ISSN: 2165-7920

Journal of Clinical Case Reports

The International Open AccessJournal of Clinical Case Reports

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Clinical Case ReportsFranco-de la Torre et al., J Clin Case Rep 2014, 4:8

http://dx.doi.org/10.4172/2165-7920.1000408

Volume 4 • Issue 8 • 1000408J Clin Case RepISSN: 2165-7920 JCCR, an open access journal

Open AccessCase Report

Giant Solitary Synovial Osteochondromatosis of The Knee in a Young FemaleLorenzo Franco de la Torre3, Mercedes Gonzalez-Hita1,2, Juan Luis Alcala-Zermeno2, Ana Teresa Montes-Leyva2, Martin Vargas-Magana1,2, Abraham Zepeda-Moreno4,Jose Rafael Villafan-Bernal1,2 and Sergio Sánchez-Enríquez1,2*1University Center for Health Science, Department of Molecular Biology and Genomics, University of Guadalajara, Mexico2Academic Group UDG-CA 533 Multidisciplinary Study of Chronic Degenerative Disease, Department of Molecular Biology and Genomics, University of Guadalajara, Mexico3“Los Altos” University Center, Department for Clinics, University of Guadalajara, Mexico4Child and Youth Cancer Research Institute, University Center for Health Science, University of Guadalajara, Mexico

*Corresponding author: Sergio Sanchez Enriquez, Centro University of Health Sciences, Department of Molecular Biology and Genomics, University of Guadalajara Sierra, Mexico; E-mail: serlucis@hotmail.com

Received July 28, 2014; Accepted August 27, 2014; Published August 29, 2014

Citation: Franco-de la Torre L, Gonzalez-Hita M, Alcala-Zermeno JL, Montes-Leyva AT, Vargas-Magana M, et al. (2014) Giant Solitary Synovial Osteochondromatosis of The Knee in a Young Female. J Clin Case Rep 4: 408. doi:10.4172/2165-7920.1000408

Copyright: © 2014 Franco-de la Torre L, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Keywords: Chondromatosis; Arthroscopy; Knee joint; Hoffa’s fat pad; Synovial metaplasia

IntroductionSynovial Osteochondromatosis (SOC) is an uncommon condition

characterized by cartilaginous metaplastic changes within the synovium of the joint that eventually ossify and are extruded into the joint space as loose bodies [1]. This disease has an incidence of 1 case per 100,000 people per year and its location in the hoffa’s body is very rare [2]. The condition usually involves a one joint, being the most frequently affected the knee joint followed by the hip, elbow, shoulder and ankle [3-5]. The extra-articular forms affect structures with a synovial lining, such as bursae and tendon sheets whose mesenchymal cells can undergo chondral metaplasia [6,7]. The etiology of SOC is unkown, however, hereditary and environmental factors, especially the biomechanical stress may be involved in its development [1-8]. Clinically, SOC usually presents with chronic pain, swelling, clicking and limitation of movement. Total local surgical excision is the treatment of choice [9]. We describe a patient with Giant solitary SOC in a 18 years old female, localized in the infrapatellar fat pad and review the literature relevant to this case.

Case ReportAn 18 year old female, recreational runner is presented with an 8

month history of pain, recurrent swelling, and movement restriction in his left knee without previous trauma. Systemic signs and symptoms were not observed. Physical examination revealed diffuse left knee swelling, and articular tenderness to palpation. Passive and active knee range motion was limited to 70 degrees of flexion and 25 degrees of extensión. There were no palpable lymphatic nodes. Radiographs showed a calcified mass in the anterior aspect of the knee (Figure 1). The lesion had smooth contour surrounded by dense sclerosis. Magnetic resonance imaging (MRI) showed a mass located in the anterior portion of Hoffa’s body, with intermediate signal intensity on T1-weighted images and high-signal intensity on the T2-weighted images, with foci of low signal intensity indicative of calcification and

inflammatory process, without bone erosion (Figure 2). No other joint involvement was evident in the bone scan. Biopsy was not performed. Laboratory test showed red blood cells count: 4.4×106/μL, hemoglobin: 13.8 g/dL, total leukocyte count: 10.2×103/μL, platelets count: 314×103/μL, erythrocyte sedimentation rate: 18 mm/hr, C reactive protein 0.5 mg/dL, rheumatoid factor 21.3 IU/L, prothrombin time: 9 secs, thromboplastin partial time: 30 secs, I.N.R. 1.

With the presumptive diagnosis of SOC, the patient underwent arthroscopy of his left knee. Arthroscopy showed hyperaemia and

AbstractIntroduction: Giant Synovial osteochondromatosis of Hoffa’s body is very uncommon. Although described as a

benign disease, it can be destructive and can cause severe osteoarthritis and pain.

Case report: We report an 18 year old female patient presented with a calcified mass inside the Hoffa’s body. Clinically, patient presented with eight-month history of progressively worsening left knee pain with associated swelling. The bony mass in the Hoffa’s body was evident on the X-ray. MRI showed synovial affectation. During the arthroscopy, all pathological synovial was removed and the bony mass was extirpated through a mini-arthrotomy. Diagnosis of a giant synovial osteochondromatosis was confirmed by histology and malignancy was ruled out. Five years after surgery the patient has been asymptomatic and motion range is complete.

Conclusion: This case of primary synovial chondromatosis is interesting because it was presented in an age, gender and unusual location. At 5 years of postoperative follow-up the patient has had no recurrence and has showed excellent performance of the knee joint.

Figure 1: AP and lateral Knee plain radiographs showed the presence of calcified tissue mass in the anterior aspect of the knee.

Citation: Franco-de la Torre L, Gonzalez-Hita M, Alcala-Zermeno JL, Montes-Leyva AT, Vargas-Magana M, et al. (2014) Giant Solitary Synovial Osteochondromatosis of The Knee in a Young Female. J Clin Case Rep 4: 408. doi:10.4172/2165-7920.1000408

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Volume 4 • Issue 8 • 1000408J Clin Case RepISSN: 2165-7920 JCCR, an open access journal

thickening of the synovium, with large hypertrophic villi floating within the joint space. Synovial tissue samples were collected for pathological examination. The patient was treated with partial synovectomy and, by lateral mini-arthrotomy to remove the bone-like mass localized in the infrapatellar fat pad, measuring 4×3×2.4 cm. The histological sections stained with H&E, showed morphologically benign neoplasm formed in the outer portion by mature cartilage tissue. Chondrocytes arranged in pairs or in a single line with a moderate amount of cytoplasm and a single ovoid shaped nucleus with homogeneous chromatin, which gave no signs of ongoing mitosis, these cells were surrounded by a faintly basophilic matrix, were observed in the histological sections. Contiguously, thin and thick trabecular bone with an acidophilic matrix can be appreciated along with osteocytes without dyskaryosis and some osteoblasts. These histological features confirmed the clinical diagnosis of SOC (Figure 3).

After the procedure, partial weight bearing with crutches was indicated for 3 weeks and both passive and active range of motion exercise in the first 4 weeks was performed.

One month post-surgery the patient had no pain in her knee and regained full range of motion. At 6 weeks post-surgery the patient was gradually integrated into her activities of daily life and even at 12 weeks postoperatively, the patient returned to her recreational sports

activities. Five years after surgery the patient has been maintained asymptomatic and her left knee range of motion is complete.

DiscussionSynovial osteochondromatosis is a benign metaplastic proliferation

of the synovium. However, some studies suggest that around 5 percent of cases may undergo transformation to chondrosarcoma [10,11]. Clinically and radiologically it is very difficult to distinguish a giant solitary synovial osteochondroma from chondrosarcoma, parosteal osteosarcoma or osteochondroma [12,13]. When calcification is present, cases can be diagnosed by plain radiograph. MRI scanning has a role in detecting radiolucent lesions. Histological examination is essential to distinguish between benign and malignant growth.

Primary SOC is a benign condition characterized by synovial membrane nodular proliferation and metaplasia. The proliferated fragments may break off from the synovial surface into the joint space, where they may grow and calcify. The calcification may vary from speckled to fully ossified bodies and size may vary from millimeters to a few centimeters [14]. The disease is progressive with gradual destruction of the joint and progression to secondary osteoarthritis. People of any age can be affected but the usual age range is 30-55 years. It is more common in males and is usually a monoarticular disease. The present case is interesting because of the unusual age, gender and location. In addition, the patient was in fourth stage of the disease despite having only 8 months symptoms, which could be explained either because the disease remained asymptomatic for a long time or because the disease showed a very rapid progression.

Although any synovial surface may be involved (including bursae), large joints are more commonly affected e.g. knees, elbows, hips and shoulders. The patient usually suffers many years of joint pain and swelling with limitation in movement and locking, as seen in this case [15]. The SOC can be classified into primary and secondary, depending on whether or not associated with osteoarthritis. Other classification is based on evolution of this clinical entity. According to Milgram [4], SOC has three phases: (1) active intrasynovial disease with no loose bodies (2) transitional stage involving active intrasynovial disease and loose body; (3) multiple osteochondral loose bodies without active synovial disease. Furthermore, Edeiken et al [12] suggested an additional phase that comprises of a large intra or extra-articular calcified cartilaginous mass. In our case we identified this large mass formed mainly of cartilage, therefore, it was classified into fourth stage of SOC. Plain radiographs are usually helpful in the diagnosis when the fragments are calcified. For non-calcified bodies and to delimitate the extent of disease, MRI or CT with arthrography may be used. Arthroscopy is helpful for the diagnosis and also to perform the synovectomy and removal of fragments [16].

Primary SOC of the knee joint may present as a localized form [3-5,10,17,18]. Helpert et al. [19] reported 12 cases of primary SOC on the knee, but none was confined to the fat pad. Bozkurt et al. [20] reported a patient with SOC widespread into all compartments of the knee. Dogan et al. [21] found a primary form giant SOC in the popliteal area associated with intra-articular calcifications. Recurrence may result from incomplete removal of the loose bodies or diseased synovial at the time of initial surgery [22]. Minimally invasive excision of the mass being extremely cautious with the extensor mechanism permitted restoration of full knee function.

ConclusionsThis case of primary synovial chondromatosis is interesting because

Figure 2: MRI showed a mass located in the anterior portion of Hoffa’s body, with intermediate signal intensity on T1-weighted images and high-signal intensity on the T2-weighted images.

Figure 3: The histological sections stained with H&E show morphologically benign neoplasm, formed in the outer portion of mature cartilage tissue, with a faintly basophilic matrix, showing chondrocytes in pairs or single, with moderate cytoplasm, well defined and a nucleus single, ovoid, homogeneous chromatin without mitosis.

Citation: Franco-de la Torre L, Gonzalez-Hita M, Alcala-Zermeno JL, Montes-Leyva AT, Vargas-Magana M, et al. (2014) Giant Solitary Synovial Osteochondromatosis of The Knee in a Young Female. J Clin Case Rep 4: 408. doi:10.4172/2165-7920.1000408

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Volume 4 • Issue 8 • 1000408J Clin Case RepISSN: 2165-7920 JCCR, an open access journal

it was presented in an age, gender and unusual location. At 5 years of postoperative follow-up the patient has had no recurrence and showed excellent performance of the knee joint.

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Citation: Franco-de la Torre L, Gonzalez-Hita M, Alcala-Zermeno JL, Montes-Leyva AT, Vargas-Magana M, et al. (2014) Giant Solitary Synovial Osteochondromatosis of The Knee in a Young Female. J Clin Case Rep 4: 408. doi:10.4172/2165-7920.1000408

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