Rice bodies in a shoulder bursa: a cadaveric and histologic case report.

INTRODUCTION: The subacromial/subdeltoid bursa can develop inflammation and effusion related to autoimmune, infectious, and musculoskeletal disorders. Rice bodies, or loose bodies within bursa, have been described as an uncommon complication of bursitis and have been the subject of case studies over a number of years. However, they have not been described in anatomical or physical therapy-related literature. METHODS: A donor body dissected for a physical therapy anatomy course was found to have an enlarged subacromial/subdeltoid bursa. This bursa, along with the biceps brachii tendon sheath, and the subscapularis muscle bursa, were filled with numerous rice-like bodies. The bursal wall was well developed and thickened. Tissue specimens were obtained of the suspected rice bodies, the subacromial/subdeltoid bursal wall, and the biceps brachii tendon sheath. The tissue was embedded, sectioned, and processed with hematoxylin and eosin or Masson's Trichrome staining for blinded histologic assessment. RESULTS: The tissue samples from within the bursa were identified as tissue similar to that in prior descriptions of rice bodies. Tissue samples from the bursal wall and tendon sheath were identified as similar to synovial membranes. CONCLUSIONS: Rice bodies found within the cadaveric body were similar histologically to those described in rheumatology, radiology, and orthopedic literature. Anatomists teaching future health-care providers and practicing physical therapists should be familiar with rice bodies as a potential finding in cadavers, and patients.

Two Cases of Temporomandibular Synovial Chondromatosis Associated with Gli1 Gene Mutation.

Synovial chondromatosis (SC) is a rare benign disease involving multifocal generation of ectopic cartilage in the synovial tissue. Herein, we report two cases of SC in the temporomandibular joint: a 38-year-old woman (patient 1) and 39-year-old woman (patient 2). Both patients had trismus, jaw joint noises, and jaw-opening pain in the temporomandibular joint. Cone-beam computed tomography (CT) and magnetic resonance imaging (MRI) in patient 1 showed multiple calcified loose bodies around the right mandibular condyle. In addition, CT and MRI in patient 2 showed multiple calcified loose bodies around the left mandibular condyle and temporal bone perforation. Following establishing a diagnosis of SC, both patients underwent tumor resection via open surgery. In immunohistochemical examinations of the resected tissues, tumor cells showed intense nuclear staining with labeled anti-Gli1 antibody. Gene sequencing revealed that both patients had a homozygous mutation in the Gli1 gene (rs2228226 G>C). In conclusion, we suggest that the Gli1 gene (rs2228226 G>C) may be involved in the etiology of SC.

An Unusual Cause of Vertebrobasilar Insufficiency in a Case of Atlantoaxial Dislocation with Anomalous Vertebral Artery.

BACKGROUND: Posterior circulation stroke resulting from atlantoaxial dislocation (AAD), although uncommon, is a well-described entity. The normally coursed V3 segment of the vertebral artery (VA) is likely to be stretched because of C1-C2 dislocation and further compromised by the C1-C2 translational mobility. The persistent first intersegmental artery (PFIA), an anomalous variant does not course through the C1 transverse foramen, but rather crosses the posterior C1-C2 joints and is unlikely to be affected by the C1-C2 dislocation. Therefore, a patient with AAD and anomalous VA presenting with stroke should be evaluated for other etiologies of VA compromise. CASE DESCRIPTION: We report a patient of AAD with PFIA who presented with posterior circulation stroke. Careful radiological evaluation revealed a loose body (LB) adjacent to the medial aspect of the left C1-C2 facet compressing the anomalous VA. Intraoperatively, there was a large LB on the posteromedial border of the joint, compressing the VA. The anomalous VA was mobilized, and the offending element removed followed by fixation of the C1-C2. CONCLUSIONS: One should be aware of such an etiology of arterial compromise in cases of AAD with coexistent anomalous VA. An underlying LB or large osteophytes resulting from instability may be the offending cause, and needs to be dealt with, as fusion alone may not benefit the patient.

Scanning electoronmicroscopical analysis of the loose bodies of synovial chondoromatosis in temporomandibular joint.

The aim of this study is to reveal the morphological property about the loose bodies (LBs) of temporomandibular joint (TMJ) by scanning electron microscope (SEM). We obtained specimens from two female cases of released loose body by surgical operation. These specimens were fixed by soaking in a mixture of 5% glutaraldehyde or 4% formaldehyde for one week. They were cut into half pieces. These specimens were observed at an accelerating voltage of 3 kV under a SEM (JSM-5500, JEOL, Tokyo). In the electron microscopic findings, it seems to be separated into two different parts as inside part and outside part. On the inside part, collagen fibers were running very densely in the same direction in an orderly neatly manner. Whereas, we observed waved collagen fibers running irregularly with many spaces on the outside part. Outside part seems to be porous pattern compared with inside part. It might be that the surface and outside part included many active fibroblasts. As results, it seems that the LBs might develop in a multi-layer style, in which fibrous tissues were piled up loosely around the inside part. The proliferating activity of LBs grows from the inside to outside of SC in TMJ.

Spontaneous resolution of posterior ankle joint loose bodies after total ankle replacement: A case report.

Late stage ankle osteoarthritis often presents with debilitating pain. It is common to find osteophytes and loose body formation around the joint. Total ankle arthroplasty can preserve joint mobility and pain relieve for such patient. However, when trying to remove the osteophytes and loose bodies at the posterior ankle joint, there is risk of damaging posterior structures such as the neurovascular bundle during the procedure. We are presenting a case where the posterior loose bodies remained untouched during the operation, and patient showed spontaneous resolution of the lesions with time. Patient enjoyed good function outcome after the surgery.

Osteochondral loose body: an unusual cause of lumbar spinal stenosis.

Lumbar spinal stenosis is most often a degenerate condition observed in the older population. We describe the case of a lady with typical claudicant symptoms with an unusual cause of stenosis identified at the time of her decompressive surgery. On review of the literature this is only the second case of osteochondral loose body as a cause for lumbar spinal stenosis and thus remains a rare phenomenon.

Multiple Osseous Loose Bodies Associated with Lumbar Isthmic Spondylolisthesis.

BACKGROUND: Multiple osseous loose bodies in the lumbar spine have never been reported. We describe a rare surgical case of multiple osseous loose bodies associated with lumbar isthmic spondylolisthesis. CASE DESCRIPTION: A 74-year-old man who experienced left foot numbness and bilateral gluteal pain was diagnosed with lumbar spondylolisthesis 7 years previously and managed conservatively. He reported recurrence of the left foot numbness 6 months previously, at which time aggressive (rather than conservative) therapy became a consideration. Radiographs of the lumbar spine revealed L5 isthmic spondylolisthesis with dynamic instability at L5/S1. Magnetic resonance imaging of the lumbar spine revealed multiple mass lesions dorsally located in the lumbar canal. Computed tomography myelography demonstrated multiple osseous materials near the isthmic portion at the L5 level where compression of the dural sac by the lesions induced lumbar canal stenosis. The patient underwent posterior decompression surgery that enabled total removal of the osseous lesions. Intraoperative findings revealed osseous lesions located in the fibrocartilage material and no connection of the lytic portion at the L5 level or ligamentum flavum. Postoperative course of the patient was uneventful as his neurological symptoms improved. CONCLUSIONS: We described the first instance of multiple loose bodies in the spinal canal with lumbar canal stenosis. It is presumed that long standing minor trauma due to dynamic instability with a trend of hyperossification induced secondary synovial osteochondromatosis forming multiple loose bodies.

Intra-articular loose body caused by avascular necrosis of the femoral head in children.

In children, avascular necrosis of the femoral head occurs easily because of the difference in the domination of blood flow compared with that in adults. Here we report a rare case of a 12-year-old girl who sustained a femoral neck fracture. The femoral head collapsed after open reduction and internal fixation. The hip developed into subluxation because of the gradually enlarged loose body in association with avascular necrosis. These results might be explained by the fact that blood circulation from the ligamentum teres temporarily increases during the ages of 8-12 years.

[Posterior fixation and fusion for treatment of Os odontoideum complicated by atlantoaxial dislocation].

OBJECTIVE: To summarize the techniques and evaluate the therapeutic effect of posterior fixation and fusion in the treatment of Os odontoideum complicated by atlantoaxial dislocation. METHODS: From March, 2007 to October, 2010, 10 patients with Os odontoideum (including 6 male and 4 female patients aged from 20 to 65 years, mean 39.8 years) were treated in our hospital. Before and after the operation, the patients underwent X ray, CT and MRI examinations to measure and evaluate the degree of dislocation and neural compression. After preoperative traction for 1-2 weeks, all the 10 patients showed deductible atlantoaxial dislocation. Through a posterior approach, Atlantoaxial pedicle screws fixation were performed in 9 cases, and C2/3 pedicle-Occiput screw fixation was performed in 1 case. All the patients wore cervical collars as external support for 3 months after the operation. RESULTS: The mean operative time was 3 h in these patients with a mean intraoperative blood loss of 420 ml. The symptoms were relieved after the surgery in all the patients, who showed no neck pain or neurological defects. The patients were followed up for 6 to 52 months (mean 22 months), and bony fusion was observed in all the 10 cases within 6 to 8 months without such complications as internal fixation failure or redislocation of the atlas. CONCLUSION: Patients with Os odontoideum complicated by atlantoaxial dislocation should undergo surgical stabilization to avoid severe neurological injury. Pedicle screw instrument in the atlas allows restoration of the spinal stability, short-segment fusion, and maximal preservation of the mobility of the neck.

Associated intra-articular ankle pathologies in patients with chronic lateral ankle instability: arthroscopic findings at the time of lateral ankle reconstruction.

UNLABELLED: Chronic lateral ankle instability (CLAI) can be a debilitating condition. The literature has shown that it is also associated with a number of intra-articular pathologies of the ankle. Some argue that if unaddressed, these intra-articular pathologies can predispose patients to osteoarthritis. Previous studies of patients who underwent prelateral stabilization ankle arthroscopy have shown a high number of pathologies, including osteochondral lesions of the talus. PURPOSE: The current study reviewed a consecutive series of patients diagnosed with CLAI who underwent ankle arthroscopy followed by a modified Brostrom-Gould procedure to validate the previous studies. METHODS: Intraoperative reports on 28 ankles in 28 consecutive patients were reviewed from 2004 to 2008. RESULT: All 28 ankles (100%) demonstrated varying degrees of synovitis. Talar cartilage fibrillation was observed in 7 patients (25%), and talar dome cartilage defect was visualized in 4 patients (14%). Talar dome osteochondral defect was seen in 2 patients (7%), loose bodies were found in 3 patients (11%), Bassett's lesion was seen in 2 patients (7%), and anterolateral impingement was seen in 4 patients (14%). Distal anterior tibial osteophytosis was seen in 4 patients (14%). CONCLUSION: This study confirms the high number of intra-articular pathologies in association with CLAI.

Subcutaneous emphysema of the upper extremity after elbow arthroscopy.

Subcutaneous emphysema of the upper extremity is rare. Crepitation on physical examination and visible gas on radiographs raise the concern of gas gangrene due to gas-producing bacteria. Rapid establishment of a differential diagnosis is necessary to initiate proper treatment. We present a case of subcutaneous emphysema after elbow arthroscopy caused by a noninfectious genesis. A 59-year-old woman with loose bodies in her left elbow due to mild degenerative joint disease and restricted range of motion was offered an elbow arthroscopy with removal of loose bodies and arthrolysis. Postoperatively, the elbow was actively put alternatively in maximum extension and flexion. On the first postoperative day, rapidly ascending swelling and subcutaneous crepitation starting from the hand to the forearm were noted. There was no clinical evidence of infection. Radiographs showed subcutaneous air. Frequent blood tests and clinical evaluation ruled out a potentially life-threatening bacterial infection, and the signs resolved after 1 week without surgical treatment. Presumably, the intensive postoperative range-of-motion exercises led to a sucking in of air into the wound during each movement. This case illustrates that it is important to differentiate nonbacterial from bacterial causes of soft-tissue gas formation to initiate the appropriate treatment.

Locked knee from superior dislocation of the patella-diagnosis and management of a rare injury.

Knee locking is often caused by a torn meniscus or loose body. A rare cause of knee locking is a superior dislocation of the patella following trauma with less than 20 reported cases in the English literature. An unusual case of a locked knee secondary to interlocking osteophytes between the medial femoral condyle and the inferior pole of the patella without any history of trauma is presented.

Intra-articular loose body removal during hip arthroscopy.

Loose bodies are common findings in hip arthroscopy. Loose body removal can be challenging because of the inner position of the acetabulum in which the loose bodies tend to accumulate. Moreover, the standard removal procedure of a considerable number of loose bodies may need a long time under limb traction, thereby increasing the risk of complications. This article describes a new easy method for intra-articular loose body removal. A flexible endotracheal catheter, connected with suction system, is inserted via the anterior or midanterior portal. The catheter can easily be directed toward the inner parts of the joint in proximity of loose bodies. The suction system allows the loose body to be captured in contact with the tip of the catheter, which is then retrieved carrying the loose body outside the cannula. We performed this technique on 4 consecutive patients with synovial chondromatosis. Patients were evaluated preoperatively and 1 month postoperatively by completing self-administered questionnaires. The technique effectiveness was evaluated in terms of overall surgery time, traction time, radiographic appearance of loose bodies left in situ, and postoperative complications. Mean overall surgery time and central time was 175 and 78 minutes, respectively. All patients showed improvement in the operated hip. All radiographs showed hip joint space free of osteochondral loose bodies. No patients reported paraesthesia, nerve palsy, or other postoperative complications. This technique allows for retrieval of a greater amount of loose bodies in a short time, reducing the possibility of undesirable complications.

Magnetic resonance imaging findings in 46 elbows with a radial head fracture.

BACKGROUND AND PURPOSE: Radial head fractures are common, and may be associated with other injuries of clinical importance. We present the results of a standard additional MRI scan for patients with a radial head fracture. PATIENTS AND METHODS: 44 patients (mean age 47 years) with 46 radial head fractures underwent MRI. 17 elbows had a Mason type-I fracture, 23 a Mason type-II fracture, and 6 elbows had a Mason type-III fracture. RESULTS: Associated injuries were found in 35 elbows: 28 elbows had a lateral collateral ligament lesion, 18 had capitellar injury, 1 had a coronoid fracture, and 1 elbow had medial collateral ligament injury. INTERPRETATION: The incidence of associated injuries with radial head fractures found with MRI was high. The clinical relevance should be investigated.

Is MRI adequate to detect lesions in patients with ankle instability?

BACKGROUND: Chondral lesions, peroneal tendon tears, and other disorders in patients with chronic ankle instability may not be detected by preoperative MRI. Also, MRI often is obtained and interpreted at the referring institution, leading to variability in reading. QUESTIONS/PURPOSES: We assessed the accuracy of the radiologists' and orthopaedic surgeon's reading of preoperative MRI for diagnosing ankle lesions in patients with ankle instability warranting surgery. PATIENTS AND METHODS: We retrospectively reviewed 133 patients who underwent 135 surgeries for lateral ankle ligament reconstruction with concomitant ankle arthroscopy and who had preoperative MRI. RESULTS: We found 72 associated lesions in 66 of the 135 surgeries, including 38 chondral injuries, 18 peroneus brevis tears, seven loose bodies, and nine other miscellaneous abnormalities. Eliminating eight lesions for which the decision to operate was not based on operative findings, there were 127 surgeries with 64 associated lesions that required intraoperative confirmation or were detected intraoperatively. In the original reports, the radiologists identified 39% (15) of the chondral injuries, 56% (10) of the peroneal tears, and 57% (four) of the loose bodies. Radiologists' MRI sensitivity for detecting lesions was 45%. The attending surgeon identified 47% (18) of the chondral injuries, 89% (16) of the loose bodies, 71% (five) of the peroneus brevis tears, and the posterior talus process lesion, with a sensitivity of 63%. CONCLUSIONS: Our data suggest orthopaedic surgeons should review preoperative MRIs and also suggest the sensitivity of MRI may not be adequate to detect lesions in these patients before surgery. LEVEL OF EVIDENCE: Level IV, diagnostic study. See the Guidelines for Authors for a complete description of levels of evidence.

Enlargement of an osseous loose body in the cervical spine with cord compression.

BACKGROUND CONTEXT: Loose bodies in the spinal canal are extremely rare, with only two cases reported previously in the literature. PURPOSE: To report a rare case of an osseous loose body in the cervical spine with radiographic evidence of dramatic enlargement of the loose body in the spinal canal over the course of 9 years. STUDY DESIGN/SETTING: Case report. PATIENT SAMPLE: A 50-year-old man presented with progressive numbness and weakness of the upper and lower extremities and swaying gait in 2007. He had a history of temporary incomplete tetraplegia after a fall in 1998. Magnetic resonance imaging revealed enlargement of the posterior mass-occupying lesion compressing the cord at C5-C6 over the course of 9 years. OUTCOME MEASURES: Neurological examination with motor and sensory status. RESULTS: Posterior decompressive laminectomy was performed. An isolated, smooth-surfaced, bony, hard mass was found between the ligamentum flavum and facet joint and removed. Histological examination demonstrated trabecular bone and peripheral cartilage mixed with fibrous and fibrocartilaginous tissue. Clinical evaluation of the patient 6 months postoperatively showed total resolution of neurological symptoms. CONCLUSION: We report herein an extremely rare case of an osseous loose body in the spinal canal with cord compression. This report represents the first documented case of growth of a loose body in the spinal canal.

Hip arthroscopy for labral pathology: prospective analysis with 10-year follow-up.

PURPOSE: The purpose of this study was to investigate the results of arthroscopic treatment of acetabular labral tears (the most common indication for hip arthroscopy) in a consecutive series of patients with 10-year follow-up. METHODS: Since 1993, all of our patients undergoing hip arthroscopy have been prospectively assessed by use of a modified Harris Hip Score preoperatively and postoperatively at 3, 12, 24, 60, and 120 months. Variables recorded include age, sex, diagnosis, duration of symptoms, onset of symptoms, center-edge angle, Workers' compensation status, and pending litigation. From a cohort of 52 procedures performed on 50 patients who had achieved 10-year follow-up, 29 patients (31 hips) were treated for a tear of the acetabular labrum and represent the substance of this study. RESULTS: There was 100% follow-up, excluding 3 patients (5 hips) who died before their 10-year assessment. The mean age was 46 years (range, 17 to 84 years); there were 13 male and 13 female patients. The median Harris Hip Score improvement was 29 points (from 52 points preoperatively to 81 points postoperatively). Among 18 patients without arthritis, 15 (83%) continued to show substantial improvement (>or=18 points) at 10-year follow-up. Among 8 patients with associated arthritis, 7 (88%) were converted to total hip arthroplasty at a mean of 63 months. Two patients underwent repeat arthroscopy, which did not preclude a successful outcome at 10-year follow-up. There were no complications. CONCLUSIONS: Selective debridement of symptomatic tears can result in favorable long-term results. The presence of clinical findings of arthritis at the time of the index procedure is a poor prognostic indicator, with uniformly poor results at 10 years. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Benign synovial disorders.

Collectively, benign synovial disorders are not uncommon, and they may be seen in general orthopaedic practices. Symptoms are nonspecific, often delaying diagnosis. In fact, synovial chondromatosis, pigmented villonodular synovitis, synovial hemangioma, and lipoma arborescens often mimic each other as well as other, more common joint disorders in presentation, making diagnosis extremely difficult. It is important to diagnose these disorders correctly in order to provide appropriate treatment and avoid secondary sequelae, such as bone erosion and cartilage degeneration.

Arthroscopic synovectomy, removal of loose bodies and selective biceps tenodesis for synovial chondromatosis of the shoulder.

We retrospectively identified 18 consecutive patients with synovial chrondromatosis of the shoulder who had arthroscopic treatment between 1989 and 2004. Of these, 15 were available for review at a mean follow-up of 5.3 years (2.3 to 16.5). There were seven patients with primary synovial chondromatosis, but for the remainder, the condition was a result of secondary causes. The mean Constant score showed that pain and activities of daily living were the most affected categories, being only 57% and 65% of the values of the normal side. Surgery resulted in a significant improvement in the mean Constant score in these domains from 8.9 (4 to 15) to 11.3 (2 to 15) and from 12.9 (5 to 20) to 18.7 (11 to 20), respectively (unpaired t-test, p = 0.04 and p < 0.0001, respectively). Movement and strength were not significantly affected. Osteoarthritis was present in eight patients at presentation and in 11 at the final review. Recurrence of the disease with new loose bodies occurred in two patients from the primary group at an interval of three and 12 years post-operatively. In nine patients, loose bodies were also present in the bicipital groove; seven of these underwent an open bicipital debridement and tenodesis. We found that arthroscopic debridement of the glenohumeral joint and open debridement and tenodesis of the long head of biceps, when indicated, are safe and effective in relieving symptoms at medium-term review.