Vol 1 | Issue 2 | Oct-Dec 2015 | page: 14-16 | RP. Jeavons, DJ. Ryan, D. Dowen, S. O’Brien.
Authors : RP. Jeavons, DJ. Ryan, D. Dowen, S. O’Brien.
 Department of Trauma and Orthopaedics, North Tees University Hospital, Stockton-on-Tees, UK
 Department of Trauma and Orthopaedics, Gloucestershire Royal Hospital, Gloucester. UK
 Department of Trauma and Orthopaedics, Sunderland Royal Hospital, Sunderland. UK
Address of Correspondence
Mr Daniel Ryan
Flat 6, Hendre, Overton Park Road, Cheltenham, Gloucestershire, GL50 3BW. UK
Introduction: Iliopsoas bursitis is a well-documented problem in those with an active disease process of the hip, and may present with a variety of symptoms. .
Case Report: A 68-year old gentleman presented to our unit with symptoms of proximal neurovascular compression, initially mistaken for a deep vein thrombosis. Further investigation revealed the cause to be a massive iliopsoas bursa requiring surgical excision. In our case, massive iliopsoas bursitis occurred in a patient with no prior symptomatic hip joint pathology. A review of symptoms and appropriate use of imaging techniques aided in correctly diagnosing the patient and with pre-operative planning.
Conclusion: A spontaneous, massive Iliopsoas bursa in a fit and well patient is very rare. Prompt accurate diagnosis and management is required to ensure rapid resolution and prevent further complications.
Keywords: Iliopsoas bursitis, deep vein thrombosis, surgical excision.
Iliopsoas bursitis is a well-documented condition. Presentation ranges from groin pain to proximal neurovascular compression. The majority of reported cases occurred in patients with an active disease process of the hip joint, following trauma or surgery [2,3,4]. Massive iliopsoas bursa (IB) can cause compression of local neurovascular structures, and requires rapid diagnosis and treatment. Here we present, to our knowledge, the first case of a massive spontaneous iliopsoas bursa causing neurovascular compromise in a fit and well patient, mistakenly diagnosed and treated as a deep vein thrombosis (DVT).
A 68 year old man, with a past medical history of hypertension and gout, presented to the Acute Medical Unit, with a one week history of right groin and leg pain; associated groin mass, erythema and pitting oedema involving the right thigh and lower limb and paraesthesia of the medial thigh and knee. He had no symptoms of infection or neoplastic process. Blood tests revealed normal serum electrolytes, white cell count of 8.43 (4-10 x 109/l), C-reactive protein of 10 mg/l (0-10 mg/l), erythrocyte sedimentation rate of 5 mm/hr and D-dimer level of 271 ng/ml (0-243 ng/ml). A provisional diagnosis of DVT was made on the medical unit on the basis of the symptoms of lower leg pain, swelling, erythema and a mildly raised D dimer. The combination of calf swelling > 3cm, pitting oedema and entire leg swelling on the affected side gave a Wells’ score of 3, placing the patient in the high risk group for DVT, and anticoagulant therapy was begun. An ultrasound scan of his leg twenty-four hours later, however, revealed only a small non-occlusive thrombus in a proximal peroneal calf vein, fully compressible right common femoral, superficial femoral, posterior tibial and popliteal veins, and normal flow on colour Doppler. A large fluid collection was noted around the right hip joint, leading to anticoagulation treatment being stopped in case of bleeding. The patient experienced no improvement in symptoms with conservative management, and owing to the persistence of swelling and pain, a local malignancy was suspected. A Computerised Tomography (CT) scan of his pelvis, performed 3 months after initial presentation , confirmed a 7×6.3 cm soft tissue mass anterior to the right hip (figure 1). Urgent referral to our Orthopaedic department for possible soft tissue neoplasia was made. On presentation at this time the patient complained of groin pain, paraesthesia in his thigh and significant lower limb swelling. Extensive pitting oedema of the right lower leg was present. A large, firm, tender mass in the right groin was palpated, with the femoral artery palpable anteriorly. Distal pulses were present. There was reduced sensation over the medial aspect of the right thigh and below the knee: all other neurological testing was normal. Magnetic Resonance (MR) scanning (figures 2a & b) demonstrated the mass to be anterior to, and communicating with the hip joint, lying posterior to the femoral vessels and causing compression. Altered bone marrow signal was noted in the femoral head and neck. A diagnosis of a massive iliopsoas bursa was made, based on the high signal appearance on T2 of a fluid-filled structure communicating with the joint (figure 2b). Expedient exploration of the right groin and excision of the mass via an anterior approach was undertaken. The bursa protruded between the femoral artery and nerve, causing compression at this point. An opening created between the femoral neurovascular structures was used to remove the mass. The bursa was found to communicate directly with the hip joint, and the capsule was incised to allow complete excision. Following removal, the joint capsule was repaired with a simple suture using a heavy, absorbable, polyfilament material (Vicryl). Post operatively, the patient was mobilised as pain allowed. At 3 week follow up, his scar had healed, all lower limb swelling and groin pain had subsided, paraesthesia of the medial thigh and knee persisted, but resolved by 6 weeks, at which point he was discharged. Histology revealed inflammatory cells and hyalinised collagen fibres, consistent with the radiological diagnosis of an enlarged bursa.
In 1936 the Knox named it as a synovial sarcoma, on the belief that since the tumor has the tendency to arise near to joint and tumor cell originated from the synovial tissue. But now days the name synovial sarcoma is misnomer sometimes, because in majority cases the synovial sarcoma originates where the synovial tissue is not present (extra-articular location) and the actual cells of the tumor is not necessarily a synovial cell. In that case, the term used is neoplasm of uncertain histogenesis [4, 5]. Usually the synovial tumor are circumscribed and situated adjacent to the joints (≤ 5 cm), but unusually in the 5% cases they are within the joints or bursa and interdigitates to the surrounding muscles, tendons or vessels [6, 7]. Exact pathology of synovial sarcoma is not well understood. But the literature has shown that genetic aberration plays a role for the occurrence of synovial sarcoma. Usually in the clinical practice the synovial sarcoma is diagnosed by histopathology but it is the molecular genetics that confirms the pathology by the presence of t(X;18) gene as a result of reciprocal translocation . This Reciprocal translocation occurs between the SS18 gene (of chromosome 18) and among one of the SSX genes ( SSX1, SSX2 and SSX4 of chromosome X). This reciprocal translocation is usually found in more than 90% of the synovial sarcoma . Utmost important components of diagnostic tools for synovial sarcoma are immunohistochemistry and cytogenetic analysis. Immunohistochemistry make the diagnosis by expressing the epithelial markers (cytokeratin or epithelial membrane antigen) in epitheloid and viamentin in the spindle form. Cytogenetics use the reverse-transcriptase polymerase chain reaction or fluorescent in situ hybridization probes, that locates the t(X;18) gene [10, 11]. Histopathology of synovial sarcoma is being classified as biphasic, monophasic and poorly differentiated type and between them the biphasic form is a most common (2/3rd of synovial sarcomas) presentation . In biphasic form the dual cell line is found, it is composed of elongated basophilic spindle cells and columnar epithelial cells. On the contrary the monophasic form has either spindle cell or very uncommonly the epithelial cell. If the monophasic form is comprised of only spindle cells, in that condition the malignant peripheral nerve sheath tumour and fibrosarcoma may be the misdiagnosis. Study of G. T. Pack et al (done over 60 patients in 1950) found that, alone surgery for synovial sarcoma has recurrence rate of 63% . And the further study of Lewis et al (2000) found that radiation therapy greatly reduces the local recurrence (up to the10%) . It is assumed that, at the time of clinical presentation of the sarcoma, there is the germane chance of the harbourage of subclinical micrometastasis. So since the few decades the chemotherapy (neoadjuvant/adjuvant) has been used to ameliorate the consequences of sarcomas. F. C. Eilber et al in his study concluded that chemotherapy is strongly correlated to improved disease specific survival . But the toxicity of the chemotherapy and smaller impact on the disease survival, the use of the chemotherapy in primary synovial sarcoma has been controversial [16, 17]. Although the primary amputation have also been used as a treatment modality  but due to the virtue-of its thin incidence, the natural history of the synovial sarcoma is not well known due to the littleness of datum.
Since there is no any optimal guideline for the treatment of synovial sarcoma, meanwhile the surgical resection with clear margins and the adjuvant chemotherapy and/or radiotherapy is available treatment modality for the synovial sarcoma. Thus the enhanced surgical techniques as well as irradiation/chemotherapy have better control over local recurrence, but the occurrence of distant metastasis is still a bet for us, so the prognosis of the synovial sarcoma is still forlorn.
Review: Although hip pain is commonly associated with the iliopsoas bursa, a literature search by the authors revealed no previous case reports of neurovascular symptoms caused by an enlarged iliopsoas bursa. As with any medical condition, investigation should begin with a thorough medical history (including drug, past medical and family histories) and clinical examination. Possible causes of lower limb swelling associated with a mass and neurovascular symptoms can be determined using the ‘surgical sieve’, and may be due to: trauma, infection, neoplasia, congenital abnormality, vascular insufficiency (venous or arterial), inflammation, bowel hernia or central or peripheral neurological conditions. The majority of these can be ruled out from the history of the progression of the disease, for example, no story of trauma, lack of a fever, timescale of onset and any other systemic or local symptoms. If, after clinical examination, the diagnosis is still in doubt, then simple, quick investigations should be performed. Basic blood tests would include a full blood count and C-reactive protein in order to provide information on infectious processes. In the context of lower limb swelling, a raised D dimer can be indicative of a DVT. X ray imaging can provide information on bony architecture, but in the case of superficial soft tissues masses, ultrasound would be the radiological imaging of choice, being able to provide information on both vascular involvement (Doppler) and the morphology and content of a mass. All of these tests can be performed in an emergency room setting, and help to differentiate between the majority of diagnoses above, particularly those that pose immediate threat to life or limb (e.g. DVT, arterial ischaemia). Beyond this, MRI and CT imaging can be used to determine more insidious diagnoses that might not otherwise be revealed by other investigations (for example, non-specific inflammatory conditions or soft-tissue or bony neoplasia, respectively). Although enlarged iliopsoas bursa is an extremely rare cause of the collection of symptoms described in the case above, this combination of clinical and radiological investigation could have improved the speed of diagnosis and treatment for this patient in two key areas. Firstly, the use of clinical scoring systems, such as the Wells’ score in this instance, can be confusing when used out of context: the presence of a groin mass was ignored initially, with the remainder of symptoms correlating with a diagnosis of DVT. Subsequently, risk of bleeding into the mass was then used as a clinical reason for stopping anticoagulant therapy. Secondly, the patient was discharged without further investigation. Following the US scan, no clear diagnosis or cause for the mass was determined: at this early stage a diagnosis of neoplasia was not considered and the patient was discharged for conservative management of the mass. Fortunately, at follow-up, this was not found to be the case. The decision-making process here highlights two key points in patient care: (1) the value of early patient follow-up (this will reveal whether or not the patient is demonstrating any improvement or worsening, warranting further investigation), and, (2) the importance of reviewing a differential diagnosis when no clear pathology can be found, which in this case would have meant earlier MRI scan and earlier treatment for the appropriate diagnosis.
Massive iliopsoas bursa is a rare cause of swelling in the groin but should be considered in the differential diagnosis. Urgent imaging combining US and MRI will exclude venous occlusion and thrombosis, whilst affording an accurate diagnosis and aid planning of management. Prompt surgical exploration and excision in those with compressive features will result in resolution of symptoms.
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|How to Cite this Article: Jeavons RP, Ryan DJ , Dowen D, O’Brien S. Massive Spontaneous Iliopsoas Bursa Mistaken as a Deep Vein Thrombosis. International Journal of Surgical Cases 2015 Oct-Dec;1(2): 14-16.