Unusual case of mixed form of femoroacetabular impingement combined with nonspecific synovitis of the hip joint in a young adult-- A case report.

INTRODUCTION: Minimal bone changes in the acetabulum and/or proximal femur, through mechanism known as femoroacetabular impingement, during flexion, adduction and internal rotation lead to early contact between femoral head-neck junction and acetabular brim, in anterosuperior region. Each additional pathological substrate which further decreases specified clearance provokes earlier onset of femoroacetabular impingement symptoms. CASE REPORT: We presented a 20-year-old male patient with groin pain, limping, positive impingement test, radiological signs of mixed form of femoroacetabular impingement and unrecognized chronic hypertrophic synovitis with earlier development of clinical hip symptoms than it has been expected. Open surgery of the left hip was done. Two years after the surgery, patient was asymptomatic, painless, and free of motion, with stable x-rays. CONCLUSION: Hypertrophic synovial tissue further reduces the distance between the femoral head-neck junction and the acetabulum, leading to the earlier onset of femoroacetabular impingement symptoms. Surgical treatment is the method of choice.

Surgical dislocation of the hip in patients with femoroacetabular impingement: Surgical techniques and our experience.

BACKGROUND/AIM: Arthrosis of the hip is the most common cause of a hip joint disorders. The aim of this study was to present our experience in the application of a safe surgical dislocation of the hip in patients with minor morphological changes in the hip joint, which, through the mechanism of femoroacetabular impingement, cause damage to the acetabular labrum and adjacent cartilage as an early sign of the hip arthrosis. METHODS: We have operated 51 patients with different morphological bone changes in the hip area and resultant soft tissue damage of the acetabular labrum and its adjacent cartilage. Surgical technique that we applied in this group of patients, was. adapted to our needs and capabilities and it was minimaly modified compared to the original procedure. RESULTS: The surgical technique presented in this paper, proved to be a good method of treatment of bone and soft tissue pathomorphological changes of the hip in patients with femoroacetabular impingement. We had no cases with avascular necrosis of the femoral head, and two patients had nonunion of the greater trochanter, 9 patients developed paraarticular ossification, without subjective symptoms, while 3 patients suffered from postoperative pain in the groin during more energetic physical activities. CONCLUSION: Utilization of our partly modified surgical technique of controlled and safe dislocation of the hip can solve all the bone and soft tissue problems in patients with femoroacetibular impingement to stop already developed osteoarthritis of the hip or to prevent mild form of it.

Non-functional parathyroid cyst--diagnostic pitfall: A case-report.

INTRODUCTION: Parathyroid cysts are relative rare and they may be misdiagnosed with thyroid nodules. Parathyroid cysts are characterized by elevated level of parathyroid hormone (PTH) in cystic fluid. CASE REPORT. We reported about middle-aged woman with palpable node in the left thyroid lobe. Ultrasound showed anechoic 40 x 25 mm lesion in the left thyroid lobe. Fine needle aspiration (FNA) obtained 13 mL colorless, watery cystic fluid. PTH value in cystic fluid was ten fold more in comparison with serum PTH. Serum PTH was slightly elevated, D vitamin was under the reference range, serum calcium and phosphorus were normal as well as thyroid hormones. Thyroglobulin antibodies (TgAb) and thyroid peroxidase antibodies (TPOAb) were not detected. Radionuclide parathyroid scintigraphy indicated at physiological metaiodbenzyl-guamidine (MIBG) distribution. After six monthsof vitamin D supplementation, serum calcium, phosphorus, vitamin D and PTH were normal. This finding was indicative that was a nonfunctional parathyroid cyst. CONCLUSION: This case report points out that thyroid cystic lesions with thin walls, and reverberation in ultrasound, must be observed as a potential parathyroid cyst. These cysts require caution during diagnostic aspiration because of danger of hypercalcemic crises due to FNA, which can be a life-threatening condition.

Early clinical results of surgical treatment of patients with femoroacetabular impingement.

INTRODUCTION: Surgical treatment is the treatment of choice in patients with symptoms and radiological signs of femoroacetabular impingement. OBJECTIVE: Our experience and early results of surgical treatment of patients with signs of femoroacetabular impingement and early hip osteoarthritis are reported. METHODS: The results of treatment of 21 patients aged 23-54 years with different types of femoroacetabular impingement are presented. Safe open surgical dislocation of the hip was performed in all patients. Before and after surgery, the WOMAC score was performed, clinical and radiographic data of the operated hips were evaluated and t-tests were used for statistical analyzes of data. RESULTS: The WOMAC score improved from 70.5 points (range 56.3 to 89.8 points) to 90.3 points (range 70.3 to 100 points) at one year of follow-up (p < 0.0001), anterior impingement test was negative in all operated cases, average hip internal rotation improved significantly, no complications were found, except trochanteric nonunion at the site of osteotomy, which was reaffixed. CONCLUSION: Postoperative results have shown that the surgical approach to treating patients with femoroacetabular impingement is the method of choice. Three operated patients, with advanced osteoarthritis of the hip, had to be converted to total hip replacement.

Contribution to the method for determining femoral neck axis.

INTRODUCTION: Femoral neck axis plotting is of great significance in measuring parameters that define femoral head-neck junction sphericity in the group of patients with the femoroacetabular impingement. Literature methods of femoral neck axis determination have weaknesses associated with the risk of obtaining inaccurate values of certain parameters. OBJECTIVE: Method of plotting of the femoral neck axis by two parallel lines that belong to the medial quarter of the femoral neck is proposed. Method was tested on the anatomic specimens and the respec tive radiograms. METHODS: A total of 31 anatomic specimens of the proximal femur and respective radiographs were used, on which three axes of the femoral neck were plotted; accordingly, alpha angle value was determined and tested with corresponding parametric tests, with the measurement error of less than 5% and the strength of the applied tests of 80%. RESULTS: Alpha angle values obtained by plotting femoral neck axis using the literature and methods we have proposed were not significantly different in our series, and, in more than a half of the specimens, the two axes overlapped each other. CONCLUSION: The advantage of the proposed method does not depend on the position of the femoral head rotation center in relation to the femoral neck, which favors proposed method for measuring the angles of femoral head sphericity in patients with the femoral head translation. Disadvantage of the study is a small sample size for valid conclusions about the applicability of this method in clinical practice.

Measuring the osteochondral connection of the femoral head and neck in patients with impingement femoroacetabular by determining the angle of 2alpha in lateral and anteroposterior hip radiographic images.

BACKGROUND/AIM: Femoroacetabular impingement, a pathophysiological mechanism of small morphological changes of the hip leads to early arthritic changes. The aim of this study was to present a simple method for the quantification of femoral head and neck junction in patients with cam form of femoroacetabular impingement, in standardized anteroposterior and profile DUNN 90 radiograms of the hips. METHODS: In standardized anteroposterior and profile DUNN 90 images of the hips we determined the angle of 2 alpha, defined by our own original method. We tested 141 hips in 81 patients without clinical signs of femoroacetabular impingement, and 153 hips in 76 patients with clinically clear signs of femoroacetabular impingement. RESULTS: The value of the angle 2 alpha in anteroposterior hip radiograms was on average 113.7 degrees for the patients with clinical symptoms of impingement, and 84.2 degrees for the control group of patients (p < or = 0.0001), and in DUNN 90 profile radiography of the hip, the value of 2 alpha angle in the patients group was 97.2 degrees, and 74.6 degrees in the control group (p < or = 0.0001). The proposed method of determining the angle 2 alpha showed a high level sensitivity (97.8%) and specificity (98.7) and positive predictive value (98.6%). It was false positive in only 1.3%, and false negative in 2.12% of patients. CONCLUSION: Using standardized anteroposterior and profile radiographs of the hips, and without determination of femoral neck axis in patients with femoroacetabular impingement with the cam effect at the junction of the femoral head and neck, we proposed the method of measuring joint abnormalities of femoral head and neck junction, very capable to predict the disease development in an asymptomatic risk group of patients and high sensitive in the diagnosis of the disease in the group of patients.

Possibilities of nontoxic autonomous thyroid nodules treatment by percutaneous ethanol injection.

BACKGROUND/AIM: According to the current principles, autonomous functional thyroid nodules are treated by surgery or by radioiodin therapy. Ultrasound guided percutaneous ethanol injection into solid tumors of the soft tissues was a starting point in attempts to treat the thyroid nodules by the same method. The aim of the study was to assess the efficiency of percutaneous injection in treating solitary, nontoxic, autonomous thyroid nodules of up to 15 mL volume. METHODS: In 25 patients with solitary nontoxic autonomous thyroid nodules diagnosed by tehnetium-99m scanning as an intensive area having a complete supremacy in the paranodal tissue, an ultrasound guided percutaneous ethanol injection was applied. The procedure was carried out repeatedly once a week until the reduction in nodule size to 50% of the initial size was achieved. RESULTS: An average size of the nodule before curing was 9.68 +/- 5.01 mL. An average quantity of the injected ethanol was 9.52 +/- 5.08 mL, ie 1.06 +/- 0.48 mL/mg of the tissue. The regression of the nodule size in the successfully (deltavol% u -57.09 +/- 13.75%, p < 0.001) and partly successfully cured (deltavol du = -48.45 +/- 14.35%, p < 0.05) was statistically significant compared to the size before the treatment. After ceasing ethanol injection, 18 months later, a further size regression (deltavol% = -79.20 +/- 9.89%) compared to the initial one (p < 0.001) was noticed. Soon, after the procedure was finished, a statistically significant concentration increase of Thyroid Stimulating Hormone (TSH) was noticed compared to the initial values (0.18 +/- 0.16 vs 0.34 +/- 0.31 mU/L, p < 0.01). According to the given criteria, in two female patients satisfactory results were not achieved, but, a year later, in one of them the nodule was not seen by repeated scintigram. The number and frequency of side effects were insignificant. CONCLUSION: Repeated percutaneous ethanol injections into nontoxic solitary autonomous thyroid nodules result in disappearing of authonomy. The regression of the nodule size of more than 50% compared to its initial volume, as well as the increase in concentration of TSH for more than 50% are the signs of a successful treatment.

[Thyrocyte morphomethric analysis significance in differential diagnosis of thyroid carcinoma].

UNLABELLED: BACKGRAUND/AIM: Conventional cytomorphology of thyroid cell aspirates is limited in preoperative differential diagnosis of follicular adenomas (FA) and hyperplastic adenomatoid nodular goiters from well differentiated thyroid follicular carcinoma (FTC) and follicular variant of thyroid papillary carcinoma (PTC). This is the reason of inaccurate presurgical differential diagnosis and in the same cases of inadequate operative managament. The aim of the study was to evaluate the role of quantitative estimation of thyreocite nuclear features (cariomorphometry) in thyroid aspirated smears in preoperative differential diagnosis of benign from malignant thyroid lesions. METHODS: A total of 48 patients with thyroid nodular disease underwent fine needle aspiration biopsy for cytomorphology, cariomorphometric analysis of the aspirates, and histopathologic explorations conducted fully postoperatively. On the basis of cytomorphology classification the patients were divided into three groups: benign (B), n = 8; malignant (M), n = 15, and suspicious for malignancy (S), n = 25. Using a microscope connected to a computerized video system, mean nuclear area, the nuclear area coefficient of variation (NACV) and anisocariosis ratio were measured and calculated. RESULTS: In all the 15 patients with cytologically malignant results the diagnosis of PTC was confirmed histopathologically. All cytologically benign lesions were confirmed histopathologically. Thyroid carcinoma was found in 15 out of 25 patients with suspicious lesions. The highest mean values of nuclear area were in the PCT (90.74 +/- 26.71 microm2), and were significantly different from all other groups (p < 0.001). The mean nuclear area in FTC was 69.20 +/- 27.31 microm2 and was significantly higher than in the benign adenomatous group (p < 0.01). There was no significant difference in mean nuclear area between FTC and FA, but there was a significant difference in NACV between these two groups (FTC: 39.46% vs FA: 23.42%,p < 0.001). In 27 out of 30 patients with thyroid carcinoma higher values of NACV than 18% were found. CONCLUSION: Preoperatively cariomorphometry is a useful method in differential diagnosis of thyroid carcinoma from benign lesions, as a complementary method to convencional cytodiagnostics. The NACV showed highest sensitivity as a parameter of malignant thyroid cell transformation.

A New PC and LabVIEW Package Based System for Electrochemical Investigations.

The paper describes a new PC and LabVIEW software package based system forelectrochemical research. An overview of well known electrochemical methods, such aspotential measurements, galvanostatic and potentiostatic method, cyclic voltammetry andEIS is given. Electrochemical impedance spectroscopy has been adapted for systemscontaining large capacitances. For signal generation and recording of the response ofinvestigated electrochemical cell, a measurement and control system was developed, basedon a PC P4. The rest of the hardware consists of a commercially available AD-DA converterand an external interface for analog signal processing. The interface is a result of authorsown research. The software platform for desired measurement methods is LabVIEW 8.2package, which is regarded as a high standard in the area of modern virtual instruments. Thedeveloped system was adjusted, tested and compared with commercially available systemand ORCAD simulation.

[Personal experience in diagnosis and localization of pheochromocytoma]. / Feohromocitom--nasa iskustva u dijagnostici i lokalizaciji.

INTRODUCTION: Pheochromocytomas are most commonly tumours of adrenal medullary origin. Pheochromocytoma by definition produces and secretes catecholamines. Similar tumours that do not secrete active substances of any kind are called non functioning paragangliomas. The hallmark clinical manifestation of pheochromocytoma is hypertension accompanied with various signs and symptoms in excess of catecholamines or other bioactive substances. The early diagnosis of pheochromocytoma is important not only because it offers the possibility of curing hypertension but also because unrecognised pheochromocytoma is a potentially lethal condition. The aim of this article is to stress the specify of the clinical finding, diagnostical values of the laboratory tests and possibilities of morphological localizing techniques in a series of 98 patients with surgically proven pheochromocytoma. RESULTS: Over the period from 1954 to 2002 pheochromocytoma was diagnosed and surgically treated in 98 patients. The diagnosis was confirmed at operation except in patients who refused operation or continued the examination in other Clinical wards. There were 59 females and 48 males (F:M = 1.23:1), the age ranged from 7 to 64 years with the pick incidence in the second and third decades of life in males and the third and fourth decades of life in females. The basic clinical characteristic was hypertension which was found in 94% of patients with an approximately equal frequency of fixed and paroxysmal hypertension cases. The most often accompanning manifestations were headache (62%), perspiration (61%) and palpitations (65%). A high level of vanyl mandelic acid (VMA) and free catecholamines in 24-hour urine collection confirmed the diagnosis in 94% of cases. In boderline cases we performed dynamic tests, the most relevant among them being the test with phentolamin. It was positive in 95% of patients. Retropneumothomography contributed to a successful localisation of tumour in 83% of cases. Computed tomography (CT) was performed in 69 patients and was positive in 97% of them. Magnetic resonance imaging (MRI) localized the tumour in all 16 patient in whom it was performed. The whole body MIBG-J-131 (metaiodobenzylguanidine) scanes were positive in 92% (45/49) and false negative in the remainder of 8% (4/49) of cases. Selective angiography was performed in 40 patients and in all it was positive. DISCUSSION: Although pheochromocytomas were among the first recognized adrenal tumours, the prompt and safe diagnosis is mandatory up to date. The average annual incidence has been estimated by several epidemiologic studies to range from 0.8 to between 1.55 and 2.1 million persons per year. It is reported that it is curable cause of hypertension in 0.1% to 1% of cases. Pheochromocytoma has been classified as a "10% tumour" because various studies have shown that each of the characteristics mentioned bellow occurs with a frequency of approximately 10%: bilateral, extra-adrenal, multiple, malignant, familial and occurring in children. Our series of patients has a similar distribution: pheochromocytoma was in 9.2% of patients extra-adrenal, in 7.1% bilateral, in 9.2% multiple and in 4.08% malignant. Hypertension was the constant finding in 94% of our patients. Three clinical patterns of hypertenson have been observed. The first is paroxysmal hypertension, and the others are fixed or combinations of fixed and paroxysmal hypertension. According to our experience there were the equal incidence of all forms of hypertension. We noticed, like others, when the triad of headache, sweating and palpitations is accompanied by hypertension, the diagnosis of pheochromocytoma can be made with specify and sensitivity over 93%. In absence of this finding the diagnosis can be excluded with certainty of 99%. As a specify of the clinical finding, we mention two patients with manifestations of hypercorticism, two patients with pheochromocytoma of the urinary bladder, and four with MEN syndrome (one with MEN 2A and three with MEN 2B). For confirming the diagnosis the most relevant laboratory test was the higher level of VMA and free catecholamines in 24-hour urine collections. Once pheochromocytoma has been diagnosed by biochemical analyses, the anatomic location of the tumour or tumors must be determined. Currently, the best approach is to obtain MIBG-J-131 scan and then to perform MRI or CT of the abdomen and other areas identified on MIBG scan in order to provide more accurate spatial information. With this approach the great majority of pheochromocytomas can be localized. CONCLUSION: There is no classic picture, no stereotype for pheochromocytoma, although the history and physical finding are helpful. Patients come to the clinician in a variety of ways and settings. They may have classic attacks of hypertension accompanied with headache, perspiration and paplpitations or they may have identical symptoms and physical findings as the patients with primary hypertension. On the other hand, they may have signs and symptoms of diabetes mellitus, hyperthyroidism, hypercalcaemia, congestive heart failure, myocardial infarction, malignant hypertension or a variety of other conditions. Rarely, they have no complaints at all. Once the diagnosis was made, spatial localizing of the tumour or tumours, and surgical treatment are necessary. Unrecognized disease may be fatal.

[The von Hippel-Lindau syndrome with pheochromocytoma]. / Sindrom fon Hipel-Lindau s feohromocitomom.

The members of four generations of a family with Von Hippel-Lindau syndrome (VHL) have been followed by one of us (I.P.) for 30 years. The disease was proved in four members of this family, in three of them associated with pheochromocytoma. The grandmother (I-1) died at the age of 16 years two months after her first birth. The cause of death was not established. Her daughter (II-1) had 9 births with 5 children alive. Paresthesia and difficulties in walking followed by paraparesis and paraplegia were the first signs of the disease at the age of 58 years. The surgical treatment was performed because of an expansive lesion at the level of Th 3-4. Pathohistological examination was not done. It seems that a haemangioblastoma might be the cause of her disease. Diagnosis of pheochromocytoma was documented in a female patient (III-2) in 1972. Two years later she was successfully operated on. Pathohistological examination proved clinical diagnosis. She had also diabetes mellitus, cholelithiasis and cardiomyopathy. She died at the age of 56 years. A right-sided pheochromocytoma was diagnosed in a next female patient (III-4) at the age of 22 years. Her surgical treatment was successful. Retinal haemangioblastomatosis was established 7 years later in this patient. She was blind at the end of her life. Haemangioblastomatosis cerebelli was diagnosed soon, and she died at the age of 51 years. A 12- year old boy (IV-3) presented severe hypertension (36/24 kPa). Left-sided pheochromocytoma was removed in this patient one year later. Right-sided pheochromocytoma was operated on in the same patient at the age of 24 years. An elevated level of urinary dopamine was documented four years after the second operation. A malignant right-sided pheochromocytoma was operated on in the same patient 15 years later. At the same time metastases were found in the lower part of the right lung lobe. A 131-I-MIBG therapy could not be realized. He died at the age of 41. Pathohistological examinations proved the clinical diagnosis in this patient after all of three surgical treatments. MEN 2 syndrome was excluded by proper genetical analyses on the RET-protooncogen. Genetical analyses are in the course to identify the possible mutations of VHL-tumour-suppressor gene through the living members of the family. Multidisciplinary approach is mandatory in diagnosis, follow up and treatment of this specific group of patients. A collaboration among specialists of different fields of medicine (internal medicine, ophthalmology, neurology, radiology, urology, neurosurgery, biochemistry, pathology and genetics) is suggested.