Case Report: Tuberculous abscess of the popliteal fossa: A case report.

Introduction Tuberculosis of the soft tissues is a rare form of extra pulmonary tuberculosis, and isolated localization in the popliteal fossa is particularly exceptional. Atypical clinical presentation can lead to delayed diagnosis and serious complications. Case report We report the case of a 17-year-old patient who was diagnosed with tuberculosis of the popliteal fossa. He presented with a painful inflammatory swelling of the right popliteal fossa associated with a homolateral inguinal lymph node, without knee joint effusion. Standard chest and knee X-rays were normal, while MRI showed an 8 cm well vascularized, partly liquefied mass in the popliteal fossa, developed in contact with the semimembranosus and medial gastrocnemius muscles, associated with a popliteal lymph node without synovial effusion or thickening. Microbiological tests did not isolate any germs. The diagnosis was made on histological examination after biopsy, which revealed a caseous granuloma surrounded by epithelioid cells. The patient was treated with anti-tuberculosis therapy for 9 months. The clinical and radiological regression of the swelling was observed without recurrence at 2 years of follow-up. Conclusion Any soft tissue abscess should raise suspicion of tuberculosis, especially in endemic countries. The importance of histopathological examination should be emphasized to establish the diagnosis in the absence of signs in favor of a primary localization.

The effect of Scarf osteotomy on the distal metatarsal articular angle in hallux valgus: a case series.

BACKGROUND: Hallux valgus is a deformity of the forefoot involving a phalangeal valgus and a metatarsal adductus. In most cases its correction requires surgical treatment with different types of osteotomies. The best known is Scarf osteotomy. AIM: To study the effet of Scarf osteotomy on distal metatarsal articular angle (DMAA) as well as the validitiy of this angle and the value of its correction after review of the literature. METHODS: It was a retrospective study including patients operated on for severe hallux valgus by a Scarf osteotomy. The clinical assessment was based on the the American-Orthopedic-Foot-and-Ankle-society (AOFAS) score. Radiologically, we calculated the metatarsophalangeal angle, the inter-metatarsal angle and the DMAA. This assessment was performed preoperatively and one year postoperatively. RESULTS: We collected 37 cases of evolved hallux valgus. The average AOFAS score went from 60.7 to 85.8 / 100 postoperatively with a gain of 25 points. We've noted a significant correction of the 3 angular measurements at one year postoperatively (the metatarsophalangeal angle, the inter-metatarsal angle and the DMAA) which went from 38.8° to 20.5°, from 17° at 10° and 13.5° to 8.5° respectively (p<0.05). CONCLUSION: The literature has shown that there is no consensus regarding the effect of HV surgery on the DMAA. As for the accuracy, reproducibility and interest of correcting this angle we deduce that the DMAA is an interesting measure in the pathology of HV. Its correction seems not to be necessary in order not to hamper the correction of metatarsus varus. But in cases where the preoperative DMAA is high (> 15 °), efforts should be made to correct it to avoid recurrence.

Symptomatic Scapular Osteochondromas: Case report.

Osteochondroma is a developmental lesion rather than a true neoplasm. Osteochondromas are composed of cortical and medullary bone with an overlying hyaline cartilage cap and must demonstrate continuity with the underlying parent bone cortex and medullary canal. Osteochondromas may be solitary or multiple. We report  the case of a patient carrying the here ditary form and who has presented a thoracic deformity and a progressive dyspnea for 5 months. Imaging was related to a bulky osteochondroma of the scapula responsible for thoracic deformity. Benign character was confirmed on the histology data and the resection was performed posteriorly with muscular preservation.

Isolated tuberculous abscess in longissimus muscle.

Muscle's tuberculosis (TB) without coexistent active skeletal involvement is very rare. We presented a case of tuberculous abscess of longissimus muscle in a young immunocompetent female. Magnetic resonance imaging showed a well-circumscribed lesion in the longissimus muscle. No bony abnormality was noticed. An ultrasound-guided biopsy revealed the presence of granulomatous features on cytological pathology. A good response was seen with antitubercular treatment. TB should be considered in the differential diagnosis of any unexplained soft-tissue swelling in people born in tubercular endemic areas. To the best of our knowledge, our observation is the third reported case in immunocompetent patient.

Effect of sesamoid position on functional outcome of operated hallux valgus.

INTRODUCTION: The loss of correct relationships between the sesamoid and the first metatarsal is one of the architectural consequences of the hallux valgus (HV). The reduction of this dislocation by lateral soft tissue release (LSTR) is one of the objectives of surgery. AIM: To study the relationship between postoperative position of sesamoid and clinical outcome at one-year postoperative follow-up. METHODS: It's a retrospective study including patients operated for evolved HV performed in la Rabta orthopedic department in Tunis. These patients had a Scarf osteotomy associated with at least one Weil osteotomy. The functional evaluation was based on the AOFAS score (American-orthopedic-foot-and-ankle-society). We classified the sesamoid position according to 3 scores: Hardy & Clapham , RCAOFAS and the Agrawal. We compared each score of the sesamoid position to the clinical outcome. RESULTS: We collected 46 cases of HV in 45 patients. The mean AOFAS score increased from 60,9 to 85,5/100 postoperatively. Our patients were divided into 2 groups: group A whose result was excellent and group B whose result was good, fair and poor. The analytical study of this work concluded that there was no relationship between the postoperative sesamoid position and the clinical outcome, regardless of the radiological classification used (p=0,361, p=0,222, p=0,260). CONCLUSION: Sesamoids that remain in postoperative dislocation are not necessarily predictive of a poor clinical outcome at one year of the surgical cure.

A knee stiffness unusual etiology.

Progressive unilateral knee stiffness is an uncommon complaint in older adult. Tumor and specific infection should be considered in addition to osteoarthritis. We report a case of intracapsular and paraarticular chondroma in the infrapatellar Hoffa's fat pad that presented as a painless limited knee in 64-year old man. A physical examination revealed a firm, movable mass in the infrapatellar area. Radiographs and Magnetic resonance images showed an ovoid, well-defined, soft tissue mass with focal calcification in the infrapatellar fat pad. The mass was completely resected surgically through a medial parapatellar approach. The final pathology revealed an intracapsular and paraarticular chondroma. At follow-up, 3 years after the operation, patient was pain-free, with complete recovery of the range of motion of the knee and without any clinical or radiographic evidence of recurrence. Intracapsular and paraarticular chondroma is a rare benign lesion of the large joints (mostly the knee). The Pathogenesis of these tumours is controversial. The diagnosis is made with correlation of clinical, radiological and histological features. The treatment of choice is surgical excision.

Midshaft clavicle fracture synthesis with twisted one-third tubular plate with anterior-inferior approach.

BACKGROUND: Fractures of the clavicle are common and usually treated as minor injuries. The middle-third fractures account for 80% of all clavicle fractures. For many years, these fractures have been treated conservatively. After recent studies, this traditional approach has been reconsidered pointing the need to operate in some cases. AIM: To describe functional and radiological outcome of midclavicular fractures fixation using one-third tubular molded plate through an anterior inferior incision and to compare it to the outcome in the literature. METHODS: It was a retrospective study, using data gathered in 40 months from 38 cases of mid-shaft clavicle fractures treated operatively using one-third tubular molded plate with minimum perspective of 12 months. RESULTS: The mean age of the patients was 27 years with a sex ratio of 4.42. 8% of patients were suffering from diabetes. 58% were manual workers. 89% of fractures occurred on the side of the dominant limb, mostly after a domestic accident. In ⅔ of cases, the fracture occurred on the right side after an indirect injury. No vascular or neurological complications were reported. Fractures were most frequently classified Allman type I, AO type A1 and A2 and Edinburgh type 2A2 and 2B1. The mean operative time was 55 minutes. Immobilization with a sling were recommended for 24 hours. The mean consolidation time was 53 days. There was no postoperative complications and none of our patients underwent plate removal for infection. The mean Constant score at last follow up was 90. CONCLUSION: Operative treatment of mid-shaft clavicle fractures using one-third tubular molded plate allows avoiding neurovascular and skin complications with a low financial cost and helps patients, especially manual workers and young athletics, recover a normal shoulder function and return sooner to their usual activities.

Diagnostic features of elastofibroma dorsi: about 4 cases.

Elastofibromas are rare benign soft tissue tumors that are commonly located at the inferior pole of the scapula, typically in the right side, deep to the serratus anterior muscle. They occur mainly in elderly women and are usually asymptomatic. We  present four cases of elastofibroma dorsi in which the clinical and ultrasound diagnosis was confirmed by CT and magnetic resonance imaging. The location of the lesions (bilateral in two cases) was typical, in the thoraco-scapular region. When the lesion show typical imaging features and produces no symptoms, as is usually the case; further investigations are probably unnecessary.

Imaging of Benign Tumors of the Osseous Spine.

The purpose of this paper is to present an overview of the imaging features of the most prevalent benign bone tumors involving the spine. Benign tumors of the osseous spine account approximately for 1% of all primary skeletal tumors. Many lesions exhibit characteristic radiologic features. In addition to age and location of the lesion, radiographs are an essential step in the initial detection and characterization but are limited to complex anatomy and superposition. CT and MR imaging are often mandatory for further characterization, assessment of local extension and guiding biopsy.

Traumatic cervical spine injuries in a patient with pycnodysostosis.

Pycnodysostosis is a rare hereditary disease, characterized by systemic bone sclerosis. Susceptibility to long bone fractures is characteristic, whereas vertebral fractures are extremely rare. We report a case of a 21-year-old man with a past history of pycnodysostosis and spontaneous leg fractures who was admitted in hospital for a neck pain after a banal fall. Radiological examination revealed C1-C2-C3 posterior arch fractures with a C3-C4 left articular fracture dislocation. A surgical stabilization was decided but refused by the patient. To the best of our knowledge, this is the first publication that reports pycnodysostosis with cervical spine traumatic staged injuries.

sFRP3 and DKK1 Regulate Fibroblast-Like Synoviocytes Markers and Wnt Elements Expression Depending on Cellular Context.

CONTEXT: Fibroblast-like synoviocytes (FLS) from rheumatoid arthritis (RA) display pathogenic behavior. Various members of the Wnt pathway, especially the canonical Wnt/ß-catenin cascade, may contribute to autonomous RA FLS activation. It has been shown that the two Wnt inhibitors: sFRP3 and DKK1 contribute to several critical aspects of joint biology. However, their effects on RA FLS are poorly characterized. The aim of our study was to investigate the effects of sFRP3 and DKK1 on FLS markers, Wnt components, and target oncogenes expression by RA FLS and compare the findings to osteoarthritic (OA) FLS. MATERIALS AND METHODS: RA and OA FLS were treated with sFRP3 and DKK1 for 6 days. Wnt signaling components (Wnt5a, LRP5 and ß-catenin), Wnt target oncogenes (cyclin E1 and WISP1), and FLS markers (fibronectin and MMP3) were analyzed using western blotting and/or qRT-PCR. RESULTS: Our data indicated that sFRP3 down-regulated the key gene ß-catenin in RA FLS. sFRP3 decreased fibronectin, a well-known downstream effectors gene of Wnt/ß-catenin pathway, and LRP5 expression in both RA and OA FLS. In OA FLS, sFRP3 induced increased expression of Wnt5a and MMP3 but did not affect their levels in RA FLS. On the other hand, DKK1 increased fibronectin expression in RA FLS and decreased its expression in OA FLS. CONCLUSION: Our results confirm the involvement of Wnt signaling in FLS transformation and show that two inhibitors of the same cascade can regulate differently the same elements and that a single inhibitor can initiate signaling depending on cellular context. ABBREVIATIONS: FLS: fibroblast-like synoviocytes; RA: rheumatoid arthritis; Wnt: Wingless; Fz: frizzled; LRP: Fz/low-density lipoprotein receptor protein; WISP1: Wnt1 inducible signaling pathway protein 1; sFRP: secreted Fz-related proteins; DKK: Dickkopf; OA: osteoarthritis; DMEM: Dulbecco's modified Eagle's medium; FBS: fetal bovine serum; PBS: phosphate buffered saline; SDS-PAGE: sodium dodecyl sulfate-polyacrylamide gel electrophoresis; ECL: enhanced chemiluminescence detection solution; MMP3: metaloproteinase 3; qRT-PCR: quantitative real-time polymerase chain reaction; S.D: standard deviation; CRD: cysteine-rich domain; MeCP2: methyl-CpG-binding protein; RANKL: nuclear factor-kappa B ligand.

Nerve surgery in obstetric brachial plexus palsy, report of 68 cases.

BACKGROUND: Obstetric brachial plexus palsy aredue to elongation of the brachial plexus during delivery by increasing thedistance between the head and shoulder. The majority of paralysis recoverspontaneously, but in some cases, nerve repair is necessary. The timing of thisnerve surgery and criteria for its indication are topics of discussion in theworld literature.The aim of this study is to askdirections and to evaluate the contribution of nerve surgery in improving theprognosis of this disease. METHODS: This is a retrospective study thathas interested 68 cases of obstetric brachial plexus palsy who needs a nerverepair, collected over a 8 year-period (2004 - 2011). We analyzed the musclequotes and evaluate the functions of the shoulder, elbow and hand pre and postoperative. A minimum 12 months'follow-up was observed. RESULTS: Seventy-eight patients werecollected, 33 boys and 35 girls with a 62 days mean age at first consultationand a mean birth weight of 4187 grams . The presentation was cephalic in 66 cases. Theright side was interested in 66%. Clinically, we reported 50% of total brachialplexus palsy and 50% of C5-C6 palsy.The mean age at time of surgery was 9 months 10 days. Preoperatively, the shoulder was listed 0 or 1 according to Gilbert classification in 70% of cases in the C5-C6 plasy and 90% of the total brachial palsy. After a mean follow up of 30 months, the rate was respectively 9% and 15%. In 75% of cases of total brachial palsy, the hand was listed 0 according to Raimondi scale, while in postoperative, 65% of cases, the hand was listed 2 and 3 according to Raimondi scale. Nerve rupture was the predominant lesion on the C5 and C6 root while fibrosis was predominant on C7, C8 and T1 roots. We noted 6 complications including respiratory distress. CONCLUSIONS: The nerve repair should not beperformed too early or too late. Too soon, we may operate those who can have aspontaneous recovery. Too late, the installation of the degeneration of motorendplates and muscle atrophy render unnecessary nerve repair. The absence ofbiceps clinical recovery in the 6th month of life and the presence of root-wrenching signs represented the absolute surgical indications. Its results areencouraging and improve functional outcome.