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J Orthop Sci (2005) 10:422–424 DOI 10.1007/s00776-005-0904-x Case report Multiple loose bodies in the elbow showing a snow storm appearance at arthroscopy Denju Osada, Kazuya Tamai, Yuichiro Yano, and Koichi Saotome Department of Orthopaedics, Dokkyo University School of Medicine, 880 Kitakobayashi, Mibu, Shimotsuga, Tochigi 321-0293, Japan (MRI) showed effusion of the elbow joint and bone defect of the capitellum but did not show any loose bodies (Fig. 2). Arthroscopy showed multiple brilliant white floating loose bodies that looked just like a snow storm (Fig. 3). There was a defect of the articular cartilage on the capitellum. The synovium was reddened but was other- wise normal; it did not show any cartilage nodules. The hundreds of loose bodies were washed out. All the loose bodies looked alike, ranging in size from minute parti- cles to 3-mm lobulated grains (Fig. 4). The elbow joint was then mobilized. Pathologic examination showed that the loose bodies were nodular chondroid matrix with plump chondro- cytes, and they lacked calcification (Fig. 5). The loose bodies also lacked zonal ring-like metaplastic cartilage underlying the layer of connective tissue. There was no layering, calcification, or evidence of remodeling of the bodies to suggest that they had been present for any length of time. There was no evidence of chondroid metaplasia in the synovial membrane. At 14 months postoperatively, he had neither pain nor swelling of his right elbow. The active range of motion of the elbow was 120° of flexion and -15° of extension. The radiographs showed neither free bodies nor new osteophytes. Discussion Most cases of multiple loose bodies have been diag- nosed as synovial chondromatosis, a condition that has never been well defined. 2,3 Jaffe 4 reported that the synovium had to have activity-producing chondroma- tous bodies at the time of operation for this diagnosis. Others made the diagnosis from the presence of loose bodies alone, with no synovial abnormality. 5,6 Milgram 7 proposed a temporal sequence of three phases, and the disease is thought to progress through Introduction Multiple loose bodies are usually attributed to synovial chondromatosis. Kay et al. 1 introduced four patients with “snow storm knee” in whom hundreds of brilliant white loose bodies were discovered by arthroscopy of the knee, representing a new, discrete clinical and pathological entity. We present a case of hundreds of brilliant white loose bodies discovered by arthroscopy of the elbow and discuss a possible diagnosis, giving histological, historical, and clinical evidence that this may be “snow storm elbow.” Case report A 47-year-old male farmer, a karateist of the eighth rank who had trained for 28 years, initially presented to our department with a 1-year history of pain and stiff- ness in his right elbow after a minor karate injury. There was tenderness of the olecranon and the medial and lateral joint space of the elbow. He felt pain at the end of a flexion or extension motion, and the active range of motion of the elbow was limited to 105° of flexion and -25° of extension. Supination and pronation move- ments were normal, as was neurologic examination of the upper limb. Consent for publication has been obtained from the patient. Radiographs showed a radiolucent area at the capitellum and slightly osteoarthritic change, but there were no free bodies (Fig. 1). Sagittal computed tomog- raphy of the elbow joint showed a subchondral bone defect of the capitellum. Magnetic resonance imaging Offprint requests to: D. Osada Received: September 2, 2004 / Accepted: March 11, 2005

Multiple loose bodies in the elbow showing a snow storm appearance at arthroscopy

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Page 1: Multiple loose bodies in the elbow showing a snow storm appearance at arthroscopy

J Orthop Sci (2005) 10:422–424DOI 10.1007/s00776-005-0904-x

Case report

Multiple loose bodies in the elbow showing a snow storm appearanceat arthroscopy

Denju Osada, Kazuya Tamai, Yuichiro Yano, and Koichi Saotome

Department of Orthopaedics, Dokkyo University School of Medicine, 880 Kitakobayashi, Mibu, Shimotsuga, Tochigi 321-0293, Japan

(MRI) showed effusion of the elbow joint and bonedefect of the capitellum but did not show any loosebodies (Fig. 2).

Arthroscopy showed multiple brilliant white floatingloose bodies that looked just like a snow storm (Fig. 3).There was a defect of the articular cartilage on thecapitellum. The synovium was reddened but was other-wise normal; it did not show any cartilage nodules. Thehundreds of loose bodies were washed out. All the loosebodies looked alike, ranging in size from minute parti-cles to 3-mm lobulated grains (Fig. 4). The elbow jointwas then mobilized.

Pathologic examination showed that the loose bodieswere nodular chondroid matrix with plump chondro-cytes, and they lacked calcification (Fig. 5). The loosebodies also lacked zonal ring-like metaplastic cartilageunderlying the layer of connective tissue. There was nolayering, calcification, or evidence of remodeling of thebodies to suggest that they had been present for anylength of time. There was no evidence of chondroidmetaplasia in the synovial membrane.

At 14 months postoperatively, he had neither painnor swelling of his right elbow. The active range ofmotion of the elbow was 120° of flexion and -15° ofextension. The radiographs showed neither free bodiesnor new osteophytes.

Discussion

Most cases of multiple loose bodies have been diag-nosed as synovial chondromatosis, a condition that hasnever been well defined.2,3 Jaffe4 reported that thesynovium had to have activity-producing chondroma-tous bodies at the time of operation for this diagnosis.Others made the diagnosis from the presence of loosebodies alone, with no synovial abnormality.5,6

Milgram7 proposed a temporal sequence of threephases, and the disease is thought to progress through

Introduction

Multiple loose bodies are usually attributed to synovialchondromatosis. Kay et al.1 introduced four patientswith “snow storm knee” in whom hundreds of brilliantwhite loose bodies were discovered by arthroscopy ofthe knee, representing a new, discrete clinical andpathological entity. We present a case of hundreds ofbrilliant white loose bodies discovered by arthroscopyof the elbow and discuss a possible diagnosis, givinghistological, historical, and clinical evidence that thismay be “snow storm elbow.”

Case report

A 47-year-old male farmer, a karateist of the eighthrank who had trained for 28 years, initially presented toour department with a 1-year history of pain and stiff-ness in his right elbow after a minor karate injury. Therewas tenderness of the olecranon and the medial andlateral joint space of the elbow. He felt pain at the endof a flexion or extension motion, and the active range ofmotion of the elbow was limited to 105° of flexionand -25° of extension. Supination and pronation move-ments were normal, as was neurologic examination ofthe upper limb.

Consent for publication has been obtained from thepatient.

Radiographs showed a radiolucent area at thecapitellum and slightly osteoarthritic change, but therewere no free bodies (Fig. 1). Sagittal computed tomog-raphy of the elbow joint showed a subchondral bonedefect of the capitellum. Magnetic resonance imaging

Offprint requests to: D. OsadaReceived: September 2, 2004 / Accepted: March 11, 2005

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Page 2: Multiple loose bodies in the elbow showing a snow storm appearance at arthroscopy

423D. Osada et al.: Multiple loose bodies in elbow

each phase in turn. On the other hand, Villacin et al.8

stated that chondrocytes of loose bodies in primarysynovial chondromatosis were usually hypercellular,plump, and binucleated. Chondrocytes in loose bodiesof secondary synovial chondromatosis were uniform in

Fig. 1. Anteroposterior radiograph showing the radiolucentarea at the capitellum of the humerus and slight osteophyte atthe ulnohumeral joint

Fig. 2. Sagittal short inversion-time inversion recovery(STIR) magnetic resonance images show severe joint effusionand small subchondral cyst of the capitellum, but they do notshow multiple intraarticular loose bodies

Fig. 3. Arthroscopy showing multiple brilliant white, loose,floating bodies

Fig. 4. Portion of multiple loose bodies

Fig. 5. Microscopic appearance of a loose body usinghematoxylin and eosin labeling with clusters of activechondrocytes. ¥100

Page 3: Multiple loose bodies in the elbow showing a snow storm appearance at arthroscopy

424 D. Osada et al.: Multiple loose bodies in elbow

appearance, evenly distributed, and not plump. Fre-quently, extensive concentric rings of calcification werepresent, with scattered empty cartilaginous lacunaewithin.

Kay et al.1 described four patients in whom hundredsof brilliant white loose bodies were discovered byarthroscopy of the knee after a short (a few months)history of pain and crepitus. All the loose bodies fromthese cases looked alike, ranging in size from minuteparticles to 5-mm lobulated grains. Histological exami-nation of the loose bodies supported the diagnosis ofprimary synovial chondromatosis, but the synovium wasbasically normal. Kay et al. emphasized that these loosebodies may represent a new, discrete clinical andpathological entity, and they proposed the term “snowstorm knee,” referring to the dramatic arthroscopicappearance.

Our case is similar to that of Kay et al. in terms ofthe hundreds of brilliant white loose bodies, the varyingsize of the loose bodies, and the apparently normalsynovium. The present patient had osteoarthritis ofthe elbow joint, so the diagnosis could be secondarychondromatosis. Histologically, however, our patientdisplayed characteristics of primary synovialchondromatosis,8,9 although clinically the case did notfit comfortably within Milgram’s classification. If thiscase were to fall into phase III, a transition through thethree phases of the disease would be unlikely during hisshort medical history. The patients of phase I or II inMilgram’s original article had histories of about 3 years,on average, and the recent literature suggests similardurations.10,11 Because the loose bodies in the currentcase lacked any changes associated with time, it is morelikely that they were formed recently. Pathological find-ings are suggestive of active chondrocyte replicationwith synthesis of a somewhat abnormal matrix. Thesynovial fluid seems to be acting as a culture medium forchondrocyte growth.2,12 There was no histological evi-dence to suggest a synovial origin for the loose bodies.On the other hand, the bone defect of the capitellumseemed to be osteochondritis dissecans by radiographyand MRI. However, arthroscopy showed only a defectof the articular cartilage on the capitellum and no dis-section of cartilage or subchondral bone, so the diagno-sis could not be osteochondritis dissecans. The currentcase is similar to the four cases of Kay et al.; therefore,the term “snow storm elbow” is appropriate. There is noprevious report, to our knowledge, that has describedsuch pathology in the elbow joint.

We approve of the view by Kay et al. that the loosebodies are the result of chondrocyte culture in the syno-vial fluid of the elbow joint. Minor trauma is probablythe initiating factor, damaging the articular cartilage

and allowing the subsequent release of cartilage andchondrocytes into the synovial fluid.1

Jazrawi et al.13 suggested that MRI improves theaccuracy of the preoperative diagnosis of synovialchondromatosis because it shows the lesion as either amultiloculated mass or multiple intraarticular loosebodies. However, the loose bodies of the present casewere not identified by MRI because they were toosmall. This is one of the unique characteristics of ourpatient.

Conclusion

This case may be referred to as “snow storm elbow.”We propose that these loose bodies represent a new anddiscrete clinical and pathological entity, similar to theknee joint lesion presented by Kay et al.1

No benefits in any form have been received or will be receivedby a commercial party related directly or indirectly to thesubject of this article.

References

1. Kay PR, Freemont AJ, Davies DRA. The aetiology of multipleloose bodies: snow storm knee. J Bone Joint Surg Br 1989;71:501–4.

2. Jones HT. Loose body formation in synovial osteochondromato-sis with special reference to the etiology and pathology. J BoneJoint Surg 1924;6:407–58.

3. McIvor RR, King D. Osteochondromatosis of the hip joint. JBone Joint Surg Am 1962;44:87–97.

4. Jaffe HL. Synovial chondromatosis and other benign articulartumors. In: Tumors and tumorous conditions of the bones andjoints. Philadelphia: Lea & Febiger; 1958. p. 558–67.

5. Wilmoth CL. Osteochondromatosis. J Bone Joint Surg 1941;23:367–74.

6. Mussey RD Jr, Henderson MS. Osteochondromatosis. J BoneJoint Surg Am 1949;31:619–27.

7. Milgram JW. Synovial osteochondromatosis: a histopathologicalstudy of thirty cases. J Bone Joint Surg Am 1977;59:792–801.

8. Villacin AB, Brigham LN, Bullough PG. Primary and secondarysynovial chondrometaplasia: histopathologic and clinicoradio-logic differences. Hum Pathol 1979;10:439–51.

9. Saotome K, Tamai K, Koguchi Y, Sakai H, Yamaguchi T. Growthpotential of loose bodies: an immunohistochemical examinationof primary and secondary synovial osteochondromatosis. JOrthop Res 1999;17:73–9.

10. Sviland L, Malcolm AJ. Synovial chondromatosis presenting aspainless soft tissue mass: a report of 19 cases. Histopathology1995;27:275–9.

11. Mueller T, Barthel T, Cramer A, Werner A, Gohlke F. Primarysynovial chondromatosis of the elbow. J Shoulder Elbow Surg2000;9:319–22.

12. Barrie HJ. Intra-articular loose bodies regarded as organ culturesin vivo. J Pathol 1978;125:163–9.

13. Jazrawi LM, Ong B, Jazrawi AJ, Rose D. Synovial chondro-matosis of the elbow. Am J Orthop 2001;30:223–4.