Hoffa's disease: A report on 5 cases

We report the case of five patients referred to our department with Hoffa's disease: three patients were at the initial stage of the disease and the two others had reached the chronic stage. This condition is one of the less well-documented causes of pain in the anterior compartment of the knee. The pathophysiological mechanism is still unclear. It is probably caused by repetitive micro trauma resulting in inflammatory, haemorrhagic and fibrous changes to Hoffa's fat pad. The final outcome of the disease is an osteochondroma. The diagnosis is established by MRI, which demonstrates inflammation of the fat pat. At the chronic stage, a standard X-ray is sufficient to demonstrate ossification of the fat pad.     

Glomus Tumor of Hoffa's Fat Pad and Its Management by Arthroscopic Excision

We present a rare case of glomus tumor of Hoffa''s fat pad in a 42-year-old woman. Magnetic resonance imaging findings along with the characteristic clinical picture led us to suspect a glomus tumor as the possible etiology. An ischemia test was found to be positive and this further substantiated our diagnosis. An arthroscopic excision was performed and the histology confirmed the diagnosis of glomus tumor of Hoffa''s fat pad. The patient responded well to the excision with immediate complete resolution of pain and she remains asymptomatic at the last follow-up after 15 months. To our knowledge, this is the second reported case of glomus tumor of Hoffa''s fat pad and the first ever to be managed by simple arthroscopic excision. The tumor poses a great challenge to an orthopedic surgeon. However, knowledge of its characteristic clinical presentation and the recognition of such a rare entity can help achieve an early diagnosis and timely management.     

Bicondylar Hoffa's fracture with patellar dislocation – a rare case

Bicondylar Hoffa''s fractures of the femur is very uncommon. Conjoint bicondylar Hoffa fracture with ipsilateral patellar dislocation, Bicondylar Hoffa''s with patellar fracture and extensor mechanism rupture has been described in literature. We report a case of unconjoint bicondylar Hoffa''s fracture with lateral patellar dislocation in 17-year-old male patient treated with open reduction and cancellous screw fixation that subsequently healed well with good functional outcome.     

Hoffa's fracture with ipsilateral fibular fracture in a 16-year-old girl:An approach to a rare injury

Hoffa''s fracture is an uncommon fracture of the femoral condyle with coronal orientation of the fracture line. The mechanism of injury in pediatric Hoffa''s fracture is road traffic accident, sports injury, and trivial injury. Clinical examination and proper imaging is important for diagnosis of pediatric Hoffa''s fracture because of high chances of missing these injuries which can lead to nonunion and malunion at the fracture site. Open reduction and anatomical reduction of intraarticular fragment is the gold standard treatment of these fractures. We present a rare case of Hoffa''s fracture in a 16-year-old girl with associated ipsilateral fibular fracture.     

Disseminated synovial chondromatosis of the knee treated by open radical synovectomy using combined anterior and posterior approaches

Synovial chondromatosis of the knee is a rare benign neoplasm of the synovium. Likewise, uncertainty on management still prevails. Though rare, it nevertheless warrants greater emphasis than it receives in the literature to allow correct diagnosis and accurate early surgical intervention. It predominantly involves the anterior compartment of the knee and disseminated disease is extremely rare. The optimal approach for surgical treatment of such an extensive synovial chondromatosis of knee remains unclear. Herein, we describe a case of extensive generalized synovial chondromatosis of the knee extending into the Baker''s cyst in a 30 years old female. A diagnosis of synovial chondromatosis was made by clinical evaluation and MR imaging and confirmed by histopathological examination. Patient was successfully treated by open radical synovectomy of knee using both anterior and posterior approaches in a single step procedure.     

Gorham's disease of femur

Gorham''s disease is a rare condition of bones characterized by spontaneous massive and progressive osteolysis. Less than 200 cases have been reported so far. Femur is an uncommon site of Gorham disease. We report a young female, presenting as pathological fracture of the femur, wherein rapid osteolysis of femur occurred. The clinical, pathological, and radiological picture suggested a diagnosis of Gorham''s disease. The patient was subjected to radiotherapy (40 Gys) and put on bisphosphonates. At a follow-up of 2 years, the disease process had stopped and partial recalcification of the bone had occurred.     

Progressively Unstable C2 Spondylolysis Requiring Spinal Fusion: Case Report

Cervical spondylolysis is a rare condition defined as a corticated cleft at the pars interarticularis in the cervical spine. This is the case of C2 spondylolysis demonstrating progressive significant instability, which was successfully treated by anterior cervical discectomy and fusion (ACDF) with cervical anterior plate. We describe a 20-year-old female with C2 spondylolysis presenting with progressive worsening of neck pain associated with progressive instability at the C2/3 segment. The progression of instability was well-documented on flexion-extension cervical spine x-rays. She was successfully treated by C2/3 ACDF with anterior cervical plate. Her preoperative significant neck pain resolved immediately after the surgical intervention. She was completely free from neurological symptoms at 1-year postoperative follow-up. We also review the literature and discuss 24 reported cases with C2 spondylolysis. When planning treatment, we should make sure to differentiate this pathology from acute traumatic fracture, which is a hangman''s fracture. Assessment of C2/3 instability associated with neurological deficits is extremely important to consider management properly. C2/3 ACDF with cervical plate is biomechanically viable, less invasive, and provides adequate surgical stabilization for unstable C2 spondylolysis.     

Full‐Endoscopic Approach Forchronic Low Back Pain from Baastrup's Disease: Interspinous Plasty

The objective was to introduce a new endoscopic technique‐interspinous plasty for low back pain from Baastrup''s disease; based on clinical manifestations, imaging findings and diagnostic test, to discuss a detailed diagnostic procedure for Baastrup''s disease; and to explore the mechanism of interspinous plasty in pain relief. To our knowledge, there is no report about the results of endoscopic lumbar technique for Baastrup''s disease. This study described the successful full‐endoscopic surgical treatment for Baastrup''s disease, providing a brand‐new therapeutic method for patients. Clinical manifestations, imaging findings, including X‐ray, computed tomography (CT) and magnetic resonance imaging, and a “positive” diagnostic test with local anesthetic were used to confirm Baastrup''s disease in the three included patients. The interspinous plasty procedure, which aimed to recover a physiological gap between the adjacent spinous processes, was performed by full‐endoscopic resection of marginal osteophytes. The removal of local inflamed tissue and reducing inflammation via intraoperative saline irrigation also lead to pain relief. Clinical outcomes included visual analog scale (VAS) for low back pain and the Oswestry Disability Index (ODI). The distance between the adjacent spinous processes was measured from the preoperative and postoperative CT scan. We calculated and recorded the difference between preoperative and postoperative measurements. Technical procedures and advantages of interspinous plasty are introduced. The three patients showed improvement in terms of the postoperative VAS of low back pain (from 8 to 2, from 7 to 1 and from 8 to 2) and ODI (from 68.9% to 33.3%, from 77.8% to 28.9% and from 71.1% to 28.9%, respectively) at the 12‐month follow‐up. Compared postoperative ODI index, the ODI index increased from 26.7% to 33.3% and from 24.4% to 28.9% in two of the cases at the 12‐month follow‐up. At 1 week, CT confirmed an obvious reduction in the marginal osteophytes between the adjacent spinous processes. Compared with those on preoperative CT images, the distance between adjacent spinous processes on postoperative CT was enlarged from 1 to 4 mm, and a repeated CT scan 3 months later reconfirmed little recrudescent osteoproliferation. In selected cases, full‐endoscopic surgical treatment for chronic mechanical back pain as part of the phenomena of Baastrup''s disease may be beneficial. The operations in this study were performed under local anesthesia, with satisfactory early clinical outcomes and a low incidence of complications or adverse events. This may be a feasible therapeutic method or an alternative option for patients who cannot tolerate general anesthesia surgery.     

Meckel's diverticulum with small bowel obstruction presenting as appendicitis in a pediatric patient

Background:

Meckel''s diverticulum is a congenital anomaly resulting from incomplete obliteration of the omphalomesenteric duct. The incidence ranges from 0.3% to 2.5% with most patients being asymptomatic. In some cases, complications involving a Meckel''s diverticulum may mimic other disease processes and obscure the clinical picture.

Methods:

This case presents an 8-year-old male with abdominal pain, nausea, and vomiting and an examination resembling appendicitis.

Results:

A CT scan revealed findings consistent with appendicitis with dilated loops of small bowel. During laparoscopic appendectomy, the appendix appeared unimpressive, and an inflamed Meckel''s diverticulum was found with an adhesive band creating an internal hernia with small bowel obstruction. The diverticulum was resected after the appendix was removed.

Conclusion:

The incidence of an internal hernia with a Meckel''s diverticulum is rare. A diseased Meckel''s diverticulum can be overlooked in many cases, especially in those resembling appendicitis. It is recommended that the small bowel be assessed in all appendectomy cases for a pathological Meckel''s diverticulum.     

Consecutive Kummell's Disease Combined with Parkinson's Disease and Experienced Internal Fixation Failure: A Case Report and Literature Review

BackgroundThe continuous occurrence of Kummell''s disease is extremely rare in clinical practice, and its treatment is difficult. The study aimed to present a rare case of consecutive Kummell''s disease combined with Parkinson''s disease (PD) and experienced internal fixation failure.Case presentationA 69‐year‐old female patient had a history of PD for 10 years, and was treated by posterior decompression, fixation, and fusion because of Kummell''s disease of T12 with neurological damage. The patient''s back pain and lower limb pain were significantly improved after surgery. Twenty‐two months later, the patient was rehospitalized for Kummell''s disease of L4 with neuropathic pain of left lower extremity. She received almost identical surgical procedures as T12 lesion, and the difference was no L4 vertebroplasty preformed due to the fact that the L4 vertebrae collapse was not obvious, the intravertebral vacuum cleft (IVC) range was small, and the pedicle screw fixation strength was high. The pain symptoms were significantly relieved after operation. Unfortunately, there was a complication of internal fixation failure that occurred a month later, and a revision operation was carried out.ConclusionOsteoporosis combined with PD may lead patients to become prone to consecutive Kummell''s disease, and patients are prone to experience failure of internal fixation. Bone cement filling of vertebral IVC and effective support of anterior vertebral column are very important procedures to ensure the clinical efficacy of treating Kummell''s disease.     

Mesentery lymphoma in a patient with Crohn's disease: An extremely rare entity

INTRODUCTIONLymphoma is a rare complication of long-standing Crohn's disease. We report a rare case of a diffuse, B-cell non-Hodgkin's lymphoma of the mesentery in a patient receiving treatment for Crohn's disease.PRESENTATION OF CASEA 52 year-old patient presented with abdominal pain, anorexia and postprandial fullness. Abdominal examination revealed a firm mass, extending from the epigastrium to the right iliac fossa. CT scan showed a large intra-abdominal mass with air-fluid levels within, and soft tissue density along its walls, surrounded by distended bowel loops. The patient was scheduled for surgery due to clinical assumption of an intra-abdominal abscess. At laparotomy an ill-defined, lobulated mass with cystic areas was noted rising from the mesentery. Frozen section biopsy of the cystic mass revealed a non-Hodgkin follicle center B-cell lymphoma of the mesentery.DISCUSSIONTo the best of our knowledge, this is an extremely rare case of lymphoma development in the mesentery, in a patient receiving treatment for Crohn's disease. Although the development of abdominal lymphomas can be justified as a possible consequence of the chronic immune-modulating therapy, their location can lead to diagnostic pitfalls.CONCLUSIONAlthough mesentery has scarcely been presented as a potential site of occurrence of abdominal lymphomas in the process of treatment of inflammatory bowel diseases, this rare entity should be considered in the differential diagnosis of intra-abdominal lymphomas in patients with inflammatory bowel disease. In cases where imaging techniques do not provide definitive answers, surgical intervention can safely pose the accurate diagnosis.     

Synovial chondroma in Hoffa’s fat pad: Case report and literature review of a rare disorder

IntroductionSynovial chrondomatosis is a rare disorder characterised by the development of hyaline cartilage from the synovial membrane. Large isolated lesions in the Hoffa's fat pad are an uncommon entity.Presentation of caseA 33 year old gentleman presented complaining of progressive knee pain associated with an enlarging lesion on the anterior aspect of the right knee, with associated locking and giving way. Examination revealed a firm 4 × 5 cm lesion adjacent to the patellar tendon.Subsequent CT and MRI demonstrated a lesion in the inferior aspect of Hoffa’s fat pad, with a second lesion adjacent to the proximal tibiofibular joint, in addition to advanced degenerative changes and a meniscal tear.He proceeded to excisional biopsy. Histological analysis was consistent with a solitary synovial osteochondroma. There were no atypical features suggestive of malignancy.DiscussionSynovial chondromatosis is a rare disorder affecting the synovial joints. The underlying pathophysiology is thought to be metaplastic change of the synovium to hyaline cartilaginous tissue. Transformation to malignancy has been described but is uncommon with an estimated risk of 5%. It is 1.5–2 times as prevalent in males versus females. Symptoms which patients may complain of include pain;locking and giving way; and palpable masses.The management usually entails removal of the mass lesion with or without accompanying synovectomy. Recurrence of disease may occur in up to 15–23% of patients.ConclusionSynovial chrondromatosis is a rare but well recognised condition. Long term follow up is advised in view of the risk of recurrence and malignant transformation.     

Severe stricturing Crohn's disease of the duodenum: A case report and review of surgical options

INTRODUCTIONDuodenal Crohn's disease is a rare clinical entity that occurs in 0.5–4.0% of patients with Crohn's disease. A unique case of Crohn's disease of the upper gastrointestinal tract characterized by multiple strictures within the duodenum and jejunum is described in our review.PRESENTATION OF CASEA 41-year-old male presented with a 2-month history of intermittent, crampy abdominal pain accompanied by nausea, bilious emesis, early satiety, anorexia and weight loss. Physical examination revealed fullness in the epigastric region. Imaging demonstrated strictures in the proximal and distal duodenum with dilatation of the intervening segments. There was also gross dilatation of the proximal jejunum, which was followed by a 9 cm strictured segment. There was no evidence of acute Crohn's disease. Although a Whipple's resection was initially considered as a form of operative intervention given the extent of disease within the duodenum, the discovery of unexpected disease intra-operatively presented a surgical dilemma. In this case, strictureplasty, surgical resection and bypass were used to treat the patient.DISCUSSIONDiffuse stricturing of the proximal gastrointestinal tract is a rare manifestation of Crohn's disease. Although imaging can aid in surgical planning, intra-operative decision-making to deal with unexpected findings will remain an important aspect of the management of this entity.CONCLUSIONThe fundamental goal of the surgical management of strictures secondary to Crohn's disease is to relieve obstruction while maximizing bowel conservation. A variety of operative techniques are currently described for the management of duodenal Crohn's disease and are reviewed in this case report.     

The efficacy of diagnostic battery in Pott's disease: A prospective study

Background:

The diagnosis of Pott''s disease is mostly based on clinicoradiological observations substantiated by the bacterial culture, staining and histopathology. Since, no single technique is enough to conclude Pott''s disease in diagnosis, the present study was undertaken to correlate the clinicoradiological, microbiological, histopathological and molecular method to evaluate the effectiveness in diagnosis of Pott''s disease.

Materials and Methods:

62 clinicoradiologically suspected cases of Pott''s disease were included in this study. The specimens for diagnostic work up were collected either during surgery or by computed tomography guided fine needle aspiration. All these specimens were tested for tuberculosis (TB) through Ziehl-Neelsen (ZN) microscopy, BACTEC culture, histopathology and polymerase chain reaction (PCR). The final diagnosis was established by the results of performed tests and clinicoradiological improvement of cases at the end of 6 months on anti tubercular treatment.

Results:

Out of 62 cases, 7 were excluded from this study as these were turned out to be neoplastic lesions on histopathology. Amongst remaining 55 cases, the TB was diagnosed in 39 (71%) on histopathology, 37 (67.5%) on PCR, 27 (49%) on BACTEC culture and 20 (36.3%) on ZN microscopy. Ultimately 45 cases were tested as positive and 10 were detected as negative for TB in combination of ZN microscopy, BACTEC culture and histopathology. PCR was positive in 37 of 45 cases and 10/55 cases remained negative. On clinical analysis of these 10 cases, it was noted that these were cases of relapse/poor compliance. The combination of PCR and histopathology was also shown positive for TB in 45 cases. Hence, the PCR showed a fair positive agreement (Κ^c = 0.63) against the combined results of all performed traditional methods.

Conclusions:

The combination of PCR and histopathology is a rapid and efficient tool for diagnosis of Pott''s disease.     

Modified Weil Osteotomy for the Treatment of Freiberg's Disease

Background

Numerous metatarsal osteotomies have been developed for the treatment of Freiberg''s disease. The purpose of this study was to evaluate the clinical outcomes of modified Weil osteotomy in the treatment of Freiberg''s disease.

Methods

From November 2001 to July 2008, nineteen patients (twenty feet), treated surgically for Freiberg''s disease, were included in this study. The average age of the patients was 33.6 years (range, 17 to 62 years), the mean follow-up period was 71.6 months (range, 41 to 121 months). Clinical outcomes were evaluated according to visual analogue scale (VAS), American Orthopaedic Foot and Ankle Society (AOFAS) lesser metatarsophalangeal-interphalangeal scale, the patients'' subjective satisfaction and range of motion (ROM) of metatarsophalangeal (MTP) joint. In the radiologic evaluation, initial metatarsal shortening by Freiberg''s disease compared to opposite site, metatarsal shortening after modified Weil osteotomy compared with preoperative radiography and term for radiologic union were observed.

Results

VAS showed improvement from 6.2 ± 1.4 to 1.4 ± 1.5 at last follow-up (p < 0.0001). Points of AOFAS score increased from 63.3 ± 14.9 to 80.4 ± 5.6 (p < 0.0001). ROM of MTP joints also improved from 31.3 ± 10.1 to 48.3 ± 13.0 degrees at last follow-up (p < 0.0001). According to Smillie''s classification system, there was no significant improvement of VAS, AOFAS score and ROM between early stages (stage I, II, and III) and late stages (stage IV and V). Out of twenty cases, nineteen (95%) were satisfied, reporting excellent or good results.

Conclusions

Modified Weil osteotomy is believed to be a useful method for the treatment of Freiberg''s disease, not only in the early stages but also in the late stages. It relieves pain and improves function via shortening of metatarsals and restoration of MTP joint congruency.     

Arthroscopy‐Assisted Treatment of Wear Debris Pseudotumor After Total Knee Arthroplasty: A Case Report

BackgroundWear debris pseudotumors are a rare complication after total knee arthroplasty (TKA) and have seldom been reported in the recent literature. There is no consensus on the best therapeutic method, but the high quality curative treatment, safe, low invasive treatments are required for the patients.Case presentationIn this paper, we present the case of a 74‐year‐old man with a wear debris pseudotumor after TKA with symptoms of severe pain and functional disability of his right knee. X‐ray examination showed that the medial compartment of the right knee was narrowing. Magnetic resonance imaging (MRI) and Doppler ultrasound both revealed a polycystic mass at the posteromedial side of the patient''s right knee. Considering the bad health condition and the minimally invasive surgery requirement of this senior patient, arthroscopic knee debridement and percutaneous cystic mass suction were carried out simultaneously. Video arthroscopy of the right knee showed visible inflammatory soft tissue, obvious polyethylene fragments, wear of the polyethylene prothesis, and a broken polyethylene insert. The intraarticular polyethylene wear debris was removed as much as possible, and inflammatory soft tissue was debrided and sent for pathology. Postoperative pathology showed polyethylene debris in the soft tissue with an apparent multinucleated giant cell response, which was consistent with foreign body granuloma. All clinical manifestation was improved and Lysholm scores were significantly better at one year with this treatment, increasing from 32 points to 71 points.ConclusionAfter two years of follow‐up, the patient''s knee joint was significantly relieved from soreness and pain, and walking was not significantly restricted. Our treatment could not address the root cause of the wear debris pseudotumor, which was due to prosthesis failure, but sometimes, such an approach is the safest, most economical, and most effective choice for patients who are intolerant to reoperation.     

Acute appendicitis with unusual dual pathology

INTRODUCTION

Meckel''s diverticulum is a rare congenital abnormality arising due to the persistence of the vitelline duct in 1–3% of the population. Clinical presentation is varied and includes rectal bleeding, intestinal obstruction, diverticulitis and ulceration; therefore diagnosis can be difficult.

PRESENTATION OF CASE

We report a case of acute appendicitis complicated by persistent post operative small bowel obstruction. Further surgical examination of the bowel revealed an non-inflamed, inverted Meckel''s diverticulum causing intussusception.

DISCUSSION

Intestinal obstruction in patients with Meckel''s diverticulum may be caused by volvulus, intussusception or incarceration of the diverticulum into a hernia. Obstruction secondary to intussusception is relatively uncommon and frequently leads to a confusing and complicated clinical picture.

CONCLUSION

Consideration of Meckel''s diverticulum although a rare diagnosis is imperative and this case raises the question “should surgeons routinely examine the bowel for Meckel''s diverticulum at laparoscopy?”     

Glomus tumor of the fat pad

The authors report an exceptional glomus tumor location in Hoffa's ligament in a 65-year-old man. Based on this observation and a literature review, the authors provide the clinical and radiographic diagnostic appearances of this type of tumor. Surgical removal of the tumor achieved immediate disappearance of knee pain. Histological examination of the tumor has established the definitive diagnosis.Arthroscopy 1998 Apr;14(3):325-8     

Chilaiditi's syndrome associated with colonic volvulus and intestinal malrotation—A rare case

INTRODUCTION

Chilaiditi''s syndrome (symptomatic hepatodiaphragmatic interposition of the colon) is an exceptionally rare cause of bowel obstruction and may present difficulty in diagnosis and management. This is the first reported case of colonic volvulus occurring in Chilaiditi''s syndrome in association with intestinal malrotation and this case study describes its successful management.

PRESENTATION OF CASE

An 18 year old male presented as an emergency with vague abdominal pain and a past history of gastroschisis repair with intestinal malrotation. CT scanning showed a closed loop obstruction due to a volvulus of the colon herniating under the falciform ligament. The patient was successfully treated by surgical reduction of the hernia, anatomical correction of the malrotation and caecopexy with a tube caecostomy. At six month follow up the patient was well and asymptomatic.

DISCUSSION

In nine of the previously reported cases of Chilaiditi''s syndrome with colonic volvulus, treatment was by partial colonic resection of which a third underwent stoma formation. One patient died as a consequence of anastomotic leak following primary anastomosis. We therefore suggest an alternative approach to management.

CONCLUSION

Chilaiditi''s syndrome with colonic volvulus in association with intestinal malrotation has not previously been described. As there is no consensus in the literature as to how to manage such a case we suggest that reduction of the volvulus, anatomical correction of the malrotation and fixation of the caecum by tube caecostomy results in a successful outcome. This approach avoids the need for colonic resection and possible stoma formation.     

活血利水中药联合复方南星止痛膏治疗慢性膝关节滑膜炎的病例对照研究

目的:探讨复方南星止痛膏联合活血利水中药治疗慢性关节滑膜炎的疗效。方法:回顾性分析2008年10月至2011年3月膝骨关节滑膜炎患者120例,分为内服组、外敷组和联合组,每组40例。内服组患者平均年龄(56.58±5.47)岁;病程(7.35±2.59)个月;左膝18例,右膝17例,双膝5例;给予活血利水中药内服,该方由五苓散合桃红四物汤组成。外敷组患者平均年龄(56.25±6.35)岁;病程(7.68±2.76)个月;左膝16例,右膝20例,双膝4例;给予复方南星止痛膏外敷。联合组患者平均年龄(55.65±4.49)岁;病程(7.50±3.36)个月;左膝16例,右膝18例,双膝6例;给予活血利水中药内服结合复方南星止痛膏外敷。治疗后采用Lysholm和Gillquist膝关节评分标准和中医病症诊断疗效标准对3组治疗效果及膝关节功能进行评价。结果:纳入统计的患者118例,其中内服组40例,外敷组39例,联合组39例。治疗后联合组治愈27例,好转9例,未愈3例;外敷组治愈15例,好转16例,未愈8例;内服组治愈13例,好转16例,未愈11例。联合组的疗效高于内服组和外敷组。联合组除交锁和不稳定外,其余各项评分均高于内服组;联合组在跛行、疼痛、支撑、肿胀和爬楼梯方面评分高于外敷组;外敷组在疼痛、支撑、爬楼梯和下蹲方面评分高于内服组。结论:复方南星止痛膏联合活血利水中药治疗膝关节慢性滑膜炎可以减轻疼痛,消除肿胀,改善关节功能。复方南星止痛膏能在一定程度上减轻疼痛,改善关节功能。