Intraarticular synovial sarcoma of the knee rising from a lateral meniscus - a case report.

Synovial sarcoma (SS) is a rare mesenchymal tumor, accounting less than 10% of soft tissue sarcomas. We report a case of intraarticular SS mimicking nodular synovitis and lateral meniscus rupture. Due to clinical and radiological presentation, arthroscopic synovectomy was performed, and histology confirmed nodular synovitis. After four years the lesion recurred and new arthroscopic biopsy was performed, revealing a monophasic SS with SYT/SSX1 translocation. Repeated histology of the first specimen confirmed appearance of a nodular synovitis microscopically, with no morphological criteria for a sarcoma, but molecular analysis showed positive SYT/SSX1 translocation. Wide extraarticular knee resection and reconstruction with a tumor megaendoprosthesis-allograft composite was performed with a negative tumor margins. This case report showed that in a case of benign histological appearance, underlying sarcoma is possible and could be identified in early stages only with an advanced pathology methods. LEVEL OF EVIDENCE: Level IV historical case.

[RARE LOCALIZATION OF OSTEOID OSTEOMA--DISTAL PHALANX OF THE RING FINGER].

With this clinical observation we would like to bring to mind osteoid osteoma as a possible cause of problems of distal phalanx of the fingers. Osteoid osteoma occurs rarely at this location and has atypical presentation. The main symptoms are swelling and redness of the fingertip with nail deformity, while typical night pain may not be present. Unusual clinical and x-ray presentation of tumor in this localization can make diagnosis of osteoid osteoma very difficult. A 20-year-old patient reported pain in the fingertip of his right ring finger persisting for five years. Swelling and redness of the fingertip combined with nail deformity was also present. X-rays showed osteolysis in the base of distal phalanx. Magnetic resonance imaging showed suspicion of osteoid osteoma, which was confirmed by computed tomography (CT). We performed surgical removal of osteoid osteoma in February 2014. The tumor was approached by longitudinal incision on the lateral side of the distal phalanx of the ring finger and the basal part of distal phalanx was cut with a small chisel to enable access to cystic change of the bone. Tumor removal with excochleation was performed and the material thus obtained was sent for histopathologic analysis. After surgery, the ring finger was immobilized in a plaster splint for a three-week period. After removal of immobilization, the patient was referred to physical therapy consisting of individual exercises in order to obtain the full range of motion in all joints of the hands and strengthen hand and forearm muscles. After surgical removal of osteoid osteoma, all symptoms disappeared completely. Histopathologic findings confirmed the diagnosis of osteoid osteoma. After physical therapy, he returned to daily activities without any problems. On regular follow ups at 3, 6 and 12 months after surgery, clinical findings were normal and the patient had no pain or discomforts. Full recovery was shown by the result of the DASH questionnaire three months after the procedure. Preoperative DASH score 54.4 decreased to 0. Distal phalanx of the finger is a very rare localization of osteoid osteoma, and typical night pain may not be present. In addition, appearance on x-rays is not typical. Instead of central enlightenment surrounded with sclerosis, x-rays usually show a lytic lesion. For this reason, it may be difficult to make the diagnosis of osteoid osteoma. The main symptom is permanent pain, swelling and redness of the finger, with nail deformity. The imaging method of choice is CT, which must be performed with thin layers of 1 to 2 mm. Furthermore, cooperation of surgeon and radiologist is extremely important to reach the accurate diagnosis. Many treatment options are described in the literature, such as CT-guided percutaneous thermocoagulation, destruction of lesions with alcohol, or CT-guided radiofrequency ablation. However, due to the proximity of neurovascular structures, tendons and joints, the best method for treatment osteoid osteoma in distal phalanx of the fingers is surgical excision or excochleation. Our conclusion is that one should always bear in mind that osteoid osteoma can be the cause of swelling of distal phalanx of the finger with nail deformity, and pain that alleviated with the use of non-steroidal anti-infl ammatory drugs. Surgical excision or excochleation is the best method for the treatment osteoid osteoma of distal phalanx of the finger.

Incidental extra-mammary findings in breast MRI.

AIM: To investigate the frequency, distribution, and nature of incidental extra-mammary findings detected with breast MRI. MATERIALS AND METHODS: Incidental findings were defined as unexpected lesions outside the breast, not previously known or suspected at the time of referral. Five hundred consecutive breast MRI studies performed from June 2010 to September 2012 were reviewed in this retrospective study for which the institutional review board granted approval and waived the requirement for informed consent. MRI findings were compared with subsequent diagnostic procedures in order to differentiate benign from malignant lesions. RESULTS: One hundred and thirty-eight incidental findings were found in 107 of the 500 (21.4%) examined patients. The most common site was the liver (61/138; 44.2%), followed by the lung (24/138; 17.4%), mediastinum (22/138; 15.9%), pleural cavity (15/138; 10.9%), bone tissue (9/138; 6.5%), spleen (3/138; 2.2%), major pectoral muscle (3/138; 2.2%), and kidney (1/138; 0.7%). Twenty-five of the 138 (18.1%) incidental findings were confirmed to be malignant, whereas the remaining 113 (81.9%) were benign. Malignant findings were exclusively detected in patients with known breast carcinoma, whereas incidental findings in patients without a history of carcinoma were all benign. Twenty-five of 100 (24.8%) incidental findings among patients with history of breast cancer were malignant. CONCLUSION: Although many of incidental findings were benign, some were malignant, altering the diagnostic work-up, staging, and treatment. Therefore, it is important to assess the entire field of view carefully for abnormalities when reviewing breast MRI studies.

Pregnancy-related severe pelvic girdle pain caused by unilateral noninfectious sacroiliitis. A case report and literature review.

Pelvic girdle pain during and after pregnancy is the clinical syndrome of persistent musculoskeletal pain localized in the posterior and/or anterior aspect of the pelvis originating from sacroiliac joints and/or pubic symphysis due to dynamic instability. We report the case of severe and disabling postpartum pelvic girdle pain caused by unilateral noninfectious sacroiliitis which resolved after 2 months by nonsteroidal anti-inflammatory drug and physical therapy. A short literature review is given on epidemiology, etiology, clinical presentation, therapy, and prognosis of pregnancy-related pelvic girdle pain.

[Acute bilateral shoulder pain as initial presentation of ochronosis: a case report and literature review]. / Akute Schulterschmerzen beidseits als Anfangssymptom einer Ochronose: Fallbericht und Literaturübersicht.

Ochronosis is a rare genetic metabolic disorder resulting from a constitutional lack of homogentisic acid oxidase and subsequent accumulation of its substrate causing destruction of connective tissues with various systemic abnormalities. Typical musculoskeletal symptoms are arthropathy and low back pain and stiffness. Arthropathy primarily affects knee and hip joints, but shoulders are less frequently involved. We describe a case of ochronosis initially presented as acute bilateral shoulder pain. Review of literature with respect to the etiology, natural course of the disease, differential diagnosis and management was made.

Retrospective study of juvenile spondylarthropathies in Croatia over the last 11 years.

OBJECTIVES: To determine the frequency of juvenile spondylarthropathies (JSpA) among other rheumatic diseases in a pediatric clinic population in an 11-year period in Croatia and to review their clinical, epidemiological, radiographic and laboratory. METHODS: Of the 1264 patients with rheumatic diseases seen at a pediatric rheumatology center, 103 (8.2%) were diagnosed as having JSpA (56 boys, mean age 13.1 years, range 4.4-17.8 years), following the strict criteria of the European Spondylarthropathy Study Group. Medical history, clinical laboratory and imaging data of the 103 patients with JSpA were analyzed. RESULTS: Eighty-two (79.6%) patients had undifferentiated spondylarthropathy, 6 (5.8%) patients had reactive arthritis/Reiter's disease, 6 (5.8%) had arthritis associated with inflammatory bowel disease, 5 (4.9%) had psoriatic arthritis, and only 4 (3.9%) patients had ankylosing spondylitis. The most common symptoms at the disease onset in patients with JSpA were peripheral and axial arthritis, followed by enthesitis. A significant increase in the number of patients with axial arthritis, peripheral arthritis, ocular symptoms and enthesitis was found during mean period of follow-up of 6.45 years. HLA-B27 was present in 78 (75.7%) patients. CONCLUSION: In our hospital population the frequency of JSpA among other rheumatic disease was 8.2%. The disease was equally distributed among male and female patients, with onset around the age of 13 years. Most of the patients were diagnosed with undifferentiated spondylarthropathy.

[Transient osteoporosis of the hip in pregnancy. Successful treatment with calcitonin: a case report]. / Schwangerschaftsassoziierte transiente Osteoporose der Hüfte. Erfolgreiche Behandlung mit Kalzitonin.

Transient osteoporosis of the hip is a rare clinical disorder of unknown etiology, characterized by hip pain and functional disability that resolves spontaneously in 6-24 months. Despite a benign prognosis, the long clinical course causes prolonged disability. We report on a case of transient osteoporosis of the hip during pregnancy that was rapidly resolved with the use of calcitonin. An accurate diagnosis was made 2 months after the onset of symptoms (4 weeks postpartum) based on findings in the form of bone marrow edema of the right hip by magnetic resonance imaging. The patient received calcitonin for 8 weeks and the beneficial effect was observed after 3 weeks of therapy with full resolution of symptoms after 8 weeks of therapy (4 months after onset of symptoms). We suggest that the use of calcitonin may be considered as a therapeutic intervention to shorten the disease duration.

[Purulent osteomyelitis with epidural abcess in an adult over a decade after cervical spine injury]. / Eiternde Osteomyelitis mit Epiduralabszess bei einem Erwachsenen mehr als ein Jahrzehnt nach zervikaler Wirbelsäulenverletzung.

Cervical osteomyelitis and epidural abscess are rare and potentially fatal conditions with severe neurological manifestations. Changes on plain radiography and computed tomography are non-specific, while contrast enhanced magnetic resonance imaging shows high sensitivity and specificity in establishing early diagnosis.

Long-term outcomes of clavicular pseudoarthrosis therapy.

BACKGROUND: Clavicular pseudoarthrosis is a rare condition, the management of which should not be underestimated because it requires re-operations and causes serious morbidity or even a lifelong handicap. PATIENTS AND METHODS: We reviewed a series of 13 patients with non-union of a clavicular fracture who underwent a surgical treatment from the year 1993 to 2002. Twelve fractures were a result of trauma and one was a result of osteomyelitis. Twelve non-unions were located in the middle third of the clavicle, while only one was in the lateral third. Seven non-unions were atrophic and six were hypertrophic. The average age of patients was 33 years (range: 14-52 years). Average post-operative follow-up time was 4.7 years (range: 1-11 years). In the study, we used intramedullar osteosynthesis such as Kirschner wire, different kinds of plates and screws, followed by autogeneous or heterogeneous bone grafting. Constant scoring system was used to evaluate mobility and strength of the upper extremity. RESULTS AND CONCLUSION: A single operation was adequate in seven cases; two operations were adequate in four cases and three operations were adequate in one case. Fractures healed properly in 11 cases, but in some cases mild-to-moderate symptoms still persisted post-operatively. The results of 13 patients who underwent various surgical procedures show that a reconstruction plate should be the first choice of osteosynthesis, followed by a dynamic-compression plate, and a semitubular plate should be the last choice. To conclude, with this kind of treatment of clavicular pseudoarthrosis, we achieved a high degree of patient satisfaction, as well as objective improvements in status reports.