Joint Pain, Severe Cartilage Destruction, and Chondrolysis: Guidelines for Improving Diagnostic Differentiation and Clinical Management (SS-22)

Abstract

Introduction Joint pain and concomitant function loss are among the most common complaints encountered by orthopedic surgeons. One emerging condition in which an entire joint is affected by cartilage loss accompanied by joint pain, stiffness, and limited range of motion is the clinical syndrome known as "chondrolysis." However, globally, the diagnosis of chondrolysis has been loosely applied to varying degrees of cartilage loss severity, resulting in inappropriate "pooling" of multiple conditions related to cartilage pathology under the same diagnosis. The purpose of this study was two-fold: (a) to examine variations in the clinical criteria applied by surgeons to diagnose chondrolysis across joints, and (b) to provide a set of clinical guidelines to standardize the diagnostic differentiation of chondrolysis among the orthopedic community. Methods A systematic literature review between 1930 to 2010 identified 127 published reports of joint chondrolysis. In totality, the reports involved 825 joints including the hip (n=621), shoulder (n=171), knee (n=29), ankle (n=3), and elbow (n=1). A myriad of clinical and demographic characteristics were extracted to determine variations in the criteria applied to differentially diagnose joint chondrolysis from other articular cartilage pathologies. Independent assessments were conducted by paired groups of orthopedic surgeons (n=4) who determined the extent to which chondrolysis was misdiagnosed for each joint. Inter-rater reliability was assessed by Cohen's Kappa statistic which ranged from .74 to 1.0, depending on the joint. Sensitivity analyses were performed using range variations in the severity of cartilage damage (uniform/diffuse v. focal cartilage loss), type of joint insult, and time to diagnosis. Results Significant variations in clinical criteria used to diagnose joint chondrolysis were observed across published studies. Sensitivity analyses revealed that the largest degree of "pooling" was evident in the knee (range, 30 to 48%), followed by the shoulder (range, 7 to 25%), and the hip (range, 2 to 5%). In the knee, pooled joints were most commonly post-meniscectomy osteoarthritis (86%) with isolated lateral compartment involvement rather than diffuse cartilage loss otherwise indicative of chondrolysis. In the shoulder, pooling was most frequently due to grouping focal with diffuse cartilage loss (42%) or inappropriately diagnosing osteoarthritis (50%) as chondrolysis. In the hip, pooling occurred most often by misdiagnosing rapid progression of pre-existing osteoarthritis (61%) and avascular necrosis (36%) as chondrolysis. Detailed analysis of patient presentations across pooled and non-pooled cases were similar in symptom quality and time frame, ultimately confusing successful differential diagnosis. Across cases with no misdiagnosis of chondrolysis, the utility of a common set of diagnostic criteria included younger patient age ( Conclusion A succinct set of standardized clinical criteria is necessary to guide the differential diagnosis of joint chondrolysis. Clinical evaluation should encompass a detailed history including review of all previous surgeries, thorough bilateral examination, orthogonal radiographs, advanced imaging, and, in some cases, arthroscopic evaluation to minimize risk of inappropriate clinical management.