelvis showing no abnormal findings on the right side,such as visible chondromas,as well as a lateral view (B). C. Coronary T2-weighted fat- suppressed MR image (TR : 5264/TE : 80) showing the presence of joint effusion and multiple intra- articular osteochondral bodies with a focal area of high signal intensity( ).
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the hip is the second most common site of involvement after the knee. Radiography reveals multiple intra-articular calcifications in 70-95% of cases of primary synovial chon- dromatosis, and the calcifications are typically distributed evenly throughout the joint. How- ever, the initial radiographic image is often negative, with the characteristic juxta-articular radiopacities not seen until much later in the disease process. In this case, the patient had consulted many hospitals, but no diagnosis had been given. Finally,a diagnosis was made with MRI,which could show the presence of multiple intra-articular osteochondral bodies.
The goals of treating synovial chondromatosis of the hip are to alleviate pain, prevent recur- rence, and delay the progression of secondary joint damage. Surgical removal of these loose bodies from the hip is generally accepted as the optimal treatment. Arthroscopic resection is effective for this condition. However,a recent report demonstrated a high incidence of recur- rence Following this method,necessitating open revision surgery. Therefore, an open surgical approach must be considered in the presence of multiple free bodies in the hip joint. Although some authors reported successful treatment of this condition through the removal of loose bodies alone, recent reports suggested that the incomplete removal of pathologic tissue may be related to the recurrence of loose bodies due to persistent metaplastic activity of the remaining synovium. While extensive debridement of loose bodies and proliferative synovial tissue provide the best chance of eradicating the dis- ease,managing hip chondromatosis is particular- ly difficult because complete access to the hip is restricted with open approaches or arthroscopy.
Full exposure of the hip joint is possible only after dislocation of the femoral head. We carried out complete debridment and synovectomy through hip dislocation. With this procedure,a full 360°view of the femoral head for debride- ment and complete synovectomy was possible.
At synovectomy, we preserved the synovial lin- ing over the retinacular vessels, because the retinacular vessels are the terminal branches of the medial femoral circumflex artery and should be preserved to avoid avascular necrosis of the femoral head.
One of the most serious complications of surgi- cal dislocation is the occurrence of avascular necrosis of the femoral head. We adopted the
approach described by Ganz et al., with no risk to the femoral head vasculature, Facilitating thorough debridement. They have already re- ported the efficacy of this approach to prevent recurrence in synovial chondromatosis of the hip,but they did not evalutate the outcomes with postoperative MRI. To our knowledge,this is the second report indicating the efficacy of pos- toperative MRI.
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