elias pretorius. soft tissue mass of the hip 46 year old male patient : painless swelling in his...
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CASE PRESENTATIONElias Pretorius
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Soft tissue mass of the hip46 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 medicationRVD Non-reactive
No history of traumaNo Surgical history
Smoker, consumes moderate amounts of EtOH
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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
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Examination
Orthopedic Examination Normal gait Normal ROM right knee and hip joint Right leg NV intact
No other masses reported/found
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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
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Follow up
Pig tail - drainage – enlarged to full size again
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1. Inflammatory
2. Infective
3. Malignancy
Differential diagnosis?
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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
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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
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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
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Etiology
Any long-standing or large effusion of any cause
Three aetiological factors: Traumatic Degenerative
osteoarthrosis Inflammatory conditions
Rheumatoid arthritis Seronegative spondyloarthropathies Crystal deposition diseases
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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)
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Frequent sites: Knee (Popliteal fossa most common) Shoulder Wrist Fingers feet
Uncommon locations : Elbows Ankles Hips Apophyseal joints of the spine
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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
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Pathophysiology
Synovitis
Formation of reactive inflammatory fluid
Raised intra-articular pressure
Formation of synovial cysts constitutes an effective decompressive mechanism
Unilateral egress of fluid from the inflammed joint
Detrimental to synovial perfusion
May cause joint instability
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Pathophysiology
No communication with the hip joint
Hypertrophic/villous proliferation of bursal lining
Fluid overproduction
Isolated bursal enlargement
Bursitis
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77 year old male patient with a synovial cyst
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Adventitial cyst
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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)
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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
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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
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Ganglion cyst of the hip
Image of Ganglion
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Geodes / Subchondral cyst are juxta-articular bone cysts that lack a
true epithelial lining pseudocyst Synovial fluid forced into bone Association with DJD
Synovial Pseudocysts
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Imaging of Synovial Cysts
Plain Radiographs Non specific
Joint evaluation Site of lesion Underlying bone involvement Calcifications
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Imaging
Arthrography Cyst communication Filling of a soft tissue mass adjacent to
the supraacetabular bone Internal derangement of the joint
Labral tears Debris
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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
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Imaging
Computed Tomography scan Peri-articular Connection? Cystic characteristics No enhancement
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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
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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 ganglionsingle vs multiple punctures were compared = equal
Surgical removal – entire cyst should be removed including attachments to joint capsule and underlying ligaments -10% recur
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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
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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. Zhongguo Gu Shang A review of diagnosis and causes of synovial cyst of the hip joint 2010 Apr;23(4):271-4.
HW Bolhuis, Van der Werf 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