Location, Clinical Presentation, Diagnostic Algorithm and Open vs. Arthroscopic Surgery of Knee Synovial Haemangioma: A Report of Four Cases and a Literature Review

Objective: The aim was to report 4 patients with intra-articular knee synovial haemangioma (KSH) and to perform a systematic review to describe the patient characteristics, patterns of tumor location, clinical presentation, usefulness of imaging examinations, pros and cons of arthroscopic vs. open resection, and follow-up in the literature.Design: From 1996 to 2016, four patients with KSH were retrospectively reviewed. A literature search was conducted in PubMed from 2000/01 to 2020/06 using the search terms “synovial haemangioma” and “knee.” Fifty full-text articles that included a total of 92 patients were included for further discussion.Results: Four adults (20–40 years) were diagnosed with KSH. Three lesions located in the suprapatellar pouch, two eroding the patella and one the supratrochlear bone, and one in the posterior compartment. Persistent anterior knee pain was the main complain. MRI revealed a benign tumor mass in all cases except one. Open excisional biopsy and regional synovectomy were performed in three patients, and by arthroscopy of the posterior compartment in the fourth. Histological type was arteriovenous in three cases and capillary in one. A pain-free knee without recurrence was achieve in all cases except one, which was successfully reoperated. Average follow-up time was 3.5 years. A literature review showed that KSH appears most frequently in children and teenagers (64.6%) and does not differ by gender. The suprapatellar and patella-femoral joint compartment was the most frequent location (47.9%). The bony tissue of the knee was rarely affected (13.5%). Pain, swelling and haemarthrosis were frequently reported (88.2, 66.7, and 47.1%). MRI was the most commonly used imaging test (98%). Treatment consisted of regional synovectomy by open surgery or arthroscopy in 66.7 and 15.6% of cases, respectively.Conclusions: KSH should be considered in the differential diagnosis of adult patients with chronic low-intensity knee pain. MRI is the most useful exam because it establishes the location, extent and benign characteristics of the tumor. Definitive diagnosis requires histological examination. We believe excisional biopsy and regional synovectomy by arthroscopy should be the treatments of choice for intra-articular tumors, but we recommend open surgery when the lesion extends to the tendons, muscle or bone.

Transportal versus all-inside techniques of anterior cruciate ligament reconstruction: a systematic review

Background Transportal (TP) and all-inside techniques (AIT) are the most commonly used anterior cruciate ligament (ACL) reconstruction procedures in current clinical practice. However, there is an ongoing debate over which procedure is superior. Therefore, the purpose of this systematic review was to evaluate and compare the clinical outcomes and complications of these two techniques to propose recommendations for future application. Our primary hypothesis was that AIT is a superior ACLR technique compared to TP. Methods A systematic literature review, using PRISMA guidelines, was conducted using PubMed, Medline, Google Scholar, and EMBASE, up to February 2021 to identify studies focusing on AIT and TP techniques of ACL reconstruction. We excluded animal experiments, cadaveric studies, retrospective studies, case reports, technical notes, and studies without quantitative data. Patients’ characteristics, surgical technical features, along with postoperative follow-up and complications were extracted and reported accordingly. Methodological quality of the included studies was assessed using the Modified Coleman Methodology Score (MCMS). Results A total of 44 studies were selected for this review, of which four were comparative studies. A total of 923 patients underwent AIT and 1678 patients underwent the TP technique for ACLR. A single semitendinosus graft was commonly used in the AIT compard to combined semitendinosus and gracilis graft in the TP group. The postoperative increase in International Knee Documentation Committee (IKDC), Lysholm, KT-1000, and Short Form-12 (physical and mental) scores were similar in the AIT group and the TP group. Contrastingly, the VAS pain score was significantly lower in the AIT group compared to the TP group. Furthermore, the pooled complication rates from all studies were similar between the two groups (AIT: 54 patients, 8.26% vs. PT: 55 patients, 6.62%). However, the four studies that prospectively compared AIT and TP techniques showed lesser complications in the AIT group than the TP group. Conclusion Since the future trend in orthopedic surgery is toward less invasive and patients’ satisfaction with good outcomes, AIT is a good alternative method considering preserving bony tissue and gracilis tendon with less post-operative pain, along with more knee flexor strength and equal outcomes compared to conventional ACL reconstruction surgery. Level of Evidence II.

The Granule Size Mediates the In Vivo Foreign Body Response and the Integration Behavior of Bone Substitutes

The physicochemical properties of synthetically produced bone substitute materials (BSM) have a major impact on biocompatibility. This affects bony tissue integration, osteoconduction, as well as the degradation pattern and the correlated inflammatory tissue responses including macrophages and multinucleated giant cells (MNGCs). Thus, influencing factors such as size, special surface morphologies, porosity, and interconnectivity have been the subject of extensive research. In the present publication, the influence of the granule size of three identically manufactured bone substitute granules based on the technology of hydroxyapatite (HA)-forming calcium phosphate cements were investigated, which includes the inflammatory response in the surrounding tissue and especially the induction of MNGCs (as a parameter of the material degradation). For the in vivo study, granules of three different size ranges (small = 0.355–0.5 mm; medium = 0.5–1 mm; big = 1–2 mm) were implanted in the subcutaneous connective tissue of 45 male BALB/c mice. At 10, 30, and 60 days post implantationem, the materials were explanted and histologically processed. The defect areas were initially examined histopathologically. Furthermore, pro- and anti-inflammatory macrophages were quantified histomorphometrically after their immunohistochemical detection. The number of MNGCs was quantified as well using a histomorphometrical approach. The results showed a granule size-dependent integration behavior. The surrounding granulation tissue has passivated in the groups of the two bigger granules at 60 days post implantationem including a fibrotic encapsulation, while a granulation tissue was still present in the group of the small granules indicating an ongoing cell-based degradation process. The histomorphometrical analysis showed that the number of proinflammatory macrophages was significantly increased in the small granules at 60 days post implantationem. Similarly, a significant increase of MNGCs was detected in this group at 30 and 60 days post implantationem. Based on these data, it can be concluded that the integration and/or degradation behavior of synthetic bone substitutes can be influenced by granule size.

A histological survey of avian post-natal skeletal ontogeny

Bone histology of crown-group birds is a research topic of great interest, permitting insight into the evolution of remarkably high growth rates in this clade and variation across the altricial-precocial spectrum. In this study, we describe microanatomical characteristics of the humerus and femur in partial growth series from 14 crown group birds representing ten major clades (Struthioniformes, Galliformes, Apodiformes, Columbiformes, Charadriiformes, Accipitriformes, Strigiformes, Psittaciformes, Falconiformes, and Passeriformes). Our goals were to: (1) describe the microanatomy of each individual; (2) make inter-and intra-taxonomic comparisons; (3) assess patterns that correspond with developmental mode; and (4) to further parse out phylogenetic, developmental, and functional constraints on avian osteological development. Across taxa, the femoral and humeral tissue of neonates can be broadly characterized as highly-vascularized, disorganized woven bone with great variation in cortical thickness (inter-and intrataxonomically, within an individual specimen, and within a single section). The tissue of precocial chicks is relatively more mature at hatching than in altricial, but other categories along the developmental spectrum were less easy to distinguish, thus we were unable to identify a definitive histological proxy for developmental mode. We did not find evidence to support hypotheses that precocial chicks exclusively have thicker cortices and more mature bone in the femur than the humerus at time of hatching; instead, this is a characteristic of nearly all taxa (regardless of developmental mode), suggesting deep evolutionary origins and the effects of developmental channeling. Bone tissue in adults exhibited unexpected variation, corresponding to differences in body size. Large-bodied birds have cortices of fibrolamellar bone, but organization of tissue increases and vascularity decreases with diminishing body size. The outer circumferential layer (OCL) also appears at earlier growth stages in small-bodied taxa. Thus, while the OCL is indicative of a cessation of appositional growth it is not always indicative of cortical maturity (that is, maximum organization of bony tissue for a given taxon). Small size is achieved by truncating the period of fast growth; manipulation of the timing of offset of bone growth is therefore an important factor in changing growth trajectories to alter adult body size.

The Effect of Injection of Saline Adrenaline (1/100000) 15ml versus 5ml on the Skin Edema and Thickness in Rhinoplasty Intraoperative

Background Nasal skin edema is a common result of soft and bony tissue trauma during rhinoplastic procedures. In a cosmetic surgery like rhinoplasty, skin edema can fade the cosmetic results and can lead to dissatisfaction for both the surgeon and the patient. Local saline /adrenaline injection is claimed to reduce the nasal skin edema intraoperative. Aim of the work To assess effect of injection of saline adrenaline (1/100000) 15ml versus 5ml on the skin oedema and thickness during rhinoplasty through thesis study. Subjects and Methods In this study 30 cases of rhinoplasty will be operated, 15 cases will be injected by saline adrenaline (1/100000) of 5ml and the others 15 cases will be injected by saline adrenaline (1/100000) of 15 ml, then measuring the skin oedema after 10 minutes of saline adrenaline (1/100000) injection, after 30 minutes and after 60 minutes of the injection at three sites; the dorsum, supratip and the tip of the nose by Seal Gouge Caliper (surgical caliber). Results the intraoperative skin edema was significantly decreased with local injection of large amount (15ml) of saline /adrenaline 1/100000 than the usual injected amount (5ml) saline /adrenaline 1/100000 specially at the tip and the supratip of the nose and specially at 30 min and 60 min after injection, but statistically significance difference only at 60min at the dorsum. Conclusion that the skin oedema much less with injection of 15ml of saline adrenaline (1/100000) in comparison to injection of 5ml of saline adrenaline (1/100000).

Ultrasound imaging features of bronchial anthracofibrosis

Purpose To determine the ultrasound imaging characteristics of participants with bronchial anthracofibrosis (BAF) and identify clinical markers for prevention and treatment. Methods We randomly selected 1,243 participants (including 113 with BAF) who underwent bronchoscopy and treatment at our institution from April 2018 to October 2019. BAF was classified as flat, deep seated retracted, or mucosal protrusion type, based on microscopy. Ultrasound probes were used to determine the maximum thickness of the tube wall and submucosa. The average values of the submucosal and bony tissue areas of the BAF subtypes were compared. Results The BAF group included 13 participants with a history of tuberculosis (11.5%) and 57 with biofuel exposure (50.4%). The average exposure time was 17.4 ± 6.2 years; BAF accounted for 10% of bronchoscopies performed. The maximum tube-wall thicknesses of the deep-seated retracted (17.3 ± 5.7) and black protruding (19.3 ± 5.4) groups were significantly greater than that of the flat group (12.5 ± 5.0; P < 0.05). The maximum thicknesses of the submucosa in the deep-retracted (9.8 ± 3.0) and black protruding (14.5 ± 5.0) groups were significantly greater than that of the flat group (6.6 ± 3.5; P < 0.05). The ratios of bone tissue in the flat and black protruding groups were 33.3 ± 9.3% and 34.9 ± 12.1%, respectively; the ratio in the deep-seated retracted group (65.2 ± 8.7%) was significantly reduced (P < 0.05). The flat type showed no significant change (P > 0.05). Conclusion Differences in BAF airway remodeling among the different subtypes may lead to varying clinical symptoms. Analyzing the characteristics of BAF airway remodeling and the regulatory pathway may provide new clues for treatment.

Non-destructive Chemical Imaging of Bone Tissue for Intraoperative and Diagnostic Applications

Bone is difficult to image using traditional histopathological methods, leading to challenges in intraoperative consultations needed in orthopedic oncology. However, intraoperative pathological evaluation is critical in guiding surgical treatment. In this study, we demonstrate that a multimodal imaging approach that combines stimulated Raman scattering (SRS) microscopy, two-photon fluorescence (TPF) microscopy, and second harmonic generation (SHG) microscopy can provide useful diagnostic information regarding intact bone tissue fragments from surgical excision or biopsy specimens. We imaged bone samples from 14 patient cases and performed comprehensive chemical and morphological analyses of both mineral and organic components of bone. Our main findings show that carbonate content combined with morphometric analysis of bone organic matrix can separate several major classes of bone cancer associated diagnostic categories with an average accuracy of 92%. This proof-of-principle study demonstrate that multimodal imaging and machine learning-based analysis of bony tissue can provide crucial diagnostic information for guiding clinical decisions in orthopedic oncology.

Effect of Preoperative Single Dose Dexamethasone Injection in Masseter Muscle on Postoperative Sequelae Following Lower Impacted Third Molar Surgery

Introduction: The surgical removal of impacted lower third molars involves trauma to soft and bony tissue and can result in pain, swelling and trismus. The purpose of this study was to evaluate the efficacy of dexamethasone, as a single 4 mg dose injected into the masseter muscle prior to extraction of impacted lower third molars on theses postoperative sequelae. Materials & Methods: This prospective, randomized clinical research consisted of 43 healthy patients. The study group received 4 mg dexamethasone into the masseter muscle via intrabuccal approach immediately before starting the procedure while the control group received no corticoid. 7 days after surgery. Data were analyzed using t-test (α = 0.05). Results: The patients administered dexamethasone showed superior results after surgery in terms of oral aperture, pain and all the facial swelling parameters, with statistically significant differences versus the controls (p value<0.001). Also there was statistically significant difference in terms of patients trismus between case and controlgroups (p value<0.001). Conclusion: The results obtained showed that 4 mg of dexamethasone injected into the masseter muscle in the immediately before starting the procedure significantly reduces swelling, trism us and pain.

Proteus syndrome: Rare cause of life-threatening haematuria

Proteus syndrome is an extremely rare sporadic hamartomatous condition characterized by random overgrowth of connective, epidermal and bony tissue. Involvement of the genitourinary system in PS is extremely rare and if present, are usually caused by enlarging cysts or neoplasms. Infrequent reports of testicular, renal and bladder involvement have been reported. The involvement of the bladder is predominantly due to vascular malformations with only three previous cases reported in literature. We report the fourth case – one of a 14-year-old male with known Proteus syndrome that presented to the emergency unit with life threatening haematuria. He appeared acutely ill in haemorrhagic shock with a haemoglobin of 4.3 g/dL on index presentation. Initial acute management involved aggressive resuscitation of the patient with intravenous fluids and blood transfusion. Cystoscopy revealed an actively-bleeding extensive venous anomalies of the bladder wall that were successfully-sealed with electrocautery.

Ultrasonic bone removal from the ossicular chain affects cochlear structure and function

Introduction Ultrasonic bone removal devices (UBD) are capable of cutting through bony tissue without injury to adjacent soft tissue. The feasibility and safety of using this technology for removal of bone from an intact ossicular chain (as might be required for otosclerosis or congenital fixation) was investigated in an animal model. Methods This was a prospective animal study conducted on seven anesthetised adult chinchillas. An UBD was used to remove bone from the malleus head in situ. Pre and post-operative distortion product otoacoustic emission (DPOAE) levels and auditory brainstem response (ABR) thresholds were recorded. Scanning electron microscopy (SEM) was used to assess cochlear haircell integrity. Results Precise removal of a small quantity of bone from the malleus head was achieved by a 30s application of UBD without disruption of the ossicular chain or tympanic membrane. DPOAEs became undetectable after the intervention with signal-to-noise ratios (SNR) < 5 dB SPL in all ears. Furthermore, ABR thresholds were elevated > 85 dB SPL in 13 ears. SEM showed significant disruption of structural integrity of the organ of Corti, specifically loss and damage of outer haircells. Conclusions Although UBD can be used to reshape an ossicle without middle ear injury, prolonged contact with the ossicular chain can cause structural and functional injury to the cochlea. Extensive cochlea pathology was found, but we did not investigate for recovery from any temporary threshold shift. In the authors’ opinion, further study should be undertaken before consideration is given to use of the device for release of ossicular fixation. Graphical abstract