Acetabular paralabral cyst: an uncommon cause of sciatica.

The association between tears of the acetabular labrum and paralabral cysts has been well documented, and magnetic resonance imaging (MRI) has been shown to be the most accurate noninvasive method of depicting not only the normal anatomic structures of the hip, but also the common pathologic processes such as labral tears and paralabral cysts. We present the case of an acetabular paralabral cyst that resulted in clinically symptomatic compression of the sciatic nerve.

Radiographic imaging of musculoskeletal neoplasia.

BACKGROUND: Imaging is an integral part of the diagnosis, staging and evaluation of outcomes for bone and soft-tissue neoplasms. Each of the available imaging tools has a different role. METHODS: The authors reviewed the efficacy of the current imaging modalities in the diagnosis, staging, and follow-up of patients with musculoskeletal neoplasia. RESULTS: Plain-film radiography remains the gold standard in the differential diagnosis of bone lesions. Bone scintigraphy is an excellent screening modality, and computed tomography is especially useful in evaluating lesions of the axial skeleton. The superior soft-tissue resolution and multiplanar capabilities achieved with magnetic resonance imaging, however, has replaced the need for CT scans in many cases. CONCLUSIONS: The technological advances seen in recent years in all areas of imaging have improved the capabilities of these modalities to assist in the diagnosis, definition of tumor extent, and accurate staging of musculoskeletal tumors.

Extraskeletal osteochondroma of the foot.

A case of pathologically proven extraskeletal osteochondroma is presented with magnetic resonance imaging (MRI), computed tomography (CT), bone scan and radiographic findings. The diagnosis of extraskeletal osteochondroma should be considered when a discrete, ossified mass is localized in the soft tissues of the distal extremities. Nomenclature surrounding this entity is controversial and is discussed.

Coccidioidomycosis--the airborne assault continues: an unusual presentation with a review of the history, epidemiology, and military relevance.

Despite remarkable advances in detection and therapy, coccidioidomycosis remains a persistent threat to military troops deployed in endemic areas. Pregnant women, immunocompromised hosts, and dark-skinned persons, particularly those of Filipino, African, Hispanic or Asian ancestry, are at greatest risk for disseminated coccidioidomycosis. The ethnically diverse military forces have susceptible active duty and reserve members stationed at or temporarily trained on bases located in endemic areas for Coccidioides immitis. Although the vast majority of infections with this organism are subclinical, unusual patterns of dissemination pose a diagnostic challenge. The military physician may be tasked with recognizing acute non-specific symptoms as well as bizarre, occult manifestations of coccidioidomycosis. We present a case of disseminated coccidioidomycosis in an active duty Caucasian male who presented with a right shoulder mass. Our patient is atypical in that he had disseminated disease although immunocompetent and Caucasian. Another unusual feature is that the mass was not preceded or accompanied by any other symptoms. We could find only two other reported cases of coccidioidomycosis presenting as a soft tissue mass, both in African-American patients. The epidemiology and history of coccidioidomycosis will be reviewed, with an emphasis on military populations. The insidious nature of coccidioidomycosis, the importance of early detection and treatment in decreasing morbidity and mortality, and the presence of large numbers of military members in the endemic areas make the lessons of this case particularly relevant for all flight surgeons.

Malignant tumors about the knee.

The knee is the most common location for malignant bony tumors as well as a number of soft-tissue sarcomas. The clinical presentation of these lesions usually involves pain and swelling, often associated with a palpable mass. This can occur rapidly or take a more indolent course. Proper evaluation and staging prior to biopsy of these tumors is necessary. This should be done by a surgeon experienced in the treatment of these tumors and at a facility where a multispecialty team can provide patient care. The primary surgical choices for treating malignant musculoskeletal tumors are limb salvage and amputation. One of the major difficulties in performing limb salvage about the knee is the lack of soft-tissue coverage after resection. Local or even free flaps are often necessary. Additionally, reattachment of the extensor mechanism is necessary. These problems and the use of allografts often lead to a high incidence of complications including infection, wound breakdown, allograft fracture, or extensor mechanism problems with resultant poor functional result.

Circumferential forearm fasciocutaneous free flap reconstruction of forequarter amputation/chest wall resection using simultaneous extra-anatomic revascularization (SEAR).

BACKGROUND: This report describes a technique in which temporary extra-anatomic revascularization of an amputated part was used to preserve a free flap while tumor resection and chest wall reconstruction were performed. METHODS: A patient with multiple local recurrences of basosquamous carcinoma of the shoulder underwent forequarter amputation with en bloc resection of the upper chest wall. During the resection, an elbow disarticulation of the amputated limb was performed. The vascular pedicle of the amputated forearm was joined to the dorsalis pedis vessels of the foot. Following completion of tumor resection and chest wall reconstruction, the forearm was disconnected from the foot and re-anastomosed to thoracic vessels, and a circumferential fasciocutaneous free flap was then harvested and inset. RESULTS: No ischemic flap complications occurred, and the patient recovered well. Ample time was afforded for complete tumor resection with negative margins and prosthetic reconstruction of the chest wall. CONCLUSIONS: The technique of temporary, simultaneous extra-anatomic revascularization of an amputated part for later free flap harvest may be helpful in avoiding potentially long flap ischemia times in selected complex oncologic resections.

MR imaging of musculoskeletal tumors and tumor mimickers with intravenous gadolinium: experience with 242 patients.

PURPOSE: This pictorial essay reviews our experience with MR scans with gadolinium in patients with musculoskeletal tumors and tumor mimickers. DESIGN: Review of 242 MR scans obtained in the initial evaluation of a possible primary musculoskeletal neoplasm. All scans included a T1-weighted, fat-suppressed sequence following intravenous administration of gadolinium. RESULTS: MR scans with gadolinium did not contribute to differential diagnosis or patient management in 89% of the patients in this series. However, intravenous gadolinium did assist in guiding the biopsy of bulky lesions and evaluating treated tumor beds for possible recurrence. MR scans with gadolinium were sometimes helpful when the differential diagnosis included synovitis, Morton's neuroma or intramuscular myxoma, and when it was important to differentiate cystic from solid lesions. CONCLUSIONS: Routine use of gadolinium in every initial MR examination of a possible musculoskeletal mass is not warranted. However, there are appropriate selected indications for gadolinium administration as outlined above.

Spine injuries in combat troops--Panama, 1989.

Operation Just Cause was until recently the largest American combat operation since Vietnam, and remains the largest nighttime parachute operation since World War II. All 252 casualties were airlifted to San Antonio, Texas, for medical treatment. Greater than 80% sustained orthopedic injuries. Sixteen patients were admitted for injuries to the back or neck. Three of the four patients with significant fractures or fracture-dislocations were paraplegic. Two of the three patients with gunshot wounds to the back required extensive reconstruction for wound management. In addition to the 252 casualties, there were 23 fatalities, among whom 7 suffered major injuries to the spine. Spine injuries represented the most significant source of long-term morbidity among those soldiers wounded in combat in Panama, and were common among the fatalities. Noteworthy in these cases was the high percentage of severe neurologic injuries in patients with significant fractures (75%), particularly fractures associated with gunshot wounds. Also of interest were the cases of major soft tissue injury associated with high-velocity gunshot wounds (66%) and the extensive soft tissue surgery needed to treat these injuries.

Acrylamide cohort mortality study.

The mortality experience of 371 employees assigned to acrylamide monomer and polymerisation operations was examined with particular emphasis on cancers at sites identified from animal studies such as the central nervous system, thyroid gland, other endocrine glands, and mesotheliomas. A total of 29 deaths was observed up until 1982 (38.0 expected). No statistically significant excesses were noted in the total cohort and no deaths were found for the hypothesised sites of cancer. The observed deaths in the total cohort for the all cancers category were somewhat in excess (11 v 7.9); however, this was due entirely to excess cancers of the digestive tract and respiratory system in the subgroup with previous exposure to organic dyes. Among those employees not exposed to organic dyes, four deaths were due to malignancies versus 6.5 expected. This study does not support a cause effect relation between exposure to acrylamide at this work site and overall mortality, total malignant neoplasms, or any specific cancers.