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| CASE REPORT |
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| Year : 2021 | Volume
: 29
| Issue : 5 | Page : 53-55 |
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Arthroscopic removal of synovial chondromatosis of the first carpometacarpal joint
Gokce Yildiran, Zekeriya Tosun
Department of Plastic, Reconstructive and Aesthetic Surgery, Division of Hand Surgery, Faculty of Medicine, Selcuk University, Konya, Turkey
| Date of Submission | 12-Apr-2020 |
| Date of Acceptance | 10-May-2020 |
| Date of Web Publication | 17-Mar-2021 |
Correspondence Address:
Dr. Gokce Yildiran
Department of Plastic, Reconstructive and Aesthetic Surgery, Division of Hand Surgery, Faculty of Medicine, Selcuk University, Konya
Turkey
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/tjps.tjps_38_20
Synovial chondromatosis or loose body is frequently encountered in the knee, elbow, and shoulder joints. However, hand is a rare localization. It is aimed to present the arthroscopic excision of the loose body inside the first carpometacarpal (CMC) joint. A 47-year-old female patient presented with pain in the left thumb root. The grind test was positive in the patient; however, there were no signs of arthritis in the first CMC joint. Tomography revealed the loose bodies inside the joint. Under traction, CMC joint was palpated, two portals were opened, dry and wet arthroscopy was performed, and loose bodies were extracted. Synovial chondromatosis is a disorder that can be solved arthroscopically and should be kept in mind in hand and wrist pain, which reminds osteoarthritis of the hand and wrist where there are no signs of osteoarthritis in the physical examination and direct radiographs.
Keywords: Arthroscopy, carpometacarpal joint, loose body, synovial chondromatosis
How to cite this article:
Yildiran G, Tosun Z. Arthroscopic removal of synovial chondromatosis of the first carpometacarpal joint. Turk J Plast Surg 2021;29, Suppl S1:53-5 |
| Introduction | |  |
First carpometacarpal (CMC) joint arthroscopy has been safely performed as a result of the advancing technological advances in arthroscopy and arthroscopic equipment. The main indications for first CMC joint arthroscopy are associated with arthritic joints and are resection arthroplasties such as debridement and partial trapeziectomy.
Loose body, synovial chondromatosis, also known as a joint mouse, is frequently encountered in the knee joint.[1],[2] It can be an early sign of osteoarthritis and is often presented with pain. Synovial chondromatosis in the hand and wrist joints are rare, although it was frequently reported that arthroscopically removable loose bodies were seen on the elbow, knee, and shoulder.[3],[4]
In this report, arthroscopic excision of synovial chondromatosis, which causes pain in the first CMC joint, is presented.
| Case Report | | |
A 47-year-old female patient was admitted to our hand surgery clinic because she has been enduring severe pain in her right-hand thumb root for 2 years already. The grind test, circumdiction movement with axial loading was positive in the patient. There was pronounced pain with joint circumdiction and opposition movements. There was no crepitation, she could not pinch. There was no trauma, no history of fracture. In the direct X-ray, no signs of arthritis were observed in the 1st CMC joint, but significant loose bodies were detected in their tomography [Figure 1]a and [Figure 1]b. Arthroscopic loose body excision for the 1st CMC joint of the patient was planned. The abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons in the first dorsal compartment were marked. Under regional anesthesia and tourniquet, the patient was placed in the supine position, and the arm was in the 90° abduction and placed in the thumb traction tower. Under 2.5 kg of traction, the CMC joint was palpated, the 1R portal which is located at the radial aspect of extensor pollicis longus at the level of thumb CMC joint and 1U portal which is located at the ulnar aspect of extensor pollicis longus at the level of thumb CMC joint were opened, immediately in the radial of the APL, and immediately ulnar of the EPB, with their green needle tip (Karl-Storz® Tuttlingen, Germany) [Figure 2]a and [Figure 2]b. Image was obtained by dry and wet arthroscopy with 2.0 mm scope. Joint debridement was performed with 1.9 mm synovial resectors and 5 cc joint irrigation, loose body was determined and excised with grasping forceps [Figure 2]c and [Figure 3]. At the postoperative 6th month, there was no pain, she performed her daily movements normally; there was no recurrence. | Figure 1: (a) Loose body inside the first carpometacarpal joint (arrow), radial side of the joint. (b) Loose body inside the first carpometacarpal joint (arrow), ulnar side of the joint
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 | Figure 2: (a) Under traction, first carpometacarpal joint was palpated and portals were marked with two green needles (red arrows). (b) The scope control of the needles' placement. (c) Bigger loose body extracted from the joint
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 | Figure 3: (a) Handling the scope. (b) Synovial chondromatosis (*) inside the joint. (c) Grasping forceps inside the joint
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| Discussion | | |
The terms of loose body and joint mice are used as the synonyms of synovial chondromatosis. Loose bodies can occur from synovial chondromatosis, osteochondral fracture fragment, and degenerative arthritis.[5] Synovial chondromatoses on the hand are rare.[6] Nakashima et al. reported an osteochondromatosis in the first CMC joint, however, due to its large size, they excised it with an open surgery.[6]
Synovial chondromatosis may cause pain due to the movement of a piece of cartilage or an osseous structure in the joint cavity. Disruption of the structure in this joint may be due to osteoarthritis. In these patients, treatments such as joint debridement, excision of loose bodies, and even partial or total trapeziectomy in Stages II and III may be required.[7] As in the case presented, synovial chondromatosis in patients cause severe pain and functional limitations. The treatment of synovial chondromatosis is the removal of the body. Therefore, arthroscopic debridement and loose body removal seem to be superior compared to an open surgery [Table 1]. Despite that, arthroscopic surgeries require technical infrastructure and surgical experience. In orthopedics and traumatology, knee, shoulder, ankle, and elbow arthroscopies have become routine, and arthroscopic interventions for upper and lower extremities are included in the residents' core training program.[8] However, arthroscopic intervention is not included in the core training program in our country in plastic surgery resident training.[9] However, many patients with hand and wrist pain apply to plastic surgery and hand surgery outpatient clinics. It is known that these pains occur due to traumatic causes such as triangular fibrocartilage complex tears, carpal bone avascular necroses, as well as osteoarthritis in patients who do not give any history of trauma. In the presented case, a synovial chondromatosis could be detected in a patient without a history of trauma. For this, the patient's complaints should be carefully listened, and a complete physical examination for the first CMC joint should be performed. The Grind test is such a test and is important for thumb CMC joint osteoarthritis.[10] Along with the axial loading, the patient performs circumdiction movement, and a marked increase in pain occurs. In the presented patient, the grind test was positive; however, there were no findings belong to osteoarthritis on X-rays such as the increase of osteophytes or sclerosis in the joint space. For this reason, tomography was taken considering that there might be another pathology in the CMC joint range. Arthroscopic excision was planned for loose bodies that were evident in the tomography. | Table 1: Advantages and disadvantages of the open approach vs. arthroscopic approach for the first carpometacarpal joint
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Open surgeries of the first CMC joint are often performed from the dorsoradial side. However, traction of the joint provides very good exposure. If the joint is tracted, loose body excision can be done easily over two portals, no need to open it. It should be noted that performing this surgery for CMC insertion may lead to many problems. In addition to complications such as damage to the dorsal sensory branch of the radial nerve, opening the capsule of the joint inevitably, damaging the joint cartilages, postoperative splinting and rest obligation are important problems. In patients undergoing arthroscopic synovial chondromatosis excision, there is no need for splinting in the postoperative period, no drain is required. The patient's hospitalization duration is short, and pain is low.
Wrist arthroscopies also have disadvantages.[11] Cartilage damage may occur if good traction cannot be achieved or if the surgeon attempted several times for accessing the joint without palpating the joint space. If the portals are not opened from the correct places or behaved inelaborate, the tendons in the first dorsal compartment and the sensory branch of the radial nerve can be damaged. Correct determination of portals and careful attention to additions are absolute necessities.
| Conclusion | | |
Synovial chondromatosis should be kept in mind in case of wrist and wrist pain reminding of osteoarthritis of the hand and wrist, but physical examination and direct X-rays are not observed, additional radiological examination should be made with computed tomography and the diagnosis should be confirmed. Arthroscopic debridement and excision are a good option since it provides early mobilization in patients diagnosed with synovial chondromatosis and less damage to the anatomical structures.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1]
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