Cameron Ballard, OMS 2028; Adam Youssef, OMS 2028; Dryden Dalbey, OMS 2028; Paul Doney, OMS 2028; Jeffrey Staudinger, PhD
Kansas City University College of Osteopathic Medicine

Abstract

Background
Synovial chondromatosis is a rare, benign condition in which synovium transforms into cartilaginous nodules that may detach as loose, intra-articular bodies, resulting in pain, swelling, and restricted motion. Although it most commonly affects the knee and hip, its occurrence in the upper extremity is rare, leading to mismanagement and delayed diagnosis. This study aims to identify optimal treatment strategies for synovial chondromatosis of the upper extremity based on joint involvement and recurrence. 

Methods
A PRISMA‑guided systematic review identified 74 case reports/series of upper‑extremity synovial chondromatosis in PubMed, Embase, and Scopus. Titles, abstracts, and full texts were screened to include studies examining the affected joint, treatment, and outcomes. Data was synthesized descriptively to evaluate joint involvement, treatment strategies, and recurrence rates by anatomical location.

Results
97 upper‑extremity synovial chondromatosis cases were identified: shoulder (56), elbow (18), biceps tendon sheath (18), hand (3), and wrist (2). Among shoulder cases, 38 arthroscopic procedures, including synovectomy (± capsular release or acromioplasty), debridement (± loose‑body removal), and related approaches, had a 10.5% recurrence (4/38) with three after synovectomy and one after arthroscopic removal. Open procedures (9), reverse arthroplasty (2), and conservative management (3) showed no recurrences. All elbow cases were recurrence-free, except for a malignant transformation after radiosynovectomy. Excisions in the biceps sheath (18), hand (3), and wrist (2) showed zero recurrences.

Conclusion
Arthroscopic and open techniques provided effective treatment of synovial chondromatosis in the shoulder, elbow, wrist, hand, and tendon‑sheath locations, with a recurrence risk of 10.5% of arthroscopy-related approaches. This may reflect greater synovial surface area and increased joint complexity within proximal joints leading to inadequate excision via arthroscopy. Selection of arthroscopic, combined, or open procedures should be guided by joint anatomy and disease extent with the importance of long-term follow-up to monitor recurrence. 

Keywords: Synovial chondromatosis, Upper Extremity, Shoulder Arthroscopy, Synovectomy, Recurrence Rate, Systematic Review

Introduction
Synovial chondromatosis is a rare, benign joint disorder characterized by the transformation of synovial membrane into cartilaginous nodules. These nodules may calcify and either remain attached to the synovium or detach as loose bodies within the affected joint (5). While the condition most commonly affects weight-bearing joints such as the knee and hip, involvement of the upper extremity, including the shoulder, elbow, wrist, and interphalangeal joints are much less common and may lead to diagnostic difficulties and suboptimal management (3, 8, 25). Therefore, understanding joint-specific treatment outcomes may aid in optimizing surgical decision-making for rare cases such as these. 

Due to the rarity of upper extremity involvement, there is no standardized treatment approach. Reported strategies range from conservative management to surgical options, including arthroscopic removal, open debridement, and partial or complete synovectomy. Outcomes vary depending on the joint involved, disease severity, and surgical technique. A previous review article published in 2013 in the Journal of Hand Surgery evaluated synovial chondromatosis within the upper extremity. However, newly reported cases and advancements in surgical techniques permit an additional analysis (75). The purpose of this systematic review was to synthesize available case-level evidence to identify treatment strategies for synovial chondromatosis of the upper extremity based on joint involvement and recurrence.

Methods

Study Design and Objective
This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (Figure 1). The objective was to synthesize published case reports and case series describing synovial chondromatosis of the upper extremity, with a focus on the joint affected, surgical techniques used, clinical outcomes, and recurrence rates. 

Search Strategy and Data Sources
A comprehensive search of PubMed, Embase, and Scopus was conducted between May and June 2025 to identify all case reports describing synovial chondromatosis of the upper extremity, including the shoulder, elbow, wrist, interphalangeal joints, and biceps tendon sheath. The search strategy was developed in consultation with a medical librarian to ensure inclusion of both indexed terms and relevant free-text keywords. No publication date restrictions were applied. Conflicts during screening or full-text review were resolved through consensus.

Inclusion Criteria
(1) Published case reports and/or small case series; (2) patients of any age/sex; (3) upper-extremity synovial chondromatosis; (4) description of management or surgical technique; (5) English language or English translation.

Exclusion Criteria
(1) Retrospective cohort studies and large series without patient-level detail; (2) reviews; (3) non-upper-extremity joints; (4) non-human studies, letters, or articles without management details; (5) low-quality reports by JBI appraisal.

Outcome Measures
The primary outcomes assessed in this PRISMA-guided systematic review were: (1) the specific joint involved in the upper extremity, (2) the surgical technique or management approach used, and (3) the clinical outcome following treatment for synovial chondromatosis. 

Data Extraction and Analysis
Titles and abstracts were screened independently by two authors to determine eligibility using a web-based systematic review platform (Rayyan). Articles meeting the initial criteria underwent full-text review to confirm inclusion. The selection process is detailed in the PRISMA flow diagram (Figure 1). 

Data extraction was performed independently to ensure consistency, using the following variables: author year/publication, joint affected, surgical approach, treatment outcome, and recurrence status (if reported). Missing data was noted as “Not reported”. A summary of the extracted data is presented in Table 1.

Treatment outcomes were considered successful if there was no recurrence of symptoms or no evidence of loose bodies on postoperative imaging. Surgical interventions were also evaluated in relation to the specific joint involved.  Due to several cases involving multiple surgical techniques or multi-site disease, treatment categories were not mutually exclusive. Therefore, the figures reflect procedural frequency rather than unique patient counts. 

Search Strategies
Search strategies were tailored to each database using appropriate syntax. The following are the exact search strings used:

• PubMed:
   (“Synovial chondromatosis”[Mesh] OR “synovial chondromatosis”[tiab] OR “primary synovial chondromatosis”[tiab] OR (synovial[tiab] AND chondromatosis[tiab]))
  AND
  (shoulder[tiab] OR elbow[tiab] OR glenohumeral[tiab] OR humerus[tiab] OR olecranon[tiab] OR “upper extremity”[tiab])
  AND
  (surgery[tiab] OR arthroscopy[tiab] OR “open excision”[tiab] OR synovectomy[tiab] OR management[tiab] OR excision[tiab] OR treatment[tiab] OR intervention[tiab])

• Embase:
  (‘synovial chondromatosis’/exp OR ‘synovial chondromatosis’:ti,ab OR ‘primary synovial chondromatosis’:ti,ab OR (synovial:ti,ab AND chondromatosis:ti,ab))
   AND
  (shoulder:ti,ab OR elbow:ti,ab OR glenohumeral:ti,ab OR humerus:ti,ab OR olecranon:ti,ab OR ‘upper extremity’:ti,ab)
  AND
  (surgery:ti,ab OR arthroscopy:ti,ab OR ‘open excision’:ti,ab OR synovectomy:ti,ab OR management:ti,ab OR excision:ti,ab OR treatment:ti,ab OR intervention:ti,ab)

• Scopus:
  TITLE-ABS-KEY ( “synovial chondromatosis” OR “primary synovial chondromatosis” AND shoulder OR elbow OR glenohumeral OR humerus OR olecranon OR “upper extremity” AND surgery OR arthroscopy OR “open excision” OR synovectomy OR management OR excision OR treatment OR intervention )
  AND ( LIMIT-TO ( SUBJAREA , “MEDI” ) )
  AND ( LIMIT-TO ( LANGUAGE , “English” ) )

Assessment of Bias
Risk of bias was independently determined through two reviewers using the Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Case Reports, which evaluates quality and potential sources of bias to determine the reliability of individual studies. Each article was scored on an 8-point scale:

• 7–8 points: high quality
• 4–6 points: moderate quality
• ≤3 points: low quality

Only studies rated as high or moderate quality were included to ensure methodological rigor and reliability of the findings.

Reporting Bias Assessment
Due to the inclusion of case reports/case series with no quantitative synthesis being performed, a formal assessment of reporting bias was not executed. 

Certainty Assessment
A formal certainty assessment was not performed due to the descriptive nature of the case reports/case series along with no comparison nor pooled statistical analyses. 

Results

Study Selection
A total of 119 articles were identified through searches of PubMed, Embase, and Scopus. Following title/abstract screening and full-text review by two independent reviewers, 74 case reports (Table 1)  met all inclusion criteria and were included in the final analysis; 67 were rated high quality and 7 were rated as moderate quality using the JBI checklist.

Table 1: Overview of 74 cases of Synovial Chondromatosis within the upper extremity by location, surgical technique/treatment, and outcome.

Data Synthesis and Analysis
Due to the rarity of synovial chondromatosis within the upper extremity and heterogeneity in reporting, a meta-analysis was not feasible. No formal exploration of the heterogeneity within the reporting was explored and no sensitivity analyses were conducted. The data was descriptively analyzed by (1) anatomical location of the condition, (2) surgical technique or other treatment modalities, and (3) reported outcomes. Patterns were examined to determine treatment effectiveness by joint. Recurrence was defined as either radiographic or symptomatic reappearance as reported in the follow-up with the patient. 

Origin of Synovial Chondromatosis
Based on the included case reports within this study, a total of 97 cases of upper-extremity synovial chondromatosis were identified (Figure 1), as several reports described multiple 

patients, and some patients had involvement of more than one anatomic site. Presentation within the shoulder predominated as the synovial chondromatosis showed its presence in 56 cases, followed by the elbow and biceps/biceps tendon sheath at 18 cases each. The remaining five cases involved the hand and wrist, with the condition appearing in three cases and two cases, respectively.

Treatment Strategy
Among the patients who were treated for synovial chondromatosis within the upper extremity, the shoulder was the region most frequently affected (Figure 2). Among the 56 cases of synovial chondromatosis within the shoulder, arthroscopic procedures occurred 38 total times, including arthroscopic subtypes. Arthroscopic approaches included synovectomy alone, synovectomy with capsulotomy, synovectomy with arthrotomy, synovectomy with debridement, synovectomy combined with debridement and acromioplasty, debridement alone, loose-body removal, arthroscopy with acromioplasty, arthrography with synovectomy, and complete labral debridement with synovectomy. Conservative procedures were performed in 3 cases, reverse arthroplasty with synovectomy in 2 cases, and open procedures in 9 cases. The counts reflect individual surgical techniques, as each procedure can be visualized within Figure 3. 

A total of 18 elbow cases were shown to have the occurrence of synovial chondromatosis. Within this region, arthroscopic procedures were shown to make up the majority, with arthroscopic synovectomy (n = 4), arthroscopic debridement (n = 2), and arthroscopic removal (n = 3) performed. Of the open approaches, arthrotomy with synovectomy was utilized the most, with a total of five cases, and arthrotomy alone was used in three cases. Additionally, a single case used radiosynovectomy as a procedure for synovial chondromatosis, but progression to secondary chondrosarcoma occurred, requiring amputation.

In terms of synovial chondromatosis within the biceps/biceps tendon sheath, there were a total of 18 occurrences. The arthroscopic approaches included synovectomy (n = 2), debridement (n = 1), synovectomy with debridement (n = 3), arthrotomy (n = 2), and arthroscopic removal (n = 1). Open approaches included arthrotomy (n = 3), arthrotomy with debridement and synovectomy (n = 1), open synovectomy (n = 1), open synovectomy with allograft insertion (n = 1), and excisional biopsy (n = 1). 

Synovial chondromatosis occurred within the wrist in only two cases, in which one patient underwent an open excision due to swelling, while the other was initially managed conservatively with nonsteroidal anti-inflammatory drugs without symptomatic improvement and subsequently underwent open synovectomy. Three total cases involved the hand/interphalangeal joints with the use of partial synovectomy (n = 1), excisional biopsy (n = 1), and arthrodesis (n = 1). 

Outcome/Recurrences
Recurrence of synovial chondromatosis following treatment was rare; however, when recurrence occurred, it predominated in the shoulder. Specifically, three recurrences occurred when arthroscopic removal with complete/partial synovectomy was utilized, and one recurrence occurred when arthroscopic removal was performed as treatment for synovial chondromatosis in the shoulder. In contrast, other surgical approaches, including open, combined, and arthroplasty-based intervention showed no signs of recurrence. In terms of the elbow, no recurrences took place within arthroscopic or open procedures, but one case documented progression of malignant transformation to chondrosarcoma after radiosynovectomy. Notably, all cases involving the biceps/biceps tendon sheath, wrist, and hand/interphalangeal joints documented zero recurrences across the diverse treatment strategies. Finally, one shoulder case reported recurrent symptoms but did not undergo further evaluation due to patient preference, and three case reports did not specify postoperative outcomes.

Discussion
This systematic review consisted of 74 case reports and series across various databases, including PubMed, Embase, and Scopus. The findings confirmed that the shoulder was the most affected site of synovial chondromatosis in the upper extremity. Involvement of the elbow and biceps/biceps tendon sheath followed, but involvement in the wrist/hand displayed a rare occurrence of this condition. The dominance of proximal joint involvement may be related to the increased synovial surface area and complexity of the joint anatomy compared to the more distal joints.

Management strategy varied when treating the shoulder. The most common approach was arthroscopic synovectomy, reflecting the minimally invasive nature and ability to visualize the joint. However, the majority of recurrences took place under this procedure, indicating the possibility that the arthroscopic technique alone might not completely eradicate the synovium of synovial chondromatosis. Other procedures may need to be combined with arthroscopy to eliminate the synovium, leading to superior long-term outcomes for patients. 

The elbow was the next most frequently involved site. Similarly, arthroscopic procedures predominated, but both arthroscopic and open procedures showed no evidence of recurrence. These findings suggest that while both approaches can produce favorable outcomes, arthroscopic management may be preferable given its minimally invasive nature and reduced surgical morbidity. There was one recurrence of progression to secondary chondrosarcoma when radiosynovectomy was performed, but a cause-and-effect analysis was not determined within the case report. 

The biceps/biceps tendon sheath, wrist, and hand all showed zero recurrences regardless of treatment approach. This could be due to a small joint space, allowing for complete excision compared to the shoulder joint. 

Collectively, arthroscopic synovectomy provided the majority of the interventions, but it also consisted of a higher recurrence rate. Therefore, arthroscopy alone may not provide complete excision of the synovium as it would with other combined approaches. However, distal joints showed favorable outcomes with a diverse set of treatment procedures reflecting complete excision within this small joint space. 

Limitations
This systematic review is subject to many limitations. First, the topic of the systematic review is of a rare condition described within the upper extremity. Therefore, the power of the meta-analysis was restricted, allowing for only a descriptive analysis to take place. Second, there is a risk for publication bias, as many of these presentations are atypical presentations. Third, follow-up duration was variable, which may allow for underestimation of recurrence rates for the treatment of this specific condition. Lastly, since only English-language/translated case reports/series were included, the exclusion of non-English publications may result in missed cases.

Conclusion
These findings show the importance of personalized treatment planning in terms of synovial chondromatosis in the upper extremity.  Therefore, careful selection of arthroscopy, combined, or open procedures should be guided by a variety of factors, including joint anatomy, extent of the condition, and other patient-specific factors contributing to the outcome. Additionally, these cases highlight the importance of long-term follow-up to monitor for recurrence or other transformations. Follow-up duration was highly variable ranging from a low of 9 days to a high of 11 years, with a median follow-up of approximately 1 year among included studies. However, interpretation is limited due to the inconsistent reporting across the included case reports. Further multicenter studies are needed to define treatment plans for evidence-based care. Increased awareness and consistent reporting practices are needed to guide future management and clarify recurrence risk.

Other Information
The systematic review was not formally registered in PROSPERO or other international databases. The authors received no external funding for the research or publication of this scientific article. The authors declare no competing interests and all information analyzed within this study are published articles. 

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