Accessory soleus presenting as a posterior ankle mass: a case report and literature review.

The accessory soleus muscle is a rare anatomic variant that may present as a mass in the posterior-medial aspect of the ankle in young adults. The presence of such a mass may result in pain and difficulty with running. We present a case of accessory soleus muscle in a 21-year-old soldier and review the literature. We present the first magnetic resonance imaging studies in the American literature, to our knowledge, of this unusual anomaly.

Castleman's disease in the extremity.

Castleman's disease is an uncommon entity that is characterized by lymphoid hyperplasia with two variants: the hyaline vascular type and the plasma cell type. We present a case affecting the lower extremity, an extremely rate site of the disease.

Arthroscopic excision of intra-articular ossifications. A case report and review of the literature.

The first reported case of arthroscopic removal of an intra-articular ossified fragment is presented in a patient with melorheostosis of the knee. In this case, the patient's medical history revealed that prior to presentation the patient had experienced transient locking problems with the same knee that spontaneously resolved. Roentgenograms confirmed a 2-cm loose body in the intra-articular space of the left knee and multiple calcified aggregations in the distal femur and proximal tibia. The patient underwent arthroscopy to remove the loose body in the knee, an an intraoperative exam revealed no other abnormalities. Two years postoperatively, the patient reported no knee problems.

Dysplasia epiphysealis hemimelica in an elderly patient.

We report a case of dysplasia epiphysealis hemimelica in an 87-year-old woman, the oldest patient, to our knowledge, who has presented with symptoms from this disease. Whereas the classic presentation is marked by painless swelling and/or deformity, our patient was found to be diffusely tender without effusion or gross deformity. Plain radiographs showed severe degenerative changes in her right knee with loss of joint space and osteophyte formation, along with an intra-articular osteochondroma. The intra-articular osteochondroma was removed, and an arthroplasty was performed without complication and with full relief of symptoms.

Scrofuloderma of the lower extremity treated with wide resection: a case report and review of the literature.

Scrofuloderma is tuberculosis of subcutaneous tissue that ulcerates and drains through the overlying skin. It most commonly occurs in the neck from a cervical lymph node source. Although such lymphatic spread is the usual clinical picture, there are sporadic reports in the literature of direct hematogenous seeding of subcutaneous tissue forming a tuberculoma, or "cold abscess." Definitive diagnosis requires the identification of Mycobacterium tuberculosis within the suspect lesion. Surgical intervention is necessary in any draining lesion and should be accompanied by appropriate antituberculous chemotherapy. Accounts of bone and joint involvement are numerous, but the orthopedic surgeon must also be aware of the soft-tissue manifestations of tuberculosis and the indications for surgery. We report on an immunocompromised patient who presented with a rare case of scrofuloderma of the lower extremity, which was treated with wide resection.

Report of the National Commission on Nurse Anesthesia Education. Study of nurse anesthesia manpower needs.

Nurse anesthesia manpower needs over a 20-year period from 1990 through 2010 are examined using data from a study conducted by Health Economics Research, Inc., which was submitted to Congress in February 1990. Two scenarios were considered: one representing no change in the capacity of the educational system and the other an annual increase. Under either scenario, the U.S. faces a significant shortage of CRNAs, now and in the future. The study points to a $1.2 billion savings to society through the increased use of CRNAs in anesthesia care.

IL-17 disrupts corneal barrier following desiccating stress.

T helper (Th)-17 is a recently identified subtype of Th response that has been implicated in host defense and autoimmunity. We investigated whether there is evidence for a Th-17 response in human and experimental murine dry eye (DE). Gene expression in the human DE conjunctiva showed increased levels of the Th-17 inducers, interleukin (IL)-23, IL-17A, and interferon-gamma (IFN-gamma). In the murine model, we found that desiccating stress increased matrix metalloproteinase-9, Th-17-associated genes (IL-6, IL-23, transforming growth factor-beta1 and -2, IL-23R, IL-17R, IL-17A, retinoid-related orphan receptor-gammat, and CC chemokine attractant ligand-20) and IFN-gamma in cornea and conjunctiva. Furthermore, we found a significantly increased concentration of IL-17 in tears and number of IL-17-producing cells on the ocular surface. Antibody neutralization of IL-17 ameliorated experimental DE-induced corneal epithelial barrier dysfunction and decreased the expression of matrix metalloproteinases 3 and 9. Taken together, these findings suggest that IL-17 has a role in corneal epithelial barrier disruption in DE.

Tips of the trade #34. Removal of broken rush pins.

Reported rates of nonunion with the nonoperative treatment of isolated humeral shaft fractures (nonpathologic bone) are low. Higher rates (13%) in open fractures are reported; open intramedullary nails may contribute to this nonunion rate. In this situation, when we identify a fractured pin, an anterolateral approach is used. The proximal pin is removed and the nonunion site is identified. The fibrous nonunion or pseudoarthrosis is excised and the distal pin fragment is identified in the intramedullary canal. A drill bit is used to remove the rod. Bone grafting is also generally utilized.

Synovial chondromatosis simulating neoplastic degeneration of osteochondroma: findings on MRI and CT.

A case is presented of synovial chondromatosis within a bursal sac overlying an osteochondroma in a patient with osteochondromatosis. This condition presented with a symptomatic soft tissue mass containing calcified bodies. It can be mistaken clinically and radiographically for malignant degeneration of an osteochondroma with development of chondrosarcoma. Magnetic resonance findings have not previously been described in this entity and proved helpful in the preoperative diagnosis. Magnetic resonance imaging was also helpful in defining the extent of the lesion. Ultrasound and other imaging modalities are also discussed, including the pathologic basis for the radiographic findings.

CRNA (certified registered nurse anesthetist) manpower forecasts: 1990-2010.

The delivery of anesthesia services is at a crossroads in the United States. In 1967, there were two certified registered nurse anesthetists (CRNAs) for every anesthesiologist providing anesthetics, and the numbers are nearly equal today. A CRNA manpower forecasting model is developed in this article that shows CRNA supply and requirements from 1990 through 2010. Two estimates of CRNA shortage are presented, one based on the current trend of anesthesiologists replacing CRNAs and another assuming that CRNAs are involved in every anesthetic under anesthesiologist supervision. The results imply that more than a twofold increase in CRNA school enrollments is needed just to fill conservative baseline needs given the predicted growth in operations in all settings. Limiting anesthesiologists to a supervisory role, at the other extreme, would require a doubling of CRNAs by 2010 and an even greater expansion of CRNA schools. However, it is estimated that reversing CRNA manpower trends could save society between $750 million and $1.2 billion annually.

MR imaging of skeletal muscle metastases.

OBJECTIVE: The purpose of this article is to describe the MR imaging appearance of skeletal muscle metastases. CONCLUSION: Skeletal muscle metastasis must be considered in patients with a known primary carcinoma who present with a painful muscle mass. Muscle metastasis may be the initial presentation of carcinoma. The MR imaging appearance, although not specific, may provide clues to the diagnosis.

Cystic hygroma of the arm: a case report and review of the literature.

Cystic hygromas arising outside of the cervicofacial, thoracic, and abdominal areas are extremely rare. Detailed descriptions of this lesions along with its MRI findings, in the extremities are lacking in the literature. The following case report describes such a lesion occurring in the arm.

Potential cost savings of MR imaging obtained before arthroscopy of the knee: evaluation of 50 consecutive patients.

OBJECTIVE: We attempted to determine the potential cost savings of prearthroscopic knee MR imaging examinations. SUBJECTS AND METHODS: This prospective study involved 50 consecutive patients. The patients met the surgical-indications-for-monitoring-appropriateness criteria for knee arthroscopy and underwent MR imaging of the knee before arthroscopy. For all patients, we compared MR imaging and arthroscopic findings. On the basis of a cost of $1000 for each MR imaging examination and $4000 for each diagnostic arthroscopy, we decided that cost-effective MR imaging would require 25% true negativity. RESULTS: The respective sensitivities and specificities of MR imaging of the knee were 100% and 90% for revealing anterior cruciate ligament interruption, 100% and 84% for revealing posterior cruciate ligament tears, 90% and 97% for revealing medial meniscal tears, 60% and 100% for revealing lateral meniscal tears, and 94% and 93% for revealing composite injury (one or more of these abnormalities). With MR imaging examinations obtained before surgery, we found 21 (42%) of 50 arthroscopies to be unnecessary. CONCLUSION: Despite stringent clinical criteria used in selecting patients for arthroscopy, 42% of our patients could have been spared surgery on the basis of the anatomy revealed by MR imaging. Our study indicates that MR imaging obtained before arthroscopy of the knee can produce a savings of as much as $680 per MR imaging examination performed on the knee.

Intraligamentous ganglion cysts of the anterior cruciate ligament: MR findings with clinical and arthroscopic correlations.

OBJECTIVE: Magnetic resonance findings with clinical and arthroscopic correlation of intraligamentous cysts of the anterior cruciate ligament (ACL) are presented. MATERIALS AND METHODS: Three cases of intraligamentous cysts of the ACL were identified out of 681 knee MRI examinations over a 2-year period. Arthroscopy and postoperative MRI were performed in all three patients, each of whom experienced knee pain with extreme flexion and extension. RESULTS: In all three cases the intraligamentous cyst was homogeneously hypointense on T1-weighted imaging and hyperintense on T2-weighted imaging relative to the ACL. Two of the three ACL cysts required a 70 degrees scope for adequate visualization and establishment of posteromedial and posterolateral portals for arthroscopic treatment. One cyst could not be visualized arthroscopically and probing of the ACL from the anterior portal resulted in drainage of the cyst. No patient had presence of ACL cyst on follow-up MRI or recurrence of symptoms at a mean of 24 months. CONCLUSION: Intraligamentous cyst of ACL is a rare cause of knee pain. It should be suspected in patients having chronic pain with extremes of motion. Magnetic resonance findings are diagnostic and help to guide arthroscopy.