IDIOPATHIC CHONDROLYSIS OF H I P
SIV A N A N T H A M A N D KUTTY
IDIOPATHIC CHONDROLYSIS OF THE HIP: CASE REPORT WITH A REVIEW OF THE LITERATURE M. SIVANANTHAM AND M. K A N N A N KUTTY Kuala Luwpur T h e first case o f idiopathic chondrolysis of t h e hip from South-East Asia i s reported, with a review of the literature. T h e problems o f differential diagnosis are discussed. As the condition is rare, it is likely to be misdiagnosed and may well be over-treated. T h e rarity of the condition and its natural history terminating i n spontaneous fusion make it mandatory that a correct preoperative diagnosis be established i n order to avoid needless radical surgery. Some o f t h e significant clinicopathological findings are high I ighted.
WALDENSTROM (1931) is credited with of chonhaving first described three drolysis Of the hip joint associated with slipped upper femoral epiphysis. Since then, however, sporadic reports have appeared in the literature on idiopathic chondrolysis of the hip (jones, 1971 ; Golding, 1973; Heppenstall et alii, 1973j. M o d e and Golding, 1974; Duncan ct a@$, 1975; Wenger et alii, 1975). Although this is now recognized as a definite clinical entity, no complete description of its salient features has been hitherto available in the literature. This is the first report of a case of idiopathic chondrolysis of the hip ( I C H ) from SouthEast Asia, particular emphasis being placed on its clinicopathological features, with a review of the literature.
evidence of active inflammation. The hip was held in the neutral position, and the legs were equal in length. Active movements of the joint were absent, and attempts at passive movements Were limited by pain. All laboratory tests of any possible relevance were carried out, hut results were uniiormly normal. Skiagrams, however, showed periarticular
CLINICALRECORD A no-year-old Indian man was admitted to hospital on November 27, 1974, with a history of spontaneous pain in the right hip joint of six months’ duration. No history of fever, chronic cough, or swelling of the hip was forthcoming. The symptoms disappeared spontaneously, only to recur two months later, with progressive stiffness of the hip accompanied by severe disability. There was no history of trauma a t any time. The patient’s general condition was good. hnsemia and pyrexia were absent, and there was no evideme of lymphadenopathy. Physical examination of the hip showed no healed sinuses, or any Reprints : Dr M. Sivanantham, M.Ch.Orth., F.R.C.S., Consultant Orthopsedic Surgeon, General Hospital, Kiiala Lumpur 03-02, Malaysia.
AIJST. N.Z. J. SURG., VOL.47-N0. HH
2,
APRIL, 1977
FIGURE I : Skiagram of right hip showing periarticular osteoporosis, uniform narrowing of the cartilage space, and subchondral sclerosis with osteophyte formation. 229
I D I O P A T H I C CHONDROLYSIS OF HIP osteoporosis, uniform narrowing of the cartilage space, and subchondral sclerosis and osteophyte formation, the shape of the femoral head and neck being normal (Figure I ) . Exploratory operation of the hip joint on January 7, 1975 showed normal muscles, a thickened capsule with hyperaemia of the synovium, and minimal serous fluid within the joint cavity. Tissue removed for histopathological examination showed cartilage degeneration, avascular necrosis with vascular invasion of the synoviochondral junction, medial hypertrophy of the arterioles of the capsule, and
SIV A N A N T H A M A N D KUTTY commencement of treatment, showed absence ( osteoporosis and fusion of the superior and inferomedial parts of the head (Figure 3 ) . Clinically a t this stage the patient was symptom-free, the hip being painless and fused.
DISCUSSION This subject received little attention until Jones documented nine such cases in 1971.To date there are only 40 cases on record (Table I ) .
FIGURE 2 : (left) photomicrograph showing a segment of vascular invasion of the synoviochondral junction ; (right) photomicrograph showing focal and perivascular collections of chronic inflammatory cells in the capsule (both haematoxylin and eosin, X400). focal and perivascular aggregates of chronic inflam1113torY cells, these inostly being lymphocytes and plasma cells in the capsular and synovial tissues (Figure 2). Bacteriological studies were not performed, as they were not felt to be necessary. After operation the limb was immobilized in functional position in a plaster spica for six months, Serial skiagrams at monthly intervals showed progressive bony ankylosis of the hip joint. The most recent one, taken eight months after
The rarity of idiopathic chondrolysis presents a diagilostic problem, and the condition is apt to be co,lfused with chondrolysis secondary to slipped upper femoral epiphysis, septic arthritis, tuberculous arthritis and juvenile monoarticular rheumatoid arthritis. A definitive diagnosis of idiopathic chondrolysis can only be arrived at by a process of exclusion on clinical, radiological and histological grounds.
230
AUST. N.Z. J. SURG., VOL.47-No.
2,
APRIL,1977
iDIOI'ATi-IIC CHONDROLYSIS O F HIP
Juvenile monoarticular rheumatoid arthritis is considered in some detail because of certain clinicopathological and radiological similarities to ICH. The former condition usually affects the knee joint, as described in most of the published series (Bywaters and Ansell, 1965 ; Calabrow and Marchesano, 1963). More than 90% of cases of this form of rheumatoid arthritis, however, progress to involve other joints, and unlike the polyarthritic variety it follows a relatively benign course, without terminating in joint destruction and bony ankylosis. This patient was diagnosed as suffering from ICH in view of his age, and the clinical pre. sentation with increasing pain and limp of
SIVANANTHAM AND KU?$Y
appearances observed in this patient were similar to those reported by Moule and Golding (1974), but no reference has been made in standard textbooks (Shanks and Kerley, Ig7.I ; Sutton, 1969) to the characteristic radiological appearances associated with the condition. The histopathological findings described by Moule and Golding (1974)and Duncan et alii (1975) were also observed in our patient, The avascular necrosis, a noteworthy feature in this case, has not hitherto been reported. As for its atiology, Golding's TABLEI Cases of I C H Refiorted zn the Literature Authors I. 2.
3. 4. 5.
6.
JonPs .. _ . Golding Heppenstail' et aiii Moule and Golding Duncan et alii .. .. Wenger et alii
Year No. of cases 1971 I973 1973 1974 1975 1975
9
13 2
g
5
2
(1973) suggestion that the condition might be due to a synovial reaction with consequent cartilage destruction in an attempt to remove the immune complexes on the surface layers of the articular cartilage has to be reckoned with. The medial hypertrophy of the capsular arterioles that we observed may be of some ztiological significance. However, its exact ztiopathogenesis still remains speculative. The condition is rare ; as such it may be overlooked or may well be over-treated. A correct diagnosis is necessary in order to avoid needless radical surgery. REFERENCES
FIGURE3 : Skiagram of hip eight months after commencement of treatment, showing absence of osteoporosis and fusion of the superior and inferomedial parts of the femoral head.
gradual onset, leading to progressive stiffness of the hip and culminating in bony fusion. The distinctive radiological findings of uniform narrowing of the cartilage space with normal femoral head contour, coupled with the histopathological features of non-specific synovitis, avascular necrosis and cartilage degeneration without any detectable cause, were the corroborative findings. T h e radiological i\UST.
N.Z. J.
SURC.,
VOL. 47-NO.
2,
APRIL,1977
BYWATERS, E. G. M. and ANSELL,B. M. (1965), Ann. rheum. Dis., 2 4 : 116. CALADROW, J. J. and MARCHESANO, J. M. (1963), Med. Clin. N . Amer., 52: 567. DUNCAN, J. W., SHRANTZ, J. L. and NASCA,R. J. (I975), I . Amer. med. Ass., 231: 382. GOLDING, J. S. R. (1973), I . Bone J t Surg., 5 5 ~ 214. : HEPPENSTALL, R. B., MARVEL,J. P. and CHUNC, S. M. D. (1973), quoted by Duncan et alii (1975), loco citato. JONES, B. S. (1971), S. A f r . med. J., 45: 196. MOULE, N. J. and GOLDING,J. S. R. (1974), Clin. Radiol., 25. SHANKS,S. C. and KERLEY, P. (eds) (1971). A Text Book of X-ray Diagnosis by British Authors, 4th edition, Lewis, London. SUTTON,D. (1969), A Text Book of Radiology, Livingstone, Edinburgh. WALDENSTROM, H. (I931), Acta chir. scand., 67: 936. D. R., MICKELSON, M. R. and PONNELIA, WENGER, I. v. (I975), J . Bone J t surg., 57A: 268. 231
SIV A N A N T H A M A N D KUTTY
IDIOPATHIC CHONDROLYSIS OF THE HIP: CASE REPORT WITH A REVIEW OF THE LITERATURE M. SIVANANTHAM AND M. K A N N A N KUTTY Kuala Luwpur T h e first case o f idiopathic chondrolysis of t h e hip from South-East Asia i s reported, with a review of the literature. T h e problems o f differential diagnosis are discussed. As the condition is rare, it is likely to be misdiagnosed and may well be over-treated. T h e rarity of the condition and its natural history terminating i n spontaneous fusion make it mandatory that a correct preoperative diagnosis be established i n order to avoid needless radical surgery. Some o f t h e significant clinicopathological findings are high I ighted.
WALDENSTROM (1931) is credited with of chonhaving first described three drolysis Of the hip joint associated with slipped upper femoral epiphysis. Since then, however, sporadic reports have appeared in the literature on idiopathic chondrolysis of the hip (jones, 1971 ; Golding, 1973; Heppenstall et alii, 1973j. M o d e and Golding, 1974; Duncan ct a@$, 1975; Wenger et alii, 1975). Although this is now recognized as a definite clinical entity, no complete description of its salient features has been hitherto available in the literature. This is the first report of a case of idiopathic chondrolysis of the hip ( I C H ) from SouthEast Asia, particular emphasis being placed on its clinicopathological features, with a review of the literature.
evidence of active inflammation. The hip was held in the neutral position, and the legs were equal in length. Active movements of the joint were absent, and attempts at passive movements Were limited by pain. All laboratory tests of any possible relevance were carried out, hut results were uniiormly normal. Skiagrams, however, showed periarticular
CLINICALRECORD A no-year-old Indian man was admitted to hospital on November 27, 1974, with a history of spontaneous pain in the right hip joint of six months’ duration. No history of fever, chronic cough, or swelling of the hip was forthcoming. The symptoms disappeared spontaneously, only to recur two months later, with progressive stiffness of the hip accompanied by severe disability. There was no history of trauma a t any time. The patient’s general condition was good. hnsemia and pyrexia were absent, and there was no evideme of lymphadenopathy. Physical examination of the hip showed no healed sinuses, or any Reprints : Dr M. Sivanantham, M.Ch.Orth., F.R.C.S., Consultant Orthopsedic Surgeon, General Hospital, Kiiala Lumpur 03-02, Malaysia.
AIJST. N.Z. J. SURG., VOL.47-N0. HH
2,
APRIL, 1977
FIGURE I : Skiagram of right hip showing periarticular osteoporosis, uniform narrowing of the cartilage space, and subchondral sclerosis with osteophyte formation. 229
I D I O P A T H I C CHONDROLYSIS OF HIP osteoporosis, uniform narrowing of the cartilage space, and subchondral sclerosis and osteophyte formation, the shape of the femoral head and neck being normal (Figure I ) . Exploratory operation of the hip joint on January 7, 1975 showed normal muscles, a thickened capsule with hyperaemia of the synovium, and minimal serous fluid within the joint cavity. Tissue removed for histopathological examination showed cartilage degeneration, avascular necrosis with vascular invasion of the synoviochondral junction, medial hypertrophy of the arterioles of the capsule, and
SIV A N A N T H A M A N D KUTTY commencement of treatment, showed absence ( osteoporosis and fusion of the superior and inferomedial parts of the head (Figure 3 ) . Clinically a t this stage the patient was symptom-free, the hip being painless and fused.
DISCUSSION This subject received little attention until Jones documented nine such cases in 1971.To date there are only 40 cases on record (Table I ) .
FIGURE 2 : (left) photomicrograph showing a segment of vascular invasion of the synoviochondral junction ; (right) photomicrograph showing focal and perivascular collections of chronic inflammatory cells in the capsule (both haematoxylin and eosin, X400). focal and perivascular aggregates of chronic inflam1113torY cells, these inostly being lymphocytes and plasma cells in the capsular and synovial tissues (Figure 2). Bacteriological studies were not performed, as they were not felt to be necessary. After operation the limb was immobilized in functional position in a plaster spica for six months, Serial skiagrams at monthly intervals showed progressive bony ankylosis of the hip joint. The most recent one, taken eight months after
The rarity of idiopathic chondrolysis presents a diagilostic problem, and the condition is apt to be co,lfused with chondrolysis secondary to slipped upper femoral epiphysis, septic arthritis, tuberculous arthritis and juvenile monoarticular rheumatoid arthritis. A definitive diagnosis of idiopathic chondrolysis can only be arrived at by a process of exclusion on clinical, radiological and histological grounds.
230
AUST. N.Z. J. SURG., VOL.47-No.
2,
APRIL,1977
iDIOI'ATi-IIC CHONDROLYSIS O F HIP
Juvenile monoarticular rheumatoid arthritis is considered in some detail because of certain clinicopathological and radiological similarities to ICH. The former condition usually affects the knee joint, as described in most of the published series (Bywaters and Ansell, 1965 ; Calabrow and Marchesano, 1963). More than 90% of cases of this form of rheumatoid arthritis, however, progress to involve other joints, and unlike the polyarthritic variety it follows a relatively benign course, without terminating in joint destruction and bony ankylosis. This patient was diagnosed as suffering from ICH in view of his age, and the clinical pre. sentation with increasing pain and limp of
SIVANANTHAM AND KU?$Y
appearances observed in this patient were similar to those reported by Moule and Golding (1974), but no reference has been made in standard textbooks (Shanks and Kerley, Ig7.I ; Sutton, 1969) to the characteristic radiological appearances associated with the condition. The histopathological findings described by Moule and Golding (1974)and Duncan et alii (1975) were also observed in our patient, The avascular necrosis, a noteworthy feature in this case, has not hitherto been reported. As for its atiology, Golding's TABLEI Cases of I C H Refiorted zn the Literature Authors I. 2.
3. 4. 5.
6.
JonPs .. _ . Golding Heppenstail' et aiii Moule and Golding Duncan et alii .. .. Wenger et alii
Year No. of cases 1971 I973 1973 1974 1975 1975
9
13 2
g
5
2
(1973) suggestion that the condition might be due to a synovial reaction with consequent cartilage destruction in an attempt to remove the immune complexes on the surface layers of the articular cartilage has to be reckoned with. The medial hypertrophy of the capsular arterioles that we observed may be of some ztiological significance. However, its exact ztiopathogenesis still remains speculative. The condition is rare ; as such it may be overlooked or may well be over-treated. A correct diagnosis is necessary in order to avoid needless radical surgery. REFERENCES
FIGURE3 : Skiagram of hip eight months after commencement of treatment, showing absence of osteoporosis and fusion of the superior and inferomedial parts of the femoral head.
gradual onset, leading to progressive stiffness of the hip and culminating in bony fusion. The distinctive radiological findings of uniform narrowing of the cartilage space with normal femoral head contour, coupled with the histopathological features of non-specific synovitis, avascular necrosis and cartilage degeneration without any detectable cause, were the corroborative findings. T h e radiological i\UST.
N.Z. J.
SURC.,
VOL. 47-NO.
2,
APRIL,1977
BYWATERS, E. G. M. and ANSELL,B. M. (1965), Ann. rheum. Dis., 2 4 : 116. CALADROW, J. J. and MARCHESANO, J. M. (1963), Med. Clin. N . Amer., 52: 567. DUNCAN, J. W., SHRANTZ, J. L. and NASCA,R. J. (I975), I . Amer. med. Ass., 231: 382. GOLDING, J. S. R. (1973), I . Bone J t Surg., 5 5 ~ 214. : HEPPENSTALL, R. B., MARVEL,J. P. and CHUNC, S. M. D. (1973), quoted by Duncan et alii (1975), loco citato. JONES, B. S. (1971), S. A f r . med. J., 45: 196. MOULE, N. J. and GOLDING,J. S. R. (1974), Clin. Radiol., 25. SHANKS,S. C. and KERLEY, P. (eds) (1971). A Text Book of X-ray Diagnosis by British Authors, 4th edition, Lewis, London. SUTTON,D. (1969), A Text Book of Radiology, Livingstone, Edinburgh. WALDENSTROM, H. (I931), Acta chir. scand., 67: 936. D. R., MICKELSON, M. R. and PONNELIA, WENGER, I. v. (I975), J . Bone J t surg., 57A: 268. 231
