CASE REPORT OF SECONDARY SYNOVIAL OSTEOCHONDROMATOSIS WITH TWO GIANT LOOSE BODIESAT THE SUBCORACOID SPACE IN LEFT SHOULDER JOINT OF43-YEAR-OLD FEMALE PATIENT

Mahmood A. Qoqandi, Emad A. Elansary, Ahmad A. Alsubahi and Mamdouh E. Almasri MBBS, Medical Resident at Saudi Board of Orthopedic Surgery, Makkah, Saudi Arabia. ...................................................................................................................... Manuscript Info Abstract ......................... ........................................................................ Manuscript History Received: 28 May 2020 Final Accepted: 30 June 2020 Published: July 2020 Synovial Osteochondromatosis is a rare and benign condition of unknown cause. Although large joints such as the knee are commonly affected, involvement of the shoulder joint is not common. Synovial Osteochondromatosis may occur secondary to preexisting joint disorders. This article reviews detailed history, examination and investigations of 43 years-old female patient known case of rheumatoid arthritis, diagnosed with loose bodies in her shoulder joint. The present report aimed to highlight the occasional involvement of subcoracoid space of the shoulder as site of loose bodiesand indicated arthroscopy for retrieval of the loose bodieswith favorable outcome. Ethical consideration: The patient was informed that data from the case would be submitted for publication, and she gave her consent. Conflicts of interest: none. Copy Right, IJAR, 2020,. All rights reserved.


ISSN: 2320-5407
Int. J. Adv. Res. 8(07), 1523-1527 1524 In Saudi Arabia, there are low number of synovial Ostoechondromatosis cases in shoulder joints. (9,10) This is the case report with detailed history, examination of 43 years-old female patient with loose bodies in her shoulder joint. The present report aimed to highlight on occasional involvement of sub-coracoid space of the shoulder as site of loose bodies and challenged arthroscopic surgical techniques that utilized as a surgical management approach for this case.
Report of the case: Clinical presentation and history: 43 years old female known case of Rheumatoid Arthritis on medications, presented to the orthopedic clinic with a two-year history of progressive left shoulder pain. Her symptom was bad enough to disturb her daily activities and usually she needs help in wearing and donning her clothes. There is no history of trauma and during this time, she did not get any improvements with conservative treatment including medication and physiotherapy.

Examination:
On examination, there was generalized tenderness over the shoulder and affected range of movement; her range of movement was restricted when compared to the other side. Flexion was up to100 degrees, and external rotation was limited to 50 degrees. Internal rotation was up to the point where the patient's hand touched her back at the level of the iliac crest. Clinical examination of the rotator cuff did not reveal any abnormalities and the rotator cuff power was normal.

Investigations and Procedure:
Initial X ray radiographs revealed that there were findings of glenohumeral arthritis at the left shoulder with no presence of loose bodies (Fig. 1).CT scan and Magnetic resonance imaging (MRI) also showed sever arthritic changes with destruction of the left humeral head. However, the CT scan and MRI ( Fig.2 and Fig. 3) performed for assessing bone stock of glenoid and overall assessment of articular joint and rotator cuff integrity. The advanced radiological imaging showed two giant loose bodies in the sub-coracoid space that had not been seen in plain X rays.
Options were discussed with the patient and she was keen to get her shoulder symptoms improved, as she had failed all non-operative treatment. And due to her age, she was not a candidate for arthroplasty. therefore, A left shoulder arthroscopy was performed, with the patient under general anesthesia, and in beach chair position. Arthroscopic left shoulder debridement along with anterior and posterior capsular release with sub acromial decompression and acromioplasty were performed to relieve patient's symptoms and improve the range of movement. Moreover, biceps tenotomy of inflamed and degenerated long head of biceps was performed. Two large loose bodies at the subcoracoid space had been removed (Fig. 4) through extendedstandard lateral arthroscopy portal.

Postoperative Management and Follow-up:
Following the surgery, the patient had a good initial improvement without post-operative complications, with a physical therapy plan aiming for improving range of motion. The patient then developed paresthesia and numbness over left side of the body and she was referred to a neurologist for further investigations that came up of no relation with our procedure. The patient was informed that data from the case would be submitted for publication.

Discussion:-
Synovial Osteochondromatosis is an uncommon condition characterized by the formation of multiple cartilaginous nodules within the synovium;after rigorous literature review, it was cleared that our understanding of this condition primarily is based on case reports and small case series studies.
Synovial Osteochondromatosis most commonly affecting large joints such as the knee and hip, involvement of the shoulder joint is a rare entity. (3) Moreover, it has a higher prevalence in the male sex and occurs between the third and the fifth decade. (1,2) The present case is female in the 40s of her age with pre-existing chronic health condition of rheumatoid arthritis and she had loose bodies in subscapular bursa where the communication with the joint cavity between the superior and middle glenohumeral ligaments. Presence of loose bodies is a contributing factor along with mainlyher gleno-humeral arthritis as the reasons behind the chronic progressive joint pain and movement restriction.
The loose bodies' characteristic of this condition are easily confirmed on plain radiographs and CT if they are calcified or ossified, (11,12) while MRI is useful in the identification of non-calcified and no ossified foci. (13,14) In the present case, the CT and MRI radiological imaging showed two giant loose bodies in the sub coracoid space that not had been seen in plain X rays.
In context of treatment, the classical treatment for synovial Osteochondromatosis is open arthrotomy, synovectomy and complete removal of the free fragments. (1, 2) For retrieval of loose bodies,there has been considerable debate over whether an arthroscopic procedure is better than an open procedure. (15) However, there is no clear evidence that an open procedure, with or without synovectomy, offers any advantage.On the other side,the advantages of arthroscopic treatment include good visualization, low morbidity, rapid healing and early rehabilitation. (16) Indications for arthroscopic treatment have been extended with recent advances in methods of arthroscopic techniques. (17) Furthermore, removal of loose bodies with partial synovectomy and joint reconstruction of the involved joints results in decreased pain, improved mechanical function, and decreased swelling in most cases.Rare re-occurrence is reported following surgical management with partial synovectomy. (18,19) The present patient underwent to arthroscopic left shoulder debridement, capsular release,biceps tenotomy, sub acromial decompression,acromioplasty and removal of loose bodies, future wise she is indicated for arthroplasty. her clinical condition and her age were considered for total shoulder arthroplasty over reverse total shoulder arthroplasty.

Conclusion:-
Synovial Osteochondromatosis is health condition that can present with joint pain and movement limitation and is best managed by an orthopedic surgeon. Presence concomitant with joint arthritis is possible and can aggravate symptoms. Plain radiographs alone for diagnosis might not be enough and further imaging modalities would be advised. (i.e. MRI for assessment of non-ossifying loose bodies) Advantages of arthroscopic surgical technique islesser morbidity, early rehabilitation, and faster recovery compared to open surgery. However, occasionally in certain conditionsopen procedures may be necessary.