A 24-year-old male presents with a painful, stiff elbow after sustaining an injury 4 months ago. A radiograph is shown in Figure A. Which of the following statements is true about his condition?
Early excision has been found to decrease rate of recurrence compared to excision after maturity
Radiographs may be used to assess maturity of the lesion
Bone scan will always be negative once the lesion is considered mature
The lesion is considered mature 12 months after initial radiographic findings are seen
Alkaline phosphatase level measurements are used to determine the maturity of the lesion
Traditional approaches to the surgical treatment of HO have recommended delaying surgical intervention until alkaline phosphotase levels normalize and the heterotopic bone is mature on radiographs and quiescent on triple bone scan. Depending on what literature you read, HO is thought to mature by 6-12 months. However, HO may still be 'positive' on bone scan after this period of time. In addition, Shehab et al. state that ALP is a recommended screening tool for HO. This lab value cannot, in isolation, be used to determine the maturity of HO because ALP levels can return to normal even when HO is in the active form.
As stated in the Orthobullets review topic, ALP, along with other factors, can help to determine timing of HO resection, although this remains controversial.
Shehab D, Elgazzar AH, Collier BD. Heterotopic ossification. J Nucl Med. 2002 Mar;43(3):346-53. Review. PubMed PMID: 11884494. Level of Evidence: Undefined.
PMID: 11884494 (Link to Abstract)
The learning Text is misleading: it says that marked decrease in bone scan activity and normalisation of Alp is helpful in determining the timing of resection while answer 5 is wrong.
Lytic lesion of the right ischium in a 42M (C2673)
42 / M - The patient is a 42 year old male who gives a history of injury to his right buttock after sustaining a fall while playing volleyball approximately 6 months ago.
He recovered well from the initial injury and was able to run and continue training.
He subsequently developed activity-related mild right buttock pain that began about ~1 month after the initial injury.
The patient feels his current pain may be related to his previous injury.
No fever / night pain / weight loss / rest pain / systemic symptoms.
What is the likely diagnosis?
there are no signs of aneurysmal bone cysyt like multible loculi or fluid level and lesion not likely to be chondrosarcoma as it is well defined even if it is alytic lesion so i think it is agiant cell tumour
Ann Surg Oncol. 2012 Apr;19(4):1081-8. Epub 2011 Nov 4.
it is very important to note that metastasis in myxoid liposarcoma and round cell liposarcoma is mainly to soft tissue and skeleton. Lung metastasis is less common. Whole body MRI should be included in the staging.Myxoid\round cell liposarcoma (MRCLS) revisited: an analysis of 418 primarily managed cases.Moreau LC, Turcotte R, Ferguson P, Wunder J, Clarkson P, Masri B, Isler M, Dion N, Werier J, Ghert M, Deheshi B, Canadian Orthopaedic Oncology Society (CANOOS).Ann Surg Oncol. 2012 Apr. doi: 10.1245/s10434-011-2127-z. 19. (4). :1081-8PMID: 22052112 (Link to Abstract)
A 61-year-old female presents with a 6 month history of pain in the left hip and thigh. A hip radiograph is shown in Figure A. Serum protein electrophoresis is normal, and a bone scan shows increased uptake in the left femur only. A biopsy is taken and shown in Figure B. What is the most likely diagnosis?
Primary lymphoma of bone
Just a typo - "....can be management with replacement..."
A 53-year old female presents to your community hospital with right shoulder pain of 2 weeks duration, night sweats, and loss of appetite. Her past medical history is significant for hypertension only. A radiograph is performed and is shown in Figure A. What is the most appropriate next step in management.
CT guided biopsy
Referral to an orthopaedic oncologist
I could not insert this reference, but you can find it on pubmed.Clin Orthop Relat Res. 2015 Mar;473(3):868-74. doi: 10.1007/s11999-014-3649-z.What is the use of imaging before referral to an orthopaedic oncologist? A prospective, multicenter investigation.
Int Orthop. 2013 May;37(5):877-82. Epub 2013 Feb 17.
Int Orthop. 2013 May;37(5):871-6. Epub 2013 Feb 23.
Musculoskeletal tumors and tumor-like conditions: common and avoidable pitfalls at imaging in patients with known or suspected cancer: Part A: benign conditions that may mimic malignancy.Ulaner G, Hwang S, Lefkowitz RA, Landa J, Panicek DMInt Orthop. 2013 May. doi: 10.1007/s00264-013-1823-7. 37. (5). :871-6PMID: 23436133 (Link to Abstract)Musculoskeletal tumours and tumour-like conditions: common and avoidable pitfalls at imaging in patients with known or suspected cancer: Part B: malignant mimics of benign tumours.Ulaner G, Hwang S, Landa J, Lefkowitz RA, Panicek DMInt Orthop. 2013 May. doi: 10.1007/s00264-013-1824-6. 37. (5). :877-82PMID: 23417556 (Link to Abstract)
As this lesion is highly suspicious for chondrosarcoma, carefully design the biopsy incision or needle insertion is even more critical, because there is no good neoadjuvant treatment for chondrosarcoma. So the outcome is purely dependent on the surgical margins including appropriately excising the area contaminated by biopsy.If there is an orthopaedic oncologist in town, and the pt can see him very quickly, I would suggest you leave to the oncologist to order further imaging studies. in the two attached papers, it has shown that there is a high prevalence of inappropriate advanced imaging studies before referral. Either some imaging studies were unnecessary, or some studies were not done correct. For example no iv contrast with MRI exam for a soft tissue mass, or the images did not cover enough area. An MRI exam for a possible bone or soft tisseu tumor should be done with a different protocol from that for a shoulder injury.However, if you have to refer the pt out of town to a long distance or the appointment is too late, order more imaging studies with good faith for sure helps to save patient's time and may expedite the treatment. A phone call with the orthopaedic oncologist will be a good idea before referral.Evaluation of imaging utilization prior to referral of musculoskeletal tumors: a prospective study.Nystrom LM, Reimer NB, Dean CW, Bush CH, Scarborough MT, Gibbs CP JrJ Bone Joint Surg Am. 2015 Jan 7. pii: 97/1/10. doi: 10.2106/JBJS.N.00186. 97. (1). :10-5PMID: 25568389 (Link to Abstract)Evaluation of imaging utilization prior to referral of musculoskeletal tumors: a prospective study.Nystrom LM, Reimer NB, Dean CW, Bush CH, Scarborough MT, Gibbs CP JrJ Bone Joint Surg Am. 2015 Jan 7. pii: 97/1/10. doi: 10.2106/JBJS.N.00186. 97. (1). :10-5PMID: 25568389 (Link to Abstract)
While I agree this is most likely tumour one must surely remember that we should biopsy every infection and culture every tumour. The next step (this is what the question asks) in this patient would be blood cultures which take 2 minutes to do followed by referral to an oncologist. Biopsy should be done at a ortho oncology unit.
A 10-year-old male presents for evaluation of a painless deformity of his lower leg. Based on the radiograph and histology slide shown in Figures A and B, what is the next best step for this patient?
Casting and monthly follow up
Curettage and bone grafting
Osteotomy with plate application
its very difficult. typically you have to follow with progression over time or have a VERY experienced pathologist to make the diagnosis of adamantinoma.
Metastatic Disease of Extremity
British Orthopedic Oncology Society and British Orthopedic Association has a very good guidelines to help deal with metastatic bone disease of extremity and spine. In addition, they discussed when to refer to an oncology specialist. I recommend going through them. I have uploaded the guidelines in the oncology group. Last guidelines revision was 2015.
Metastatic Disease of Spine
A 44-year-old male reports a mass at his right iliac crest that bothers him when he wears a belt. He denies constitutional symptoms and has no bowel function disturbance. His ESR and CRP are normal. His chest CT is normal. Pelvis radiograph, CT, and MRI images are shown in Figures A-D. A biopsy is performed with histology shown in Figure E. What is the next most appropriate step in management?
Repeat CT scan in 3 months
Neoadjuvant radiation followed by marginal surgical resection followed by adjuvant chemotherapy
Marginal surgical resection
Wide surgical resection
Neoadjuvant chemotherapy followed by marginal surgical resection followed by adjuvant chemotherapy
Dr Stefanides - Cartilage cap >2cm is suspicious for malignant transformation on the MRI. I'm no pathologist so this was why I thought it was malignant!
Metastatic bone disease HAVE WE IMPROVED AFTER A DECADE OF GUIDELINES?
This article discuss case series of metastatic bone disease with common faulty management. It shows good examples how metastatic bone disease can be difficult in diagnosis and management and should be dealt with very cautiously.[PMLINK][PMTITLE]Metastatic bone disease: Have we improved after a decade of guidelines?[/PMTITLE] [PMAUTH]Harvie P, Whitwell D[/PMAUTH] [PMSRC]Bone Joint Res. 2013. pii: 2/6/96. doi: 10.1302/2046-3758.26.2000154. 2. (6). :96-101[/PMSRC] [PMID]23836473[/PMID][/PMLINK]
skip lesions are poor prognostic indicator for osteosarcoma
presence of skip lesions in osteosarcoma. It also indicate existence of distant metastasis and poor response to chemotherapy.[PMLINK][PMTITLE]Secondary bone lesions in the affected limb in osteosarcoma (skip lesions), its classification and prognosis.[/PMTITLE] [PMAUTH]Ahmed AR[/PMAUTH] [PMSRC]Arch Orthop Trauma Surg. 2011 Oct. doi: 10.1007/s00402-011-1304-7. 131. (10). :1351-5[/PMSRC] [PMID]21484427[/PMID][/PMLINK]
Great question. How can you tell whether this is an adamantinoma radiographically and histologically?
A 53-year-old woman with a history of Paget's disease and bilateral total hip arthroplasties presents with left hip pain and dysuria. An AP pelvic radiograph and CT scan are shown in Figure A and B. What is the next most appropriate step in management?
Revise the left hip total arthroplasty with a cemented stem
Open reduction and internal fixation of the acetabular fracture
Rest, IV bisphosphanates and follow-up in 6 weeks
Technetium Tc 99 and CT of the chest, abdomen and pelvis
Dr. Harris - the first paragraph of the question covers the concept and even refers to the multiple distractors in this scenario. This is a real-life type question, and when the mass is noted on a CT of the pelvis, further investigation must be performed, and none of the other answers are diagnostic in nature. The question is currently getting 82% correct from our users, which is in our target range.