Assessment and management of chronic pain in patients with stable total hip arthroplasty

Total hip arthroplasty (THA) is one of the most successful operations that can restore function and relieve pain. Although a majority of the patients achieve significant pain relief after THA, there are a number of patients that develop chronic pain for unknown reasons. A literature search was performed looking for chronic pain after total hip arthroplasty and stable THA. Major causes of chronic pain include aseptic loosening or infection. However, there is a subset of patients with a stable THA that present with chronic pain which can have several aetiologies. These include soft tissue, bony, neurological, vascular and psychological causes. Essential for successful treatment is the ability to make the correct diagnosis. Thus therapy may be either non-operative or operative. In addition, diagnosis and management often may require multidisciplinary approaches to successfully alleviate chronic pain in these patients with a stable prosthesis.     

Cecal splenosis mimicking gastrointestinal stroma tumor. Case report and review of the literature

IntroductionAbdominal splenosis is a rare condition where autotransplanted ectopic spleen tissue is found in the abdominal cavity after spleen injury or splenectomy. While abdominal splenosis is mostly described as asymptomatic, bowel splenosis can present with abdominal pain, obstipation or gastrointestinal (GI) bleeding. Scarce information on bowel splenosis exists and high index of suspicion is needed for diagnosis. We present the case of a patient with abdominal pain and a cecal mass mimicking gastrointestinal stroma tumor (GIST) found to have bowel splenosis after laparoscopic resection.Presentation of caseA 45-year-old female was evaluated for a 6-month history of abdominal pain in right-lower quadrant. She had past medical history of blunt abdominal trauma and splenectomy 35 years before symptoms. An abdominal contrast-enhanced computed tomography (CT) reported a 4.2 × 4.6 × 4.6 cm solid mass located in the antimesenteric border of the cecum, with calcifications and arterial enhancement. Colonoscopy found no epithelial lesions. A diagnostic laparoscopy was done, and resection of the mass achieved. Transoperative histopathological diagnosis revealed ectopic spleen tissue.DiscussionIt is difficult to know whether abdominal pain in bowel splenosis is actually triggered by splenosis itself or by an unrelated cause, making diagnosis incidental. There are no particular imaging findings suggestive of splenosis, and surgical resection is often done under uncertain diagnosis.ConclusionBowel splenosis could present as abdominal pain variable time after spleen injury or splenectomy. Clinical features and imaging characteristics are nonspecific and similar to those of GIST. Most cases of splenosis are diagnosed after surgery.     

腹股沟疝修补术后慢性疼痛的诊治体会

目的 报告腹股沟疝修补术后慢性疼痛的诊治经验.方法 回顾性分析35例腹股沟疝修补术后慢性疼痛患者的临床资料,总结其诊断和治疗经验.结果 28例患者经物理治疗联合药物治疗疼痛缓解;4例经神经阻滞治疗后好转;3例手术治疗,1例神经瘤形成,切除瘤体后将断端植入肌肉后治愈,1例补片移位,1例补片内环口固定过紧,皆经手术清除补片和周围瘢痕组织而治愈.结论 疝修补术后慢性疼痛要早期积极治疗,应先行理疗、药物治疗或神经阻滞等保守治疗,疗效差者或疼痛程度严重者才考虑手术治疗.     

Popliteal soft tissue tumor associated with hamstring injury

We report herein a very rare case of semitendinosus tear that formed a tumor in the popliteal region after not having recovered as a result of only being instructed to rest. The soft tissue tumor was discovered on ultrasonography 4 months after pain and sensation of discomfort appeared in the popliteal region. We considered this symptom as dependent on the presence of the tumor and selected surgical treatment. Intraoperatively, this soft tissue tumor was connected with the pes anserinus by tendinous tissue. On pathological examination, the soft tissue tumor was diagnosed as skeletal muscle showing necrosis. From imaging, operative findings, and pathological diagnosis, this was considered to represent a rare case in which myorrhexis developed into a soft tissue tumor in the popliteal region after a semitendinosus tear remained unhealed and was neglected over the long term. Although we had trouble confirming a diagnosis and treatment procedure, we were able to acquire good results with surgical treatment. This is, to the best of our knowledge, the first report of damaged semitendinosus becoming a soft tissue tumor in the popliteal region after long-term neglect without healing.     

A case of a ganglion cyst originating from the hip joint and surgical outcome

Ganglion cysts are the most common soft tissue tumors of the hand, wrist, and foot. However, those originating from the hip joint are not so frequent. This case report presents a 36-year-old woman who complained of pain in the right groin. A diagnosis of atypical ganglion cyst of the hip was made and the lesion was surgically removed. The diagnosis was confirmed histopathologically. No complaints were observed after a follow-up period of 18 months.     

Myeloproliferative disorder as the cause of peripheral ischemia in a young patient

A 35-year-old patient with rest pain and peripheral gangrene was referred with a diagnosis of Takayasu's disease but had myeloproliferative disorder (primary thrombocythemia). The angiogram revealed surgically noncorrectable small vessel occlusive disease with no evidence of atheroma. Medical therapy with cytotoxic and antiplatelet agents achieved satisfactory results with excellent wound healing after surgical amputation of necrotic tissue. The need for early diagnosis of this condition is emphasized.     

Splenosis in a port site after laparoscopic splenectomy

Splenosis, the autotransplantation of splenic tissue, is most commonly seen after traumatic splenic rupture and splenectomy. It also can occur during embryonic development. Intraperitoneal, intrathoracic, and retroperitoneal sites have been reported. Although the presence of the splenic tissue often is asymptomatic and an incidental finding, it may present with pain or be confused with various pathologies including neoplasia. Because most pediatric splenectomies are performed for hemolytic disorders, parenchymal disruption must be contained to avoid recurrent disease. We present a case in which the devascularized spleen was contained in a bag and fragmented in situ. Splenosis developed in the retrieval port site after laparoscopic splenectomy and cholecystectomy. Port-site splenosis needs to be considered in the differential diagnosis of port-site pain and a palpable nodule postsplenectomy.     

Tumor oder Trauma

The authors present two case histories of children with synovial soft tissue tumor of the ankle. Synovial soft tissue tumors of the ankle in childhood are rare. The symptoms are unspecific so that the clinical diagnosis is difficult. In both cases the children came primarily to the clinic with painful swelling at the ankle after trauma, which further complicated the diagnosis. It should be taken into consideration that the rare differential diagnosis of pain at the ankle could be synovial soft tissue tumor especially when the clinical course is protracted.     

Painful total hip replacement due to sciatic nerve entrapment in scar tissue and lipoma

Painful total hip replacement remains a challenging problem because of the large amount of possible diagnoses. We report about a 64-year-old female patient who was misdiagnosed during 4 years as psychiatric. She suffered of excruciating left retrotrochanteric pain after the implantation of a cementless total hip replacement and revision because of recurrent hip dislocations. Walking was limited to short distances using two crutches. The work-up at this time included the usual diagnoses and remained unsuccessful. No loosening, infection or malposition of the prosthesis could be found, and she had no neurologic deficits in her operated leg. An MRI was obtained to visualize the retrotrochanteric soft tissues and showed a tight scar surrounding the sciatic nerve, which was also compressed by an adjacent lipoma. Therefore, she was reoperated on to remove the lipoma and the scar tissue around the sciatic nerve. To decrease the risk of recurrent scarring around the sciatic nerve, an adhesion barrier was applied before closure. One year after the operation, the patient has no neurologic deficit, no more pain and is able to walk unlimited distances without crutches. Scar tissue around the sciatic nerve is frequently observed during revision surgery. However, we feel that sciatic nerve entrapment by scar tissue should be a part of the differential diagnosis of painful THR. MRI may be a useful tool to achieve this diagnosis.     

Myositis ossificans in the paraspinal muscles of the neck after acupuncture: a case report

Background contextAlthough traumatic myositis ossificans (MO) has been reported occasionally, MO of paraspinal muscles has been rarely seen in the cervical spine after minor injury. This is difficult to distinguish from benign and malignant soft lesions in cases of a lack of definite trauma history.PurposeWe report a case of MO in the cervical paraspinal muscle after acupuncture and describe methods for diagnosis and proper treatment, including classification, etiology, and radiologic and histologic features.Study designCase report.MethodsA 26-year-old woman complained of posterior neck pain that had began 2 months earlier and neck swelling after acupuncture. No abnormal finding existed on the X-ray except soft tissue swelling. Magnetic resonance imaging was evaluated because of constant neck pain. To obtain more accurate assessment, computed tomography-guided biopsy was performed and a diagnosis of MO was made.ResultsThe patient was conservatively treated through rest and analgesics. Posterior neck pain and swelling improved for a several months. The hyperdensity was comparable with the bony density, and the size of the calcified lesion on X-ray diminished until the last follow-up.ConclusionsMyositis ossificans that can occur after acupuncture should be recognized as a possible cause of persistent neck pain and swelling despite no definite trauma after thorough evaluation of the neoplasm and infection.     

Anterior iliopsoas impingement after total hip arthroplasty

Pain after total hip arthroplasty (THA) can be caused by a multitude of conditions, including infection, aseptic loosening, heterotopic ossification, and referred pain. It is also recognized that soft tissue inflammation about the hip, such as trochanteric bursitis, can lead to hip pain after THA. Two cases of persistent iliopsoas tendinitis following THA are reported, which are believed to be caused by psoas tendon impingement against a malpositioned, uncemented, metal-backed acetabular component. The authors are unaware of previous reports of this problem, and suggest that the problem be considered in the differential diagnosis of groin pain following THA.     

关节镜下治疗踝关节软组织撞击综合征

目的 对踝关节软组织撞击综合征的关节镜下诊断和治疗进行初步探讨。方法 对近年来３０例踝关节软组织撞击综合征的关节镜下诊治经验进行总结。术前体检发现肿胀和疼痛以踝前外侧为主２４例,以踝前内侧为主６例在伤后半年～１年进行手术。关节镜下见到不同程度的滑膜增生、肥厚,韧带的撕裂或软骨损伤,均在关节镜下予以切除并清理关节。结果 术后平均随访２年４个月,优７例,良１９例,可４例,优良率８７％。结论 踝关节扭伤     

Myositis ossificans in the right inferior thoracic wall as an unusual cause of lower thoracic-upper abdominal pain: Report of a case

We report a case of thoracic wall myositis ossificans (MO) located anterior to the ninth rib, causing right lower thoracic-upper abdominal pain. The diagnosis was based on the findings of ultrasonography (US) and computed tomography (CT). Numerous disorders can be included in the differential diagnosis of right lower thoracic-upper abdominal pain, so we must first establish if the pain is somatic or visceral in origin. Somatic pain in this region can be caused by traumatic muscle pain, overuse myalgia, costochondritis, or thoracic wall malignancies. Although rare, MO should also be considered in the differential diagnosis of pain and thoracic wall masses in this region. As the calcifications may not be seen on a plain chest X-ray in the early course of this condition, superficial tissue US or CT should be performed to establish the diagnosis.     

Dorsal extradural thoracic disc fragment: a diagnostic challenge

Dorsal epidural migration of an extruded disc fragment is an infrequent event, especially in the thoracic spine. An uncommon case involving a 55-year-old man is presented, with a 1-month history of paraparesis and thoracolumbar pain. Magnetic resonance imaging demonstrated a dorsally located, extramedullary mass at the T10-T11 intervertebral level. The lesion was suspected to be a tumor. The patient underwent a T10-T11 laminectomy. Intraoperatively, an encapsulated mass of soft tissue adherent to the dural sac was found. The pathologic diagnosis was inflammatory tissue and disc material. Six months after the operation, the patient remained asymptomatic, and radiologic control showed no residual mass. Although rare, a sequestered disc fragment should be included in the differential diagnosis of an enhancing posterior extramedullary thoracic mass. Preoperative diagnosis of such pathology is difficult because the clinical signs and radiologic images may not entirely exclude other more common thoracic spinal lesions, especially tumors.     

Laparoscopic resection of a torsioned appendix epiploica in a previously appendectomized patient

Torsion of the appendices epiploicae is a rare condition that may present with acute abdominal pain and mimics appendicitis. We report a 20-year-old previously appendectomized man presenting with right lower abdominal quadrant pain. Abdominal ultrasonography showed a localized omental thickening in the right paracolic region. Contrast-enhanced computed tomography revealed well-circumscribed fatty tissue adjacent to the cecum with heterogeneous hyperdense infiltration of the mesentery near the sigmoid colon. Diagnostic laparoscopy revealed 2-cm diameter torsioned and edematous fatty tissue floating on the omentum in the right lower quadrant. The torsioned mass was elevated, and a thick stalk was seen to be connecting the fatty tissue to the sigmoid colon. At this point, the torsioned fatty tissue was considered as a sigmoidal appendix epiploica that was elongated and neighboring on the previously operated-on region. The lesion was removed by laparoscopic means using 3 ports. Grossly, fat necrosis and internal bleeding were seen. Histopathologic analysis of the resected tissue demonstrated adipose tissue surrounded by fibrotic inflammatory changes with marked infiltration of numerous lymphocytes and histiocytes. In conclusion, torsion of appendices epiploicae should be included in the differential diagnosis of acute abdomen when evaluating patients with right lower quadrant pain and a history of appendectomy. Laparoscopic surgery provides definite diagnosis and prevents unnecessary open procedures for such lesions leading to peritoneal irritation.     

Spontaneous hemorrhage and arterial hypertension as complication of Adrenal Pseudocyst. Report of a case

Adrenal Pseudocyst are uncommon and asymptomatic tumors. We report an unusual case who had previous high blood pressure and acute hemorrhage presented with abdominal pain and shock. Diagnosis was made with ultrasonography and computed tomography revealed the presence of large retroperitoneal hematoma around the superior pole of the left kidney. Urgent surgery was made with a complete excision of a 10 cm. tumor with preservation of adrenal tissue and the left kidney. Histopathological diagnosis was: Adrenal Pseudocyst. Blood pressure normalized after surgery.     

Mesenteric fibromatosis of the ileocolic area: a case report

Fibromatosis is a kind of spindle cell tumor which is characterized by the remarkable proliferation and invasive growth of fibrous tissue. It often arises from the abdominal wall or the extremities and rarely from the mesentery and abdominal organs. The patient was 35 year old female whose major complaints were an abdominal mass and pain. She underwent a right hemicolectomy after the tumor was confirmed by abdominal ultrasonography and computerized tomography. Hereby the pathophysiology, diagnosis and the treatment of the disease is discussed.     

Intercostal hemangioma

This paper presents a case of intercostal hemangioma, in which a complete surgical resection was accomplished based upon a tentative diagnosis provided by magnetic resonance imaging (MRI). A 27-year-old man visited our hospital for the evaluation of chest pain and shortness of breath after exertion. Computed tomography showed a soft tissue mass, 5.5×3.5 cm in size, arising from the right lateral 7th intercostal space. Dynamic MRI showed that the mass was enhanced rapidly in the early phase and that this early enhancement was maintained during the delayed phase, which was compatible with a diagnosis of intercostal hemangioma. The patient underwent surgery, and a complete resection of the tumor with the right 7th and 8th ribs and their intercostal muscles was accomplished. Histopathological examination confirmed the diagnosis of intramuscular hemangioma of the large-vessel type. Presently, 6 months after the operation, the patient is doing well, without any evidence of local recurrence.