Para-articular Soft Tissues Research Articles

Case Report: Giant Extrasynovial Osteochondroma in the Infra-Patellar Fat Pad of Knee

Extraskeletal paraarticular osteochondromas are a rare benign intracapsular tumour. They are caused by osteocartilaginous metaplasia in the paraarticular soft tissue of the joint. Here we present a case of 38-year-old woman attended with a complaint of a enlarged lump on her left knee, along with insidious onset of pain and limited range of motion. Plain x-ray and MRI radiographs showed a partially calcified giant mass in the infra-patellar fat pad. The patient underwent removal of the mass. Histopathology confirmed the diagnosis of extraskeletal paraarticular osteochondroma. Surgical excision can effectively treat this condition with no recurrences. If not addressed, it can progress to patellar tendinopathy and functional impairments.

Neurogenic heterotopic ossification: A review. Part 1

BACKGROUND: Heterotopic ossification is the formation of bone tissues in the soft tissues of the body. A distinct form of heterotopic ossification is neurogenic, that is, resulting from severe injury to the brain or spinal cord of different genesis. Neurogenic heterotopic ossification is a complex multifactorial process of differentiated bone formation in the paraarticular soft tissues of large joints. Heterotopic ossification leads to the formation of persistent contractures and ankylosis, which cause severe disability and complicate rehabilitation.
 AIM: To analyze publications dealing with various aspects of neurogenic heterotopic ossification.
 MATERIALS AND METHODS: In the first part of our review, we present the results of the literature analysis on the epidemiology, risk factors, pathogenesis, and clinic and laboratory diagnosis of neurogenic heterotopic ossification. Scientific literature databases PubMed, Google Scholar, Cochrane Library, Crossref, and eLibrary were searched for without language limitations.
 RESULTS: Current literature data on heterotopic ossification in patients with central nervous system pathologies are presented. Topical questions of etiology, risk factors, pathogenesis, and clinic and laboratory diagnostics of this pathological process are highlighted.
 CONCLUSIONS: Understanding the risk factors of heterotopic ossification development and their prevention in the context of the modern knowledge of heterotopic ossification pathogenesis may help reduce the incidence of heterotopic ossification in patients with severe central nervous system injury.

New classification for septic arthritis of the hand.

The severity of septic arthritis of the hand and the prospects for restoration of joint function are determined by a complex of factors. Among them, the leading role belongs to local changes in tissue structures. This includes the destruction of articular cartilage and bone tissue with the development of osteomyelitis, the involvement of paraarticular soft tissues in the purulent process, and the destruction of the flexor/extensor tendons of the fingers. The currently missing specialized classification of septic arthritis could help in systematizing the diseases, determining treatment tactics, and predicting the results of treatment. The classification of septic arthritis of the hand proposed for discussion is based on the following principle: Joint-Wound-Tendon (JxWxTx); Jx characterizes damage to the osteochondral structures of the joint, Wx is the presence of paraarticular purulent wounds or fistulas, and Tx is destruction of the flexor/extensor tendons of the finger. The classification of the diagnosis makes it possible to assess the nature and severity of damage to the structures of the joint and may also be useful when comparing the results of treatment of septic arthritis of the hand.

Extraskeletal Para-Articular Osteochondroma of Hoffa’s Fat Pad

Extraskeletal para-articular osteochondromas are rare benign intracapsular tumours. They occur due to osteocartilaginous metaplasia in the para-articular soft tissue in the elderly. We report the same in the knee in a young patient, arising from Hoffa’s fat pad. A 26-year-old male presented with a gradually enlarging anterior left knee swelling of 3-year duration and inability to flex the knee fully. Clinical and radiological evaluation detected an ossified mass in Hoffa’s fat pad with features of osteochondroma. He underwent an excision of the mass and histopathology confirmed the diagnosis of extraskeletal para-articular osteochondroma. He was asymptomatic with functional improvement at 5-month follow-up. Extraskeletal para-articular osteochondromas are slow-growing, benign extrasynovial tumours arising in soft tissues with rare occurrence. They can present even in young and can only be diagnosed with a high index of suspicion, radiological features and clinicopathological correlation. They have to be distinguished from synovial chondromatosis and chondrosarcoma. It can be treated by surgical excision without any recurrence. If left untreated may lead to patellar tendinopathy and functional limitations.

Clinical Features of the Course of Musculoskeletal Infection after Local Administration of Glucocorticoids

Summary. In the treatment of patients with inflammatory and degenerative-dystrophic lesions of the joints, soft tissues and ligaments, local administration of drugs is often used in practice, usually (mainly) glucocorticoids.
 Objective: to determine the place and role of local administration of glucocorticoids in the occurrence and development of musculoskeletal infection.
 Materials and Methods. The peculiarities of the occurrence and development of infectious complications, their clinical manifestations, laboratory and anamnestic data after local administration of glucocorticoids in 56 patients aged 24 to 78 years were analyzed.
 Results. 44 patients had moderate and severe subcompensated comorbidities. Betamethasone was the most commonly used for injections (32 patients, 57.2%). Glucocorticoids were administered intra-articularly to 43 (76.8%) patients: knee joint (37.5%), shoulder (25.0%), ankle (7.1%), hip (3.6%), elbow and 1st metatarsophalangeal (1 case each). In other cases (bursitis, enthesitis, etc.), glucocorticoids were administered paraarticularly. It was a single injection only in 32%; the rest of patients were injected 2 – 20 times. In 96% of cases, monocultures were microbiologically isolated (S.aureus in 52%). At the time of hospitalization, the acute stage of the infectious process was detected in 22 (39.3%) patients, subacute in 16 (28.6%), and chronic active fistula phase in 18 (32.1%). All cases of clinically similar manifestations are systematized into groups of symptom complexes – clinical variants: 1) abscess and/or phlegmon of paraarticular soft tissues, necrotizing fasciitis; 2) septic bursitis; 3) septic arthritis (synovitis); 4) septic destructive arthritis; 5) osteomyelitis.
 Conclusions. We found no clinical differences depending on the drugs used. The most important reasons for the development of infectious complications are ignoring the principles of dosing, multiplicity and time intervals of administration, unreasonable repeated use, and the presence of serious subcompensated comorbidities, which should be considered as a relative contraindication and as a risk factor.

Radiotherapy CT-based contouring atlas for non-malignant skeletal and soft tissue disorders: a practical proposal from Spanish experience.

Interest in low-dose radiotherapy (LD-RT) for the symptomatic treatment of nonmalignant conditions, including inflammatory and degenerative disorders of the joints and para-articular soft tissues, has increased substantially in recent years. In the present document, we provide a CT-based contouring atlas to help identify and delineate the most common osteoarticular regions susceptible to LD-RT. The clinical efficacy of LD-RT is supported by a large body of evidence. However, there is no consensus on the parameters for contouring the planning target volume (PTV). Moreover, 3D simulation and planning should be the standard of care even for nonmalignant disorders. For this reason, the present guidelines were prepared to help guide PTV contouring based on CT images, with the same quality criteria for patient immobilization, treatment simulation, planning and delivery as those routinely applied for cancer radiotherapy. PTV for radiotherapy requires precise identification of the target areas based on CT and other imaging techniques. Using a series of cases treated at our institution, we have defined the PTVs for each location on the simulation CT to establish the relationship between the image and the anatomical structures to be treated. We also specify the immobilization systems used to ensure treatment accuracy and reproducibility. This comprehensive atlas based on CT images may be of value to radiation oncologists who wish to use LD-RT for the symptomatic treatment of degenerative or inflammatory osteoarticular diseases. The recommendations and contouring atlas described in this article provide an eminently practical tool for LD-RT in non-malignant conditions, based on the same quality criteria recommended for all modern radiotherapy treatments in Spain.

MRI evaluation of knee trauma and its correlation with clinical examination and arthroscopic findings

Knee joint is the largest and complex joint of the body and also most frequently injured joint in sportsmen due to the lack of bony support. The stability of the joint is highly dependent on its supporting ligamentous structures; therefore, injuries of ligaments and menisci are extremely common. MRI has virtually replaced conventional arthrography and other modalities for the evaluation of menisci and cruciate ligaments [3]. Compared with CT scans, MRI provides superior anatomic and pathological status of soft tissues, ligaments, fibro cartilage and articular cartilage. Since the 1980’s, diagnostic arthroscopy has been used frequently to show intra-articular abnormalities with more than 95% accuracy depending on the expertise of the arthroscopist [6]. During arthroscopy, all the internal structures are visualized, the abnormality detected and treated as well. MRI has enormous impact on musculoskeletal imaging and knee is the most frequently imaged joint. It is non- invasive and does not require ionizing radiation. Advantages of MRI include excellent inherent soft tissue contrast, multiplanar imaging capability, lack of patient exposure to radiation, ability to visualize ligaments, tendons, articular cartilages, menisci, para-articular soft tissues and the bone marrow.

Shoulder gouty arthritis with tophus: a case report and literature review

Gout is a common metabolic disease. Gouty arthritis is associated with the deposition of urate crystals in the synovial fluid or para-articular soft tissues, which often affects the hands, feet, wrists, ankle and knees joints. However, the shoulder joint is unusual involved. In the present study, a 49-year-old male patient complained of right shoulder pain for 9 months and aggravating with limited range of motion for 2 weeks. Physical examination showed that the external rotation was 10° and hand back was S5 of the right shoulder. The MRI showed shoulder joint effusion and intra-articular bodies. The patient was admitted to the hospital with the diagnosis of loose bodies of the right shoulder with synovial chondromatosis possibly. Arthroscopic examination revealed that a lots of urate crystals were deposited on synovium, cartilage and rotator cuff. Loose bodies removal and joint debridement were performed. Histopathologic examination of the specimen demonstrated synovitis hyperplasia with urate crystals deposition. Shoulder gouty arthritis characterized by pain and limited movement. The imaging of tophi depends on the calcium-containing deposits. Tophus with calcium deposits can be found on X-ray and CT. MRI can not only evaluate the tophus but also the evaluate the other intra-articular pathologies. Due to no typical manifestations and specific images of shoulder gouty arthritis, pathological diagnosis is the gold standard. Shoulder arthroscopy provide a minimal invasive technique in diagnosing and treating of the shoulder disease. Undoubtedly, it could be a reliable diagnosis and treatment method for shoulder gouty arthritis. Key words: Arthritis, gouty; Shoulder joint; Arthroscopy

Top-Ten Tips for Ultrasound-Guided Joint Injection.

Ultrasound-guided joint injection is more accurate than palpation-guided injection and performed more frequently. Joint injection is helpful for therapeutic and diagnostic purposes as well as for injecting contrast agents for magnetic resonance imaging or computed tomography arthrography. Ultrasound-guided joint injection helps ensure intra-articular injection and minimizes injury to para-articular soft tissues.

Post-Burn Roentgengraphic Study of the Foot in Children

Foot burns in a pediatric patient require special consideration. In deep burns of III-IV degree in children, covering 5% and more of the body surface, that cause the development of burn disease, most patients develop osteoporosis of uniform, spotted and reparative type. 79 patients aged 14 years and younger underwent X-ray examination at the Burn department of RSCUMA and the Samarkand Inter-Regional Burn Centre. X-ray method is the main in recognition and study of the pathology of bones and cartilages of the foot and ankle joint. In prolonged treatment of burn disease premature degenerative changes of joint, sublaxations, ankilosis and calcification in para-articular soft tissues were observed. The early surgical treatment of burnt foot deformation leads to definite positive changes in bones.

Monophasic Synovial Sarcoma of Prostatic Fascia: Case Report and Literature Review

Synovial sarcoma (SS) primarily occurs in the para-articular soft tissue of the lower extremities in young adults and it is extremely rare in the prostatic region. We report a case of a 46-year-old man who presented with urinary retention. Pelvic ultrasound (US) examination, computed tomography (CT), and magnetic resonance imaging (MRI) demonstrated an 8.5 cm mass that appeared to originate in the prostatic fascia of the right lobe. Preoperative prostatic ultrasound transrectal needle biopsy revealed mesenchymal neoplastic tissue. Patient underwent surgery. The final pathologic findings were consistent with the diagnosis of monophasic synovial sarcoma.

Potentialities of Plastic and Reconstructive Microsurgery in Treatment of Patients with Pathology of Large Joints of Extremities

Potentialities of reconstructive and plastic microsurgery in patients with different pathology of large joints of the extremities were studied. Results of 265 microsurgical operations with pedicle flap (65.7%) and free tissue (34.3%) grafting were assessed. It was shown that use of microsurgical techniques provided reconstruction of full value para-articular soft tissues, increased range of joint movement and created the conditions for effective arrest of local inflammatory process. Besides, they possessed potentialities for the performance and increase of the efficacy in arthroplasty and some other high technology operations on large joints. The more distally the joint is located the higher is the need in reconstructive-plastic microsurgical operations and free tissue grafting on upper and lower extremities.

Synovial sarcoma metastasis to the heart presenting with LV dysfunction and heart failure

Soft tissue sarcomas comprise just 1% of all cancers that are diagnosed annually. Synovial sarcoma typically arises from Para-articular soft tissues of the extremities and is rarely found at sites that have no apparent synovial structures. Here we describe a case of synovial sarcoma diagnosed pathologically by biopsy from primary site and treated with chemotherapy and radiotherapy. Later, patient presented with metastasis to the heart causing severe LV dysfunction and heart failure, which was diagnosed by 2D Echo cardiography, Computed Tomography of chest and Contrast Enhanced Computed Tomography of Abdomen. Patient died and autopsy was done and diagnosis confirmed.

TECHNOLOGIES OF PLASTIC AND RECONSTRUCTIVE MICROSURGERY IN TREATMENT OF PATIENTS WITH PATHOLOGY OF HIP REGION

Objective: This study aimed to determine the capabilities of plastic and reconstructive microsurgery in treatment of patients with traumas and diseases of hip. Material and methods: We have studied the results of surgical treatment of 10 patients with pathology of hip. All the patients were treated in Vreden Russian Research Institute of Traumatology and Orthopedics (Saint-Petersburg, Russia) within the period from 2000 to 2011. All the patients had pedicled flap transfer (10 cases) or free tissue transfer (1 case). 6 patients had additionally primary or revision total hip replacement. Results and conclusions: Microsurgical operations mainly aimed to correct various pathological changes of soft tissues and to cure infectious process in hip area. It was stated that microsurgical operations themselves is an effective method of treatment of wide neurotrophic sores located in the area of hip joint as well as hematogenic osteomyelitis of hip joint. Only microsurgical technologies provide opportunities for successful total hip replacement in patients with combined pathology of para-articular soft tissues and bones.

Review of para-articular soft tissue osteochondromas of the knee

Para-articular osteochondromas (PAOCs) are a rare benign subtype of chondroma that occur in the soft tissues around the joints. Initially hypothesized to be derived from cartilaginous metaplasia, its aetiology and pathogenesis are still not fully understood. This tumour often causes a diagnostic and management dilemma due to similar clinical and histopathological features compared with other pathology. We report the fourth case of PAOC arising from the suprapatella region of the knee joint and review the literature to update our understanding of this tumour. From the data analysed, a distinctive pattern of tumour formation within or adjacent to a fat pad structure was evident, while trauma appears to play a role in its pathogenesis. Histologically, the tumour consists of a cartilage cap, with varying degrees of trabecular bone and endochondral ossification. Importantly, there are no features of nuclear pleomorphism or increased mitotic activity suggestive of a malignant process. All tumours were surgically removed and behaved in a benign fashion without evidence of recurrence. PAOC may often be suspected for more malignant processes; thus, recognition of this entity is important as simple excision is curative.

Tuberculosis Arthritis and Tenosynovitis

The incidence of extrapulmonary tuberculosis (TB) has been rising due to the increasing number of immunosuppressed patients. Musculoskeletal system accounts for 25% of extrapulmonary TB. Most of the musculoskeletal TB involves the spine. TB of peripheral joints and tendons occur infrequently, but if untreated, it can cause serious joint and tendon destruction as well as spread of the infection to the surrounding bursa, muscle, and other soft tissues. The diagnosis of TB of joints and tendons is difficult due to the nonspecific clinical manifestations and imaging features. Concurrent active pulmonary TB is present in <50% of the patients. A positive chest radiographic finding or a positive tuberculin test supports the diagnosis, but negative results do not exclude diagnosis. Although imaging features of TB of joints and tendons are nonspecific, certain findings such as relatively preserved joint space, juxta-articular osteoporosis, cold abscesses, para-articular soft tissue calcification, and rice bodies are suggestive of TB infection. Familiarity with these imaging features can help in making an early diagnosis and facilitating proper management.

Magnetic resonance imaging in Löfgren’s syndrome: demonstration of periarthritis

In Löfgren's syndrome, pain and swelling commonly involves the ankle joints. In this prospective case series, the magnetic resonance imaging findings of ankle joint involvement are described. Extensive subcutaneous and soft tissue oedema was commonly seen around the ankles. Bone, cartilage, ligaments and tendons were typically uninvolved. Small amounts of joint and tenosynovial fluid were present without evidence of synovial thickening or synovitis. The fluid is probably reactive to adjacent inflammation in the para-articular soft tissues and probably not representing a primary site of involvement. These findings demonstrate that the arthritis in Löfgren's syndrome stems primarily from periarthritis. This is consistent with prior descriptions using ultrasonography.

Uncommon synovial cysts in children

Popliteal synovial cysts (Baker's cysts) are a common occurrence in children and adults. Synovial cysts in other locations and/or with atypical extension are less common and may be confounded with tumors or other medical conditions. In this article we describe the underlying disease, clinical presentation and clinical course in six children with a sudden onset of paraarticular soft tissue masses or non-specific chronic pain. Ultrasound was the initial imaging method used in all cases; this was supplemented by MRI in three patients. Four children were diagnosed to be suffering from juvenile idiopathic arthritis (JIA), one child from Lyme Arthritis, whereas in one child no underlying disease was identified. Well-demarcated hypoechogenic lesions without signs of perfusion extending from the shoulder (two patients), elbow (one patient), hip (one patient), knee (1) or ankle (one patient) far into the adjacent musculature were detected on ultrasonography. A direct connection to the joint was demonstrated in all cases. All synovial cysts in the five arthritic patients resolved rapidly with medical treatment for arthritis, whereas the cyst persisted in the non-JIA patient. Uncommon synovial cysts occur in particular as a complication of arthritis. Ultrasonography is the initial and follow-up imaging method of choice, which can be supplemented by MRI in unusual cases. Apart from treatment for arthritis, no specific therapeutic interventions were required in the present cases.

Late solitary bone metastasis of a primary pulmonary synovial sarcoma with SYT-SSX1 translocation type: case report with a long follow-up

Primary synovial sarcoma outside its classical presentation in para-articular soft tissue of young patients is rare but regularly reported. One of the rarest primary locations is the lung. We describe a 73-year-old female patient who presented with a solitary malignant bone tumor 8 years after the resection of a lung neoplasm. The bone tumor was classified as an osteosarcoma and the lung tumor as an atypical carcinoid tumor at their first respective diagnostic work-ups. The resection of the affected humerus with allograft and endoprosthesis implantation followed. Reevaluation of the tumor samples at the time of the local recurrence of the bone tumor 6 years following the initial symptoms of the bone tumor lead to the reclassification of both specimens as synovial sarcomas. Both neoplasms contained the SYT-SSX1 type of the diagnostic translocation t(X;18) as detected by the reverse-transcription polymerase chain reaction analysis. The patient died 14 years after the resection of the primary synovial sarcoma of the lung and 6 years following the occurrence of the bone metastasis. This prolonged clinical course is uncommon for the SYT-SSX1 translocation, which, in other locations, is usually associated with an unfavorable prognosis.

SYNOVIAL SARCOMA OF THE PROSTATE

Synovial sarcoma is a mesenchymal neoplasm that typically arises in the para-articular soft tissues of the lower extremities in young adults. While it has been described in a variety of sites including the parapharyngeal space, abdominal wall and retroperitoneum, involvement in the genitourinary tract is exceedingly rare. We report a case of synovial sarcoma of prostatic origin that invaded the cavernous bodies.