Differential Diagnosis of Pain Around the Hip Joint

The differential diagnosis of hip pain is broad and includes intra-articular pathology, extra-articular pathology, and mimickers, including the joints of the pelvic ring. With the current advancements in hip arthroscopy, more patients are being evaluated for hip pain. In recent years, our understanding of the functional anatomy around the hip has improved. In addition, because of advancements in magnetic resonance imaging, the diagnosis of soft tissue causes of hip pain has improved. All of these advances have broadened the differential diagnosis of pain around the hip joint and improved the treatment of these problems. In this review, we discuss the causes of intra-articular hip pain that can be addressed arthroscopically: labral tears, loose bodies, femoroacetabular impingement, capsular laxity, tears of the ligamentum teres, and chondral damage. Extra-articular diagnoses that can be managed arthroscopically are also discussed, including: iliopsoas tendonitis, “internal” snapping hip, “external” snapping hip, iliotibial band and greater trochanteric bursitis, and gluteal tendon injury. Finally, we discuss extra-articular causes of hip pain that are often managed nonoperatively or in an open fashion: femoral neck stress fracture, adductor strain, piriformis syndrome, sacroiliac joint pain, athletic pubalgia, “sports hernia,” “Gilmore's groin,” and osteitis pubis.     

Vibration arthrometry

Throughout the ages, physicians have listened to sounds and felt vibrations from human joints in their attempts to diagnose pathology. They have used a wide vocabulary to describe these phenomena, but technology has been slow to provide recording and analytic equipment. Lately, accelerometers have been used with considerable success in a new noninvasive method now known as vibration arthrometry (formerly “arthrography”). The technique has been used in early detection of congenital dislocation of the hip and also in diagnosis of meniscal pathology. More recently, patellar vibration has been used to assess the mechanical properties of articular cartilage. Vibration arthrometry has also yielded new information on a possible damage mechanism associated with shock vibration that arises during cavitation of synovial fluid. Joint vibrations are therefore useful aids to diagnosis and may even be etiologic in orthopedic disease.     

Radiculopathies of structural origin

In dealing with foot pain of a radicular nature, it is important to interpret the clinical signs and symptoms of the pathology carefully and arrive at an adequate diagnosis. All appropriate ancillary aids should be used to help confirm the diagnosis. Appropriate treatment plans will follow; most often they will include referrals to qualified orthopedic specialists. In this sense, the treatment of lower-extremity radiculopathy is seen as a multidisciplinary problem. The podiatrist has the opportunity to make the diagnosis, explain the problem to the patient, and perhaps deal with the resolution of the pathology. This article attempted to present a differential diagnosis of a structural radiculopathy presenting in the lower extremity. It is hoped that the discussion of symptomatology, diagnostic aids, and numerous illustrations help to add to the knowledge of this disease process.     

The Significance of Lobular Carcinoma In Situ and Atypical Lobular Hyperplasia of the Breast

Background

The significance of lobular neoplasia (LN), lobular carcinoma in situ (LCIS) and atypical lobular hyperplasia (ALH)) found at core needle biopsy (CNB) of the breast remains uncertain. There is a consistent risk of underestimating malignancy after the diagnosis of LN on CNB. The aim of this study was to determine if patients with a CNB result of LN need surgical excision.

Methods

Patients were identified by searching the institutions pathology database for the terms ??lobular carcinoma in situ?? and ??atypical lobular hyperplasia?? over 20?years. Excluded from this study were those with core needle biopsy (CNB) results of ductal carcinoma in situ, atypical ductal hyperplasia, radial scar, or papilloma. Upgrade was defined as final surgical pathology of invasive carcinoma and/or ductal carcinoma in situ that was directly correlated to the site of the initial biopsy containing LN.

Results

LN was found at CNB in 285 patients, and 71?% (n?=?201) had subsequent surgical excisions. All patients with pleomorphic LCIS (pLCIS) underwent surgical excision. Following patients with pLCIS, patients with the diagnosis of LCIS were most likely to undergo surgical excision (80?%). Final pathology of the surgically excised specimens confirmed LN in 72?% (n?=?144). Also, 13?% (n?=?26) of the operated patients were upgraded to malignancy, including 8?% of ALH and 19?% of LCIS cases.

Conclusion

This is the largest series of surgical excisional pathology following LN on CNB ever reported. The likelihood of finding malignancy at surgical excision after CNB showing LN was 13?%. Patients with the diagnosis of LN on CNB should be considered for surgical excision.     

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??Essentials of pathologic diagnosis in soft tissue tumor WANG Jian. Department of Pathology, Fudan University Shanghai Cancer Center; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
Abstract Owing to the low incidence, complexity in histological appearance, overlapping features between different entities, lots of pseudosarcomatous lesions and tumors of intermediate malignancy, the diagnosis of soft tissue tumors is one of most challenging job in surgical pathology. It is recommended that pathologists should not only rely on the histology alone. The correlations between clinic, radiology and pathology are essential in arriving at the correct diagnosis. Moreover, regular screening of the recent literatures with focus on the advancement of soft tissue tumors and newly described entities are also very important.     

Pediatric bicycle trauma

Bicycle-related trauma is a serious pediatric problem. Serious injuries and even fatalities can occur, and care must be taken to avoid undertreating these patients. In an effort to further define the problem, 201 consecutive patients admitted for bicycle trauma were reviewed. The patients ranged in age from 3 to 16 years and 76% (153/201) were male. Head trauma was the most common admission diagnosis (99/201; 49%). Fourteen per cent (28/201) were admitted to the Intensive Care Unit and 23% (47/201) required an operative procedure. The average hospital stay was 3 days; however, patients who were admitted at least 24 hours after injury had an average hospital stay of 7 days.     

Accuracy of intraoperative consultation for bone tumors: experience in an orthopedic hospital

Background Intraoperative consultation is an integral part of surgical pathology. However, there are few reports concerning intraoperative pathology consultation exclusively for bone tumors. Method Our hospital is an orthopedic institution that specializes in the diagnosis and treatment of bone tumors, and we retrospectively reviewed the intraoperative consultations for bone tumors on our service from January 2002 to February 2006. The objectives of this work were to: (1) evaluate the clinical reasons for intraoperative consultation on bone tumors; (2) identify discordant diagnoses between the intraoperative consultation diagnosis and the definitive diagnosis; (3) determine in how many cases it was possible to establish a specific diagnosis; and (4) analyze the accuracy of the intraoperative consultation diagnosis on the bone tumors. Results The two most common reasons for an intraoperative consultation were to rule out malignancy and to determine the adequacy of the resection margins. The third most common reason was to establish a diagnosis. In the latter cases, it was possible to establish a specific diagnosis in 86.3% of the cases; and we had only one discordant case. Conclusions Intraoperative consultation on bone tumors has problems and limitations. They are due mainly to the characteristics of the material that comprise the specimen from this type of lesion. It is important that similar assays be carried out at medical institutions that specialized in bone tumors to determine the effectiveness rates of intraoperative consultation in this field throughout the world. This is the first series that has analyzed the accuracy of intraoperative consultation on bone tumors with respect to the clinical reasons for the consultation.     

Pathology of the Aorta

The aorta is a distinctive surgical pathology specimen removed most frequently for aneurysm or dissection. Genetic syndromes, inflammatory processes and acquired diseases of aging result in aortic pathology; these are presented in terms of pathology, differential diagnosis and classification schemes. The pathologic context of a variety of commonly encountered histopathologies is described.     

Special radiographic techniques in the evaluation of arthritic disease

The radiographic modalities discussed in this article are useful adjunctive techniques in the evaluation of arthritic disease. None of these modalities should be considered for baseline study. Rather, they should be considered following plain film examination when further information is required. The one modality that may be considered for a screening examination is radionuclide imaging. It is most useful when early diagnostic information regarding the extent of pathology is required. A pattern of activity can provide important information to the clinician, enabling an accurate diagnosis. Arthrography is best reserved for the evaluation of articular cartilage of a particular joint. A double-contrast arthrogram should be performed in this case. The technique has little application in the evaluation of polyarticular disease. Tenography is most useful in differentiating tenosynovitis from stenosing tenosynovitis. The differentiation is important because a diagnosis of stenosing tenosynovitis usually necessitates surgical intervention. Spontaneous rupture can be evaluated with tenography, but is is probably best evaluated with MRI. CT may be used in the evaluation of both soft-tissue and articular pathology. It is perhaps best employed in the evaluation of articular pathology of the rearfoot. This technique should not be used as a screening examination for vague foot pain. MRI is the newest and most exciting imaging modality available. The excellent soft-tissue contrast provides an accurate means of evaluating the extraarticular manifestations of arthritic disease. MRI may aid in differentiating rheumatoid nodules from neuromas in rheumatoid patients with excessive forefoot disease. It is also useful in the evaluation of tendon pathology, particularly spontaneous ruptures. This technique is only in its infancy, but technologic advances are rapidly making it a major force in the field of diagnostic imaging.     

Usefulness of Thyroglobulin Measurement in Fine-needle Aspiration Biopsy Specimens for Diagnosing Cervical Lymph Node Metastasis in Patients with Papillary Thyroid Cancer

The diagnosis of lymph node metastasis in patients with papillary thyroid cancer is an important factor when deciding to perform neck dissection at the initial surgery, as well as for evaluating the lymph node swelling after surgery. Ultrasound (US)-guided fine-needle aspiration biopsy cytology (FNAB-C) is the most useful technique for diagnosing lymph node metastasis. Recently, however, measurement of thyroglobulin in the wash-out of the needle (FNAB-Tg) has been proposed for early detection of neck lymph node metastasis in patients with differentiated thyroid cancer. The purpose of this study was to evaluate the usefulness of FNAB-Tg in detecting lymph node metastasis prior to initial or reoperative thyroid surgery. US-guided FNAB-C was performed on 129 enlarged lymph nodes of 111 patients before surgery. All of them were later histologically confirmed to contain metastasis. Immediately after obtaining an FNAB-C specimen, the needle was rinsed with 0.5 ml of normal saline solution, and the wash-out was subjected to measurement of the Tg level (FNAB-Tg). If the FNAB-Tg level was higher than the serum Tg of the patient, we diagnosed the lymph node as positive (metastatic lymph node). FNAB-Tg sensitivity was 81.4%, and FNAB-C sensitivity was 78.0%. Altogether, 4 (36.4%) of 11 cases judged “benign” and 6 (37.5%) of 16 cases judged “inadequate” by FNAB-C were positive by the FNAB-Tg measurement. Thyroglobulin measurement in fine-needle aspiration biopsy wash-out is thus a useful technique for diagnosing lymph node metastasis of papillary thyroid cancer.     

Discussion paper: what happened to the ‘bio’ in the bio-psycho-social model of low back pain?

Purpose

Over 20 years ago the term non-specific low back pain became popular to convey the limitations of our knowledge of the pathological source of most people’s low back pain. Knowledge of underlying pathology has advanced little since then, despite limited improvements in outcomes for patients with low back pain.

Methods

This paper discusses potential misunderstandings related to diagnostic studies in the field of low back pain and argues that future diagnostic studies should include and investigate pathological sources of low back pain.

Results

Six potential misunderstandings are discussed. (1) Until diagnosis is shown to improve outcomes it is not worth investigating; (2) without a gold standard it is not possible to investigate diagnosis of low back pain; (3) the presence of pathology in some people without low back pain means it is not important; (4) dismissal of the ability to diagnose low back pain in clinical guidelines is supported by the same level of evidence as recommendations for therapy; (5) suggesting use of a diagnostic test in research is misinterpreted as endorsing its use in current clinical practice; (6) we seem to have forgotten the ‘bio’ in biopsychosocial low back pain.

Conclusions

We believe the misunderstandings presented in this paper partly explain the lack of investigation into pathology as an important component of the low back pain experience. A better understanding of the biological component of low back pain in relation, and in addition, to psychosocial factors is important for a more rational approach to management of low back pain.     

Mondor病的诊治进展

目的 探讨Mondor病的流行病学、病因、病理、临床表现、诊断治疗、复发和预后。方法 复习国内、外文献，结合我们自己的临床工作经验，对Mondor病进行全面分析。结果 Mondor病作为一种罕见病在临床上较易误诊，但预后一般较好。目前尚不清楚该病是否与乳腺癌发病有关。结论 对Mondor病的诊断和治疗应引起重视，应警惕是否伴发乳腺癌。     

What is the pathologist saying? Interpretation of the prostate pathology report

Management of patients presenting with elevated serum prostate-specific antigen levels, or those with previously diagnosed prostate carcinoma, is very much dependent on the pathology report on needle biopsy or radical prostatectomy specimens obtained from these patients. In contrast to a diagnosis of benignity or high-grade prostatic intraepithelial neoplasia, a diagnosis of atypia on needle core biopsy is usually an indication for a repeat biopsy; however, it is important to understand that atypia and other related terms are not specific diagnoses. The pathology report on different prostate specimens with a diagnosis of carcinoma usually includes the Gleason grade and extent of carcinoma among other morphological prognostic and predictive factors. Understanding the significance of these morphological factors and how they are evaluated and incorporated into the pathology report, as well as newer developments in this field, can assist urologists in the interpretation of the pathological findings and ultimately lead to better clinical care.     

原发性膀胱神经鞘瘤1例报告并文献复习

目的 探讨原发于膀胱的神经鞘瘤和恶性周围神经鞘瘤在组织病理学、临床表现、治疗和预后上的特点,确立两者的鉴别诊断思路.方法 回顾1例原发于膀胱的神经鞘瘤的临床诊疗过程,结合有关膀胱神经鞘瘤及膀胱恶性周围神经鞘瘤的文献资料进行分析.结果 在组织病理和免疫组化方面,原发于膀胱的神经鞘瘤和恶性周围神经鞘瘤有明显差异.结论 原发于膀胱的神经鞘瘤临床极其少见,易与膀胱常见肿瘤混淆,造成误诊,免疫组化为重要的确诊依据.膀胱恶性周围神经鞘瘤应以高度恶性的软组织肉瘤进行处理.临床上应重视两种疾病的鉴别,以正确地指导临床诊疗.     

Extension of the “Elephant Trunk” Technique in Complex Aortic Pathology: The “Bidirectional” Option

Background. The “elephant trunk” technique, using a free-floating vascular prosthesis, was originally described to facilitate a subsequent operation on the downstream aorta. We developed an additional refinement of this technique, called the “bidirectional elephant trunk.” This option may represent an interesting tool in more complex aortic operations, especially when the descending aorta has to be replaced first in patients with concomitant pathology of the ascending aorta or of the aortic arch.

Methods. The initial operation is performed through a left thoracotomy. The proximal elephant trunk is created by invaginating the future aortic arch graft into the descending aortic graft. The proximal anastomosis between the doubled graft and the proximal descending aorta is performed first. During construction of the distal anastomosis, a distal elephant trunk may be inserted likewise. If the aortic arch and ascending aorta have to be replaced later, this second step is performed through a median sternotomy. The free-floating arch graft is pulled out of the proximal descending aorta with a nerve hook, unfolded, and used for total arch replacement.

Results. This technique was used successfully in 3 patients without mortality. No major complications were observed excepted persistent hoarseness in a patient with preoperative paresis of the recurrent nerve. No perfusion problems due to the unfolding of the free-floating graft occurred during the second operation.

Conclusions. The bidirectional elephant trunk technique is an interesting option that may be suitable for patients presenting with a complex pathology of the whole thoracic aorta when the descending segment has to be replaced first.     

Use of ultrasonography in the evaluation of the infertile man

Summary Transrectal ultrasonography (TRUS) is a modality that most urologists are familiar with in the interpretation of prostate anatomy and pathology. Understanding the anatomy and pathology of the genital ductal system will help in the diagnosis of disease entities related to male infertility. Familiarity with both scrotal and transrectal ultrasound is vital to the understanding and diagnosis of treatable causes of male infertility.     

膀胱内翻性乳头状瘤的诊治

目的：探讨膀胱内翻性乳头状瘤的临床特点、病因、病理和诊断治疗。方法：回顾性分析50例膀胱内翻性乳头状瘤的临床资料,复习相关文献,并随访患者。结果：所有患者均接受经尿道膀胱肿瘤电切术（TURBT）治疗;术后病理证实均为膀胱内翻性乳头状瘤,其中29例合并膀胱移行细胞癌;术后42例行膀胱灌注治疗,随访3个月～5年,1例患者肿瘤复发。结论：膀胱内翻性乳头状瘤是泌尿系少见的良性肿瘤,易合并移行细胞癌,很少复发,预后良好。确诊需行内镜检查及活检。TURBT是其标准治疗方法。术后予膀胱灌注有利于防治复发。     

无功能性甲状旁腺囊肿：附15例报告

目的 了解无功能性甲状旁腺囊肿的临床特点,探讨其诊治方法.方法 对近16年来收治的无功能性甲状旁腺囊肿15例患者的临床资料进行回顾性分析研究.结果 术前均未获得诊断,均经术后病理检查证实.全组均行手术切除获得治愈,随访无复发.结论 对无功能性甲状旁腺囊肿,病理学检查是最可靠的诊断方法,针刺抽液测定PTH或细胞学检查有助于术前诊断.手术切除是最理想的治疗方法.     

201Tl-SPECT and 1H-MRS study of benign lateral ventricle tumors: differential diagnosis of subependymoma

The introduction of computed tomography (CT) and magnetic resonance (MR) imaging has resulted in the detection of increasing numbers of asymptomatic intraventricular tumors. Establishing the correct preoperative diagnosis is important to prevent unnecessary surgical intervention. Our study includes nine cases of benign lateral ventricle tumors including two cases of central neurocytoma, two of subependymal giant cell astrocytoma, two of pilocytic astrocytoma and three of subependymoma treated surgically between 1996 and 2003. MR imaging, proton MR spectroscopy (¹H-MRS) and thallium-201 single photon emission computed tomography (²⁰¹Tl-SPECT) were performed in all patients. All three types of tumor demonstrated heterogeneous enhancement on MR imaging with gadolinium-diethylenetriamine pentaacetic acid (Gd-DTPA) and increased choline (Cho) peak and decreased N-acetyl aspartate (NAA) and creatine (Cre) peaks on ¹H-MRS. ²⁰¹Tl-SPECT showed high uptake of ²⁰¹Tl without wash out in all cases of central neurocytoma, subependymal giant cell astrocytoma and pilocytic astrocytoma, but no uptake in cases of subependymoma. Absence of ²⁰¹Tl uptake in contrast with enhancement on MR imaging and the ¹H-MRS features of modest elevation of the Cho/Cre ratio, reduction of the NAA peak and presence of lactate/lipid peaks are characteristic features of subependymomas and useful to establish a preoperative diagnosis.