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Imaging and histopathological evaluation of a cystlike formation in subchondral insufficiency fracture of the femoral head: A case report and literature review.

Fukui K, Kaneuji A, Fukushima M, Matsumoto T - Int J Surg Case Rep (2014)

Bottom Line: This case was a rare SIF of the femoral head which had a cystlike formation with a low signal intensity on T1-weighted images and a very high signal intensity on STIR sequences in the superolateral portion of the femoral head, surrounded by a pattern of edema in the bone marrow.To our knowledge, no similar cases were cited in the literature.It is important for surgeons to keep in mind that sometimes SIFs of the femoral head can appear as a round cystlike formation.

View Article: PubMed Central - PubMed

Affiliation: Department of Orthopaedic Surgery, Kanazawa Medical University, Kahokugun, Japan. Electronic address: 66406kf@kanazawa-med.ac.jp.

No MeSH data available.


Related in: MedlinePlus

(A) During surgery, the anterosuperior labrum was found to be inverted into the articular space (arrowheads). (B) After resection of the inverted labrum (asterisk) and (C) resection of the femoral head, it was apparent that only the area of the articular cartilage in contact with the inverted labrum was damaged (arrows). (D) Illustration indicating how the inverted labrum affect articular cartilage and subchondral bone.
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fig0025: (A) During surgery, the anterosuperior labrum was found to be inverted into the articular space (arrowheads). (B) After resection of the inverted labrum (asterisk) and (C) resection of the femoral head, it was apparent that only the area of the articular cartilage in contact with the inverted labrum was damaged (arrows). (D) Illustration indicating how the inverted labrum affect articular cartilage and subchondral bone.

Mentions: A 71-year-old-woman presented with a 1-month history of right hip pain without any history of antecedent trauma. She had no history of corticosteroid therapy or alcoholism. Her height was 150 cm, and at a weight of 51.0 kg and a body mass index of 22.7 kg/m2, she was not overweight.6 The range of motion in her right hip was 100° in flexion, 10° in extension, 30° in abduction, 20° in adduction, 20° in external rotation, and 0° in internal rotation. Her values on laboratory tests—C-reactive protein, lipid profile, liver and renal function, alkaline phosphatase, serum calcium and phosphorus, and clotting function—were all within normal ranges. Furthermore, findings were negative for rheumatoid factor and anticyclic citrullinated peptide antibodies. Her bone mineral density, measured by dual X-ray absorptiometry, was 0.739 g/cm2 (T score, −2.5) for her lumbar spine and 0.576 g/cm2 (T score, −2.1) for her right femoral head. Initial radiographs obtained 1 month after pain onset revealed mild acetabular dysplasia [center-edge angle,7 15°; inclination angle of the weight-bearing portion of the acetabulum,8 13°] and joint-space narrowing in the weight-bearing area (Fig. 1). There was no history of any corticosteroid intake. Also, No evidence of malignancy, infection or inflammatory diseases was noted. The patient was treated with an intra-articular injection (1.65 mg of dexamethasone sodium phosphate and 3 ml of 0.5% lidocaine) and instructed to take an anti-inflammatory drug (loxoprofen, 60 mg, three times daily). However those treatments only relieved her temporarily. At 2 months after the onset of hip pain, radiographs showed no significant changes since the initial radiographs (Fig. 2A). Computed tomography (CT) showed a cystlike formation in the superolateral portion of the femoral head, facing the acetabular rim (Fig. 2B). MRI showed a low signal intensity on T1-weight images and a very high signal intensity on the short τ inversion recovery (STIR) sequence of the superolateral portion of the femoral head, which was surrounded by a pattern of edema in the bone marrow. The edema pattern was found not only in the femoral head but also in the acetabulum facing the cystic lesion on the femoral head (Fig. 2C, D). Interestingly, although radiographs obtained just before surgery showed no remarkable changes (Fig. 3A), MRI performed at the same time showed that the edema pattern had been slightly alleviated compared with 1 month earlier (Fig. 3B, C). Three months after the onset of hip pain, we performed a total hip arthroplasty for the patient because of her persistent pain (Fig. 4). During surgery, we found an inverted labrum (Fig. 5A) with degenerative changes in the acetabular cartilage just beneath it (Fig. 5B). Similarly, there were degenerative changes of the femoral head cartilage on the superolateral portion, which corresponded to the area of the inverted labrum (Fig. 5C). A midcoronal cross-section showed a round, whitish gray mass of tissue under the cartilage (Fig. 6A). There was no well-demarcated, wedge-shaped, opaque yellow necrotic region, such as is seen in osteonecrosis.9 Microscopically, the whitish gray region consisted of fracture callus and granulation tissue (Fig. 6B), which corresponded to the round, low-intensity area on T1-weighted magnetic resonance images. Both edematous changes and vascular-rich granulation tissue were seen around this fractured lesion. There was no evidence of osteonecrosis characterized by zone formation (into separate areas of necrotic, reparative, and viable tissue) in any part of the femoral head. Also, detritic synovitis, as is found in rapidly destructive arthrosis (RDA) of the hip joint, was not seen. These histopathological findings confirmed the diagnosis of SIF. Surprisingly, subchondral bone just beneath the articular cartilage was intact despite the breakage of slightly distal trabeculae (Fig. 6B). Although the articular cartilage on the broken trabeculae had mild degenerative changes, it maintained continuity. Therefore, we found no articular cartilage fragments in the area surrounded by the round, low-intensity band that appeared on T1-weighted magnetic resonance images.


Imaging and histopathological evaluation of a cystlike formation in subchondral insufficiency fracture of the femoral head: A case report and literature review.

Fukui K, Kaneuji A, Fukushima M, Matsumoto T - Int J Surg Case Rep (2014)

(A) During surgery, the anterosuperior labrum was found to be inverted into the articular space (arrowheads). (B) After resection of the inverted labrum (asterisk) and (C) resection of the femoral head, it was apparent that only the area of the articular cartilage in contact with the inverted labrum was damaged (arrows). (D) Illustration indicating how the inverted labrum affect articular cartilage and subchondral bone.
© Copyright Policy - CC BY-NC-ND
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4066577&req=5

fig0025: (A) During surgery, the anterosuperior labrum was found to be inverted into the articular space (arrowheads). (B) After resection of the inverted labrum (asterisk) and (C) resection of the femoral head, it was apparent that only the area of the articular cartilage in contact with the inverted labrum was damaged (arrows). (D) Illustration indicating how the inverted labrum affect articular cartilage and subchondral bone.
Mentions: A 71-year-old-woman presented with a 1-month history of right hip pain without any history of antecedent trauma. She had no history of corticosteroid therapy or alcoholism. Her height was 150 cm, and at a weight of 51.0 kg and a body mass index of 22.7 kg/m2, she was not overweight.6 The range of motion in her right hip was 100° in flexion, 10° in extension, 30° in abduction, 20° in adduction, 20° in external rotation, and 0° in internal rotation. Her values on laboratory tests—C-reactive protein, lipid profile, liver and renal function, alkaline phosphatase, serum calcium and phosphorus, and clotting function—were all within normal ranges. Furthermore, findings were negative for rheumatoid factor and anticyclic citrullinated peptide antibodies. Her bone mineral density, measured by dual X-ray absorptiometry, was 0.739 g/cm2 (T score, −2.5) for her lumbar spine and 0.576 g/cm2 (T score, −2.1) for her right femoral head. Initial radiographs obtained 1 month after pain onset revealed mild acetabular dysplasia [center-edge angle,7 15°; inclination angle of the weight-bearing portion of the acetabulum,8 13°] and joint-space narrowing in the weight-bearing area (Fig. 1). There was no history of any corticosteroid intake. Also, No evidence of malignancy, infection or inflammatory diseases was noted. The patient was treated with an intra-articular injection (1.65 mg of dexamethasone sodium phosphate and 3 ml of 0.5% lidocaine) and instructed to take an anti-inflammatory drug (loxoprofen, 60 mg, three times daily). However those treatments only relieved her temporarily. At 2 months after the onset of hip pain, radiographs showed no significant changes since the initial radiographs (Fig. 2A). Computed tomography (CT) showed a cystlike formation in the superolateral portion of the femoral head, facing the acetabular rim (Fig. 2B). MRI showed a low signal intensity on T1-weight images and a very high signal intensity on the short τ inversion recovery (STIR) sequence of the superolateral portion of the femoral head, which was surrounded by a pattern of edema in the bone marrow. The edema pattern was found not only in the femoral head but also in the acetabulum facing the cystic lesion on the femoral head (Fig. 2C, D). Interestingly, although radiographs obtained just before surgery showed no remarkable changes (Fig. 3A), MRI performed at the same time showed that the edema pattern had been slightly alleviated compared with 1 month earlier (Fig. 3B, C). Three months after the onset of hip pain, we performed a total hip arthroplasty for the patient because of her persistent pain (Fig. 4). During surgery, we found an inverted labrum (Fig. 5A) with degenerative changes in the acetabular cartilage just beneath it (Fig. 5B). Similarly, there were degenerative changes of the femoral head cartilage on the superolateral portion, which corresponded to the area of the inverted labrum (Fig. 5C). A midcoronal cross-section showed a round, whitish gray mass of tissue under the cartilage (Fig. 6A). There was no well-demarcated, wedge-shaped, opaque yellow necrotic region, such as is seen in osteonecrosis.9 Microscopically, the whitish gray region consisted of fracture callus and granulation tissue (Fig. 6B), which corresponded to the round, low-intensity area on T1-weighted magnetic resonance images. Both edematous changes and vascular-rich granulation tissue were seen around this fractured lesion. There was no evidence of osteonecrosis characterized by zone formation (into separate areas of necrotic, reparative, and viable tissue) in any part of the femoral head. Also, detritic synovitis, as is found in rapidly destructive arthrosis (RDA) of the hip joint, was not seen. These histopathological findings confirmed the diagnosis of SIF. Surprisingly, subchondral bone just beneath the articular cartilage was intact despite the breakage of slightly distal trabeculae (Fig. 6B). Although the articular cartilage on the broken trabeculae had mild degenerative changes, it maintained continuity. Therefore, we found no articular cartilage fragments in the area surrounded by the round, low-intensity band that appeared on T1-weighted magnetic resonance images.

Bottom Line: This case was a rare SIF of the femoral head which had a cystlike formation with a low signal intensity on T1-weighted images and a very high signal intensity on STIR sequences in the superolateral portion of the femoral head, surrounded by a pattern of edema in the bone marrow.To our knowledge, no similar cases were cited in the literature.It is important for surgeons to keep in mind that sometimes SIFs of the femoral head can appear as a round cystlike formation.

View Article: PubMed Central - PubMed

Affiliation: Department of Orthopaedic Surgery, Kanazawa Medical University, Kahokugun, Japan. Electronic address: 66406kf@kanazawa-med.ac.jp.

No MeSH data available.


Related in: MedlinePlus