Intraarticular synovial sarcoma of the knee rising from a lateral meniscus - a case report.

Synovial sarcoma (SS) is a rare mesenchymal tumor, accounting less than 10% of soft tissue sarcomas. We report a case of intraarticular SS mimicking nodular synovitis and lateral meniscus rupture. Due to clinical and radiological presentation, arthroscopic synovectomy was performed, and histology confirmed nodular synovitis. After four years the lesion recurred and new arthroscopic biopsy was performed, revealing a monophasic SS with SYT/SSX1 translocation. Repeated histology of the first specimen confirmed appearance of a nodular synovitis microscopically, with no morphological criteria for a sarcoma, but molecular analysis showed positive SYT/SSX1 translocation. Wide extraarticular knee resection and reconstruction with a tumor megaendoprosthesis-allograft composite was performed with a negative tumor margins. This case report showed that in a case of benign histological appearance, underlying sarcoma is possible and could be identified in early stages only with an advanced pathology methods. LEVEL OF EVIDENCE: Level IV historical case.

Lower limb salvage surgery: modular endoprosthesis in bone tumour treatment.

We retrospectively analysed 90 patients who underwent "en bloc" resection and modular endoprosthesis reconstruction in the lower limbs between 1987-2003. After proximal femur resection, reconstruction was performed with a modular endoprosthesis by Howmedica (KFTR, designed by Kotz) and modular revision endoprosthesis by W. Link or Lima-Lto (Revision system, designed by Wagner). The knee joint was reconstructed with a modular endoprosthesis (Howmedica, KFTR designed by Kotz) after distal femur or proximal tibia resection. Malignant bone tumours were present in 58 patients (64.5%), benign tumours in 16 (17.8%), metastases in 8 (8.9%), tumour-like lesions in 4 (4.4 %) and non-tumour-related destruction of the femur in 4 patients (4.4%). High-grade tumours were found in the majority of malignant bone tumours (70.7%). Treatment complications, which occurred in 26 patients, were: local recurrence of the tumour, deep infection, acetabular destruction following hemiarthroplasty, recurrent dislocations of endoprosthesis, periprosthetic fracture and hardware problems. In total, 23 patients (25.6%) died due to tumours. Endoprostheses should be considered as a treatment of choice for bone tumours in the hip and knee joint region. Advances in limb salvage surgery are, and will long continue to be, a great challenge for orthopaedic oncologists of the 21st century.

Surgical treatment of extension contractures caused by war injuries to the knee.

Immobilization with external fixation bridging the knee joint in extension is frequently used after sustaining a war injury to the region of the knee joint with femoral and tibial bone fractures. Immobilization of the knee with plaster splints is performed in the same position. This usually prolonged treatment results in extension contractures of the knee joint. From June 1991 until March 1994, 54 patients with extension contractures of the knee caused by war wounds were treated at the Department of Orthopedics, Zagreb University Hospital Center, in Zagreb, Croatia. Results of surgical treatment of 44 patients are presented. The operative procedure consisted of extensive intra- and extra-articular adhesiolysis of the knee. The control group included 30 patients with knee contractures caused by injuries sustained in car crashes or secondary to previous operative procedures. The mean duration of immobilization was 5 months and 6 days. The mean preoperative knee motion amplitude ranged from 5 degrees in extension to 38 degrees in flexion. The mean postoperative knee motion was 98 degrees (range, 2 to 110 degrees). Treatment results did not depend on either duration of preoperative immobilization of the knee or previous infection in the region of injury. Previous knee joint bridging with an external fixator had no impact on the results of extension contracture treatment. Adequate intra- and extra-articular adhesiolysis with appropriate long-term postoperative rehabilitation is essential for the success of the operative treatment for knee joint contracture.

Scoliosis curve correction, thoracic volume changes, and thoracic diameters in scoliotic patients after anterior and after posterior instrumentation.

Thoracic volume was calculated in 50 adolescent patients operated on for severe idiopathic thoracic scoliosis. In 25, anterior instrumentation was used (group 1), and posterior instrumentation in the other 25 patients (group 2). Calculation of thoracic volume was made from measurements of pre-operative and post-operative radiographs. The mean spinal curvature in group 1 was 73+/-12.4 degrees before the operation, and 19+/-15 degrees after the operation, and in group 2 the curvature was 75+/-13 degrees before the operation and 37+/-10 degrees after the operation. The calculated thoracic volume in the group with anterior instrumentation increased from 5234 ml pre-operatively to 6043 ml post-operatively, while with posterior instrumentation it increased from 5155 ml to 5489 ml. The correlation between the change in the Cobb angle and the thoracic volume change was poor for both groups. To determine the role in the thoracic volume increase of the frontal, sagittal and vertical thoracic diameters, further correlation tests were made between these and the thoracic volume increase in each diameter. The best correlation was found between the frontal and vertical increase of diameters in group 1, whereas in group 2 the best correlation was found between the volume increase and the sagittal parameters.

[Overuse injury syndromes of the calf and foot] ]. / Sindromi prenaprezanja na potkoljenici i stopalu.

The lower leg, foot and ankle form a functional unit of the locomotor system with an important static and dynamic function. Injury or loss of function of any muscle group of the lower leg and the foot influences normal gait or impedes standing. Increased or frequent loads on the muscle group may lead to pain syndromes known as overuse syndromes or overuse injuries. Athletes and certain professions involving standing or walking for a long time are especially susceptible to increased muscle strains. This article describes and clarifies the causes and the development of the pain syndromes in the lower leg, foot and ankle associated with certain professions or sports. The description of anatomical relationships and functions of individual muscle groups is here to clarify the occurrence of overuse injuries which may involve the muscle itself, the tendon, or the point of their attachment to the bone. The article describes observations and experiences from everyday clinical practice, but it also summarises results described in recent publications. The focus is also put on the therapy, which is usually conservative. Particular mention is given to new non-invasive surgical techniques. The article describes the most common overuse injuries of the lower leg such as shin splints, tibialis posterior syndrome, chronic anterior compartment syndrome, overuse injury of the Achilles tendon, enthesitis of the tendo Achilles, retrocalcanear bursitis and rupture of the Achilles tendon. In the foot area the most frequent overuse syndromes are the plantar fasciitis, tibialis posterior tendinitis, tendinitis of the long flexor of the toe, toe extensor tendinitis, and also anterior and posterior impingement syndromes of the ankle.

Surgical treatment of infected knee contracture after war injury.

From June 1991 till March 1994, sixteen patients with extension knee contracture as a war injury complication were operatively treated at the Department of Orthopedics, Zagreb University School of Medicine. Infection was present in all patients. During the same period of time, 32 patients with extension knee contracture as a war injury complication and free from the signs of infection were also treated at the Department and served as a control group. The mean age at the time of wounding was 28.3 and 31.8 years in the study and control group, respectively. Operative procedures of extensive intra- and extra-articular adhesiolysis of the knee were performed in all patients. The mean duration of immobilization following injury infliction was 5.5 and 4.9 months in the study and control group, respectively. The mean preoperative knee motion amplitude ranged from 8 degrees in extension to 37 degrees in flexion in the study group, and from 5 degrees in extension to 38 degrees in flexion in the control group. Postoperatively, the mean knee motion amplitude ranged from 2.8 degrees in extension to 97 degrees in flexion in the study group, and from 1.9 degrees in extension to 100 degrees in flexion in the control group. Treatment results did not depend on either the presence of infection in the region of injury or on the duration of preoperative knee immobilization. The treatment of infection was most important for the success of operative treatment of knee contracture. A significant role was also played by adequate intra- and extra-articular adhesiolysis with appropriate intensive postoperative rehabilitation.

[War injuries of the extremities. Use of the CMC fixator]. / Ratne ozljede ekstremiteta. Primjena CMC fiksatora.

The injuries of the extremities in the military setting, during hostilities, are classified to be the most frequent in general. Among them there are those caused by the missiles from rifles and automatic and semiautomatic weapons and those due to mine and shell fragments. The characteristics of modern array of weapons are missiles of high kinetic energy provoking extensive tissue injuries, often together with fractures of the long bones. When taking care of such fractures, in addition to surgical treatment of the wounds, the administration of medicine and prevention, the immobilization of the fragments is of fundamental significance. All modern armies in the world use external fixators for the immobilization of the fragments, those fixators being the most reliable and the most uncomplicated means of immobilization. The paper presents a new type of the external fixator to be used in war surgery. It is called the CMC fixator (Croatian Medical Corps). The fixator is made according to the original designs in the factory (Instrumentarija) at Zagreb. Following its biomechanic characteristics the fixator is classified into the group of unilateral or joining external fixators. It is designed for fixation of the long bone fractures in the war setting and disaster conditions. It may be used for two purposes: 1. for the transport immobilization to a medical facility where the problem is to be finally solved, 2. as the means of an external immobilization until the final secondary bone-healing. The fixator has only three elements and the universal kee. It is easily applied. The way how to apply this fixator is described in details. The first experiences in the field have given satisfactory results.

[New aspects in the use of artificial hip joints]. / Novosti u primjeni umjetnog zgloba kuka.

The implantation of hip joint endoprosthesis is one of the greatest achievements in orthopedic science. At present, research is aimed at permanent fixation of endoprosthesis into the bone bearing. Refinements of both endoprosthesis and cementation techniques are being made. Uncemented endoprostheses are usually applied in younger patients and in revision surgery. Personal experience in use of uncemented endoprosthesis of patients under 50 years of age is presented. Reconstruction of the hip joint by using endoprosthesis enables overcoming of numerous problems of young persons such as limping, difference in length of the lower extremities, painfulness, early development of degenerative changes and for some persons very important visible cosmetic problems and sexual difficulties. Use of the special tumor modular uncemented endoprosthesis which is a highly differentiated surgical procedure, necessitates special technical preparations and the experience of most distinguished centralized orthopedic institutions. Use of most up-to-date hip endoprosthesis now makes it possible to restore painlessness, movability and to improve the quality of life of treated patients.