Large malignant granular cell tumor with suprascapular nerve and brachial plexus invasion: A case report and literature review

RATIONALE

Malignant granular cell tumor is a kind of rare and highly aggressive malignant tumor that commonly occurs in lower extremity, trunk, and peritoneal cavity. Huge malignant granular cell tumor (MGCT) with suprascapular nerve and brachial plexus invasion was extremely rare.

PATIENT CONCERNS

We present a special case of a 48-year-old orthopedist who suffered from MGCT. The orthopedist had regarded that he suffered from scapulohumeral periarthritis.

DIAGNOSES

The disease was noticed until a painless mass on his right neck was discovered 9 months later. MRI result confirmed a large occupying in axillary fossa, supraclavicular and infraclavicular region.

INTERVENTIONS

During the operation, a tumor measuring 22 × 13 × 6 cm with suprascapular nerve and brachial plexus invasion was identified. The tumor was fractional resected carefully to maintain the integrity of nerves and vessels. Lymph nodes were simultaneously resected.

OUTCOMES

The motor function and sensation of the upper extremity were same to that of preoperation. The postoperative histological diagnosis was MGCT. At a 12-month follow-up, there was no recurrence of the tumor showed by MRI.

LESSONS

This study presents a rare case of large MGCT with suprascapular nerve and brachial plexus invasion that was successfully managed by surgery.

Haemodynamically stimulated and in vivo generated axially vascularized soft-tissue free flaps for closure of complex defects: Evaluation in a small animal model

The arteriovenous (AV) loop model permits the creation of significant volumes of axially vascularized tissue that represents an alternative to conventional free flaps, circumventing their common limitations. However, such AV loop-based flaps have never before been examined in standardized animal models with respect to their suitability for reconstruction of critical bone-exposing defects. In the course of our preliminary studies, we implemented a novel defect model in rats that provides standardized and critical wound conditions and evaluated whether AV loop-generated flaps are suitable for free microsurgical transfer and closure of composite defects. We compared three groups of rodents with similar scapular defects: one received the AV flap, whereas controls were left to heal by secondary intention or with supplementary acellular matrix alone. To create the flaps, AV loops were placed into subcutaneous Teflon chambers filled with acellular matrix and transferred to the thigh region. Flap maturation was evaluated by histological analysis of angiogenesis and cell migration at days 14 and 28 after loop creation. Flap transfer to the scapular region and microsurgical anastomoses were performed after 14 days. Postoperative defect closure and perfusion were continually compared between groups. Within the AV flap chamber, the mean vessel number, cell count and the proportion of proliferating cells increased significantly over time. The novel defect model revealed that stable wound coverage with homogeneous vascular integration was achieved by AV loop-vascularized soft-tissue free flaps compared with controls. In summary, our study indicates for the first time that complex composite defects in rats can successfully be treated with AV loop-based free flaps.

Intrarater and interrater reliability of three classifications for scapular dyskinesis in athletes

Clinical evaluation of scapular dyskinesis (SD) aims to identify abnormal scapulothoracic movement, underlying causal factors, and the potential relationship with shoulder symptoms. The literature proposes different methods of dynamic clinical evaluation of SD, but improved reliability and agreement values are needed. The present study aimed to evaluate the intrarater and interrater agreement and reliability of three SD classifications: 1) 4-type classification, 2) Yes/No classification, and 3) scapular dyskinesis test (SDT). Seventy-five young athletes, including 45 men and 30 women, were evaluated. Raters evaluated the SD based on the three methods during one series of 8-10 cycles (at least eight and maximum of ten) of forward flexion and abduction with an external load under the observation of two raters trained to diagnose SD. The evaluation protocol was repeated after 3 h for intrarater analysis. The agreement percentage was calculated by dividing the observed agreement by the total number of observations. Reliability was calculated using Cohen Kappa coefficient, with a 95% confidence interval (CI), defined by Kappa coefficient ±1.96 multiplied by the measurement standard error. The interrater analyses showed an agreement percentage between 80% and 95.9% and an almost perfect reliability (k>0.81) for the three classification methods in all the test conditions, except the 4-type and SDT classification methods, which had substantial reliability (k<0.80) in shoulder abduction. Intrarater analyses showed agreement percentages between 80.7% and 89.3% and substantial reliability (0.67 to 0.81) for both raters in the three classifications. CIs ranged from moderate to almost perfect categories. This indicates that the three SD classification methods investigated in this study showed high reliability values for both intrarater and interrater evaluation throughout a protocol that provided SD evaluation training of raters and included several repetitions of arm movements with external load during a live assessment.

Glenohumeral and scapulothoracic strength impairments exists in patients with subacromial impingement, but these are not reflected in the shoulder pain and disability index

BACKGROUND

Pain and loss of function are cardinal symptoms associated with Subacromial impingement syndrome (SIS), while the presence and magnitude of deficits in strength and range of motion (ROM) are largely undescribed in non-athletic patients with SIS. Moreover, the relevance of impairments in strength and ROM to patient-reported shoulder function is not well described, even though testing of strength is recommended in clinical guidelines. The purpose of this study was, first, to investigate impairments in glenohumeral and scapulothoracic strength and in abduction and internal rotation ROM in patients with SIS. Secondly, to investigate the influence of these impairments on patient-reported shoulder function.

METHODS

Cross-sectional study based on a consecutive cohort of 157 patients referred to specialist examination and diagnosed with shoulder impingement (SIS) using predefined validated diagnostic criteria. Prior to specialist examination, questionnaires regarding shoulder function (Shoulder Pain And Disability Index, SPADI) demographics and kinesiophobia (TSK-11) were collected, and shoulder strength and ROM was measured by trained testers, with the patient reporting pain levels during testing and for the last week. Impairments in strength (abduction, external-rotation, (protraction and horizontal-extension) and ROM (abduction and internal rotation) were investigated in patients with unilateral shoulder pain, using one-sample t-tests. SPADI total score (SPADI) and SPADI function score (SPADI-F), were chosen as dependent variables in multiple regressions to investigate the influence of impairments on patient-reported shoulder function. Independent variables of interest were; strength in abduction and external rotation, abduction ROM, pain-during-tests, pain-last-week and kinesiophobia.

RESULTS

Significant impairments were found for all impairment tests, but most pronounced for glenohumeral strength and abduction ROM (29-33% deficits), and less for scapulothoracic strength and internal rotation ROM (8-18% deficits). Pain variables influenced SPADI and SPADI-F score to a high degree (R2 = 23.4-31.6%, p < 0.001), while strength and ROM did not.

CONCLUSION

Substantial strength and ROM impairments were found in patients with SIS. Only pain significantly influenced patient-reported function, while impairments did not. As SPADI score does not reflect the substantial strength and ROM impairments in external rotation and abduction observed in patients with SIS, supplemental assessment of these impairments seems important.

A Posterolateral Approach to the Scapula for Evacuation of a Subscapular Abscess: A Case Report

CASE

We present the case of a subscapular abscess that was drained via a posterolateral approach to the scapula. Complete evacuation of the abscess was achieved, and the incisions healed without difficulty. There were no immediate postoperative complications from this approach.

CONCLUSION

To our knowledge, a posterolateral approach for evacuating a subscapular abscess has not been described previously in the literature. Utilizing the internervous plane between the teres major and latissimus dorsi muscles, along with medial counterincisions, allows for safe drainage of this rare type of abscess.

Winging of the scapula diagnosed as Parsonage-Turner syndrome: a case report

A 24-year-old active duty female Soldier complained of right shoulder burning, stinging, electrical shock-like pain with radiation to the right hand after completing a ruck march. She also complained of swelling and feelings of her cold right hand. Examination showed a deficit in the deltoid, upper trapezius, supraspinatus, and also right winging of the scapula. She also exhibited weakness to right arm, weak right hand grip, and decreased sensation over the dorsal right hand. The right hand was also noticed to be colder to touch than the left one. She had tenderness to palpation over right paracervical muscles from C3 to C7. A previous magnetic resonance arthrogram of the right shoulder revealed no findings. The cervical magnetic resonance imagery showed mild disc protrusion at C5-C6 without spinal cord impingement. Based on the history and the physical findings, the patient was diagnosed with Parsonage-Turner syndrome.

Proximal-type epithelioid sarcoma: a new case report and literature review

Proximal-type epithelioid sarcoma is a rare soft tissue neoplasm which arises from the more proximal part of body and occurs more often in young people; the definite diagnosis depends mainly on the pathological examination; early detection and complete excision remain the foundation of treatment. Due to its aggressive behavior, high capacity of recurrence and the great ability to metastasize, a careful clinical long-term monitoring is required. We report a new case of a 20 years old girl, presented with proximal-type epithelioid sarcoma in her right scapular region, confirmed by pathological examination and removed surgically without recurrence or metastasis at eighteen months of follow-up.

A comparison of normal and osteoarthritic humeral head size and morphology

BACKGROUND

The purpose of this study was to evaluate and to compare the size and morphologic patterns among normal and osteoarthritic (OA) humeral heads.

METHODS

This comparative anatomic imaging study evaluated 150 humeral heads that were separated into 3 cohorts: normal, OA with symmetric glenoid erosion, and OA with asymmetric (type B2) glenoid erosion. Three-dimensional models were created of the humeral head from computed tomography data, and point coordinates were extracted for evaluation. Parameters measured were diameter (sphere fit and circle fit), chord distance (superoinferior and anteroposterior), and humeral head height.

RESULTS

The sphere-fit diameter of the humeral head for the entire OA cohort (100 patients; mean diameter, 59 ± 9 mm) was significantly greater (P < .001) than that of the normal cohort (50 patients; mean diameter, 49 ± 5 mm). Similarly, the humeral head circle-fit diameters in the superoinferior and anteroposterior planes were significantly greater (P < .001) in the combined OA cohorts (59 ± 9 mm and 56 ± 10 mm, respectively) compared with the normal cohort (51 ± 5 mm and 47 ± 5 mm, respectively). However, there were no significant differences (P ≥ .099) between the symmetric and asymmetric OA cohorts in sphere-fit or circle-fit diameters. The mean values of humeral head heights were not significantly different (P = .382) between cohorts, 19 ± 2 mm, 18 ± 2 mm, and 18 ± 2 mm for the normal, symmetric, and asymmetric cohorts, respectively.

DISCUSSION

Although OA humeral head morphology varies significantly from normal, it does not vary as a function of the Walch classification between symmetric and asymmetric glenoids. Understanding of the morphologic variability of the pathologic humeral head may provide insight into the pathoanatomy of osteoarthritis and the development of various erosion patterns.

The Reduction in Stability From Combined Humeral Head and Glenoid Bony Defects Is Influenced by Arm Position

BACKGROUND

Combined defects of the glenoid and humeral head are often a cause for recurrent shoulder instability.

PURPOSE/HYPOTHESIS

The aim of this study was to evaluate the influence of combined bony lesions on shoulder instability through varying glenohumeral positions. The hypothesis was that instability due to combined defects would be magnified with increasing abduction and external rotation.

STUDY DESIGN

Controlled laboratory study.

METHODS

Eighteen cadaveric shoulders were tested. Experiments were performed at combinations of glenohumeral abduction angles of 20°, 40°, and 60° and external rotations of 0°, 40°, and 80°. The various glenoid defect sizes created were 10%, 20%, and 30% of the glenoid width. Four humeral head defects were created based on humeral head diameter (6%, 19%, 31%, and 44%). Each experiment consisted of translating the glenoid in a posterior direction to simulate an anterior dislocation under a 50-N load. The instability was measured as a percentage of intact translation (ie, loss in translational distance normalized to the no-defect condition).

RESULTS

At 20° of abduction, instability increased from 100% to 85%, 70%, and 43% with increasing glenoid defect sizes of 10%, 20% and 30%, respectively, with a 6% humeral head defect. However, at a functional arm position of apprehension, these values were significantly decreased (P < .05) for humeral head defect sizes of 19%, 31%, and 44%, with translation values of 49%, 27%, and 2%, respectively.

CONCLUSION

A humeral defect leads to rotational instability with the arm rotated into a functional position rather than a resting position. However, a significant glenoid defect can lead to loss of translation independent of changes in arm position. Combined defects as large as 44% of humeral head and 20% glenoid did not show instability at 20° of abduction and neutral position; however, defects as small as 19% humeral defect and 10% glenoid defect led to significant instability in the position of apprehension.

CLINICAL RELEVANCE

Instability at lower levels of abduction and external rotation clinically indicates larger bony defects and may need to be directly addressed, depending on the patient's age and function.

Scapular Notching

Developed in 1985, the Grammont-style reverse total shoulder arthroplasty offered a biomechanical advantage for the deltoid muscle as well as predictably reduced pain and improved shoulder function in rotator cuff-deficient shoulders. Despite favorable outcomes, reverse total shoulder arthroplasty is associated with a unique set of complications, one of which is scapular notching. Scapular notching is believed to be a result of mechanical impingement of the humeral component on the lateral scapular pillar. Although it appears that scapular notching progresses with time, its effect on implant survivorship and clinical outcomes is unknown. Factors associated with scapular notching are categorized into several groups, including patient-specific risk factors, surgical approach and technique, and prosthetic design. Surgical strategies to reduce the rate of scapular notching include inferior positioning of the glenosphere, inferior tilting of the glenosphere, and increasing the size of the glenosphere. A lateralized center of rotation and a decreased humeral shaft-neck angle also decrease the incidence of scapular notching. As the indications for reverse total shoulder arthroplasty expand, it is important for orthopaedic surgeons to understand the etiology and incidence, predictive factors, and clinical relevance of scapular notching as well as strategies to avoid it.

[Myofascial meridional reflexotherapy of scapulohumeral periarthrosis in the course of the combined spa and health resort-based treatment]

The authors draw attention to the role of a whiplash injury in the pathogenesis of scapulohumeral periarthrosis (SHP). Peculiarities of the specific pathological biomechanical changes associated with this condition are described. The study included a group of 64 patients in whom the localization of the myofascial trigger points (MFTT) of the shortened muscles is described with reference to the differential techniques for soft-tissue manual therapy. Spatial emphasis is laid on the diagnostic dynamic ischemic compression of trigger points (TT) for their inactivation using the method proposed by J. Travel in the original modifications proposed by the authors of the present article. The results of the application of myofascial meridional reflexotherapy of scapulohumeral periarthrosis are presented and analysed in the context of the combined spa and health resort-based treatment.

Bilateral weighted radiographs are required for accurate classification of acromioclavicular separation: an observational study of 59 cases

INTRODUCTION

Misinterpretation of the Rockwood classification system for acromioclavicular joint (ACJ) separations has resulted in a trend towards using unilateral radiographs for grading. Further, the use of weighted views to 'unmask' a grade III injury has fallen out of favour. Recent evidence suggests that many radiographic grade III injuries represent only a partial injury to the stabilising ligaments. This study aimed to determine (1) whether accurate classification is possible on unilateral radiographs and (2) the efficacy of weighted bilateral radiographs in unmasking higher-grade injuries.

METHODS

Complete bilateral non-weighted and weighted sets of radiographs for patients presenting with an acromioclavicular separation over a 10-year period were analysed retrospectively, and they were graded I-VI according to Rockwood's criteria. Comparison was made between grading based on (1) a single antero-posterior (AP) view of the injured side, (2) bilateral non-weighted views and (3) bilateral weighted views. Radiographic measurements for cases that changed grade after weighted views were statistically compared to see if this could have been predicted beforehand.

RESULTS

Fifty-nine sets of radiographs on 59 patients (48 male, mean age of 33 years) were included. Compared with unilateral radiographs, non-weighted bilateral comparison films resulted in a grade change for 44 patients (74.5%). Twenty-eight of 56 patients initially graded as I, II or III were upgraded to grade V and two of three initial grade V patients were downgraded to grade III. The addition of a weighted view further upgraded 10 patients to grade V. No grade II injury was changed to grade III and no injury of any severity was downgraded by a weighted view. Grade III injuries upgraded on weighted views had a significantly greater baseline median percentage coracoclavicular distance increase than those that were not upgraded (80.7% vs. 55.4%, p=0.015). However, no cut-off point for this value could be identified to predict an upgrade.

CONCLUSIONS

The accurate classification of ACJ separation requires weighted bilateral comparative views. Attempts to predict grade on a single AP radiograph result in a gross underestimation of severity. The value of bilateral weighted views is to 'unmask' a grade V injury, and it is recommended as a first-line investigation.

Scapular Notching on Kinematic Simulated Range of Motion After Reverse Shoulder Arthroplasty Is Not the Result of Impingement in Adduction

Impingement after reverse shoulder arthroplasty (RSA) is believed to occur from repetitive contact in adduction between the humeral component and the inferior scapular pillar. The primary purpose of this biomechanical study was to confirm the presence of different types of impingement and to examine which daily-life movements are responsible for them. A secondary aim was to provide recommendations on the type of components that would best minimize notching and loss of range of motion (ROM). The study included 12 fresh frozen shoulder specimens; each had a computed tomography (CT) image of the entire scapula and humerus in order to acquire topological information of the bones before RSA implantation. Cyclic tests were run postimplantation with 3 shoulders in each modalities. To quantify bone loss due to impingement, 3-dimensional anatomical models of the scapula were reconstructed from the CT scans and compared to their intact states. We found 8 bony impingements in 7 specimens: 2 at the lateral acromion, 1 at the inferior acromion, 4 scapular notching, and 1 with the glenoid resulting to wear at the 3:00 to 6:00 clock-face position. Impingements occurred in all kinds of tested motions, except for the internal/external rotation at 90° of abduction. The 3 specimens tested in abduction/adduction presented bone loss on the acromion side only. Scapular notching was noted in flexion/extension and in internal/external rotation at 0° of abduction. The humeral polyethylene liner was worn in 2 specimens--1 at the 6:00 to 8:00 clock-face position during internal/external rotation at 0° of abduction and 1 at the 4:00 clock-face position during flexion/extension. The present study revealed that 2 types of impingement interactions coexist and correspond to a frank abutment or lead to a scapular notching (friction-type impingement). Scapular notching seems to be caused by more movements or combination of movements than previously considered, and in particular by movements of flexion/extension and internal/external rotation with the arm at the side. Polyethylene cups with a notch between 3 and 9 o'clock and lower neck-shaft angle (145° or 135°) may play an important role in postoperative ROM limiting scapular notching.

Osteochondroma With Contiguous Bronchogenic Cyst of the Scapula

Osteochondroma is a benign bone tumor composed of a bony protrusion with an overlying cartilage cap. Osteochondromas arise in the scapula in 3% to 5% of cases, making them the most common benign bone tumor in this location. Scapular osteochondromas cause various pathologies of the shoulder girdle, including snapping scapula syndrome, chest wall deformity, shoulder impingement, and bursa formation. Bronchogenic cyst is an exceedingly rare finding in the periscapular area. It is a congenital cystic mass lined by tracheobronchial structures and respiratory epithelium. To our knowledge, there are no reports of a contiguous osteochondroma and bronchogenic cyst. A 12-month-old boy presented with an incidentally noted mass on the spine of the scapula, which drained scant, clear fluid through an adjacent pinprick-sized hole. Imaging revealed an exostosis with an adjacent cystic mass. The mass and cyst were excised en bloc, and histopathologic examination confirmed the diagnosis of osteochondroma with contiguous bronchogenic cyst. In this case, we present the report of a novel dual lesion.

A primary inflammatory myofibroblastic tumor of the scapula in a child: imaging findings

Inflammatory myofibroblastic tumor (IMT) is an uncommon tumor characterized by inflammatory cell infiltration and differentiated myofibroblastic spindle cells. IMT was first described in the lung and retroperitoneum. Occurrence in bone has been well described in the maxilla and occasionally in the long bones in the adult population. We present a unique case of IMT arising primarily from the scapula in an 8-year-old patient, not described previously in the pediatric or adult literature. Imaging demonstrated an ill-defined and aggressive osteolytic lesion with cortical bone destruction associated with an important soft tissue component that extended into the adjacent muscles. Histologically, the tumor was composed of spindle and polygonal cells distributed in an inflammatory background with different proportions of plasma cells, lymphocytes, eosinophils and neutrophils. The absence of cellular atypia helped to differentiate this entity from malignant spindle cell tumors, and imaging could differentiate the tumor from the nontumoral inflammatory reaction.

New parameters describing morphological variations in the suprascapular notch region as potential predictors of suprascapular nerve entrapment

BACKGROUND

The suprascapular notch (SSN), bridged by the superior transverse scapular ligament (STSL), creates a pathway for the suprascapular nerve (SN). Morphological variations in the SSN region are common and can increase the risk of neuropathy by constricting the space for the nerve. The aim of this study was to establish new objective parameters that take this complex morphology into account.

METHODS

The SSN region of 100 formalin-fixed cadaveric shoulders was dissected. The dimensions of the SSN, the STSL and the anterior coracoscapular ligament (ACSL), as well as diameters of the SN, associated vessels and SN passage area, were measured by means of quantitative visual data analysis software to assign those structures to present classifications. The area reduction coefficient (ARC) and the ambit occupation coefficient (AOC) were defined and calculated for each shoulder.

RESULTS

The mean ARC and AOC for ligaments in the suprascapular region were: ARCSTSL = 71.6%, ARCACSL = 9.6%, AOCSTSL = 56.8% and AOCACSL = 9.1%. The SN passage area, ARC and AOC did not differ significantly between SSN types. The SN passage area and ARC differed significantly between band- and fan-shaped types of STSL. A significant relationship was observed between ARC and AOC (R=0.6855; p<0.0001). The SN passage area correlated significantly with ARC (R=-0.7555; p<0.0001) and AOC (R=-0.5609; p<0.0001).

CONCLUSIONS

The proposed parameters convey the complex morphology of the SSN region in a quantitative manner. The area reduction coefficient seems to be a more relevant indicator than the AOC as it better correlates with the SN passage area. Contrary to the SSN type, the STSL type significantly influences SN passage area and ARC.

Comparison of two different measurement methods to determine glenoid bone defects: area or width?

BACKGROUND

This study compared two different techniques that have been used to measure the glenoids of patients with recurrent anterior shoulder dislocation.

METHODS

We analyzed 36 patients who had received arthroscopic Bankart repair for anterior shoulder instability. Retrospectively, 3-dimensional computed tomography images of both shoulders were available for these patients. Two measurement methods were compared to determine the glenoid defects. One of these techniques is based on linear measurement, previously defined as the glenoid index. The other method is based on surface area measurement. Subsequently, 3 more diameters and the average values obtained from these diameters were compared with the surface measurement method. Pearson correlation coefficient (r) was assessed to determine the relationship.

RESULTS

There was an almost perfect relationship between measurement methods when the defect area was less than 6% of the inferior glenoid circle (r, 0.915; P < .001). This relation decreased and the difference became more pronounced (r, 0.343; P = .657) when the bone loss exceeded 14% of the inferior glenoid circle. The highest correlations with the actual defects were the average values obtained from 4 different diameters (r, 0.964; P < .001) and the 4-o'clock position of the single diameter measurements (r, 0.860; P = .001). In addition, 11 patients had crescent-like defects, demonstrating a relatively low correlation between the measurement methods (r, 0.679; P = .021).

CONCLUSION

Although the best correlation was achieved from average values obtained from different diameter positions, in practical use, we advise a linear measurement to estimate the glenoid bone loss at the 4-o'clock position to achieve a high correlation between the measurement techniques.

Malawer limb salvage surgery for the treatment of scapular chondrosarcoma

Chondrosarcoma is a common malignant bone tumor, which accounts for 20% of all malignant bone tumors. It often occurs in the long bones, but the incidence of scapular chondrosarcoma is rare. Here, we describe a case of a large chondrosarcoma occurring in the scapula which was treated with Malawer limb salvage surgery. The patient retained considerable limb function after complete removal of the tumor tissue as assessed at the follow-up visit two years and ten months following surgery.

[Discussion on relationship between soft tissue tension and cervical physiological curvature change of patients with scapular muscle fasciitis]

OBJECTIVE

To discuss the relative association of soft tissue tension and cervical physiological curvature chang in patients with scapula muscle fasciitis.

METHODS

From February 2012 to December 2012,29 patients with scapula muscle fasciitis were investigated. There were 10 males and 19 females with an average age of 27.77 years old (ranged from 22 to 40 years old). Routine AP and lateral cervical X-rays were done in all patients. Cervical lordosis was measured according to Borden's method and the pain point tension was measured by soft tissue tension meter. Finally,perform statistic analysis to bove data.

RESULTS

Lateral X-rays showed 9 cases were normal cervical lordosis, 18 cases were cervical lordosis decreased, 2 cases were cervical lordosis increased. The regression equation of cerical lordosis changes D(Y) and soft tissue tension displacement D0.5 kg (X) was Y = -15.069 + 3.673X.

CONCLUSION

There is linear relationship between soft tissue tension and cervical physiological curvature change. With the soft tissue tension increases, the cervical lordosis trend to decrease.

Elastofibroma: management and surgical outcome

Elastofibroma is a benign slow-growing neoplasm of soft tissues, originally defined Elastofibroma dorsi because of the typical localization in the connective tissue placed between the bottom corner of the scapula and the chest wall. From 1990 to 2013 at our center, 115 patients underwent elestofibroma surgical removal, including 2 bilateral and one relapsed. For all the patients ultrasound preoperative examination was requested, sometimes with a diagnosis of lipoma or fibrolipoma because of the rarity of this type of lesion and therefore the lack of experience of the radiologists. In all 115 patients the lesion was detected and removed, only in 7 cases it was necessary, intraoperatively, to mobilize the upper limb and shoulder in order to better visualize the lesion. On the operating table the lesion was situated below the muscle planes and looks like a solid mass, oval, with a pole firmly attached to the periosteum of the ribs and intercostal ligaments, with net margins and a diameter of 5-10 cm. The sides not attached to the chest wall were in continuity with the adipose tissue. The cutting surface was pink-graysh, with fibrous appearance. Foci of cystic degeneration interspersed with islands of fat that are vaguely reminiscent of the fibrolipoma could be found. The treatment of choice is the surgical excision and subsequent histological examination solve the diagnostic dilemma. If the removal is radical, it is definitve because the lesion has no tendency to relapse.

[Primary study on tissue engineered periosteum osteogenesis to repair scapula defect in vivo in allogenic rabbit]

OBJECTIVE

To investigate the feasibility of tissue engineered periosteum (TEP) constructed by porcine small intestinal submucosa (SIS) and bone marrow mesenchymal stem cells (BMSCs) of rabbit to repair the large irregular bone defects in allogenic rabbits.

METHODS

The BMSCs were cultivated from the bone marrow of New Zealand white rabbits (aged, 2 weeks-1 month). SIS was fabricated by porcine proximal jejunum. The TEP constructed by SIS scaffold and BMSCs was prepared in vitro. Eighteen 6-month-old New Zealand white rabbits whose scapula was incompletely resected to establish one side large irregular bone defects (3 cm x 3 cm) model. The bone defects were repaired with TEP (experimental group, n = 9) and SIS (control group, n = 9), respectively. At 8 weeks after operation, the rabbits were sacrificed, and the implants were harvested. The general condition of the rabbits was observed; X-ray radiography and score according to Lane-Sandhu criteria, and histological examination (HE staining and Masson staining) were performed.

RESULTS

After operation, all animals had normal behavior and diet; the incision healed normally. The X-ray results showed new bone formation with normal bone density in the defect area of experimental group; but no bone formation was observed in control group. The X-ray score was 6.67 +/- 0.32 in experimental group and was 0.32 +/- 0.04 in control group, showing significant difference (t = 19.871, P = 0.001). The general observation of the specimens showed bone healing at both ends of the defect, and the defect was filled by new bone in experimental group; no new bone formed in the control group. The histological staining showed new bone tissue where there were a lot of new vessels and medullary cavity, and no macrophages or lymphocytes infiltration was observed in the defect area of experimental group; only some connective tissue was found in the control group.

CONCLUSION

TEP constructed by porcine SIS and BMSCs of rabbit can form new bone in allogenic rabbit and has the feasibility to repair the large irregular bone defects.

[On the possibility to reconstruct the initial position of the body of a victim from the configuration of wound canals in the scapular region]

The objective of the present study was to estimate the influence of the position of an upper extremity on the formation of wound canals resulting from the injury to the scapular region and the chest. The secondary objective was to substantiate the possibility of the detection of the position of the upper extremity at the time of wound infliction. A few series of experiments were carried out with the differently positioned upper extremities. They allowed to determine: 1) the degree of tissue displacement in the scapular and thoracic regions, 2) disjunctive (discontinuous) dislocation of the wound canal, and 3) the possibility to detect the relative position of the upper extremity at the time of wound infliction in the scapular region.

Epithelioid osteosarcoma of the scapula

Epithelioid and epithelial neoplasms of bone are rare. They include different epithelioid variants of vascular lesions, osteoblastoma, chondroblastoma and most importantly metastatic carcinoma. Up to now, only few cases of epithelioid osteosarcoma were described. In this case the authors report a 53-year-old patient presented with a medical history of chronic shoulder pain for 3 years. Magnetic resonance imaging (MRI and computed tomography (CT) showed a destructive, partially calcified osseous lesion of the scapula with expansion into the surrounding soft tissue, suggestive of a primary bone tumor. Histologically, the tumor consisted of epithelioid cells with expression of cytokeratine and the lesion was primarily diagnosed as metastatic carcinoma. With regard to the MRI morphology untypical for metastatic disease the histopathologic slides were re-evaluated and detection of tumor osteoid led to the diagnosis of epithelioid osteosarcoma. Chemotherapy was initiated, however follow-up imaging studies showed rapidly progressive disease of both primary tumor and lung metastases. In conclusion, epithelioid neoplasms of the bone are extremetumourly rare and must be distinguished from metastatic carcinoma. Despite the presence of cytokeratine positive cells a thorough histological evaluation is mandatory and osteoid detection is essential in order to establish the correct diagnosis and further treatment. Key words: osteosarcoma, epithelioid, aneurysmal bone cyst, chondrosarcoma, pathology, immunohistochemistry.