Dorsal exostosis of the scapula with unique localization (а clinical case)

IntroductionExostosis is a benign tumor of cartilaginous origin whose etiology is not fully understood. Some authors associate its appearance with a fracture of Solter and Harris, others with previous surgical interventions in the same place. There are scientific reports that link the formation with radiation therapy, as well as genetic causes—autosomal dominant inheritance or mutations. Most often, exostosis originates from the epiphyseal areas of the long tubular bones and is located near large joints. The localization of the exostosis in the scapula is extremely rare, between 3–4.6% according to various authors. In addition, the cases of dorsal and medially located scapular exostosis, such as the patient presented in this article, are almost casuistic. According to the available literature, the case has a unique localization for our country.Aim The aim of this article is to focus on an extremely rare exostosis localization.Patients and Methods The presented patient is a 14-year-old girl with dorso-medially located exostosis of the scapula.Results To date, eight years after the removal of the tumor, the patient is without complaints, without recurrence, with the left upper limb in excellent functional condition.Conclusion Although the exostosis of the scapula, especially its dorsal location, is an almost casuistic case, it should not be excluded from the differential diagnosis.        Dorsal exostosis of the scapula with unique localization(clinical case)Yavor GrigorovLozenets University Hospital - Sofia, Bulgaria Abstract Exostosis is a benign tumor of cartilaginous origin whose etiology is not fully understood. Some authors associate its appearance with a fracture of Solter and Harris, others with previous surgical interventions in the same place, there are scientific reports that link the formation with radiation therapy, as well as genetic causes - autosomal dominant inheritance or mutations. Most often, exostosis originates from the epiphyseal areas of the long tubular bones and is located near large joints. The localization of the exostosis in the scapula is extremely rare, between 3% - 4.6% according to various authors. In addition, the cases of dorsal and medially located scapular exostosis, such as the patient presented in this article, are almost casuistic. According to the available literature, the case has a unique localization for our country.The aim To pay attention to an extremely rare localization of Exostosis.Material and method The presented patient is a 14-year-old girl with dorso-medially located exostosis of the scapula.Results To date, eight years after the removal of the tumor, the patient is without complaints, without recurrence, with the left upper limb in excellent functional condition.Conclusion Although the exostosis of the scapula, especially its dorsal location, is an almost casuistic case, it should not be excluded from the differential diagnosis.Key words  benign tumor, exostosis, shoulder girdle, scapul

Successfully treated osteomyelitis with 20 years of evolution, covering the whole humerus (case report)

Infections affecting the humerus are a serious therapeutic challenge, especially when they are spread along the entire length of the humerus and have a long evolution. Their origin can be both hematogenous and exogenous. Unsuccessfully treated osteomyelitis of the humerus can be the cause of severe disability, intoxication and even lead to amputation. The aim: To pay attention to the difficulties associated with the treatment of a rare localization of osteomyelitis affecting the entire humerus. Material and methods: One patient is presented, a 63-year-old man who underwent multiple operations for osteomyelitis of the humerus about 20 years ago. Results: The early postoperative period went smoothly. The surgical wound healed primarily, the bone infection was completely repaired, and the right upper extremity is in good functional condition, with no evidence of circulatory or neurological problems. Conclusion: The presented patient is a clear example that the key to the successful treatment of osteomyelitis is the correct choice of the main method, namely the method providing full revascularization of the bone or the replacement of the affected bone segment with autoosteoplastic material.

Two Cases of Liposarcoma in the Thigh Area

The liposarcoma are not rare in the thigh area. Two patients both men, 56 and 39 years of age were operated within a few months because of giant liposarcoma in the left thigh region. The liposarcoma of these patients was strikingly similar. Upon suspicion of malignancy, resection of the tumor without prior diagnostic biopsy is recommended. The early postoperative period of both patients passed smoothly. The full range of movement was achieved in left hip and knee joints. Operative wounds healed per primam intentionem. Up till now, several months after tumors removal, both patients have no data of local or distant metastases.The liposarcoma are not rare in the thigh area. Two patients both men, 56 and 39 years of age were operated within a few months because of giant liposarcoma in the left thigh region. The liposarcoma of these patients was strikingly similar. Upon suspicion of malignancy, resection of the tumor without prior diagnostic biopsy is recommended. The early postoperative period of both patients passed smoothly. The full range of movement was achieved in left hip and knee joints. Operative wounds healed per primam intentionem. Up till now, several months after tumors removal, both patients have no data of local or distant metastases

Synovial lipomatosis of the foot - a unique location. Case report

IntroductionSynovial lipomatosis, also called lipoma arborescens, is an extremely rare chronic, benign disease. Less than 100 cases have been reported in the available literature. It is characterized by substitution of the sub-synovial connective tissue with mature fat cells and villous proliferation of the synovium. The etiology in most cases remains unknown, although some authors attribute it to trauma, degenerative changes in the joint, septic arthritis, psoriatic arthritis, chikungunya viral disease, etc. The most common locations of synovial lipomatosis are the knee, shoulder, elbow and bracelet, exceptionally affecting the hip and ankle joints, etc. Locations in the foot region are extremely rare. The patient described in this article has a unique location.AimThe aim of this article is to draw attention to a rare disease, with an even rarer localization.Materials and MethodsThe presented patient is a man at the age of 53 with synovial lipomatosis on the plantar side of the left foot.ResultsUp to this moment, three and a half years after the operation, the patient has no complaints and no recurrence data. The functional condition of the limb is excellent.ConclusionSynovial lipomatosis, especially that located in the foot area, is extremely rare, almost casuistic. However, it should not be excluded from the differential diagnosis

Giant thigh liposarcoma

IntroductionLiposarcoma is a heterogeneous group of adipocyte tumors in which cells differentiate into lipoblasts and lipocytes. Tumor localized in the extremities affects men more often. It rarely occurs before age 20. Diseases such as obesitas, gout, psoriasis, etc. seem to predispose to the development of this type of tumor. Lipomas (liposarcoma) are considered "giant", if they exceed 10 cm in one dimension or weigh at least 1000 grams. The thigh liposarcoma described in this article is the biggest reported in Bulgaria and one of the largest excised in the world practice.AimThe aim of this article is to draw attention to the difficulties associated with the surgical removal of a giant de-differentiated femoral liposarcoma, as well as the late metastases of such tumors.Patients and methodsThe patient presented is a 74-year-old male with a giant thigh liposarcoma weighing 7.65 kg, which has been subjected to an en bloc tumor excision.ResultsUp to now, a year and a half after surgery, no recurrence or metastases have been detected. The functional state of the limb is very good.ConclusionGiant thigh liposarcomas are a real surgical challenge. They are always located near the femoral vesels, engaging muscles and vessels, often growing proximal to lig. inguinale.IntroductionLiposarcoma is a heterogeneous group of adipocyte tumors in which cells differentiate into lipoblasts and lipocytes. Tumor localized in the extremities affects men more often. It rarely occurs before age 20. Diseases such as obesitas, gout, psoriasis, etc. seem to predispose to the development of this type of tumor. Lipomas (liposarcoma) are considered "giant", if they exceed 10 cm in one dimension or weigh at least 1000 grams. The thigh liposarcoma described in this article is the biggest reported in Bulgaria and one of the largest excised in the world practice.Aim The aim of this article is to draw attention to the difficulties associated with the surgical removal of a giant de-differentiated femoral liposarcoma, as well as the late metastases of such tumors.Patients and methods The patient presented is a 74-year-old male with a giant thigh liposarcoma weighing 7.65 kg, which has been subjected to an en bloc tumor excision.Results Up to now, a year and a half after surgery, no recurrence or metastases have been detected. The functional state of the limb is very good.Conclusion Giant thigh liposarcomas are a real surgical challenge. They are always located near the femoral vesels, engaging muscles and vessels, often growing proximal to lig. inguinale

Successfully treated osteomyelitis involving the entire ischium in a patient with lower-limb paraplegia (a case report)

Introduction: Pelvic bones, probably due to their anatomical features (deep location, good blood supply and other unknown reasons), are rarely affected by exogenous or hematogenous infections. Usually, the flora isolated from the infected pelvic bone is polymicrobial, with the most common microorganisms causing this type of infection being Staphylococcus aureus, Streptococcus, Pseudomonas aeruginosa. The ischial bone (os ischii) is the pelvic bone most often affected by infections, adjacent to deep IV degree decubitus wounds. These wounds are typical for patients with severe neurological symptoms—paraplegics or quadriplegics, as well as those with cerebral disorders, and the process may remain undiagnosed for a long time.Aim: The aim of this article is to focus on the difficulties associated with the early diagnosis of an infection affecting the entire ischial bone and the soft tissues of the adjacent pelvis, as well as the high risk to the patient if adequate treatment is not carried out.Patient and Methods: One patient, a 60-year-old man, with lower-limb paraplegia, after a spinal cord trauma dating back to 10 years ago, is presented.Results: After the applied treatment—resection, removal of the entire ischial bone, and soft tissue debridement, the surgical wound healed primarily, the bone and soft tissue infection of the pelvis was successfully managed. General intoxication of the body was prevented.Conclusion: Accurate and timely debridement, including the risky total excision of the os ischii, as well as the infected adjacent soft tissues in the pelvis, combined with appropriate drainage, may prove to be the only effective and life-saving procedure for the patient

Giant plexiform fibrohistiocytic tumor of the lower leg (a case report)

Introduction: The plexiform fibrohistiocytic tumor is rare, typical for children and adolescents, affects more often the female sex and is most often localized in the upper limb—the region of the wrist joint and the hand. The tumor originates from the subcutaneous adipose tissue, but it is possible to involve the dermis and skeletal muscle. It is characterized by slow growth and sizes between 0.5 and 8 cm, with minimal or no cellular atypism. Three histological varieties have been described: fibrohistiocytic, fibroblastic, and mixed type, which occur with almost equal frequency.Aim: The aim of this article is to present an extremely rare pathohistologically large tumor atypical for the patient’s gender, location and age, and address the surgical challenges of its removal.Patients and Methods: The presented patient is a 54-year-old man with a giant tumor formation involving the anteromedial part of the proximal lower leg, with evolution of over 25 years, and an accompanying disease—cerebral palsy.Result: After en bloc excision of the tumor formation, part of the surgical wound healed secondary. No recurrences were recorded.Conclusion: The pathohistological nature of the tumor is a prerequisite for a complete cure, but the removal of such giant soft tissue formations from the proximal and medial side of the lower leg is a real surgical challenge. The exposed large area of the tibia, with no soft tissue and periosteum, is difficult to cover by local skin plastic surgery, and at the same time it is extremely unsuitable for free plastic procedure

Subungual Squamous Cell Carcinoma Associated with Long Standing Onychomycosis: Aggressive Surgical Approach with a Favourable Outcome

BACKGROUND: Tumours of the nail bed are rare. Squamous cell carcinoma is the most frequent among them. Chronic infection, chemical or physical trauma/microtrauma, genetic disorders such as congenital ectodermal dysplasia, radiation, tar, arsenic or exposure to minerals, sun exposure, immunosuppression, and previous HPV infection have all been discussed as etiologic factors. The diagnosis is often delayed because of the variety of clinical manifestations, often resembling benign or common infectious processes. Rapidly growing ulcerative lesions should also be considered as potential malignancy. Furthermore, a lack of antifungal or antibacterial treatment response is the most indicative symptom, always requiring subungual biopsy. Early diagnosis is of great importance for therapeutic effectiveness.CASE PRESENTATION: We present a case of subungual squamous cell carcinoma, associated with long-lasting onychomycosis in a 76-year-old female patient, treated with amputation of the distal phalanx and the distal part of the proximal phalanx.CONCLUSION: Although there are no available data in the literature to confirm or reject the contribution of the chronic nail infection to the malignant process, we emphasise the importance of this co-existence regarding the possible disguising of the malignant process. An early biopsy of a chronic persistent nail lesion may be preventive and beneficial regarding avoiding more aggressive treatments and achieving a favourable prognosis

Subungual Exostosis in a Young Soccer Player

BACKGROUND: Subungual exostosis is a relatively uncommon, benign osteocartilaginous tumor of the distal phalanx of the toes or fingers in young adults, considered as a rare variant of osteochondroma. Differential diagnoses include subungual verruca (viral wart), pyogenic granuloma, osteochondroma, amelanotic subungual melanoma and glomus tumour. Misdiagnosis and total onychodystrophy frequently occur as a result of late treatment or inadequate treatment strategy. Dermoscopy could be a useful technique, involved in the diagnostic process, although X-ray examination and histopathology are mandatory for the diagnosis.CASE REPORT: We report a rare case of subungual exostosis of the great toe associated with repeated trauma of the nail bed. The lack of radiographic and histopathological examination could lead to misdiagnosis and inadequate treatment. Although completely benign, subungual exostosis should be considered in differential diagnosis of nail bed tumors in young adults, in order to avoid associated complications and unneeded aggressive surgical interventions.CONCLUSION: Complete excision of the lesion and delicate separation from the underlying nail bed structures results in total resolve of the problem, by providing the lowest risk of recurrences

Successful Craniotomy for Advanced Basal Cell Carcinomas with Cranial Bone Invasion and Dura Mater Infiltration - Unique Presentation in a Bulgarian Patient

BACKGROUND: Basal cell carcinomas (BCC) located in the sun-exposed regions are a serious therapeutic challenge. Therefore early diagnosis and adequate therapy should be of a high priority for every dermatologic surgeon.CASE PRESENTATION: We are presenting a patient with multiple BCCs, located on the area of the scalp, who had been treated several years ago with electrocautery and curettage after histopathological verification. However, the last few years the tumours have advanced, infiltrating firstly the tabula external and a year later the tabula interna of the cranium. A computed -tomography (CT) imaging and radiography of the skull were performed to reveal the definite tumour localisation, needed for planning an one - step surgical intervention. Both of the instrumental examinations confirmed the existence of osteolytic tumour lesions. Craniotomy with precise removal of the BCCs infiltrating the cranial bone in all of its thickness was performed. Partial resection of dura mater was also performed also because intraoperative findings established the involvement of the dura. Histopathological verification revealed bone and dural invasion with clean resection margins. The bone defect was recovered with hydroxyapatite cement. Reconstruction as the shape of the skull was carefully modified and adapted to its initial size and form. Layered closure of the skin and soft tissues were performed after the complete removal of the BCCs. The postoperative period had no serious complications.CONCLUSION: Precisely managed therapy of BCC is curative in most of the cases as it ensures good prognosis for the patient