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A 32 year old from Nicaragua with a large tumor in the knee

Case Identification
Case ID Number: 
20120102FJ
Benign/Malignant: 
Benign
Clinical case information
Case presentation: 

FJ is a 32-year-old father of two small children who presented to the local hospital in Nicaragua with a painful tumor in the left distal femur. A biopsy was made and the diagnosis was giant cell tumor. The patient was told that he needed an amputation, but he refused.

Radiological findings:: 
The patient did not wish to have an amputation and he returned home. Several months later he presented again, this time with severe pain. He was no longer able to walk or move due to the pain. The tumor had enlarged and there was an unstable pathological fracture of the distal femur. The x-rays show a destructive, lytic lesion, with no bone formation or matrix which had completely destroyed the distal femur. A displaced and unstable pathological fracture was also noted. It was uncertain if the osteopenia in the proximal tibia was due to disuse or due to extension the tumor.
Laboratory results:: 
No laboratory examinations ordered.
Differential Diagnosis: 
The diagnosis had been confirmed by pathological examination to be giant cell tumor.
Pathology results:: 
Confirmed as giant cell tumor.
Treatment Options:: 
In developed countries, this patient would be treated with a distal femoral replacement, either using a mega prosthesis or a distal femoral allograft. However, these resources were not available, and the only remaining option was some type of amputation. Fortunately, the patient had healthy, normal bone and soft tissue below the knee that could be saved. As a result, the patient was a good candidate for rotationplasty. A rotationplasty is a modified amputation where the distal portion of the leg is saved rather than being cut off. This procedure has the potential to give the patient a far better functional result than an above-knee amputation.
Special Features of this Case:: 
Due to the limited local resources, some sort of amputation was the only option. A rotationplasty is a modified amputation where the distal portion of the leg is saved rather than being cut off. The leg and ankle are turned 180 degrees, so that the strong and healthy ankle joint can function as a knee joint. This allows the patient to use shorter prosthesis and walk crutch-free. However, to achieve this goal, the patient still faces a long period of rehabilitation and a complex prosthetic fitting. Because of his extremely limited resources and the limited resources of his country, a donated prosthesis will be required. Special fitting and re-configuration of the socket portion of the prosthesis will be required so that the patient can get back on his own two feet.

A 36 year old woman with metatarsal lesion

Case Identification
Case ID Number: 
20091110FP
Periosteal Reaction: 
absent
Benign/Malignant: 
Benign
Clinical case information
Case presentation: 

The patient is a very pleasant 36 year old woman who has noticed a pain in the foot since approximately one month ago.

Radiological findings:: 
Plain radiographs, a bone scan, and MRI are assessed. A lytic, slightly multilocular lesion in the midportion of the second ray is seen. The dimensions are approximately 2 0.5 cm x 1 cm. It seems to extend through one cortex. It does not have any matrix mineralization. It is non-expansile and there is no periosteal reaction.The bone scan shows that the lesion has abnormally increased uptake. The MRI shows a lesion in the above-named location that has bright signal on T2 weighted images. There is destruction of one cortex. There is some surrounding edema.
Further Work Up Needed:: 
This lesion needs to be characterized by biopsy. Possible choices include chondromyxoid fibroma, or other benign lesion. It does not have malignant appearance. Nevertheless, malignancy is still a possibility.

A 42-year-old man with massive swelling in the knee

Case Identification
Case ID Number: 
03302009a
Benign/Malignant: 
unknown
Clinical case information
Case presentation: 

Patient is a professional chef, and reports pain in the knee for more than 10 years. There is reduced motion accompanied by a palpable vibration in the knee when the patient flexes and extends the joint.

Radiological findings:: 
Examination of the left knee shows dramatic the of the right with a known swelling, there is reduced motion due to fluid. There is so much fluid in the knee that flexing and extending the knee is slow because the fluid needs to move to allow the motion. This is accompanied by a palpable vibration in the knee when the patient flexes and extends the joint. No loose bodies or crepitus is felt. Rather the palpable sensation in the knee with motion seems to be related to fluid shift. The x-ray findings are consistent with moderate to severely advanced osteoarthritis, but show no other definitive features. There is generalized joint space narrowing, some mild irregularity of there are some small bone spurs and the opposite knee shows totally normal bone anatomy. The MRI shows severe damage to the joint and an impressive effusion. There is generalized narrowing of the cartilage, subchondral bone edema, bone spurs, and a large effusion that had extended into the posterior aspect of the knee around the hamstring tendons. No loose bodies are seen in the joint
Differential Diagnosis: 
PVNS
Special Features of this Case:: 
This case is typical of the underlying diagnosis. It has reached a relatively advanced stage. In this particular case, the patient has been able to maintain his function by taking large daily doses of narcotic pain medicines. This may actually allow exacerbation or potentiation of the reactive process.

A 43 year old woman with breast cancer presents with severe hip pain and inability to walk

Case Identification
Case ID Number: 
20091117AA
Benign/Malignant: 
unknown
Clinical case information
Case presentation: 

A 43 year old woman with a history of breast cancer with bone metastasis presents with severe hip pain and inability to walk. Plain radiographs and a CT image of her right proximal femur are shown.

Radiological findings:: 
The patient has been active and her general condition is quite good. You have decided that the patient has the appropriate indications for operative intervention. What procedure do you choose?
Treatment Options:: 
The failure rate associated with fixation devices used to stabilize metastatic lesions of the proximal femur has been published . What is the liklihood of failure of a proximal femoral plate and compression screw device based on this report? What is the reported overall failure rate at 60 months for femoral fixation?
Special Features of this Case:: 
Here is a abstract of a publication that addresses this reconstructive challenge: Clin Orthop 1990 Feb;(251):213-9 Metastatic bone disease. A study of the surgical treatment of 166 pathologic humeral and femoral fractures. Yazawa Y, Frassica FJ, Chao EY, Pritchard DJ, Sim FH, Shives TC. Department of Orthopedics, Mayo Clinic, Rochester, MN 55905. A retrospective study of the surgical treatment of 166 metastatic lesions of the humerus and femur in 147 patients was performed. There were 106 women and 41 men whose average age was 62 years. Two-thirds of the patients were treated for complete fractures, while one-third were treated for impending fractures. Breast, lung, and kidney carcinoma accounted for the majority of the primary lesions. One-half of the patients died within nine months of surgery, while one-quarter were alive 19.1 months after surgery. The patients with breast cancer had the best prognosis, while the patients with lung cancer had the worst. The probability of implant failure increased linearly with time to 33% at 60 months. The probability of failure for the femoral lesions was greater, with 44% at 60 months. The average survival in the patients with failed fixation in the femoral lesions was 34.5 months with a mean interval to failure at 17.7 months. The failure rate was high (23%) in proximal femoral lesions treated with a compression screw or nail plate. Common reasons for failure included poor initial fixation, improper implant selection, and progression of disease within the operative field. Bone cement augmentation should be used with the fixation device when possible. Complications due to hip-screw cut-out from the head may also be reduced by applying bone cement around the screw threads.
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