Histology and molecular pathology of iliotibial tract contracture in patients with gluteal muscle contracture.

The present study aimed to examine the pathologic changes of the iliotibial tract and discusses its relationship with gluteal muscle contracture. Samples of contractual iliotibial tracts were collected from six patients with contractures of the gluteal muscles and iliotibial tracts during their surgical treatment. Samples of normal iliotibial tracts were collected from six patients receiving surgeries for avascular necrosis of the femoral head who had no contractures of the gluteal muscles and iliotibial tracts. The tissue samples were stained using Hematoxylin and Eosin (H&E), Masson's trichrome, and Sirius Red. The mRNA and protein levels of various tissue repair genes were determined using quantitative real-time PCR and Western blotting. Both the normal and contractual iliotibial tracts consisted of type I and III collagens. The contractual iliotibial tracts had a significantly higher proportion of type III collagen in comparison with the normal iliotibial tracts. The mRNA expression levels and protein levels of tissue repair genes TGFß 1, bFGF, and matrix metalloproteinase-1 (MMP-1) in the contractual iliotibial tracts were up-regulated in comparison with that in the normal iliotibial tracts. However, the mRNA expression levels and protein levels of tissue inhibitors of metalloproteinase-1 (TIMP) in the contractual iliotibial tracts were down-regulated in comparison with that in the normal iliotibial tracts. The contractures of both the gluteal muscles and the iliotibial tracts share similar histology and molecular pathology. Our results indicate that iliotibial tract contracture is secondary to the gluteal muscle contracture and is a constant tissue repair process.

Gluteal Fibrosis and Its Surgical Treatment.

BACKGROUND: The objective of this study was to analyze the literature regarding the diagnosis, pathogenesis, and prevalence of gluteal fibrosis (GF) and the outcomes of treatment. METHODS: We searched PubMed, Embase, and Cochrane literature databases, from database inception to December 15, 2016. We used the following search terms including variants: "contracture," "fibrosis," "injections," "injections, adverse reactions,' "gluteal," and "hip." All titles and abstracts of potentially relevant studies were scanned to determine whether the subject matter was potentially related to GF, using predefined inclusion and exclusion criteria. If the abstract had subject matter involving GF, the paper was selected for review if full text was available. Only papers including ≥10 subjects who underwent surgical treatment were included in the systematic analysis. Data abstracted included the number of patients, patient age and sex, the type of surgical treatment, the method of outcome measurement, and outcomes and complications. RESULTS: The literature search yielded 2,512 titles. Of these, 82 had a focus on GF, with 50 papers meeting the inclusion criteria. Of the 50 papers reviewed, 18 addressed surgical outcomes. The surgical techniques in these papers included open, minimally invasive, and arthroscopic release and radiofrequency ablation. Of 3,733 operatively treated patients in 6 reports who were evaluated on the basis of the criteria of Liu et al., 83% were found to have excellent results. Few papers focused on the incidence, prevalence, and natural history of GF, precluding quantitative synthesis of the evidence in these domains. CONCLUSIONS: This study provided a systematic review of surgical outcomes and a summary of what has been reported on the prevalence, diagnosis, prognosis, and pathogenesis of GF. Although GF has been reported throughout the world, it requires further study to determine the exact etiology, pathogenesis, and appropriate treatment. Surgical outcomes appear satisfactory. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Shear-wave elastography assessment of gluteal muscle contracture: Three case reports.

RATIONALE: Gluteal muscle contracture (GMC) is a clinical syndrome characterized by limited hip joint function due to fibrosis and contracture of the gluteal muscle and fascia fiber. Imaging examination is significant for its diagnosis and guidance of surgical treatment. PATIENT CONCERNS: This report presents 3 cases of GMC with bilateral involvement and summarizes the literature on the imaging findings of this disease. The clinical symptoms and presentations of the 3 cases well-matched the clinical diagnosis of GMC. Preoperative ultrasonography including elastography was performed. To our knowledge, studies based on the elastography findings of the disease are limited. DIAGNOSES: The diagnosis of GMC was finally confirmed by postoperative pathologic examination. INTERVENTIONS: All 3 patients then have a surgical therapy which cut off the contracture tract. OUTCOME: Symptoms of abnormal gait and limited hip joint function were greatly improved after surgical treatment. LESSONS: The elasticity of the GMC zone in patients with GMC is higher than that of the muscles in the corresponding sites of healthy people.

Mucopolysaccharidoses and other lysosomal storage diseases.

Mucopolysaccharidosis and other lysosomal storage diseases are rare, chronic, and progressive inherited diseases caused by a deficit of lysosomal enzymes. Patients are affected by a wide variety of symptoms. For some lysosomal storage diseases, effective treatments to arrest disease progression, or slow the pathologic process, and increase patient life expectancy are available or being developed. Timely diagnosis is crucial. Rheumatologists, orthopedics, and neurologists are commonly consulted due to unspecific musculoskeletal signs and symptoms. Pain, stiffness, contractures of joints in absence of clinical signs of inflammation, bone pain or abnormalities, osteopenia, osteonecrosis, secondary osteoarthritis or hip dysplasia are the alerting symptoms that should induce suspicion of a lysosomal storage disease.

Pelvic deformity secondary to tensor fascia lata tightness associated with desmoid tumor.

The iliotibial band is a thick, condensed fascia that, when contracted, leads to a hip flexion, abduction, and external rotation contracture in addition to other joint contractures. Iliotibial band tightness occurs secondary to iliotibial band friction syndrome, which commonly occurs at the lateral femoral epicondylar region. However, a proximal cause of iliotibial band/tensor fascia lata friction syndrome leading to a secondary hip contracture is swelling around the hip; this swelling being a desmoid tumor has not been explicitly described in the literature. The authors present a rare case of a hip contracture in a 28-year-old active man who presented with a functionally disabling hip flexion contracture of 20° with further flexion possible up to 130°, a 45° abduction contracture, and a 20° external rotation contracture with further rotation possible up to 40° with a bony hard swelling in the left gluteal region. Ober's test was positive. Opposite hip and spine examinations were normal. The goals of treatment were to establish the causality between the 2 and to diagnose the etiology of the gluteal mass. Radiographs were normal, with only a pelvic obliquity evident. Magnetic resonance imaging revealed an extra-articular mass abutting the iliac blade. Histopathology confirmed the mass to be a desmoid tumor in the left gluteal region. A wide surgical excision of the mass was performed with negative margins; no postoperative radiotherapy was administered. After rigorous physiotherapy, the hip deformity disappeared at 6 months and there was no evidence of recurrence at 2.5-year follow-up, with the patient able to sit cross-legged and squat.

Total hip arthroplasty in a patient with arthrogryphosis and an ipsilateral above knee amputation.

The authors present the case of a young man with arthrogryphosis multiplex congenita and an above knee amputation who underwent an ipsilateral total hip replacement. The unique aspects of the case and technical difficulties are highlighted. Follow-up at five years revealed an excellent clinical and radiological outcome.

Idiopathic chondrolysis treated with etanercept.

Idiopathic chondrolysis of the hip in children has been well documented in the literature. The insidious nature of the symptoms and lack of early radiographic findings and diagnostic testing often delay diagnosis. Children often report a stiff, painful hip and have an associated limp in the absence of trauma or constitutional symptoms. Despite these symptoms it remains a poorly understood diagnosis with no identifiable cause. Some have speculated an inflammatory cause, as this disease exhibits joint space narrowing, presumably due to enzymatic activity similar to juvenile rheumatoid arthritis. Despite case reports attempting traction, physical therapy, nonsteroidal anti-inflammatories, steroids, and even operative intervention, no current treatment regimen exists that offers proven appreciable benefit. We hypothesized the powerful anti-inflammatory properties of etanercept would provide symptomatic and radiographic improvement of idiopathic chondrolysis of the hip. This article presents a case of an adolescent boy with a stiff, painful left hip that failed treatment with traction, physical therapy, naproxen, and methotrexate, prior to initiating etanercept. After 1 year of daily etanercept therapy, the patient's hip motion improved in all directions and his pain completely resolved. This novel therapeutic approach offered symptomatic relief and radiographic improvement, and may provide an effective treatment strategy for this difficult disease.

Arthroscopic gluteal muscle contracture release with radiofrequency energy.

Gluteal muscle contracture is common after repeated intramuscular injections and sometimes is sufficiently debilitating to require open surgery. We asked whether arthroscopic release of gluteal muscle contracture using radiofrequency energy would decrease complications with clinically acceptable results. We retrospectively reviewed 108 patients with bilateral gluteal muscle contractures (57 males, 51 females; mean age, 23.7 years). We used inferior, anterosuperior, and posterosuperior portals. With the patient lying laterally, we developed and enlarged a potential space between the gluteal muscle group and the subcutaneous fat using blunt dissection. Under arthroscopic guidance through the inferior portal, we débrided and removed fatty tissue overlying the contractile band of the gluteal muscle group using a motorized shaver introduced through the superior portal. Radiofrequency then was introduced through the superior portal to gradually excise the contracted bands from superior to inferior. Finally, hemostasis was ensured using radiofrequency. Patients were followed a minimum of 7 months (mean, 17.4 months; range, 7-42 months). At last followup, the adduction and flexion ranges of the hip were 45.3 degrees +/- 8.7 degrees and 110.2 degrees +/- 11.9 degrees, compared with 10.4 degrees +/- 7.2 degrees and 44.8 degrees +/- 14.1 degrees before surgery. No hip abductor contracture recurred and no patient had residual hip pain or gluteal muscle wasting. We found gluteal muscle contracture could be released effectively with radiofrequency energy.

Elevated plasma vascular endothelial growth factor levels in 2 patients with hemangioendothelioma.

Two patients with hemangioendothelioma and elevated plasma vascular endothelial growth factor (VEGF) levels are presented. A reduction in the plasma VEGF level after therapeutic intervention correlated with a successful clinical response. Conversely, a stable plasma VEGF level correlated with therapeutic failure.

Dynamic implications of hip flexion contractures.

Hip flexion contractures are a common complication in disabled patients. However, no previous study has examined reduced hip motion during gait. This retrospective analysis evaluates the relationship between the degree of hip flexion contracture found on static testing and the degree found during gait and also assesses the strength of the association between hip flexion contractures and compensatory mechanisms such as anterior pelvic tilting, increased knee flexion, and decreased contralateral step length. Clinical and quantitative gait laboratory data were obtained from 41 consecutive patients with mostly neurologically based impairments who presented with bilateral hip flexion contractures on Thomas testing (82 limbs). Correlation studies demonstrated a relatively weak association between the degree of peak hip extension during gait and hip flexion contracture by Thomas testing (r = 0.41, P < 0.0001). Limited hip extension was most closely associated with anterior pelvic tilting (r = 0.60, P < 0.0001), whereas Thomas test measurements yielded a correlation with anterior pelvic tilt of only r = 0.36 (P < 0.001) and were insignificant predictor variables of anterior pelvic tilting in regression analysis. Thus, peak hip extension and anterior pelvic tilting assessed during gait were poorly associated with the static Thomas test measurements, and anterior pelvic tilt was most strongly correlated with reduced hip extension during gait compared with the other compensatory mechanisms.

Olivo-ponto-cerebellar atrophy with muscular atrophy, joint contractures and pulmonary hypoplasia of prenatal onset.

The clinical and pathological features of a female neonate with congenital joint contractures and pulmonary hypoplasia are described. Neuropathological examination revealed a widespread neuronal degeneration with a predominantly olivo-ponto-cerebellar distribution and muscle pathology consistent with neurogenic atrophy. This is the first reported case of congenital joint contractures and pulmonary hypoplasia with pathologically documented olivo-ponto-cerebellar degeneration. The observation further illustrates that the so-called fetal akinesia sequence or Pena-Shokeir I syndrome is an aetiologically non-specific symptom complex that can be caused by a number of underlying mechanisms.

Pelvic obliquity. Its causes and its treatment.

Pelvic obliquity can be caused by leg length inequality, contractures about the hips, as part of a structural scoliosis, or as a combination of two or more of these causes. Careful physical and radiologic evaluations are necessary to establish the correct diagnosis. Treatment is then directed toward the specific cause, ie, leg length balancing, release of hip contractures, or scoliosis correction. Structural scolioses with pelvic obliquity may be either congenital or paralytic. If a traction roentgenogram reveals the curve to be flexible enough that the pelvis can be fully leveled, then a posterior fusion only is necessary. If the pelvis will not level with traction, then anterior convex wedge excisions (discectomies for the paralytic, hemivertebra excision for the congenital) are necessary for achieving adequate correction. Posterior instrumentation and fusion must follow the anterior procedure. Various forms of internal correction and fixation devices are now available, and there is no single best procedure. Anterior internal fixation devices are being used less and less, while posterior segmental fixation with Luque rods are wires is being used more and more.