Osteochondromatosis of the hip with concomitant osteoarthritis: a case report

Burne, Graham BSc Hons Sports Science, BSc Hons Physiotherapy1

1Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom

 Key Words:osteochondromatosis, hip, osteoarthritis, case report

 Introduction

 Synovial osteochodromatosis (OC) represents a rarebenign condition characterised by synovial metaplasia and the formation of cartilaginous and osteocartilaginonus bodies in the capsule[1]. This condition affects the knee (50-65%), but its occurrence in the hip is relatively uncommon[2]. Clinical symptoms are usually non-specific and insidious. Thus, clinical diagnosis of OC of the hip may be difficult and delayed. It may progress over several years before being diagnosed on the basis of radiographic evidence of loose osseous bodies[3]. Recurrence and true malignant transformation of synovial chondromatosis to chondrosarcoma is rare and has low reported incidence[4]. Early detection and treatment prevents complications associated with accelerated osteoarthritis due to cartilage wear[5].A case of synovial OCand progressive osteoarthritis of the hip in a 50 year old female patient is presented.

 Case Report

A 50 year old female attended a musculoskeletal assessment clinic with a 6 month history of insidious right groin pain. Initially symptoms were severe with subsequent attendance to A&E due to pain limiting function and discharged with tramadol and soft tissue injury diagnosis. She further described concomitant right gluteal pain with no evidence of radiculopathy. Nil previous episodes of low back pain, however previous intermittent hip pain with full spontaneous resolution. Symptoms were aggravated with cycling, sustained sitting, rising from sitting and lying supine. Eased with analgesia and self hip manipulation. She had a past medical history of vitamin D deficiency. On physical examination full lumbar range of motion was noted with no pain elicited. Neurologically was unremarkable throughout. Hip range of motion was restricted in 90° flexion, 25° external rotation and 20° internal rotation. FABER’s test and FADDIR’s test reproduced pain.

Initial hypothesis was of early osteoarthritis with x-ray requested and reviewed on the day. On review, x-ray noted osteocartilagenous loose bodies in the capsule and osteoarthritis (figure 1.). This was discussed with the patient and subsequently hip multi-discipline team to exclude monoarticular disease entities such as pigmented villonodular synovitis (PVNS). Orthopaedic reviewconfirmed the presence of the floating loose bodies in keeping with OC diagnosis. Subsequently agreed in a shared decision making model of management with uncemented ceramic-on-ceramic total hip replacement over arthroscopic synovectomy, based on the severity of the osteoarthritis. No further imaging was requested. The patient is currently on the orthopaedic waiting list.

Imaging

Digital X-rays with anterior-posterior and lateral views of the right hip were requested. X-rays revealed multiple radiopaque loose bodies around the femoral head and extrinsic erosion into the acetabulum (figure 1).  Radiographs should be initial imaging of choice, commonly revealing multiple intra-articular calcifications in typically distributed evenly throughout the joinanda typical chondroid ring-and-arc pattern of mineralisation[6].  Features of multiple (>5) calcified or osseous bodies within the joint identified on x-ray is considered part of the diagnostic characteristic of OC[7].Extrinsic erosion of bone is much more frequent in less capacious joints such as the hip[8].

Hips AP. Case study

Hips lateral. Case study

Figure 1. (a) Anterior-posterior radiograph of the hip. Enlargement of the acetabular fossa is shown (large arrow) with multiple calcified masses about the hip (small arrows) with superior joint space narrowing resulting from secondary osteoarthritis (b) lateral x-ray of the hip with multiple calcified masses

Discussion

 OC is a rare characteristically single joint condition where the synovial lining of joints, tendon, or bursa undergoes metaplastic change. This results in the formation of multiple cartilaginous loose bodies in the joint. Differential diagnosis includes: synovial chondrosarcoma, chondrosarcoma, osteochondritis dissecans, osteoarthritis, charcot joint, tumoral calcinosis[9]. The disease is seen mainly in patients between 20 and 50 years of age, with males being more commonly affected[10]. The duration of clinical symptoms before diagnosis is often long, with an average of 5 years[11].

Milgram[12]categorised the disease progress into three stages:

1. Early: No loose bodies but active synovial disease
2. Transitional: Active synovial disease and loose bodies
3. Late: Loose bodies but no synovial disease.

Clinical presentation is usually characterised by mechanical symptoms when loose bodies interfere with the function of the joint, stiffness, restriction of range of movement, locking and pain[13]. In a review of 53 cases of OCD covering a period of 30 year period the authors found that the condition was always monarticular, the most common site being the knee joint (70%) followed by the hip (20%)[14]Degenerative joint disease was demonstrated in 3 patients (5% all within the hip), 9 patients suffered recurrence (15%), and 3 patients (5%)6 underwent malignant change6.

 Plain radiographs show the presence of loose bodies in only 50% of the cases. Furthermore, an 80% falsenegative rate for imaging studies including plain X – ray, bone scintigraphy, CT, and MRI has been reported[15].  Thus, clinicians should be vigilant in their reasoning and change in presentation during follow up care. OCD has he potential for developing degenerative joint disease and malignant transformation (5%), thus the condition should not be neglected.

Recommended treatment is open synovectomy and removal of the loose bodies[16]. This procedure has high success rate, but its obstacles are the invasiveness of surgery, long rehabilitation periods, and many major complications such as avascular necrosis of the femoral head, fracture of the femoral neck, and nerve injury3. By comparison, hip arthroscopy has fewer complications permits rapid return to daily life after the surgery and a short rehabilitation period[17]. In this case the joint had moderate severity osteoarthritis and arthoscopy was not deemed sufficient to reduce symptoms of pain and improve function appropriately. In patients who present with recurrent OC with moderate/severe osteoarthritis, a total hip arthroplasty is management of choice[18].

 Clinical Message

OC of the hip joint is a rare condition. This case is reported owing to its rarity and clinical significance. A diagnosis of OC is made by physical examination and 50% with use of radiography. X-rays of the affected joint will show multiple radiopaque loose bodies which can be either intra-articular or extra-articular. The treatment option includes either open or arthroscopic loose body removal and synovectomy. Arthroplasty is considered as a treatment if concomitant osteoarthritis is noted.

 Disclosure

No conflicts of interest were declared by the author

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