Secondary Degenerative Changes Research Articles

TEMPOROMANDIBULAR JOINT SYNOVIAL CHONDROMATOSIS: A RARE CASE

Synovial chondromatosis (osteochondromatosis) is a rare lesion originating from the synovial membrane. It develops as a result of metaplasia of the tendon sheath or synovial membrane of the bursa in the joint and causes the formation of chondral or osteochondral foci in the synovium. These cartilaginous lesions can cause secondary degenerative changes as free bodies within the joint. Between the ages of 30 and 50, the knee joint is less commonly seen in the hip, ankle, shoulder and elbow joints. Clinically, joint pain and progressive limitation of motion, effusion and recurrent locking in some cases are seen. In this case, we aimed to present SC radiologic (CBCT and MR) and clinical findings in TME of a 53 years old female patient who applied to our clinic for synovial chondromatosis.

Central Serous Chorioretinopathy - an Overview.

Central serous chorioretinopathy (CSCR) is characterised by retinal serous detachment usually localised in the macular region. CSCR predominantly affects men between 30 and 50years of age. Traditional classification differentiates between acute (duration shorter than 4 to 6 months) and chronic disease (duration longer than 4 to 6 months). The pathogenesis is multifactorial and current thinking assumes the presence of localised choroidal hyperpermeability with subsequent secondary changes in the retinal pigment epithelium (RPE). The symptoms of acute CSCR include central blurred vision, often with deterioration in visual acuity. Optical coherence tomography (OCT) reveals subretinal fluid (SRF) and/or single retinal pigment epithelial detachments. Fluorescein angiography (FA) usually shows a leaking point with absent or only minor RPE changes in the acute phase and indocyanine green angiography (ICG) highlights circumscribed areas of thickened and hyperpermeable choroid. Acute cases may show spontaneous resolution of SRF, but may also recur and/or become chronic. After the initial diagnosis, spontaneous remission is seen in about 70 to 80% of cases, with a recurrence rate of about 50%. Due to the favourable spontaneous course, it is recommended to wait for 4 to 6 months after the first symptoms manifest. Steroid therapy is considered as a major risk factor. Chronic cases are characterised by slow deterioration in visual acuity with reduced contrast and colour perception. There are extensive RPE changes, with secondary degenerative changes of the photoreceptors. The disease can by complicated by choroidal neovascularisation (CNV), especially in elderly patients. The literature lists a number of treatments: The leakage point (visible in the FA) can be treated by focal laser therapy, either micropulse laser or, if sufficiently distant from the fovea, by argon laser coagulation. Randomised trials in chronic CSCR demonstrated good outcomes with photodynamic therapy. With observation periods ranging from 3 to 6 months, several case series reports found improvement after systemic administration of mineralocorticoid receptor antagonists, carbonic anhydrase inhibitors or non-steroidal anti-inflammatory drugs. In the presence of secondary CNV, anti-VEGF treatment should be initiated. It is unclear whether the combination with PDT might be useful.

RETROSTERNAL GOITRE WITH VARIED HISTOMORPHOLOGY: A CLINICOPATHOLOGICAL CASE REPORT

The term such as retrosternal or substernal is used when a goitre extends below thoracic inlet. Retrosternal goitre is rare and accounts for 5–20% of thyroidectomy patients. Majority of the patients present with symptoms of dyspnoea as in our case. Also, patients can come with change of voice, stridor and a huge swelling. Most of the cases of retrosternal goitre can be removed with conventional collar incision, however sternotomy may be required in few cases. Our patient was euthyroid at presentation and a right hemithyroidectomy was done for her. A detailed histopathological evaluation (HPE) showed evidence of long-standing Adenomatoid goitre with extensive hyalinization, thickened capsule and secondary degenerative changes in the right lobe of thyroid and evidence of chronic lymphocytic thyroiditis in the sections examined from the portion of isthmus. The procedure was uneventful. The patient was doing well after three months of clinical follow up.

Joint-preserving surgical correction of advanced flexible planovalgus deformity of the adult foot

Adult acquired flatfoot deformity is characterized by aprogressive functional deficit of the foot that leads to an eversion of the subtalar joint complex with heel valgus, abduction of the forefoot and collapse of the medial arch. In the case of aflexible deformity, ajoint-preserving operative reconstruction is advisable, which should correct all elements of the deformity. Acalcaneal lengthening osteotomy can correct excessive abduction of the forefoot, which can be measured by the amount of talar head uncoverage visible on AP weight-bearing x‑rays of the foot. Any calcaneal lengthening osteotomy leads to an incongruence between talar and calcaneal joint surfaces of the subtalar joint, which is arisk factor for secondary degenerative changes. It is, therefore, advisable to limit the amount of lengthening to thenecessary minimum. Aresidual heel valgus can be corrected by an additional medial displacement osteotomy as adjunct to the calcaneal lengthening. Calcaneal osteotomies are usually part of acomplex reconstruction of advanced but still flexible adult flatfoot deformities. In addition to the correction of the hindfoot deformity, persistent forefoot supination needs to be corrected. In cases of midfoot instability, which is frequently located in the naviculo-cuneiforme joint line, acorrective arthrodesis is recommended. Without midfoot instability forefoot aCotton osteotomy is able to reduce forefoot supination and add to reconstruction of the medial arch of the foot. All bony corrections should be combined with soft tissue reconstruction, i.e. spring ligament repair, Flexor tendon transfer and, in cases of gastrocnemius shortening, agastroc recession.

Functional outcome of arthroscopic reconstruction of chronic anterior cruciate ligament ruptures using single-bundle triple-weaved hamstring tendons in northern Nigeria

Though anterior cruciate ligament (ACL) is the most commonly reconstructed ligament all over the world, its arthroscopic reconstruction was relatively less frequent in the West African sub region until recently. The patronage of the traditional bone setters in the acute phase of closed knee injuries has made Chronic ACL injury the main form of presentation with significant secondary injuries and degenerative changes from sub-optimal initial care. The aim of this study was to determine functional outcome and patient’s satisfaction from Arthroscopic chronic ACL injury repair. Diagnoses were made using clinical parameters and MRI. Lysholm scores were determined preoperatively, and repeated with patient’s satisfaction assessment (using the Likert scale) at 3, 6, 12, 24 and 48 months postoperatively. Arthroscopic single-bundle ACL repair using a triple-weaved hamstring tendon (s) was done for all the patients. Debridement and meniscectomy were done for various degrees of degenerative changes and irreparable meniscal injuries respectively. No one was dissatisfied and 91.4% of the patients had well to excellent Lysholm scores at 2 years of follow up. It was concluded that arthroscopic chronic ACL rupture reconstruction using single-bundle triple-weaved hamstring autografts with good rehabilitation offers good to excellent knee function and patients’ satisfaction with minimal complications.

Osteonecrosis of the Lesser Metatarsal Heads

Osteonecrosis of the lesser metatarsal heads may be detected in both children and adults. It is also defined as Freiberg’s disease. It is an uncommon syndrome whose etiology combines potential developmental anomalies, biomechanical stresses or traumatic events, subchondral fracture and vascular injury. The second metatarsal head is the most commonly involved. The disease is much more common in females and athletes. The diagnosis is based on the clinical findings and is confirmed with plain radiographs. On physical examination, the palpable swelling, the discomfort and the motion restriction are well localized at the affected metatarsophalangeal joint. The history may be one of exacerbations and remissions, with pain aggravated by activity and relieved by rest. However, in a group of patients the disorder escapes diagnosis, until the foot is radiographically examined for a totally different reason. Radiographically, the metatarsal head may have a flattened, enlarged appearance with areas of increased sclerosis, fragmentation and collapse, resulting in incongruity of the joint surface. In the long-standing disease, the affected metatarsophalangeal joint may be narrowed and prominent secondary degenerative changes may be evident. The goal of treatment is early identification and conservative treatment of the patient, to allow bone healing and prevent rapid progression to osteoarthritis. No operative treatment modalities are effective in the early stages but surgical intervention is usually required in the late stages of the disease. The purpose of this editorial is to retrospectively review the incidence of osteonecrosis of the lesser metatarsal heads in children and adults referred at our institution and to review the relevant publications.

Multiple hereditary exostoses and enchondromatosis.

Multiple hereditary exostoses (MHE) and enchondromatosis are rare multifocal benign disorders usually causing skeletal deformities appearing already in childhood. MHE is a dominant autosomal inherited disorder characterized by multiple osteochondromas (exostoses) growing outward from the metaphyses of long bones as well as from flat bones. They may cause reduced joint motion and pain due to tendon, muscle, and nerve compression. Enchondromatosis (or Ollier's disease) is a noninherited disorder characterized by the presence of multiple intraosseous enchondromas located asymmetrically in the skeleton and with a wide variation regarding location, size, and number ranging from the involvement of a single hand to the involvement of the entire skeleton. It can occur together with soft-tissue hemangiomas in Maffucci's syndrome. Clinical problems caused by the enchondromas are mainly related to skeletal deformities causing malalignment and restricted motion of joint. In both disorders, there is a risk of malignant transformation as well as secondary degenerative joint changes.

Corrective osteotomy after malunited distal radius fractures.

Posttraumatic malunion or secondary dislocation can cause wrist joint incongruency. Uncorrected malalignment increases the risk of secondary degenerative changes and chronic pain. Therefore, early correction using the available fixed-angle devices, cancellous bone grafting only becomes necessary in larger bony defects. Premounting the plate through a palmar approach with regard to the desired correction angles leads to predictable results by precise correction. In case of posttraumatic growth arrest with larger discrepancy of the radius and the ulna, a two-staged procedure is advisable.

Structural Changes and Astrocyte Response of the Lateral Geniculate Nucleus in a Ferret Model of Ocular Hypertension.

We investigated structural changes and astrocyte responses of the lateral geniculate nucleus (LGN) in a ferret model of ocular hypertension (OH). In 10 ferrets, OH was induced via the injection of cultured conjunctival cells into the anterior chamber of the right eye; six normal ferrets were used as controls. Anterograde axonal tracing with cholera toxin B revealed that atrophic damage was evident in the LGN layers receiving projections from OH eyes. Immunohistochemical analysis with antibodies against NeuN, glial fibrillary acidic protein (GFAP), and Iba-1 was performed to specifically label neurons, astrocytes, and microglia in the LGN. Significantly decreased NeuN immunoreactivity and increased GFAP and Iba-1 immunoreactivities were observed in the LGN layers receiving projections from OH eyes. Interestingly, the changes in the immunoreactivities were significantly different among the LGN layers. The C layers showed more severe damage than the A and A1 layers. Secondary degenerative changes in the LGN were also observed, including neuronal damage and astrocyte reactions in each LGN layer. These results suggest that our ferret model of OH is valuable for investigating damages during the retina–brain transmission of the visual pathway in glaucoma. The vulnerability of the C layers was revealed for the first time.

Magnetic resonance imaging of the meniscal roots.

The meniscal roots and supporting structures anchor the menisci to the tibial plateau and resist hoop stress, thereby preventing radial displacement of the menisci and secondary degenerative tibiofemoral compartment changes that may occur if this is compromised. The anatomy of the four meniscal roots and their supporting structures on magnetic resonance imaging (MRI) will be outlined in this review article, as well as the imaging appearances of meniscal root-related pathology, namely meniscal root degeneration and tears, meniscal extrusion and tibial plateau cystic lesions.

Dislocation of the metacarpophalangeal joint in a female red deer: Case report

The paper presents a post-traumatic anomaly of the metacarpal joint of a front limb of a female red deer, which was the cause of joint dislocation. This anomaly arose due to an incorrect positioning of the limb during movement, especially during fast running, most probably when the frightened animal was escaping from danger. Other mechanical causes cannot be excluded, such as entrapment of the limb in a net fence for crops and forest youngsters, which is commonly used to protect the forest from wild animals. The study showed that the resulting injury had led to secondary degenerative changes and deformities of the lopsided axis of the limb. The result was an incorrect directional orientation of the metacarpal bone and toes, and consequently of the hooves of the third and fourth fingertips. At the same time, the second and fifth toes, residual in this species, became retarded. The joint dislocation led to an incorrect positioning of the hooves during the animal’s movement and, consequently, to their excessive growth. These changes, however, despite their long-standing character, did not affect the animal’s condition, as evidenced by its carcass weight, which was above average for a female deer of this age and in this region of Poland.

Anterior Lumbar Interbody Fusion With Cement Augmentation Without Posterior Fixation to Treat Isthmic Spondylolisthesis in an Osteopenic Patient-A Surgical Technique.

Anterior lumbar interbody fusion (ALIF) has been well established as an effective surgical intervention for chronic back pain due to osteoporotic vertebral collapse. Historically, ALIF has consisted of an anterior approach to disc height restoration with a subsequent posterior pedicle screw fixation. Although the applications of cement augmentation with posterior fixation have been previously reported, treatment of patients with both isthmic spondylolisthesis and decreased bone mineral density using a stand-alone ALIF is controversial because of concerns for decreased fusion rates and increased subsidence risk, respectively. We report a case of stand-alone ALIF used to treat a low-grade isthmic spondylolisthesis in the setting of idiopathic thoraco-lumbar scoliosis in a patient with secondary degenerative changes and discuss the benefits of this surgical technique in a patient with several comorbidities. An osteopenic 66-year-old woman with multiple medical comorbidities and 2 years of left radicular leg pain was found to have a Myerding grade I isthmic spondylolisthesis in the setting of idiopathic thoraco-lumbar scoliosis with secondary changes. The patient underwent an L5-S1 stand-alone ALIF with anterior cement augmentation without posterior pedicle screw fixation. The patient experienced immediate relief of radicular leg pain postoperatively and had an uneventful course. At 2 years follow-up, she remained symptom free, and radiographs showed excellent fusion and maintenance of intervertebral disc height. The use of stand-alone ALIF with anterior cement augmentation of the vertebral bodies is a surgical technique that could produce excellent improvement in patients with low-grade isthmic spondylolisthesis in the setting of osteopenia. The use of the all-anterior approach in similar patients with multiple medical comorbidities can also be a useful technique, as it decreases associated morbidity of surgery and complication risks associated with prolonged operative times.

Severe focal myelopathy secondary to chronic compression by an arachnoid pseudocyst in a Rottweiler

A four-year old Rottweiler was presented with tetraplegia, established progressively over a 4-month period. Initiallythe dog developed paresis of the posterior limbs that subsequently evolved to tetraparesis and finally tetraplegia. Upon neurological examination the dog exhibited spastic tetraplegia with exaggerated spinal reflexes in all four limbs. The neuroanatomical lesion localization indicated a focal or diffuse cervical spinal cord disease. Cisternal myelography revealed obstruction of the contrast medium flow at the level of C5 vertebral body. Magnetic resonance imaging disclosed intradural-extramedullary compression of the spinal cord at the level of C5-C6 intervertebral disc by a spinal arachnoid pseudocyst, syrinx formation and myelopathy expressed as abnormally higher signal on T2-weighted images at the C5 segment level. Severe demyelination, involving exclusively the white matter of the grossly affected segments and extending rostrally into the brainstem and caudally into the thoracic spinal cord segments, was noticed on histopathology. The unusually severe secondary degenerative change in the cervical spinal cord white matter, inflicted by focal SAP compression, was the most interesting finding.

Sesamoid osteonecrosis treated with radial extracorporeal shock wave therapy

Sesamoid osteonecrosis is a disabling condition resulting in severe forefoot pain, for which there are limited treatment options. We present a 52-year-old man with 1-year history of pain, aggravated by...

Morphological spectrum of peripheral nerve sheath tumors: An insight into World Health Organization 2013 classification.

Introduction:Peripheral nerve sheath tumors (PNSTs) are neuroectodermal in origin. Now these tumors are classified under World Health Organization (WHO) classification of tumors of soft tissue and bone 2013.Objective:To study the morphological spectrum of PNST and to study the secondary degenerative changes associated with it.Materials and Methods:This study was conducted from January 2010 to June 2015. The gross details of tumor and patient's demographic profiles were reviewed. The hematoxylin and eosin stained slides were reassessed and the lesions were categorized and classified as per the WHO 2013 classification. The tumors were also assessed for secondary degenerative changes.Results:Our study comprised 143 cases of PNST. Age of the patients ranged from 5 to 75 years. 21–30 years is the most common age of occurrence with head and neck being the most common site. The PNSTs observed in the present study were neurofibroma (NF) (61.5%), schwannoma (36%), malignant PNST (2%), and granular cell tumor (0.5%). Nearly 10% of NF fulfilled the criteria for neurofibromatosis 1 (NF1). Rare tumors such as plexiform schwannoma and granular cell tumor were also observed. Malignant tumors were larger in dimension than benign. Myxoid, cystic, and hyaline changes were commonly associated with benign tumors while necrosis, hemorrhage, and mitotic activity were seen with malignant tumors.Conclusion:This series highlights the pathological variants of PNST along with their morphological changes and NF1 association. It is essential to be familiar with all these variants of PNST for accurate diagnosis as they have varied biological behavior.

Vascular evaluation after cervical hip fractures in children: a case series of eight children examined by scintigraphy after surgery for cervical hip fracture and evaluated for development of secondary radiological changes.

Femoral neck fractures in children and young adults are rare, but have a high risk of avascular necrosis (AVN) and subsequent gradual collapse of the femoral head. In 2006, we initiated the use of scintigraphy for the diagnosis of vascular impairment after a cervical fracture in children. In the present retrospective case study, we evaluated the effect of the remaining postoperative circulation in the femoral head after fracture in terms of the development of AVN and secondary degenerative changes of the hip joint. Eight children, four girls and four boys [mean age 11.5 years (7-16)], had been operated for a cervical or a basocervical hip fracture between 2006 and 2012. The femoral head circulation was evaluated postoperatively with scintigraphy and all children had been followed radiographically for a minimum of 1 year. The Ficat classification was used to stage the AVN and the Stulberg classification was used to stage the sphericity of the femoral head at follow-up. In two patients, the femoral head had normal circulation postoperatively and they also had normal radiographs at follow-up. In two patients, the entire femoral head was avascular postoperatively and at follow-up, one patient had normal radiographs and one had both subchondral sclerosis and flattening. These two patients had been treated with bisphosphonates and prolonged non-weight-bearing. Four patients had postoperatively retained circulation in parts of the femoral head. Three of these four patients had normal radiographs at follow-up. Evaluation of the remaining circulation after surgery may help to predict the outcome and guide the postoperative regime in children with a femoral neck fracture.

Three-dimensional invivo dynamic motion analysis of anterior cruciate ligament-deficient knees during squatting using geometric center axis of the femur.

Anterior cruciate ligament (ACL) injury often leads to symptoms of instability, which may cause meniscus injury, osteochondral lesions, and degenerative changes. For thorough evaluation of the effects of abnormal motion of ACL-deficient (ACLD) knees on the meniscus and articular cartilage, it is necessary to assess tibiofemoral motion in the medial and lateral compartments separately. Our aim was to determine if invivo three-dimensional (3D) dynamic motion of ACLD knees differs from that of contralateral uninjured knees by assessing knee motion in the medial and lateral compartments respectively. A total of 22 patients with an isolated ACL-injured knee were examined. 3D to two-dimensional registration was used to determine 3D knee motion during squatting from full knee extension to full flexion for both ACLD and contralateral uninjured knees. The knee motion was evaluated by the movement of the geometric center axis of the femur projected onto the tibial axial plane. In ACLD knees the lateral femoral condyle was located significantly more posteriorly during nearly full extension than in contralateral uninjured knees. The range of anteroposterior translation of the medial femoral condyle was significantly greater than those of contralateral uninjured knees. Almost all of the contralateral uninjured knees demonstrated medial pivot motion, while the ACLD knees showed higher variance. The ACLD knees exhibited a motion pattern different from those of contralateral uninjured knees with higher variance. During nearly full extension of the ACLD knees, the lateral femoral condyle translated posteriorly and the screw-home movement seemed to be impaired. The ACL might have an important role in maintaining normal knee function, especially during the early flexion phase. The larger range of anteroposterior translation of the medial femoral condyle in ACLD knees may be associated with a risk of secondary meniscal injury and degenerative change in the articular cartilage. Level IV.

Factors affecting the aluminium content of human femoral head and neck

Tissues for the study were obtained intraoperatively during hip replacement procedures from 96 patients. In all the cases, the indication for this treatment was primary or secondary degenerative changes in the hip joint. The subject of the study was the head and neck of the femur, resected in situ. Aluminium concentrations measured in femoral head and neck samples from patients aged between 25 and 91 were varied. Statistical methods were applied to determine the variations in relation to the parameters from the background survey. Significant differences in the aluminium content of femoral head samples were observed between patients under and over 60years of age. Based on the results, it was confirmed that the aluminium accumulates in bones over a lifetime. The study showed that the content of aluminium in the head and neck of the femur depends on the factors such as: type of medicines taken, contact with chemicals at work, differences in body anatomy and sex. The study on the levels of aluminium in bones and the factors affecting its concentration is a valuable source of information for further research on the role of aluminium in bone diseases. Based on the investigations, it was found that the GF-AAS technique is the best analytical tool for routine analysis of aluminium in complex matrix samples. The use of femoral heads in the investigations was approved by the Bioethics Committee of the University of Medical Sciences in Poznań (Poland).

Localized acral hypertrophy.

A 35-year-old male presented with complaints of a progressive increase in the size of his right thumb. There was a significant increase in subcutaneous tissue, which was most prominent on the palmar aspect. He was experiencing difficulty in his day-to-day work due to restricted movement. There was no history of trauma, infection, or a family history suggestive of neurofibromatosis or any similar disease. He had undergone surgery two years prior for similar complaints in the index finger. Plain radiograph of the hand [Figure 1] was advised following this magnetic resonance imaging (MRI) of the right hand was performed to confirm the diagnosis and assess the disease status [Figure 2]. Figure 1 (a) Clinical photograph showing localized enlargement of thumb with postoperative changes in index finger. (b) X-ray imaging of the hand shows hypertrophy of soft tissue and bone with mushroom shaped terminal phalanx. Secondary degenerative changes are ... Figure 2 Magnetic resonance imaging of the fingers. (a) T1-weighted imaging shows proliferation of the fibro-fatty tissue of the thumb. (b and d) Proton Density fat saturated image confirms the fatty nature. (c) T2-weighted imaging shows osteophyte formation with ... A plain X-ray of the hand of another patient with similar complaints in the middle finger showed increased lengths of metacarpals and phalanges of the middle finger with prominent soft tissue and is shown in Figure 3. Figure 3 X-ray imaging of the hand of another patient shows hypertrophy of soft tissue and bone of middle finger with advanced degenerative changes in the involved digits.

"Sliding angulation osteotomy": preliminary report of a novel technique of treatment for chronic radial head dislocation following missed Monteggia injuries.

Neglected anterior radial head dislocation in type I Monteggia lesions leads to restriction of movement, deformity and instability of the affected elbow. If left untreated this leads to a painful arthritic elbow due to secondary degenerative changes. This is a difficult problem to manage and many intra-articular, extra-articular and combined procedures have been described with variable results. We report a new technique of sliding angulation osteotomy for this condition, which allows both lengthening and angulation of the ulna. A novel technique of sliding angulation osteotomy of the proximal ulna was done to achieve reduction of the radial head. Four patients with persistent anterior radial head dislocation were treated at our institution with this technique. All of them had good clinical and radiological outcomes at final follow-up. Sliding angulation osteotomy is a technically simple procedure, which achieves lengthening and angulation of the ulna simultaneously in the sagittal plane and reduces the radial head.