The use of posteromedial portal for arthroscopic treatment of synovial chondromatosis of the knee: a case report

Abstract

Background The synovial chondromatosis is an uncommon proliferative metaplastic process of the synovial cells that can develop in any synovial joint. An isolated primary chondromatosis of the posterior compartment of the knee is uncommon and few cases are reported in literature. Our purpose is to describe a rare case of primary chondromatosis of the knee posterior compartment and report the arthroscopic loose bodies excision through a difficult posteromedial portal, avoiding the use of the accessory posterior portal, most commonly reported for approaching this disease. Case presentation We report a rare case of a 35-year-old Caucasian male patient with diagnosis of chondromatosis of the posterior knee compartment. The radiographs showed multiple loose bodies of the posterior compartment. The MRI revealed minimal synovial hypertrophy areas, multiple osteophytes in the intercondylar notch, and loose bodies in the posteromedial compartment. The CT allowed us to assess the bony structures, the morphology of the intercondylar notch, and the presence osteophytes of the medial and lateral femoral condyles. The CT images were crucial to plan how to reach the posterior compartments of the knee through a trans-notch passage. The patient underwent arthroscopic surgery using anteromedial, anterolateral, and posteromedial portals. The tunneling through the intercondylar osteophytes was performed to allow the arthroscope to pass trans-notch. To avoid additional accessory posterior portals, we used a 70° arthroscope to better explore the posterior knee compartment. The cartilage-like bodies were removed and synovectomy of the inflamed areas was performed. The clinical and radiological follow-up was 12 months and the patient showed excellent clinical outcomes, returning to his activities of daily living and sport activity. Conclusion Our case report highlights the importance of the arthroscopic approach to treat synovial chondromatosis, despite the involvement of the posterior compartment of the knee. An optimal preoperative imaging allows to plan for the proper surgical procedure even in patients with severe osteoarthritis. Moreover, the adoption of an intercondylar notch tunneling and a 70° arthroscope can help surgeons to better explore the posterior knee compartment, avoiding an accessory posterior trans-septal portal. Therefore, a synovectomy of the inflamed foci may be useful to prevent recurrence.

Arthroscopic Synovectomy and Removal of Loose Bodies in Synovial Osteochondromatosis of the Knee

“…Synovial osteochondromatosis of the knee can present with pain and swelling of the joint, stiffness, crepitus, giving away, catching or locking symptoms. 1 , 2 , 3 , 4 It usually involves the anterior compartment, including infrapatellar fat pad, suprapatellar pouch, and anterior interval, and it rarely involves the posterior compartment of the knee. 1 , 3 , 4 , 5 , 6 …”

“… 1 , 2 , 3 , 4 It usually involves the anterior compartment, including infrapatellar fat pad, suprapatellar pouch, and anterior interval, and it rarely involves the posterior compartment of the knee. 1 , 3 , 4 , 5 , 6 …”

“… 6 , 7 Owing to the metaplastic nature of the disease, there is a small risk of transformation to chondrosarcoma. 4 …”

“…Diagnosis and treatment of synovial osteochondromatosis at its early phase are crucial to prevent the occurrence of secondary osteoarthritis and malignant transformation. 4 , 8 The differential diagnosis for synovial osteochondromatosis should include any condition that may present with either the presence of intra-articular loose bodies or joint effusions, such as crystal deposition diseases, psoriatic arthritis, rheumatoid arthritis, pigmented villonodular synovitis, infective arthritis, and osteochondritis dissecans. 1 , 8 …”

“… 1 , 4 Other nonoperative treatment, such as chemotherapy and radiotherapy, usually has no role in the treatment of synovial osteochondromatosis. 3 , 4 Surgical options include arthroscopic versus open removal of loose bodies and synovectomy with the aims of symptoms control, prevention of recurrence, and further joint destruction. 1 , 2 , 3 , 4 …”