Soft Tissue Components Research Articles

A clinical case of single-stage correction of penetration combined orofacial defect with two microsurgical autografts

After surgical treatment for locally advanced oral tumors with resection of soft tissues, mucosal membrane, and facial skeletal structures, there are penetration combined defects, removal of which is a challenge for reconstructive surgeons. Mandibular repair is one of the problems in the correction of combined oral defects. Surgeons use different grafts to remove mandibular defects. One-flap transplantation does not always solve all reconstruction problems and ensure the repair of the mucosal membrane, a soft-tissue component, skin integuments, and facial skeleton. The authors describe a clinical case of successful single-stage correction of penetration combined orofacial defect after resection of the tongue, mouth floor, en bloc resection of the lower jaw and mental soft tissues, bilateral cervical supramyochoroidal lymphadenectomy, stage LCL CM mandibular defect formation after J. Boyd, by using two microsurgical autografts (a peroneal skin-muscle-skin autograft and a radial skin-fascia one) in a 39-year-old female patient clinically diagnosed with carcinoma of the left mandibular alveolar ridge mucosa, Stage IVA (T4аN0M0). The Department of Microsurgery, P.A. Herzen Moscow Oncology Research Institute, Ministry of Health of Russia, has gained experience in comprehensively correcting extensive combined maxillofacial defects with two or more grafts in 27 patients who underwent autografting with a total of 73 flaps. The most functionally incapacitating and life-incompatible defect was removed at Stage 1 of reconstructive treatment. Delayed reconstruction was made after a complex of specialized antitumor therapy and assessment of treatment results in the absence of progressive growth. A great problem during multi-stage defect correction is presented by the lack of recipient vessels after cervical lymphadenectomy, the presence of soft tissue scar changes, trismus, temporomandibular joint ankylosis, contractures and displacement of the edges of the resected mandible, and autografting into the chronically infected area. Single-stage repair, including that using a few microsurgical autografts, is the operation of choice for adequate anatomic and functional rehabilitation, permits the promptest recovery of patients, reduces a postoperative period, and allows them to undergo an antitumor treatment cycle. However, the repair is possible, when the risk of disease progression is low, in specialized centers and when there are trained head and neck surgery and reconstructive microsurgery specialists and anesthesiologists.

Ancient DNA comes of age

If you think about it, extracting DNA from bones of people long dead is an impressive achievement. The decomposition of soft tissue is a fairly quick (and smelly) process that generally takes about 2–3 months under normal South African summer weather conditions. Buried bone tends to lose its soft tissue components after a few years, becoming light and friable. Most archaeological bones have lost the integrity of their collagen matrix after a century or two, and structurally and microscopically well-preserved bone elements are fairly rare after a few thousand years. That is what makes it absolutely amazing that the detail of DNA can survive such long periods and can be recovered by scientists.

Improved visualization of breast cancer features in multifocal carcinoma using phase-contrast and dark-field mammography: an ex vivo study.

ObjectivesConventional X-ray attenuation-based contrast is inherently low for the soft-tissue components of the female breast. To overcome this limitation, we investigate the diagnostic merits arising from dark-field mammography by means of certain tumour structures enclosed within freshly dissected mastectomy samples.MethodsWe performed grating-based absorption, absolute phase and dark-field mammography of three freshly dissected mastectomy samples containing bi- and multifocal carcinoma using a compact, laboratory Talbot-Lau interferometer. Preoperative in vivo imaging (digital mammography, ultrasound, MRI), postoperative histopathological analysis and ex vivo digital mammograms of all samples were acquired for the diagnostic verification of our results.ResultsIn the diagnosis of multifocal tumour growth, dark-field mammography seems superior to standard breast imaging modalities, providing a better resolution of small, calcified tumour nodules, demarcation of tumour boundaries with desmoplastic stromal response and spiculated soft-tissue strands extending from an invasive ductal breast cancer.ConclusionsOn the basis of selected cases, we demonstrate that dark-field mammography is capable of outperforming conventional mammographic imaging of tumour features in both calcified and non-calcified tumours. Presuming dose optimization, our results encourage further studies on larger patient cohorts to identify those patients that will benefit the most from this promising additional imaging modality.Key Points• X-ray dark-field mammography provides significantly improved visualization of tumour features• X-ray dark-field mammography is capable of outperforming conventional mammographic imaging• X-ray dark-field mammography provides imaging sensitivity towards highly dispersed calcium grains

A Method for Combining Thin and Thick Malleable Titanium Mesh in the Repair of Cranial Defects

Introduction: Cranial defects following the removal of tumor involved bone require repair and reconstruction for brain protection and cosmesis. A variety of autologous bone substrates and synthetic materials can be employed, alone or in combination. In this article, we describe the use of dual thin and thick titanium mesh, connected together using plate hardware, to repair a right frontotemporal sphenoidal bone defect following resection of a hyperostosing sphenoid wing meningioma.Methods: Reconstruction of the pterion was done with a dual mesh cranioplasty. After replacement of the native orbitozygomatic and frontotemporal bone pieces, a piece of thinner mesh was molded to the pterional defect connecting the two bone pieces and re-creating the concave shape of the pterion below the superior temporal line. The circular area of the bony defect overlying the frontal and temporal lobes was supplemented by cutting and molding an additional piece of thicker mesh which was secured to the thinner mesh with burr hole cover sectors using rescue screws.Results: A 30-year-old woman presented with painless proptosis and was found to have a hyperostosing right sphenoid wing meningioma. The patient underwent a frontotemporal orbitozygomatic craniotomy for tumor resection and extensive bony osteotomy. Repair and reconstruction of the cranial defect in the region were accomplished at the time of open operation using two thicknesses of mesh connected one to another with titanium plate pieces and rescue screws. The patient underwent gross total resection of the meningioma and near total resection of the soft tissue and bony components (Simpson Grade II). The external cosmetic results following the orbital-cranial reconstruction with the dual mesh technique was deemed “very good” by the surgeon and patient. Postoperative CT imaging demonstrated symmetric re-approximation of the shape of the pterion as compared to the opposite side.Conclusions: We present a method for connecting two titanium mesh sheets with available hardware to improve the strength in compression while maintaining the ability to mold thinner sheets as necessary for the best cosmetic results. This method is an option for coverage of bony defects in the region of the pterion for young, physically active patients providing them with additional mesh cranioplasty strength.

From the ground up: Integrative research in primate locomotion.

Primate locomotor adaptation and evolution is a principal and thriving area of research by biological anthropologists. Research in this field generally targets hypotheses regarding locomotor kinetics and kinematics, form-function associations in both the soft and hard tissue components of the musculoskeletal system, and reconstructing locomotor behavior in fossil primates. A wide array of methodological approaches is used to address adaptive hypotheses in all of these realms. Recent advances in three-dimensional shape capture, musculoskeletal physiological measurements, and analytical processing technologies (e.g., laser and CT-scans, 3D motion analysis systems, finite element analysis) have facilitated the collection and analysis of larger and more complex locomotor datasets than previously possible. With these advances in technology, new methods of form-function analyses can be developed to produce a more thorough understanding of how form reflects an organism's mechanical requirements, how shape is influenced by external environmental factors, and how these investigations of living taxa can inform questions of primate paleobiology. The papers in this special section of the American Journal of Physical Anthropology present research that builds on that foundation, by combining new data on living primates and new methodologies and approaches to answer a range of questions on extant and extinct primates.

Computed tomography findings of paracoccidiodomycosis in musculoskeletal system.

ObjectiveTo evaluate musculoskeletal involvement in paracoccidioidomycosis at computed tomography.Materials and MethodsDevelopment of a retrospective study based on a review of radiologic and pathologic reports in the institution database. Patients with histopathologically confirmed musculoskeletal paracoccidioidomycosis and submitted to computed tomography were included in the present study. The imaging findings were consensually described by two radiologists. In order to avoid bias in the analysis, one patient with uncountable bone lesions was excluded from the study.ResultsA total of seven patients were included in the present study. A total of 18 bone lesions were counted. The study group consisted of 7 patients. A total number of 18 bone lesions were counted. Osteoarticular lesions were the first manifestation of the disease in four patients (57.14%). Bone lesions were multiple in 42.85% of patients. Appendicular and axial skeleton were affected in 85.71% and 42.85% of cases, respectively. Bone involvement was characterized by well-demarcated osteolytic lesions. Marginal osteosclerosis was identified in 72.22% of the lesions, while lamellar periosteal reaction and soft tissue component were present in 5.55% of them. One patient showed multiple small lesions with bone sequestra.ConclusionParacoccidioidomycosis can be included in the differential diagnosis of either single or multiple osteolytic lesions in young patients even in the absence of a previous diagnosis of pulmonary or visceral paracoccidioidomycosis

Assessment of Apical Periodontitis by MRI: A Feasibility Study

The purpose of this clinical feasibility study was to evaluate the applicability of magnetic resonance imaging (MRI) for the assessment of apical periodontitis in direct comparison with cone beam CT (CBCT). 19 consecutive patients (average age 43 ± 13 years) with 34 lesions in total (13 molars, 14 premolars and 7 front teeth) were enrolled in this feasibility study. Periapical lesions were defined as periapical radiolucencies (CBCT) or structural changes in the spongy bone signal (MRI), which were connected with the apical part of a root and with at least twice the width of the periodontal ligament space. The location and dimension of the lesions were compared between MRI and CBCT. While mainly mineralized tissue components such as teeth and bone were visible with CBCT, complimentary information of the soft tissue components was assessable with MRI. The MRI images provided sufficient diagnostic detail for the assessment of the main structures of interest. Heterogeneous contrast was observed within the lesion, with often a clear enhancement close to the apical foramen and the periodontal gap. No difference for lesion visibility was observed between MRI and CBCT. The lesion dimensions corresponded well, but were slightly but significantly overestimated with MRI. A heterogeneous lesion appearance was observed in several patients. Four patients presented with a well circumscribed hyperintense signal in the vicinity of the apical foramen. The MRI capability of soft tissue characterization may facilitate detailed analysis of periapical lesions. This clinical study confirms the applicability of multi-contrast MRI for the identification of periapical lesions. MRI can be applied for the identification of periapical lesions without ionizing radiation exposure. MRI might facilitate more detailed characterization of periapical lesions. MRI might provide more accurate lesion dimensions as X-ray-based methods.

Imaging Evaluation of Pediatric Sensorineural Hearing Loss in Potential Candidates for Cochlear Implantation.

Computerized tomography (CT) and magnetic resonance (MR) are complementary in the imaging of the labyrinth, the internal auditory canal and the brain in children with sensorineural hearing loss who are being evaluated for cochlear implantation. An accurate anatomical description of the inner ear is essential in the preoperative work up. Computerized tomography visualizes the bony structures, whereas MR can discern soft-tissue components including intra labyrinthine fluid, cerebrospinal fluid (CSF), nerves, and vessels within the IAC. This prospective study was conducted in the Department of Otorhinolaryngology, Head & Neck Surgery, Government Medical College, Srinagar. 40 children in the age group of 1-16years with unidentified causes of bilateral SNHL were analysed radiologically over the period of 2years from Dec 2011 to Jan 2014. Each patient underwent MRI and high resolution CT scanning of temporal bone in axial and coronal planes. Out of the 40 patients 22 were males (55%) and 18 were females (45%). 30 patients (72.5%)in our study had normal radiological scans. Five patients (12.5%) had B/L large vestibular aqueduct and two patients (5%) had internal auditory canal stenosis with cochlear nerve hypoplasia on CT and MR imaging. Cochlear dysplasia was present in two patients (5%) and semicircular canal dysplasia was present in one patient (2.5%) as an isolated finding on HRCT. In addition isolated cochlear nerve hypoplasia was present in one patient (2.5%). Hyperintense basal ganglia lesion suggestive of kernicterus was present in one patient (2.5%) and hyperintense posterior parietal and occipital white matter lesions suggestive of congenital CMV infection was present in one patient (2.5%) on MR imaging. Arachnoid cysts of middle cranial fossa was an incidental finding present in one patient. Radiological abnormalities of the inner ear are not uncommon. Computerized tomography and MRI are important modalities to analyze the inner ear in children with unexplained SNHL. MRI with an extremely small field of view should be used to study possible abnormalities of the vestibulocochlear nerves.

Percutaneous C-arm-guided Wide Bore Needle Biopsy for Intraosseous Spinal Lesions

ABSTRACT Study design Retrospective analysis of data of those patients who underwent a percutaneous transpedicular biopsy at our hospital was done. All patients had a bony lesion in a vertebra (thoracic, lumbar, sacrum) without a soft tissue component around the bone and neurodeficit. Objective To analyze the role of percutaneous wide bore needle biopsy in vertebral lesions without any soft tissue component. Summary of background data Adequate treatment of spinal lesions requires formulation of diagnosis-best achieved by a tissue biopsy when all attempts at diagnosis fail by noninvasive methods. Percutaneous CT guided fine needle biopsy is technically difficult in intraosseous lesions leading to frequent inconclusive results and hence the necessity of wide bore needle biopsy. Materials and methods Retrospective analysis of data of 26 patients with mean age of 58.8 years who underwent a percutaneous transpedicular biopsy at our hospital was done. All patients had a bony lesion in a vertebra (thoracic, lumbar, saccrum) without a soft tissue component around the bone and neurodeficit. The procedure was done under local anesthesia with sedation. Results Positive diagnosis was achieved in 23 out of 26, i.e. 88.4% of cases (adequacy). Out of 26, there were 13 cases of malignancy (50%), 8 cases of tuberculosis (30.7%), 2 cases of osteoporosis (7.6%) and biopsy was inconclusive in 3 (11.5%) cases. Of the 13 malignancies, 7 cases were of metastasis (53.8%), 5 cases of plasmocytoma (38.4%) and 1 case of lymphoma (7.6%). Conclusion Percutaneous biopsy under fluoroscopic guidance by transpedicular approach is quite safe and gives high adequacy (88.4%) without significant complications that are associated with open and paraspinal techniques. How to cite this article Basu S, Tikoo A, Malik FH, Ghosh JD, Jain M, Sarangi T. Percutaneous C-arm-guided Wide Bore Needle Biopsy for Intraosseous Spinal Lesions. J Postgrad Med Edu Res 2015;49(1):5-9.

Spinal Tuberculosis Resembling Neoplastic Lesions on MRI.

Tuberculous spondylitis is one of the commonest forms of skeletal tuberculosis in developing countries like India causing significant morbidity due to compression of spinal cord and adjacent nerve roots. Diagnosis and intervention at early stage can prevent permanent damage such as spinal deformity and neurological deficits. The purpose of this study was to demonstrate atypical MRI features in cases of tubercular spondylitis resembling neoplastic lesions and to stress that tuberculous spondylitis should be one of the differential diagnoses in any spinal pathology especially in developing countries. This was a prospective study done in the patients diagnosed as tuberculous spondylitis on 0.2 T Siemens MRI between June 2011 and December 2014 in a tertiary care hospital in India. Total 529 cases of tubercular spinal lesions were diagnosed. Out of which only 59 patients showed atypical features on MR imaging which resembled neoplastic lesions were included in the study. The diagnosis was confirmed by cytology, histopathology, serology and corroborative findings. Lumbo-sacral region involvement (30.5%) is the commonest in our study followed by dorsal and cervical region. Multiple level lesions are seen in 14 cases (23.7%). All the 59 (100%) cases show no involvement of intervetebral disc. Posterior appendage involvement seen in 32 cases (54.2%). Soft tissue component seen in Intraspinal (37.2%) and paraspinal (45.7%) compartments. Cord compression seen in 19 cases (32.2%), out which only 7 cases (11.8%) shows cord oedema. On MRI, tubercular spondylitis may have variable pictures on imaging. For any spinal and paraspinal lesions, we should also consider the possibility of tubercular aetiology along with other. Since early diagnosis avoids unnecessary delay in the treatment thereby reducing morbidity and possible complications.

Sclerotic changes on plain X-ray led to early diagnosis and successful treatment of primary lymphoma of iliac bone.

Sir, A previously healthy 54-year-old woman presented to our hospital with a 3-month history of pelvic pain. There was no history of constitutional symptoms such as unintentional weight loss, fever, and loss of appetite. Clinical examination revealed pain on deep palpation of the right iliac region. There was no evidence of soft tissue swelling or redness in the site of patient's pain. The rest of physical exam was unremarkable. Laboratory investigations were within normal limits (erythrocytes sedimentation rate of 20 mm in the 1st h, negative C-reactive protein and white blood count of 4800 per μl). A plain radiograph of the pelvis showed slightly lytic-sclerotic changes of right iliac bone with indistinct margins, which at a shallow observation confused with bowel gases [Figure 1]. A computed tomography (CT) was performed and showed a slightly expansile lytic-sclerotic lesion with small soft tissue component in the right iliac bone [Figure 2]. The bone scan also revealed isolated uptake of technetium-99m in the right ilium [Figure 3]. According to the patient age, the differential diagnosis included metastasis, lymphoma, plasmacytoma, and chronic osteomyelitis. Figure 1 Radiograph of pelvis demonstrates lytic-sclerotic changes of right iliac bone Figure 2 Pelvic computed tomography image shows a slightly expansile lytic-sclerotic lesion in the right iliac bone with no extension to the sacroiliac joint Figure 3 Bone scan revealed isolated uptake of technetium-99 m in the right ilium The core needle biopsy result was consistent with the diagnosis of diffuse large B-cell nonHodgkin's lymphoma. There was not any other site of involvement on CT scan of the chest, abdomen, and pelvis. Positron emission tomography (PET) also showed no secondary absorption of fluorodeoxyglucose [Figure 4]. The diagnosis of primary nonHodgkin lymphoma of bone was made, and the patient was successfully treated with a combination of chemotherapy and radiotherapy. Figure 4 Positron emission tomography scan showed no secondary absorption of fluorodeoxyglucose NonHodgkin's lymphoma of bone is a rare entity which is limited to the long bones and axial skeleton, with the femur being the most common site of involvement. Primary involvement of iliac bone is extremely rare. There are no clinical or radiological characteristics which be diagnostic for primary bone lymphoma. The image findings in radiograph or CT scan are variable and nonspecific, range from near normal to diffuse permeative pattern.[1,2,3,4,5,6] A review article performed by Mulligan et al., revealed that the most common features on imaging studies are lytic (70%), including permeative or moth-eaten pattern, and mixed lytic and sclerotic density (28%). Periosteal reaction and soft tissue mass were reported in 58%, and 80-100% of cases, respectively, in this study.[2] Sequestrum formation considered as a radiological feature which may help to differentiate between plasmablastic lymphoma (PBL) and other conditions such as metastasis and myeloma. Sequestrum formation has been reported in 11-16% of PBL cases.[7] Cross-sectional imaging studies are useful adjuncts to conventional radiography. Extensive involvement of bone marrow cavity with a surrounding soft tissue component and without extensive cortical destruction is a pattern, which is reported only in PBL, Ewing sarcoma, and myeloma.[8] The key educational message of our case is that any change on plain X-ray is valuable and should not be overlooked. This case also reminds us the importance of considering primary nonHodgkin lymphoma as a valuable differential diagnosis in lytic and sclerotic lesions of iliac bone. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Anti-HMGB1 monoclonal antibody ameliorates immunosuppression after peripheral tissue trauma: attenuated T-lymphocyte response and increased splenic CD11b (+) Gr-1 (+) myeloid-derived suppressor cells require HMGB1.

Although tissue-derived high mobility group box 1 (HMGB1) is involved in many aspects of inflammation and tissue injury after trauma, its role in trauma-induced immune suppression remains elusive. Using an established mouse model of peripheral tissue trauma, which includes soft tissue and fracture components, we report here that treatment with anti-HMGB1 monoclonal antibody ameliorated the trauma-induced attenuated T-cell responses and accumulation of CD11b+Gr-1+ myeloid-derived suppressor cells in the spleens seen two days after injury. Our data suggest that HMGB1 released after tissue trauma contributes to signaling pathways that lead to attenuation of T-lymphocyte responses and enhancement of myeloid-derived suppressor cell expansion.

Spondylodiscitis Challenging Diagnosis in Immune Competent Child: A Case Report.

Spondylodiscitis, a combination of spondylitis and discitis, is an infection of the spine that involves the intervertebral disc and the vertebral body. Patients presented with little specific symptoms and suspicion for diagnosis is required. This report aimed to describe a female child patient with spondylodiscitis and to describe the diagnostic and therapeutic tools of such patient. This report recorded 2 year-old female child presented by fever, pain associated with standing and sitting, and 10 days history of refusal to walk in Prince Sultan Medical City, Riyadh, Saudi Arabia. Laboratory investigations as well as hip and knee ultrasound showed no abnormalities. However, and hip and lower back Magnetic Resonance Image (MRI) showed evidence of abnormal hyper intensity with enhancement of the bone marrow involving the vertebral bodies and adjacent endplates of 5th lumber (L5) and 1st sacral (S1) vertebrae with involvement of intervertebral disc space and paravertebral soft tissue component. Spondylodiscitis was suggested in the child, and conservative management by medical team of pediatrics and orthopedics consultant has immediately started. The treatment included antibiotics, non-steroidal analgesia and physical rehabilitation. The patient was completely evolved from condition within days. MRI taken 6 weeks later showed significant interval improvement of signs of spondylodiscitis, and the girl has been seen in the clinic after 4 months from discharge in good condition. Spondylodiscitis has to be considered in young children with acute ambulation changes. Prompt diagnosis and treatment involving the entire multidisciplinary team is emphasized in order to improve the prognosis of such patients.

Primary multifocal skull vault lymphoma in an acquired immunodeficiency syndrome patient

Primary skull vault non-Hodgkin's lymphoma with extra- and intra-cranial soft tissue components in an immunocompromised patient is extremely rare. There are only four cases reported in literature till date and in none were the lesions multifocal or had a discrete intraorbital component. We report such a case of multifocal primary skull vault lymphoma successfully managed in an acquired immunodeficiency syndrome patient. Distinguishing primary bone lymphoma from other skull vault lesions is important because of different management protocols.

Primary Tubercular Osteomyelitis of Manubrio Sternal Joint: A Case Report

Primary tubercular osteomyelitis of sternum is a rare clinical entity and involvement of manubrio-sternal joint is even rarer, with only few cases reported in the literature. Tuberculous sternal involvement is seen in approximately 1% of all skeletal TB cases. We report an unusual case of primary manubrio-sternal joint tuberculosis presenting as vague anterior chest wall swelling and pain. ESR and CRP were elevated, Montoux was positive and PCR for tuberculosis was positive. Computed tomography of chest done after giving intravenous contrast showed erosion at manubrio-sternal joint with minimal soft tissue component. The patient is put on anti-tubercular drugs and is responding well with regular follow-up.

Difference in clinical outcome between total shoulder arthroplasty and reverse shoulder arthroplasty used in hemiarthroplasty revision surgery.

Introduction:The increase of shoulder replacements will lead to a higher revision rate of shoulder arthroplasties. The aim of this study is to evaluate the clinical results of revision surgery performed in our hospital, distinguish the differences in clinical outcome according to revision indication and differences between total shoulder arthroplasty (TSA) and reverse shoulder arthroplasty (RSA) in hemiarthroplasty (HA) revision surgery.Materials and Methods:All patients with an indication for revision of HA were retrospectively included. Clinical evaluation consisted of pre- and post-operative constant scores, disability of arm-shoulder-hand-score (DASH), Dutch translation of the simple shoulder test ((D)SST), Oxford shoulder score test (OSS), short form (SF-36) and the complication rate.Results:From July 1994 to July 2008, 39 patients (40 shoulders) underwent revision arthroplasty. Of 19 patients (19 shoulders) we obtained a complete follow-up. The mean age at revision surgery 69 ± 10 years (range: 46-83) and the mean follow-up 41 ± 31 months (range: 10-113). In 7 cases TSA was used for revision when the cuff was intact, 12 times RSA was performed. The indications for the revision were glenoid erosion (n = 4), humeral component malposition (n = 2), cuff-pathology (n = 12) and infection (n = 1). Postoperative constant score 51.7 ± 11.4 for TSA and 31.1 ± 18.7 for RSA (P = 0.008). The DASH was 48.3 ± 25.1 and 68.7 ± 17.5, respectively (P = 0.09). DSST showed 6 ± 4 and 4 ± 4 (P = 0.414). OSS 41.3 ± 10.1 and 28.1 ± 10.3 (P = 0.017). SF-36 43.3 ± 22.1 and 24.5 ± 12.8 (P = 0.072). Four shoulders (21%) presented four complications.Conclusions:In this study, revision surgery showed poor to reasonable postoperative results and better clinical outcome for TSA. When a revision after HA was needed, and the soft-tissue component of the shoulder was intact, a TSA proved to be a preferable solution.

Parésia do Nervo Motor Ocular Comum em Contexto de Sinusite Esfenoidal

Sphenoid sinus disease is particular not only for its clinical presentation, as well as their complications. Although rare, these may present as cranial nerve deficits, so it is important to have a high index of suspicion and be familiar with its diagnosis and management. Symptoms are often nonspecific, but the most common are headache, changes in visual acuity and diplopia due to dysfunction of one or more ocular motor nerves. The authors report a case of a 59 years-old male, who was referred to the ENT emergency department with frontal headaches for one week which had progressively worsened and were associated, since the last 12 hours, with diplopia caused by left third cranial nerve palsy. Neurologic examination was normal aside from the left third cranial nerve palsy. Anterior and posterior rhinoscopy excluded the presence of nasal masses and purulent rhinorrhea. The CT scan revealed a soft tissue component and erosion of the roof of the left sphenoid sinus. Patient was admitted for intravenous antibiotics and steroids treatment without any benefit after 48 hours. He was submitted to endoscopic sinus surgery with resolution of the symptoms 10 days after surgery. The authors present this case for its rarity focusing on the importance of differential diagnosis in patients with headaches and cranial nerves palsies.

Multiple Occipital, Parietal, Temporal, and Frontal Foramina: A Variant of Enlarged Parietal Foramina in an Infant

Calvarial lesions are often detected incidentally in routine radiology. Most lytic lesions of the skull are benign. Enlarged parietal foramina are benign lesions caused by deficient intramembranous ossification. An 11 month-old female patient was admitted with a mass on the right of the back of the head. Physical examination showed a soft 5 cm mass area with no palpable bone in the right occipital. The family history revealed a similar mass in a maternal cousin that resolved over time. Craniography showed lytic lesions, and there were no other pathologies on a complete skeletal X-ray. Computed tomography (CT) showed regular-shaped defects in the bilateral temporal bones, right parietal bone, bilateral frontal bones in the upper-medial orbital wall, and particularly in the occipital bone. The well-defined contours, absence of a soft tissue component, and normal structure and density of the adjacent calvarial bones all pointed to a congenital defect. No change in the lesions was observed during a three-year ultrasound follow-up period. To the best of our knowledge, this is the first described case of multiple occipital, parietal, temporal, and frontal foramina in the cranium. A diagnosis of enlarged parietal foramina variant should be considered after ruling out the differential diagnosis in patients with multiple calvarial lesions. CT may provide valuable findings for the differential diagnosis, and sonography may be used for follow-up.

Tumour response of osteosarcoma to neoadjuvant chemotherapy evaluated by magnetic resonance imaging as prognostic factor for outcome.

This study evaluated the feasibility of computed magnetic resonance imaging (MRI) volumetry in conventional osteosarcomas. Secondly, we investigated whether computed volumetry provides new prognostic indicators for histological response of osteosarcomas after neoadjuvant chemotherapy. In a retrospective cohort study, data from the Vienna Bone Tumour Registry was used. MR images from 14 patients (male:female = 1.8, mean age 19 years) were analysed prior to and after neoadjuvant chemotherapy according to current therapy regimens. Histological response to chemotherapy was graded according to the Salzer-Kuntschik classification. Computed volumetry was performed for the intraosseous part, as well as the soft-tissue component and the tumour as a whole. In a setting of appropriate radiological equipment, the method has been considered to be well implementable into clinical routine. The mean tumour volume prior to chemotherapy was 321 (±351) ml. In good responders (n = 6), overall tumour volume decreased by 47% (p = 0.345), whereas poor responders (n = 8) showed a 19% decrease (p = 0.128). Neoadjuvant multidrug therapy remarkably changed the tumour composition. This is seen in a decrease of the mean ratio of soft-tissue to intraosseous tumour volume from 8.67 in poor responders and 1.15 in good responders to 1.26 and 0.45 (p = 0.065), respectively. Interestingly, the bony compartment of good responders showed a volume increase during neoadjuvant chemotherapy (p = 0.073). However, we did not find prognostic markers for histological tumour response to pre-operative chemotherapy. Separated volumetry of tumour segments revealed interesting insights into therapy-induced growth patterns. If verified in a larger study population, these results should be taken into account when planning ablative surgery.

The effects of the sagittal plane malpositioning of the patella and concomitant quadriceps hypotrophy on the patellofemoral joint: a finite element analysis.

Anterior knee pain is a common symptom after intramedullary nailing in tibia shaft fracture. Moreover, patellofemoral malalignment is also known to be a major reason for anterior knee pain. Patellofemoral malalignment predisposes to increased loading in patellar cartilage. In the previous study, we have demonstrated the quadriceps atrophy and patellofemoral malalignment after intramedullary nailing due to tibia shaft fracture. In this study, our aim was to clarify the effects of quadriceps atrophy and patellofemoral malalignment with the pathologic loading on the joint cartilage. Mesh models of patellofemoral joint were constructed with CT images and integrated with soft tissue components such as menisci and ligaments. Physiological and sagittal tilt models during extension and flexion at 15°, 30° and 60° were created generating eight models. All the models were applied with 137N force to present the effects of normal loading and 115.7N force for the simulation of quadriceps atrophy. Different degrees of loading were applied to evaluate the joint contact area and pressure value with the finite element analysis. There was increased patellofemoral contact area in patellar tilt models with respect to normal models. The similar loading patterns were diagnosed in all models at 0° and 15° knee flexion when 137N force was applied. Higher loading values were obtained at 30° and 60° knee flexions in sagittal tilt models. Furthermore, in the sagittal tilt models, in which the quadriceps atrophy was simulated, the loadings at 30° and 60° knee flexion were higher than in the physiological ones. Sagittal malalignment of the patellofemoral joint is a new concept that results in different loading patterns in the patellofemoral joint biomechanics. This malalignment in sagittal plane leads to increased loading values on the patellofemoral joint at 30° and 60° of the knee flexions. This new concept should be kept in mind during the course of diagnosis and treatment in patients with anterior knee pain. Definition of the exact biomechanical effects of the sagittal tilting will lead to the development of new treatment modalities.