IN FRA PA TEL LAR FAT PAD HA E MAN GI O MA — CA SE RE PORT
Dzo le va-To lev ska Ro za
, Po po ska Ana sta si ka, Sa mard zi ski Mi lan, Ge or gi e va Da ni e la
Uni ver sity Cli nic for Or t ho pa e dic Sur gery, Sko pje, R. Ma c e do nia
Pri mljen/Re ce i ved 31. 03. 2014. god. Pri hva }en/Ac cep ted 06. 05. 2014. god.
Ab stract:We pre s ent a ca se of a 38yearold wo -man with a soft tis sue mass on the right knee in me dial in fra pa tel lar area. The fle xi on of the knee ap pe a red to be li m i ted and a pain was pre s ent at ma x i mal fle xi on. Ul tra so no graphy, stan dard X-ray and CT scan we re per for med for di ag no sis of this soft tis sue tu mo ur. MRI was not do ne due to tec h ni cal pro b lems. Any how the MRI co uld pro vi de us with mo re pre sump ti ons of the type of the tu mo ur, but it will not af fect the sur geon’s de ci sion for op e r a tion. Any way the fi nal di ag no sis will co me out of the hi sto pa to lo gi cal fin d ings.
Ar thro sco p ic ex a m i na ti on was per for med in or der to eli m i na te pos si ble pro b lems in to the jo int fol lo wed by open wi de ex ci si on. A soft tis sue tu mo ur with di men si ons of 5 x 4 x 1.5 cm was ex ci sed. Hi sto pat ho lo -gi cal di ag no sis was syno vial ha e man -gi o ma lo ca ted in the in fra pa tel lar fat pad. The pa ti ent was asymp to m a tic po st o p e r a ti vely.
Ha e man gi o mas lo ca ted in in fra pa tel lar fat pad are ra re. Or t ho pa e dic sur ge ons can of ten be con fu sed by mo re com mon en ti ti es li ke chon dro mal la tia of pa tel la, syno vi tis of the knee, Hof fa’s di s e a se, ot her soft tis sue tu mo urs, even le sion of me ni s cus. So, ac cu ra te di ag no sis is very im por tant for dif fe r en ti a tion. Op e r a ti ve ex ci si on, ar thro sco p ic or open wi de, is de fi n i ti ve tre at -ment for this be nign tu mo ur.
Key words: Ha e man gi o ma, in fra pa tel lar fat pad, knee.
IN TRO DUC TION
The in fra pa tel lar fat pad (Hof fa) is an in tra cap su -lar, ex trasyno vial struc tu re that fills up the an te ri or knee com part ment. It is richly vas cu la ri sed and in ner va ted. The pre ci se fun c tion of the IFP is un k nown. Stu d i es ha ve shown that it may play a ro le in the bi o mec -ha nics of the knee or act as a sto re for re pa r a ti ve cells af ter in jury (1).
Hof fa’s di s e a se is not very fre qu ent. It is of ten im pli ca ted as a so ur ce of an te ri or knee pain. The se di s e a
-ses of the in fra pa tel lar fat pad vary be t we en tra u ma, im pin ge ment, in flam ma tion and tu mo ur.
The most com mon tu mo ur or tu mo urli ke ab nor ma l i ti es of the in fra pa tel lar fat pad are re por ted as pa raar ti c u lar chon dro ma/oste oc hon dro ma, fo cal pig men ted vil lo no du lar syno vi tis, syno vial li po ma, fi bro li po ma, syno vial chon dro ma to sis, syno vial ha e man gi -o ma, gan glia/cysts, and in tra-ar ti c u lar ma lig nancy (2).
Syno vial ha e man gi o ma is a ra re be nign tu mo ur. Hi sto pat ho lo gi cally, the re is anoc cu ran ce of three types: ca p il lary, ca v er n o us, or mi xed (3).
A ha e man gi o ma lo ca ted in the in fra pa tel lar fat pad might ca u se per si s tent pain, swel l ing and ad di ti o -nal fun c ti o -nal pro b lems.
CA SE RE PORT
We pre s ent a ca se of a 38- year -old wo man with soft tis sue mass on the right knee in me dial in fra pa tel lar area. The pa ti ent de c la red mul ti ple mi nor in ju ri es in this lo ca tion. The soft tis sue mass had been no ti ced by the pa ti ent 3 months pri or, but the pain be low the pa tel la had been pre s ent for se v e ral years. The pain per si sted du r ing the who le day and was ab sent du r ing the night.
Phys i cal ex a m i na ti on re ve a led a pal pa ble mass in Hof fa’s fat pad. The over ly ing skin was nor mal with no di s co l o r a tion and no lo cal tem pe r a tu re ra i se. The re was a pain on pal pa tion. The fle xi on of the knee ap pe a red to be li m i ted and a pain was pre s ent at ma x i mal fle -xi on.
Ul tra so und was the first step in di ag no sis. The re was a hypo ec ho ic ir re g u lar mass lo ca ted on the me dial in fra pa tel lar si de, with few cal ci fied ar e as. Fur t her ex a m i na ti ons we re do ne for dif fe r en tial di ag no sis of ot -her soft tis sue tu mo urs.
A stan dard X-ray ex a m i na ti on re ve a led os se o us struc tu re in the in fra pa tel lar area (Fi g u re 1).
CT scan sho wed soft tis sue mass with os se o us con tent in the in fra pa tel lar re gion (Fi g u res 2 and 3).
UDK: 616.728.3-006.31
2014; 9(2): 177–180 ID: 208287756
Dif fe r en tial di ag no sis be t we en syno vial oste oc hon dro ma to sis, syno vial sar co ma, pa raar ti c u lar oste -oc hon dro ma or syno vial ha e man gi o ma co uld not be de ter mi ned on CT scan.
MRI was not do ne due to tec h ni cal pro b lems. MRI co uld pro vi de us with mo re pre sump ti ons of the type of the tu mo ur, but it did not ef fect the de ci sion for op e r a tion. Any way the fi nal di ag no sis was co m ing out from the hi sto pa to lo gi cal fin d ings.
Pa ti ent was sche d u led for sur gi cal ex ci si on. Ar thro sco p ic ex a m i na ti on was per for med in or der to eli -m i na te pos si ble pro b le-ms in to the jo int fol lo wed by open wi de ex ci si on. A soft tis sue tu mo ur with di men si -ons of 5 x 4 x 1.5 cm was ex ci sed (Fi g u res 4 and 5).
Hi sto pat ho lo gi cal eva l u a tion re ve a led a fat and con nec ti ve tis sue, par ti ally co v e red with atro p hic syno via. In si de the re was a nod for med by se v e ral big -178 Dzo le va-To lev ska Ro za, Po po ska Ana sta si ka, Sa mard zi ski Mi lan, Ge or gi e va Da ni e la
Fi g u re 1. X ray Fi g u re 2. CT scan Fi g u re 3. CT scan
Fi g u re 5. Mac ro sco pic vi ew of in fra pa tel lar fat pad ha e man gi o ma
Fi g u re 4. Mac ro sco pic vi ew of in fra pa tel lar fat pad ha e man gi o ma
Fi g u re 6. Mi c ro sco pic vi ew of in fra pa tel lar fat pad ha e man gi o ma
ger ar tery type of blood ves sels. Aro und them the re was a mass of ana sto mi sed vas cu lar cham ber. The walls of the ves sels con si sted of thin con nec ti ve tis sue and co v e red with lar ge en do tel cells. So me of the big -ger blood ves sels we re cal ci fied and so me con ta i ned fresh blood throm bus. Hi sto pat ho lo gi cal di ag no sis was syno vial ha e man gi o ma lo ca ted in the in fra pa tel lar fat pad (Fi g u res 6 and 7).
One year af ter op e r a tion the ge n e ral con di tion of the pa ti ent was sa t is fy ing and the knee pain was not pre s ent. The knee had no fun c ti o nal li m i ta ti ons and the re we re no signs of tu mo ur re ci di ves.
DI S CUS SION
Ha e man gi o mas con sti tu te 7–10% of all soft tis sue tu mo urs (4).
By de f i ni tion, a syno vial he man gi o ma is “a be -nign vas cu lar le sion ari s ing from any struc tu re li ned by syno vi um in clu d ing the in tra-ar ti c u lar re gion, bur sal spa ces and ten don she aths (3).
Ha e man gi o mas in the knee join of ten ca u ses pain, swel l ing, re cur rent he mar thro sis, fun c ti o nal li m i ta ti -ons etc. The symp toms usu ally per sist for se v e ral years be fo re the ti me of di ag no sis.
Akgün I et al. and Price et al. r e fer of intra-ar tic u lar hemangioma of the knee that causes pain and spon ta ne -ous hemarthrosis, of ten seen as an in ter nal de range ment of the knee in chil dren and young adults (5, 6).
G.I. Drosos re ports of two cases with
haemangi-omas around the knee mim ick ing me dial meniscal
tears and an te rior knee pain (7).
Aynaci O et al. re port a ca se with ten der ness and pain at the an te ro la te ral tri an gu la tion of the knee jo int ca u sed by syno vial ha e man gi o ma (8).
In our ca se, ha e man gi o ma lo ca ted in the in fra pa -tel lar fat pad ca u sed pain, no swel l ing or ha e mart ho sis in the knee, mi m ic k ing chon dro mal la tia of the pa tel la or Hof fa’s di s e a se.
Di ag no sis of this soft tis sue tu mo ur al ways in clu -des ul tra so und, plain ra di o graphs, CT scan and MRI. Ra di o graphs are ge n e r ally in con clu si ve, re ve a l ing only an ab nor mal soft tis sue mass. Oc ca si o nal cal ci fied phle bo liths may be pre s ent in 25% of ca ses, but do es not ap pe ar to be a con stant fe a tu re. Ul tra so no grams may re -veal com plex hypo ec ho ic mass and if phle bo liths are pre s ent, aco u s tic sha d o w ing may al so be do c u men ted. MRI is very pro m i s ing in ve s ti ga tion, which is nonin va -si ve, helps in di ag no -sis and de fi n ing the lo ca tion (9, 10).
In su s pec ted ca ses when we are not su re abo ut di ag no sis, we must fol lo wed the stan dard steps of di ag no s tics, al ways thin k ing of va r i o us dif fe r en tial di ag no -s tic en ti ti e-s -such a-s: pig men ted vil lo no du lar -syno vi ti-s, non-spe ci fic syno vi tis, li po ma, oste oc hon dro ma etc.
Yamashita H. pres ents a case of intra and ex -tra-ar tic u lar lo cal ized pig mented villonodular syno-vitis. Also Ozalay M et al. re fer lo cal ized pig mented villonodular synovitis orig i nat ing from the extensor mech a nism or fat pad (11, 12).
Gigis I re ported a fibrolipoma with os se ous and car ti lag i nous metaplasia of Hoffa’s fat pad (2).
Keser S et al. and Soler T at al. di ag nosed intraar-ticular lipoma orig i nat ing from infrapatellar fat pad (13, 14).
Turhan et al. re ported a gi ant extrasyno vial oste oc hon dro ma in the in fra pa tel lar fat pad. The in fra pa tel -lar fat pad con ta ins the en ti re pro ge n i tor cells for the de ve l op ment of an oste oc hon dro ma and chro nic im -pin ge ment may ha ve pro mo t ing ef fect on this is sue, thus, an oste oc hon dro ma may oc cur at the end-sta ge Hof fa’s di s e a se (15).
Osti L et al. re fer of syno vial chon dro ma to sis lo -ca l i zed in to the Hof fa’s fat pad.
Ge n e r ally, tre at ment of all the se tu mo urs or tu mo urli ke le si ons lo ca ted in the Hof fa’s fat pad is the sa -me. It de pends on an a to m i cal di s tri bu tion of the le sion. If the le sion is pe dun cu la ted and well-cir cum scri bed an ar thro sco p ic ex ci si on can be car ried out. Dif fu se le si ons are dif fi cult to be ex ci se ar thro sco pi cally, so in the -se ca -ses an open wi de ex ci si on is re c om men ded (16).
Dra goo JL and Oza lay M re fer of eva l u a tion and tre at ment of in fra pa tel lar fat pad di s or ders. Its pa t ho l ogy is re frac tory to phys i cal the r apy and can be ap pro ac hed thro ugh a va ri ety of op e r a ti ve tre at ments. Ar -thro sco p ic par tial re sec tion for IFP im pin ge ment and Hof fa’s di s e a se has sho wed fa vo u r a ble re sults (1, 12).
CON CLU SION
Ha e man gi o mas lo ca ted in in fra pa tel lar fat pad are ra re.
Or t ho pa e dic sur ge ons can of ten be con fu sed by mo re com mon en ti ti es li ke chon dro mal la tia of pa tel la, syno vi tis of the knee, Hof fa’s di s e a se, ot her soft tis sue tu mo urs, even le sion of me ni s cus. So, ac cu ra te di ag no sis is very im por tant for dif fe r en ti a tion. Op e r a ti ve ex ci si on, ar thro sco p ic or open wi de, is de fi n i ti ve tre at -ment for this be nign tu mo ur.
Sa `e tak
HE MAN GI OM IN FRA PA TE LAR NOG MA SNOG TKI VA —PRI KAZ SLU ^A JA
Dzo le va-To lev ska Ro za, Po po ska Ana sta si ka, Sa mard zi ski Mi lan, Ge or gi e va Da ni e la
Uni ver sity Cli nic for Or t ho pa e dic Sur gery, Sko pje, R. Ma c e do nia
Pred sta vlja mo slu ~aj pa ci jent ki nje sta ro sti 38 go di -na sa me kot kiv nom ma som u pre de lu de snog ko le -na u me di jal noj in fra pa te lar noj re gi ji. Flek si ja ko le na je bi la ogra ni ~e na i bol pri su tan pri mak si mal noj flek si ji. Ul tra -so no gra fi ja, stan dard na rent ge no gra fi ja i CT su iz ve de ni za di jag no zu ovog tu mo ra me kog tki va. MRI ni je iz ve -den zbog teh ni~ kih pro ble ma.. MRI bi sva ka ko dao vi {e po da ta ka o ti pu tu mo ra, ali na laz ne bi uti cao na od lu ku hi rur ga o ope ra ci ji. U sva kom slu ~a ju, ko na~ na di jag no -za pro iz i la zi iz hi sto pa to lo {kog na la -za.
Ar tro sko pi ja je iz ve de na ka ko bi se iz be gli mo gu }i pro ble mi u zglo bu to kom {i ro ko otvo re ne eks ci zi je. Me kot kiv ni tu mor di men zi ja 5 x 4 x 1.5 cm je eks ci di ran. Hi
-sto pa to lo {ka ana li za je po ka za la da se ra di o si no vi jal nom he man gi o mu lo ka li zo va nom u in fra pa te lar nom ma snom tki vu. Pa ci jent je bio bez te go ba na kon ope ra ci je.
He man gi o mi lo ka li zo va ni u in fra pa te lar nom ma -snom tki vu su ret ki. Or to pe di ~e sto mo gu bi ti zbu nje ni ~e {}im en ti te ti ma kao {to su hon dro ma la ci ja pa te le, si no vi tis ko le na, Hof faovo obo lje nje, dru gi tu mo ri me kih tki va, ~ak i le zi ja me ni sku sa. Da kle, ta~ na di jag no za je ve o ma va `na za di fe ren ci ja ci ju. Eks ci zi ja, ar tro -skop ska ili {i ro ko otvo re na, je de fi ni ti van vid le ~e nja ovog be nig nog tu mo ra.
Klju~ ne re ~i: He man gi om, in fra pa te lar no ma sno tki vo, ko le no.
180 Dzo le va-To lev ska Ro za, Po po ska Ana sta si ka, Sa mard zi ski Mi lan, Ge or gi e va Da ni e la
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4. HYPERLINK “http://www.ncbi.nlm.nih.gov/pubmed? term=Moser%20RP%20Jr%5BAuthor%5D&cauthor=true&ca uthor_uid=8192029"Moser RP Jr, HYPERLINK ”http://www. ncbi.nlm.nih.gov/pubmed?term=Barr%20MS%5BAuthor%5D &cauthor=true&cauthor_uid=8192029"Barr MS. Musculoske-letal case of the day. In tra mus cu lar hemangioma of the thigh. AJR Am J Roentgenol. 1994;162(6):1465–6.
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Cor re spon den ce to/Autor za ko re spon den ci ju
Dzo le va-To lev ska Ro za, M.D, MSci Uni ver sity Cli nic for Or t ho pa e dic Sur gery Sko pje, R. Ma c e do nia
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