1 / 38

Case Presentation

Elias Pretorius. Case Presentation. Soft tissue mass of the hip. 46 year old male patient : Painless swelling in his right thigh Insidious onset Gradual enlargement over two years Painless not causing any functional impairment No significant medical history, no chronic medication

sunee
Download Presentation

Case Presentation

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Elias Pretorius Case Presentation

  2. Soft tissue mass of the hip 46 year old male patient : Painless swelling in his right thigh • Insidious onset • Gradual enlargement over two years • Painless • not causing any functional impairment No significant medical history, no chronic medication RVD Non-reactive No history of trauma No Surgical history Smoker, consumes moderate amounts of EtOH

  3. Examination Examined by the Orthopedic Surgeon : • Generally good condition • Normal systemic examination recorded MASS : • Obvious ovoid mass visible below the right buttock • Extending to postero-lateral thigh • 10x10cm • Soft • Fluctuant, movable • Non-tender • Non-pulsatile • No Inflammatory features

  4. Examination • Orthopedic Examination • Normal gait • Normal ROM right knee and hip joint • Right leg NV intact • No other masses reported/found

  5. Investigations • Bloods - normal • CXR • US • Well defined cystic mass containing echogenic material • No vascularity within • US guided Aspirate • Serous, straw colored material • Cytology: inconclusive • MCS: gram stain negative, culture negative(incl TB) • MRI right femur

  6. Follow up • Pig tail - drainage – enlarged to full size again

  7. Differential diagnosis? Inflammatory Infective Malignancy

  8. Excision Biopsy • Intra-op • Large cystic mass resected • filled with a cloudy yellowish fluid • Small communicating tractus with the right hip joint • Histology • Cystic structure lined by ulcerated synovium • Cyst wall comprised of fibroconnective tissue • No features of tuberculosis or malignancy Dx: Right thigh synovial cyst

  9. Synovial cysts (myxoid-, mucous cyst) • Peri-articular fluid collections • Leakage of joint fluid into the soft tissue • lined by synovial membrane • May or may not communicate with the adjacent joint • Common in the extremities

  10. The first published reports of a synovial cyst : 1840, Irish surgeon, Adams Recorded observations on synovial cysts resulting in the common eponym Baker cysts, for popliteal cysts : 1877, William Baker

  11. Etiology • Any long-standing or large effusion of any cause • Three aetiological factors: • Traumatic • Degenerative • osteoarthrosis • Inflammatory conditions • Rheumatoid arthritis • Seronegativespondyloarthropathies • Crystal deposition diseases

  12. Clinical features • Manifests as a peri-articular swelling • Any age / gender • Usually asymptomatic • Complications : • Pain or limitation of joint mobility • Compression of the neighbouring neurovasular structures • Acute rupture occur infrequently which may dissect into adjacent soft tissues • Secondary infection and abscess formation Colesante et al(2006)

  13. Frequent sites: • Knee (Popliteal fossa most common) • Shoulder • Wrist • Fingers • feet • Uncommon locations : • Elbows • Ankles • Hips • Apophyseal joints of the spine

  14. Synovial cyst of the hip • Extremely rare • Originates : • True articular synovial herniation without bursal involvement • may develop from bursal cavities • Ilioinguinal bursa (largest synovial bursa of the hip) • The presence of hip joint abnormalities favours a joint synovial cyst

  15. Pathophysiology • Detrimental to synovial perfusion • May cause joint instability

  16. Pathophysiology

  17. 77 year old male patient with a synovial cyst

  18. Adventitial cyst

  19. Adventitial cyst • Close proximity to synovial joint • Exact aetiology of formation remains unclear • Interesting theory: • Develops from synovial rests sequestrated in the vessel wall during development • Communication between the cyst and joint can be demonstrated (knee)

  20. Synovial Pseudocysts • Ganglion • Myxomatous degeneration of the fibrous tissue structures • Do not have a lining of synovial cells at histologic analysis • Adjacent to a tendon sheath or joint capsule • which contains mucoid fluid • Therefore, most ganglia are pseudocysts

  21. Exact aetiology unknown • Traumatic • Degenerative • Inflammatory • Around hip, associated with unusual/ various clinical presentations • Mimics : • Inguinal hernia • Pulsitile groin mass/ aneurysm • Lymphnodes / mets • Synovial Cysts

  22. Ganglion cyst of the hip • Image of Ganglion

  23. Synovial Pseudocysts • Geodes / Subchondral cyst • are juxta-articular bone cysts that lack a true epithelial lining • pseudocyst • Synovial fluid forced into bone • Association with DJD

  24. Imaging of Synovial Cysts • Plain Radiographs • Non specific • Joint evaluation • Site of lesion • Underlying bone involvement • Calcifications

  25. Imaging • Arthrography • Cyst communication • Filling of a soft tissue mass adjacent to the supraacetabular bone • Internal derangement of the joint • Labral tears • Debris

  26. Imaging • Ultrasound • As sensitive at arthrography for true synovial cysts • Considering the deep location of the hip, MRI is more effective than US in the assessment of synovial cysts

  27. Imaging • Computed Tomography scan • Peri-articular • Connection? • Cystic characteristics • No enhancement

  28. Imaging • MRI • Best imaging modality • Optimal delineation of the extent • Confirm the synovial nature of the cyst • Communication with the hip joint or an adjacent bursitis • Assessment of the associated causative disorder • Characteristics • intermediate signal intensity on T1WI • High signal intensity on T2WI • Ring enhancing synovial lining

  29. Soft tissue mass : synovial cyst • Treatment • May spontaneously disappear, thus expectant management is appropriate • When symptomatic • Aspiration and injection of steroids optimal aspiration occurs at the base of the ganglion single vs multiple punctures were compared = equal • Surgical removal – entire cyst should be removed including attachments to joint capsule and underlying ligaments -10% recur

  30. Conclusion • Synovial cysts of the hip is rare • Typically due to RA or DJD • May mimic different disorders and should be kept in mind in the differential diagnosis of unusual groin pain, radicular pain and peripheral vascular disorders

  31. References • Dr G van Staden, Orthopedic Surgeon – Kimberley Hospital Complex • D Patkar, J Shah, S Prasad Giant rheumatoid synovial cyst of the hip joint: diagnosed by MRI 1999 vol.45:issue 4: 118-119 • Wang LF, Xu SZ, Lin XJ. ZhongguoGu Shang A review of diagnosis and causes of synovial cyst of the hip joint 2010 Apr;23(4):271-4. • HW Bolhuis, Van derWerf TS, Tjabbes T Giant synovial cyst of the hip joint presenting with femoral vein compression Neth J Surg 1990 Jun;42(3)88-91 • Vo P, Wright T, Hayden F, Dell P Chidgey evaluating dorsal wrist pain: MRI diagnosis of occult dorsal wrist ganglion J Hand Surg Am. 1995;20(4):667 • UpToDate • Apley’s System of Orthopedics and fractures

More Related