ISSN: 2165-7920

Journal of Clinical Case Reports

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Journal of Clinical Case Reports

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Clinical Case Reports

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

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

Case Report

Open Access

Giant Solitary Synovial Osteochondromatosis of The Knee in a Young

Female
Lorenzo 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 Snchez-Enrquez1,2*
University Center for Health Science, Department of Molecular Biology and Genomics, University of Guadalajara, Mexico
Academic Group UDG-CA 533 Multidisciplinary Study of Chronic Degenerative Disease, Department of Molecular Biology and Genomics, University of Guadalajara,
Mexico
3
Los Altos University Center, Department for Clinics, University of Guadalajara, Mexico
4
Child and Youth Cancer Research Institute, University Center for Health Science, University of Guadalajara, Mexico
1
2

Abstract
Introduction: Giant Synovial osteochondromatosis of Hoffas 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 Hoffas body.
Clinically, patient presented with eight-month history of progressively worsening left knee pain with associated
swelling. The bony mass in the Hoffas 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.

Keywords: Chondromatosis; Arthroscopy; Knee joint; Hoffas fat

pad; Synovial metaplasia
Introduction
Synovial 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 hoffas 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 Report
An 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
extensin. 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 Hoffas 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

J Clin Case Rep

ISSN: 2165-7920 JCCR, an open access journal

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: 4.4106/L, hemoglobin:
13.8 g/dL, total leukocyte count: 10.2103/L, platelets count: 314103/
L, 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

Figure 1: AP and lateral Knee plain radiographs showed the presence of

calcified tissue mass in the anterior aspect of the knee.

*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:10.4172/21657920.1000408
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.

Volume 4 Issue 8 1000408

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

Page 2 of 3

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

Discussion
Synovial 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.
Figure 2: MRI showed a mass located in the anterior portion of Hoffas
body, with intermediate signal intensity on T1-weighted images and highsignal 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.

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 432.4 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
J Clin Case Rep
ISSN: 2165-7920 JCCR, an open access journal

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.

Conclusions
This case of primary synovial chondromatosis is interesting because

Volume 4 Issue 8 1000408

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

Page 3 of 3

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

J Clin Case Rep

ISSN: 2165-7920 JCCR, an open access journal

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