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We describe the clinical course of a 5-year-old girl with severe arterial hypertension that was uncontrollable with antihypertensive medication. Renal angiography revealed bilateral renal artery stenoses. Because percutaneous transluminal renal angioplasty (PTRA) failed to dilate the stenotic lesions, a renal artery bypass grafting in both renal arteries was performed. The patient remained normotensive for 7 months, and after that the arterial pressure increased again. Digital subtraction angiography demonstrated stenosis at the peripheral and central anastomosis of the vein graft that was used for revascularization of the left kidney. PTRA was decided on and successful patency was achieved. The patient has now been normotensive for a period of 5 years. [ABSTRACT FROM AUTHOR]

Osteoid osteomas are benign bone tumors characterized by severe localized pain, often challenging the daily lives of young patients. While these tumors are typically solitary, rare cases of multiple osteoid osteomas have been reported. This research paper presents a case series of 2 young patients with multiple osteoid osteomas, highlighting their clinical presentation, diagnostic workup, treatment with cryoablation, and follow-up. The paper emphasizes the effectiveness of cryoablation as a minimally invasive treatment option for these challenging cases., (© 2024 The Authors.)

Objective: Tibial stress injuries are challenging in terms of early diagnosis, management strategy, and safe return-to-play. In the present study, pain production associated with the application of therapeutic ultrasound (TUS) was used as a primary diagnostic tool to assess tibial bone stress injuries, and the sensitivity of this procedure was compared with Magnetic Resonance Imaging (MRI)., Subject and Methods: The study was designed as a retrospective analysis of prospectively collected data on tibial bone stress injuries in elite Track and field athletes attending the National Track and Field Athletics Centre in Thessaloniki, Greece, in the period 1995-2007. All patients underwent evaluation by TUS, and the sensitivity of the procedure was compared with MRI., Results: Four of 29 athletes showed a positive TUS examination for stress injury while MRI showed normal findings. Additionally, 5 athletes evidenced MRI findings typical of a tibial bone stress injury, while TUS evaluation was negative. Using MRI as the standard, TUS displayed a sensitivity of 79.2%., Conclusion: Therapeutic ultrasound is a reproducible modality with satisfactory reliability and sensitivity related to MRI, and could represent a useful tool for clinicians to primarily assess suspected tibial bone stress injuries in high qualification Track and Field athletes., Competing Interests: Declaration of competing interest None., (Copyright © 2022 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.)

Introduction: Bilateral testicular tumors are very rare, accounting for 1%-5% of all testicular germ-cell tumors (TGCTs). The vast majority of primary bilateral TGCTs are metachronous, with synchronous tumors comprising approximately 0.5%-1% of all cases. Those occurring synchronously share mostly the same histological pattern, predominantly seminoma, with synchronous bilateral TGCTs (SBTGCTs) with discordant subtypes being extremely rare., Case Presentation: We present the case of a 20-year-old male complaining of a palpable painless right testicular mass incidentally noticed during sexual intercourse. Ultrasonography (US) and magnetic resonance imaging (MRI) of the scrotum demonstrated bilateral testicular lesions, while staging with contrast-enhanced computed tomography (CT) exhibited normal findings. Right radical orchiectomy and left testis-sparing surgery (TSS) with concomitant onco-testicular sperm extraction (onco-TESE) were initially performed. Histology of the right testis revealed a mixed germ-cell tumor, consisting of seminoma and embryonal carcinoma, while that from the left testis disclosed embryonal carcinoma and intratubular germ-cell neoplasia unclassified (IGCNU) infiltrating the surgical margins. Hence, left orchiectomy was subsequently scheduled with histology unveiling IGCNU in the greatest part of the remaining testicular parenchyma. Following adjuvant chemotherapy, with bleomycin, etoposide, and cisplatin (BEP), the patient received testosterone replacement therapy and remained free of recurrence at an 18-month follow-up., Conclusion: This case highlights both the rarity of a bilateral testicular tumor's synchronous appearance and its extremely infrequent discordant histopathology. A comprehensive review of the major series of SBTGCTs with discordant histology cited in the literature is additionally presented.

Background and Aim: The synchronous occurrence of renal cell carcinoma and urothelial carcinoma of the renal pelvis in the same kidney is extremely rare, although previously reported. With this study we aim to present our case and provide a literature review on this entity., Methods: An otherwise healthy 43-year-old military male with the chief complaint of left plank pain was seen in the office. Imaging revealed the presence of a 3.5 cm left renal mass. Left laparoscopic radical nephrectomy was performed for presumed renal malignancy. Pathology confirmed the presence of a clear cell RCC and revealed an area of low-grade UC arising from the ipsilateral renal pelvis, not visible in the preoperative imaging. Furthermore, a Pubmed database search in English language was conducted, up to June 2021, to identify the rate of simultaneous RCC and UC of the renal pelvis or ureter in RN specimen performed for presumed RCC or renal malignancy and subsequent management in these cases., Results: A total of 53 articles reporting on 56 patients with synchronous ipsilateral RCC and UC of the renal pelvis were identified, together with our case. Eight cases (14%) were initially managed with RN, thereby requiring further management of the ureteral stump. Of these, six (75%) were managed with distal ureterectomy, one (12.5%) with active surveillance of the ureteral stump, while one case (12.5%) did not report subsequent management. To our knowledge, we present the youngest patient recorded in the literature, with this histology combination presenting synchronously in the same kidney., Conclusions: Although uncommon, the final pathology report may reveal neoplasms of dissimilar histology that may involve the renal pelvis. It is crucial for urologists and pathologists to be vigilant of such cases during a solid renal mass workup. Additional therapeutic adjustments may be necessitated, derailing the initial treatment plan.

Psoriatic onycho-pachydermo periostitis (POPP) is characterized by psoriatic onychodystrophy, connective tissue thickening, and periostitis of the distal phalanges (DPs), producing a drumstick-like deformity. Our aim was to present the first case of POPP treated successfully with an IL-17 inhibitor, perform a literature review of its characteristics and treatment, and explore the possible pathogenesis. We conducted a systematic review of previously presented POPP cases. We present a patient with methotrexate (MTX)-resistant treatment POPP, who had significant resolution of symptoms and inflammatory lesions on post-treatment MRI with secukinumab 150 mg. We also identified 31 cases of POPP (27 males; mean age 44.9 years) in the literature review. There was great toe involvement in 24 cases, and distal interphalangeal (DIP) involvement in 14 cases, with frequent radiographically evident damage. Seventeen of 31 patients received systematic treatment other than biologics, mostly MTX, with no satisfactory results. Anti-TNF agents were used successfully in 5 cases, mostly after disease modifying anti-rheumatic drug (DMARD) failure. Imaging studies in nail psoriasis and DIP psoriatic arthritis have shown an anatomical link among the nail, the DP bone, and the DIP joint entheses, suggesting that POPP may be a subtype of nail disease with excessive involvement of DP tissues (nail, soft tissue, enthesis, and bone). IL-17 inhibition could be an alternative therapeutic option in DMARD-resistant cases of POPP. Conventional treatment achieves modest success, but anti-TNF agents appear to be much more effective. Based on imaging studies, POPP may be a particular subtype of nail disease., (© 2021. International League of Associations for Rheumatology (ILAR).)

Background: During notchplasty in anterior cruciate ligament (ACL) reconstruction, bone is excised from the lateral and roof area of the notch to widen the intercondylar space and avoid notch-graft impingement in extension. There are concerns that bone regrowth of the area will cause narrowing and increase the risk of complications., Purpose: To determine the possibility of late narrowing of the notch after notchplasty using computed tomography (CT) analysis., Study Design: Case series; Level of evidence, 4., Methods: Measurements were performed on CT scans (axial and sagittal planes with knee in extension) in patients who had undergone single-bundle anatomic ACL reconstruction using hamstring graft. Two axial image levels were used: at the anterior outlet and the anterior one-eighth level of the notch. The maximum notch height and width, the notch width at one-third and two-thirds of the preoperative notch midwidth height, the maximum condylar width, and the surface area of the lateral half of the notch were measured preoperatively and at 1 week and 2 years postoperatively., Results: Included were 20 consecutive patients (mean ± standard deviation age, 28 ± 7.3 years; follow-up, 24.2 ± 3.3 months). At the anterior notch outlet, the maximum notch width increased by 1.9 ± 1.7 mm at 1 week postoperatively and narrowed by 0.3 ± 1.1 mm at the final follow-up, while the maximum notch height increased by 1.7 ± 1.9 mm and narrowed by 0.8 ± 1.8 mm, respectively. At one-eighth of the roof length, the maximum notch width increased by 1.1 ± 1.7 mm at 1 week postoperatively and narrowed by 0.1 ± 1.1 mm at the final follow-up, and the maximum notch height increased by 1.2 ± 1.5 mm and narrowed by 0.5 ± 1.5 mm, respectively. All differences were statistically significant when comparing the pre- to the immediate postoperative measurements, and they were nonsignificant when comparing the immediate postoperative to the final follow-up measurements. The same applied for the ratio of maximum notch width to maximum condylar width, indicating no postoperative narrowing of the notch., Conclusion: Notch size-shape after a 2-mm notchplasty did not change significantly in stable knees during the first 2 years after anatomic ACL reconstruction. Surgeons should consider performing this adjuvant technique when there is notch-graft impingement during surgery., Competing Interests: The authors declared that they have no conflicts of interest in the authorship and publication of this contribution. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto., (© The Author(s) 2021.)

Case: We present a case of a 35-year-old-man with a giant sclerosing epithelioid fibrosarcoma (SEF) of the thigh. The patient presented with a history of a painful thigh mass. Plain radiographs revealed a soft-tissue mass with extensive calcifications, whereas on magnetic resonance imaging, a lobulated mass between the adductors and the posterior muscles of the thigh was noted. A wide en block resection was undertaken, and the histopathology confirmed the diagnosis of SEF. Postoperative radiation therapy was followed. The patient had no signs of recurrence at the 4-year follow-up., Conclusion: The clinicopathological, imaging characteristics, and treatment options of this rare soft-tissue tumor are discussed., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/B471)., (Copyright © 2021 by The Journal of Bone and Joint Surgery, Incorporated.)

Purpose: To measure the safe range of angles during tunnel drilling and map ideal patella tunnel placement with the use of preoperative computed tomography (CT) scan and compare results after medial patellofemoral ligament (MPFL) reconstruction using a hardware-free patellar fixation technique with two semi-patellar tunnels between a) a free-hand technique, and b) its modification with the use of an anterior cruciate ligament (ACL) tibia aiming device., Methods: CT scan was performed on 30 fresh-frozen cadaveric knees a) prior to any intervention and b) after MPFL reconstruction. For MPFL reconstruction, specimens were randomly allocated to 1) Group A, which consisted of knees operated with free-hand, hardware-free patellar fixation technique with two semi-patellar tunnels and 2) Group B, which consisted of knees operated on with a technique modification with the ACL tibia device., Patellar Measurements: L1 was the maximal patellar length. L2 was the minimum possible distance of placement for the upper tunnel from the proximal pole of the patella. The maximum bone bridge between tunnels was calculated as half of L1 minus the L2 distance (L1/2-L2). We also measured R1 and R2 angles at the proximal and distal tunnel that represent safe angles at the entry point during tunnel drilling (without breaching the anterior cortex or articular cartilage)., Results: Preoperatively, mean L1 was 3.45 cm (range 3.05-4.52). Mean L2 was 0.62 cm (range 0.49-0.89). The mean maximum possible bone bridge between tunnels (L1/2-L2) was 1.1 cm (range 0.77-1.58). R1 was 6.05 0 (range 4.78-7.44), R2 was 6.64 0 (range 4.57-9.03), and their difference reached statistical significance (p = 0.03). Postoperatively, in group A, in 4 out of 15 patellas, multiple attempts were made during tunnel drilling in order to avoid anterior cortex or cartilage breaching. In group B, all tunnels were correctly drilled with the first attempt. Bone bridge between tunnels was significantly shorter postoperatively (0.93 cm, p < 0.01)., Conclusion: Small-size patellae correlate with short maximum bone bridge between tunnels, which makes anatomic, double-bundle, hardware-free patella fixation, with two semi-patellar tunnels MPFL reconstruction challenging. Furthermore, R angles create a narrow window to avoid intraoperative breaching, rendering the use of the ACL tibia device an extremely useful instrument., Level of Evidence: II.

Background: Zinner syndrome represents a rare congenital malformation of the urinary tract. It comprises a constellation of Wolffian duct anomalies and is almost exclusively encountered as a classic triad of seminal vesicle cysts, ejaculatory duct obstruction and renal agenesis. Patients can be either asymptomatic or symptomatic. Recently, minimally invasive surgical techniques have emerged, superseding traditional surgery for select symptomatic cases. Our case highlights the finding of a rare clinical syndrome that was incidentally detected during a routine mass screening of military recruits in the Greek Armed Forces., Case Presentation: Herein, we present a case of a 19-year-old male who reported having a solitary right kidney when examined in a military training center of Northern Greece. No additional clinical information was available; thus, referral to a tertiary urology department for further investigation ensued. Imaging studies, namely, computed tomography and magnetic resonance imaging, revealed left renal aplasia, multiple left seminal vesicle cysts, and ejaculatory duct obstruction. Laboratory values and urinalysis were within normal range. Semen analysis was significant for cryptozoospermia. Our patient remained asymptomatic during the entire hospitalization. Long-term follow-up was recommended. Nevertheless, he declined further investigation and sought treatment in a private practice setting., Conclusions: This article aims to present the incidental diagnosis of a rare syndrome in a military setting. Population screening conducted in the armed forces permits the identification of undiagnosed diseases that warrant further investigation. To the best of our knowledge, this was the first report of Zinner syndrome in a military recruit and the second case cited of a Greek patient in the published literature. Regular follow-up is the key to timely intervention in conservatively managed cases.

Background: There are an estimated 1-2 cases per million per year of adrenocortical carcinoma in the USA. It represents a rare and aggressive malignancy; it is the second most aggressive endocrine malignant disease after anaplastic thyroid carcinoma. Non-secretory adrenal masses are diagnosed late due to a mass effect or metastatic disease or found incidentally (adrenal incidentalomas)., Case Presentation: The first case report describes a 39-year-old Greek woman who presented to our department with complaints of repeated symptoms of flatulence and epigastric discomfort over a few months. The second case report is about a 67-year-old Greek woman who presented to our department after being evaluated for fatigue, mass effect, and epigastric discomfort. Both of them were diagnosed as having a nonfunctioning adrenocortical carcinoma and underwent open adrenalectomy., Conclusions: Approximately 60% of patients with adrenocortical carcinoma present with symptoms and signs of hormonal secretion. Our cases' adrenocortical carcinomas were not functional. Hormone secretion is not a discriminating feature between benign and malignant adrenocortical masses. The silent clinical nature of nonfunctioning adrenocortical carcinoma results in late diagnosis, while the majority of patients present with locally advanced and/or metastatic disease. Adrenocortical carcinoma is a rare endocrine tumor with a poor prognosis that can be diagnostically challenging and demands high clinical suspicion. The work-up for adrenal masses must include determination of whether the mass is functioning or nonfunctioning and whether it is benign or malignant.

We report a case of a symptomatic tensor fasciae suralis (TFS) muscle in an elite jumper, with a very rare tear in its origin. The TFS muscle must be recognized and differentiated from other pathologic entities in the popliteal region. The magnetic resonance imaging (MRI) and ultrasound (US) can reliably identify this variant and its pathology.

Background: Several tumour-like conditions of the soft tissues may be encountered in clinical practice, or when patients undergo radiologic examinations. Al-though advances in cross sectional imaging (ultra-sound, MDCT and MRI) play a pivotal role in the correct evaluation of tumour-like lesions, a systematic approach is needed to achieve a definitive diagnosis or limit the differential diagnosis. Clinical history, physical examination and anatomic location are of paramount importance., Methods: In this pictorial essay we review some of the most frequent benign soft tissue conditions which may be mistaken for malignancy and thus lead to need-less referrals, unnecessary biopsies and great anxiety to the patients and their carers., Level of Evidence: IV., Competing Interests: Conflict of interests The Authors declare that they have no conflict of interests regarding the publication of this paper.

Objective: The aim of the study was to gain information about the incidence of mechanical Low Back Pain (MLBP) injuries etiology in elite track and field athletes and to assess the recurrence rate., Background: The prevalence and the etiology of Low Back Pain (LBP) in athletic populations at the elite level of competition lack of longitudinal studies focused on certain sport fields. The present study evaluates MLBP incidents in elite track and field athletes visiting National Track and Field Centre in Thessaloniki, Greece and classifies MLBP according to etiology., Methods: One hundred and thirty Elite Track and Field Athletes with MLBP injuries were included in a 20-year observational cohort study recording the initial MLBP etiology according to a classification system based on mechanical diagnosis. It was examined if age, gender and sport category predispose the incidence of the initial MLBP etiology and if they consist risk factors for MLBP recurrence., Results: Discogenic MLBP in elite track and field athletes was significantly higher at 46.9% (α= 0.05) compared with the other MLBP etiologies under consideration. Secondary findings of the present study regarding the incidence of MLBP etiology categories did not reveal significant associations with gender, age and contest categories (α= 0.05). Additionally, recurrence pathophysiology showed that discogenic MLBP obtained high recurrence rates at 0.48 (14 athletes from 29 athletes recurred) compared with other etiologies, followed by back elements injury recurrence rate at 0.24 (7 athletes out of 29)., Conclusions: The study provided us with evidence of higher incidence of discogenic etiology of MLBP in elite track and field athletes. Further research is suggested in the use of etiology related LBP classification system in order to evaluate causes, prevalence and epidemiology of MLBP in athletic populations of specific sport categories.

Competing Interests: Disclosure The authors report no conflicts of interest in this work.

Objective: To ascertain whether therapeutic ultrasound (TUS) can be used to assess the progression of conservative management in navicular stress injuries., Design: This is a prospective, clinical case series. Level of evidence IV., Setting: All participants were examined and followed up in a private Sports Injury Clinic., Participants: Ten elite track and field athletes with severe dorsal midfoot pain over the navicular bone participated in this study., Interventions: All patients underwent both TUS and magnetic resonance imaging (MRI) evaluation. The painful threshold of TUS on initial evaluation was a mean of 0.707 ± 149 W/cm, and MRI detected a navicular stress injury in all patients. The athletes received conservative treatment and underwent sequential TUS evaluations at 4, 8, 12 and 16 weeks., Main Outcome Measures: Therapeutic ultrasound pain threshold values were recorded, and the patients were additionally asked to grade local tenderness on a Visual Analogue Scale. Time to return to play was also recorded., Results: The level of pain produced by the application of TUS on a navicular stress fracture seemed to correlate well with Visual Analogue Scale scores and the grade of fracture demonstrated on MRI. The initial low TUS painful mean value increased to a normal mean value of 1.97 ± 0.067 W/cm by 16 weeks. When clinical and TUS findings had returned to normal, the patients were allowed to return to sports activities, with no recurrences experienced during the study period., Conclusions: The production of pain associated with the application of TUS on a navicular stress fracture is a safe and reproducible method of monitoring the resolution of these fractures. We have used it successfully in making return-to-play decisions for elite level track and field athletes.

Purpose: The aim of this prospective study was to assess the natural history of the donor hamstrings, compared to the contralateral knee and thigh., Methods: In 47 patients who had ACL reconstruction (hamstrings technique), bilateral knees and thighs were investigated using MRI scans, up to 2 years post-operatively., Results: Tendon regeneration below the knee joint line of the semitendinosus occurred in 30/47 (64 %) patients and of the gracilis tendon in 17/47 (36 %) patients. Insertion of both tendons at the "pes anserinus", with normal anatomic relations, was observed in 5/47 (11 %) patients. Semitendinosus and gracilis donor muscles were found retracted in 41/47 (87 %) patients. In 25/47 (53 %) patients, there was evidence of fatty infiltration of the semitendinosus muscle. All (47/47) (100 %) patients showed semitendinosus muscle atrophy and 41/47 (87 %) patients showed gracilis muscle atrophy, compared to the contralateral limb. High signal intensity on STIR images was observed in the semitendinosus in 22/47 (46 %) patients and in the gracilis muscle in 30/47 (64 %) patients, on MRI examination performed up to 24 months post-operatively., Conclusions: The "regenerated" hamstrings tendons most commonly do not regenerate fully anatomically, so they should not be considered as a first choice for re-harvesting in revision ACL reconstruction. The "donor hamstrings muscles" are found to be shorter, contracted, thinner and with a long-term abnormal MRI signal, features which are considered to be related to reduced muscle performance (knee flexion and internal rotation) post-operatively., Level of Evidence: II.

The purpose of this study was to examine the correlation in semitendinosus (ST) and gracilis (GT) tendon cross-sectional area (CSA) evaluated directly during anterior cruciate ligament (ACL) surgery and pre-operatively using ultrasound (US) and magnetic resonance imaging (MRI). A total of 14 patients undergoing ACL reconstruction with a quadruple ST-GT graft by the same orthopaedic surgeon participated in this study. Pre-operative evaluation included determination of ST and GT CSA area using US and MRI. Intraoperative measurement of the diameters of the ST, GT and the final ACL graft using a closed-hole sizing block with 0.5-mm increments was made and this diameter was used to estimate tendon CSA. The correlation between graft diameter and CSA were 0.563 (GT) and 0.807 (ST) for MRI and 0.498 (GT) and 0.612 (ST) for US. The final ACL graft diameter displayed a correlation coefficient of 0.813 with MRI CSA and 0.518 with US CSA. No differences in CSA were observed between intraoperative, MRI and US methods (p>0.05). The intraclass correlation coefficients between the US, MRI and intraoperative graft methods for the ST and GT data ranged from 0.502 to 0.903 with an estimation error ranging from 1.41% to 2.26%. These results indicate that in clinical situations where MRI is contra-indicated or not accessible, US can provide measurable values which could predict sufficient diameter of the ACL graft. In addition, determination of tendon CSA using US displays errors less than 2% which is similar to that observed using MRI. This suggests that the application of US can be applied to in vivo examination of the ST and GT CSA., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

The growing number of patients undergoing arthroscopy or surgery of the knee for ligamentous injuries has led to a greater need for postoperative imaging because of poor outcome, recurrent symptoms, or a new injury. MRI is the most important imaging method when evaluating the postoperative knee. Radiologists should be familiar with the particular reconstruction technique applied to each examinee, know the spectrum of normal postoperative findings, recognize those findings that may be related to symptoms of failed reconstruction, as well as those lesions that are irrelevant to the previous surgery yet responsible for the new clinical symptoms. In view of the continually evolving surgical techniques, this review presents the current concepts of MRI evaluation of the postoperative knee ligaments based on recent literature reports., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

A seven-year-old, not-castrated male, Airedale Terrier presented with a history of ataxia and intention tremor of the head of three-week duration. Neurologic examination demonstrated severe hypermetria, intention tremor of the head and a bilateral menace response deficit. Magnetic resonance imaging revealed a well demarcated cerebellar vermis mass, hypointense on T1-weighted images, hyperintense on T2-weighted images, with multiple small foci of high signal similar to that of CSF. Foci dispersed in the mass creating a speckled appearance. Homogeneous faint, wispy post-contrast enhancement of the mass was noted; as a result the tumor became isointense to gray matter and was not clearly evident in post contrast images. The histopathological diagnosis of the excised tumor was cerebellar medulloblastoma.