Left Distal Thigh Research Articles

Spontaneous distal migration of Kuntscher intramedullary nail into leg from malunited distal femur fracture: A rare case report

Kuntscher cloverleaf nail, also called as K-nail, is an intramedullary nail (IMN), made from stainless steel with a slot along the longitudinal axis. It is used in fixation of short oblique, simple transverse, Winquist- I and II comminuted fractures of femur. This was a case in which the Kuntscher nail spontaneously migrated distally, and was extruded completely from the femur into the leg along the posterior aspect till the ankle with the most probable cause being malunion of an oblique distal femur fracture. There were no recent reports on this type of distal migration till date. A 72-year-old male, who is working as farmer in a rural area, came to our institution with pain and swelling on & off around the left ankle for last two months during May 2022. Local examination of left lower limb revealed that there was swelling around the left ankle. There was a palpable hard metallic object posterior to the left medial malleolus. There is a single well healed surgical scar of length 10 cms on the lateral aspect of left distal thigh. Radiological workup was done accordingly. Final diagnosis was – Postoperative spontaneous migration of Kuntscher nail into the leg from a malunited fracture of lower 1/3 of left femur. Treatment plan was implant removal. After implant removal, the patient was discharged in a stable condition and follow-up till 6 months revealed no complaints around the ankle or knee joints. Distal migration of K-nail across the knee joint after femur diaphyseal fracture fixation is a rare and preventable complication. It is recommended that K-nails should be routinely removed as soon as radiological union and consolidation of the fracture is confirmed, to avoid rare postoperative complication of distal migration of the K-nail.

PROSTHETIC VALVE INFECTIVE ENDOCARDITIS CAUSED BY SERRATIA MARCESCENS IN A PATIENT WITH SURGICAL WOUND INFECTION

PROSTHETIC VALVE INFECTIVE ENDOCARDITIS CAUSED BY SERRATIA MARCESCENS IN A PATIENT WITH SURGICAL WOUND INFECTION

S3080 Metastatic Merkel Cell Carcinoma Presenting as Silent Infiltrative Liver Disease: A Lesson Emphasizing the Utility of Liver Biopsy in the Exclusion of Immune Checkpoint Inhibitor-Mediated Hepatotoxicity

Introduction: Merkel cell carcinoma (MCC) is a rare neuroendocrine tumor that arises on skin exposed to the sun and occurs in patients who are Caucasian, elderly, and immunocompromised. The mortality of MCC is about 33% and disseminated disease suggests poor prognosis. Metastasis to the liver is exceedingly rare, with only few reported cases presenting as infiltrative liver disease. We present a case of MCC with “silent” infiltration in the liver effectively differentiated from suspected immune checkpoint inhibitor-mediated hepatotoxicity (IMH) by liver biopsy Case Description/Methods: A 76-year-old man with a history of metastatic MCC of the left distal thigh status-post stem cell transplant presented to a cancer care center for evaluation of fatigue, nausea, and dyspnea. He reported consuming 10 alcoholic drinks a week for many years until 2 years ago. He was started on a treatment regimen of pembrolizumab and plinabulin (a phase I microtubule inhibitor) with radiation to the liver 2 months ago. On admission, serum transaminases were elevated from baseline as indicated in Table 1. After an initial period of observation, the patient was started on oral budesonide 9 mg/d and ursodiol 1000 mg/d for empiric treatment of IMH without subsequent improvement in liver enzymes. Liver imaging was unrevealing for liver lesions. A diagnostic parenchymal liver biopsy was performed to clarify the underlying diagnosis, including possible IMH, drug-induced liver injury from plinabulin toxicity, radiation-induced liver injury, or metastatic disease. Histology showed that the tumor cells were strongly positive for synaptophysin, chromogranin, and extensive metastatic MCC. The steroids were discontinued, and the worsening hepatitis was attributed to Merkel cell liver infiltration. The patient subsequently passed away 3 months later from cancer. (Figure) Discussion: Traditionally when there is high suspicion, IMH is clinically diagnosed without expectation for liver biopsy, and steroids are often prescribed upfront. One critique regarding the role of liver biopsy may be that histological features associated with IMH are nonspecific, with features of lobular to pan-lobular hepatitis. However, the absence of an alternative findings on the biopsy confers additional confidence towards the diagnosis of IMH. This case highlights the importance of the diagnostic liver biopsy prior to immunosuppressive treatment for suspected IMH to exclude other differentials and guide the decision for empiric steroids.Figure 1.: Solid nests and lobules of poorly differentiated neuroendocrine cells are seen in this liver biopsy A) Merkel cell chromogranin - Tumor cells are strongly and diffusely positive for chromogranin. B) Merkel cell CK20- Tumor cells show perinuclear dot-like reactivity to Cytokeratin20 C) Merkel cell synaptophysin- Tumor cells are strongly and diffusely positive for neuroendocrine marker Synaptophysin. Table 1. - Prior to initiating immunotherapy, serum transaminases rose slowly but remained within 3x upper limits of normal (ULN) Laboratory Value Prior to Admission On Immunotherapy Day 1 Of Admission After Initiating Steroids Aspartate Aminotransferase (AST) 41 U/L 269 U/L 281 U/L Alanine Aminotransferase (ALT) 46 U/L 315 U/L 240 U/L Alkaline Phosphatase (ALP) 87 U/L 226 U/L 227 U/L Total Bilirubin 0.3 mg/dL 0.7 mg/dL 1.1 mg/dL International Normalized Ratio (INR) 1.06 1.15 1.18 At the end of treatment, transaminases reached >5 times ULN. No improvement was seen in liver enzymes after initiating empiric steroid therapy for suspected IMH.

Tumoral Calcinosis in Distal Femur: First Documented Case in a Tertiary Medical Center in Philippines

Tumoral calcinosis is a rare clinical and histopathologic syndrome characterized by calcium phosphate deposition in peri-articular soft tissue regions, most commonly in the large joints of the hips, shoulders, and elbows. We present the case of a 49-year old female with 8 months history of gradual increasing, painless swelling along her left distal thigh. Plain radiography demonstrated a dense lobulated cluster of calcific nodules within soft tissues consistent with a diagnosis of tumoral calcinosis, as confirmed by histopathological examination. Using this case as illustration, the first case of such nature in our institution, we reviewed pertinent literature related to the management of tumoral calcinosis. Although the pathogenesis in tumoral calcinosis is controversial, the ideal management is surgical excision with complete removal of abnormal tissue to prevent recurrence and to focus on the reduction of serum phosphate levels.

UNUSUAL AND AGGRESSIVE COURSE OF GIANT CELL-RICH OSTEOSARCOMA OF FEMUR: A CASE REPORT

Primary tumors of bones are rare and composed of around 0.2% of the total load of tumors in humans. Among primary tumors, osteosarcoma is the most common primary non-hematopoietic malignancy. Giant cell-rich osteosarcoma (GCRO) is a rarest histologic variant and comprised of only 1–3% of the total burden of conventional osteosarcoma. Here, we present the case of a 16-year-old female patient with complaints of pain in the left distal thigh for 3 weeks and swelling for 1 week. The X-ray showed the lytic lesions, with a wide zone of transition over the meta-diaphyseal distal femur with a pathological fracture in the supracondylar area and Codman’s triangle. Further investigation revealed the diagnosis of GCRO with the proximal tibia and lung metastasis. The prognosis was explained and radical amputation was planned in the form of above-knee amputation. However, in the post-operative period and before the commencement of the adjuvant therapy, the patient became dyspneic and her Glasgow coma scale started deteriorated and unfortunately, she could not be revived.

SUN-483 A Retrospective Diagnosis of Malignant Struma Ovarii After Discovery of Pulmonary Metastases

Background: Malignant struma ovarii is a rare ovarian tumor that is histologically identical to differentiated thyroid carcinoma.1 We present a case of a struma ovarii that was recognized as being malignant only after the discovery of pulmonary metastases. Clinical Case: A 29 year old female presented to the hospital with acute right lower abdominal pain, suspicious for ovarian torsion. She underwent urgent right salpingoopherectomy and pathology demonstrated a mature cystic teratoma with benign struma ovarii. Two years later, a CT of the abdomen incidentally revealed bilateral pulmonary nodules. Review of the imaging showed that these pulmonary nodules were also present two years prior, and had since become larger. Video-assisted thoracoscopic surgery was performed and lung biopsy was positive for well-differentiated thyroid carcinoma. The patient then underwent total thyroidectomy which revealed a 0.3 x 0.3 cm infiltrative papillary thyroid cancer, follicular variant, without lymphovascular invasion. Thyroglobulin level decreased from 169 ng/mL pre-operatively to 80 ng/mL post-operatively, but then continued to be variable ranging from 56 to 252 ng/mL (1.6-50 ng/mL). Thyroglobulin antibodies remained negative.Pathology from right ovary was re-reviewed at a second institution and found to be consistent with highly differentiated thyroid carcinoma with characteristic nuclear features of papillary thyroid carcinoma.A diagnostic whole body I-131 scan showed uptake within the thyroid bed, bilateral lung nodules, left distal thigh and right mid thigh. These thigh lesions were not visualized on lower extremity ultrasound. After dosimetry was performed, the patient received radioactive iodine-131 200 mCI. Post-therapy scan six days later demonstrated uptake in the thyroid bed, bilateral lungs and bilateral thighs. About five months later, thyroglobulin level had decreased to 0.4 ng/mL with a suppressed TSH. A repeat CT chest demonstrated that the lung nodules had all decreased in size, largest from 0.5 cm to 0.3 cm. Conclusion: Careful examination of struma ovarii pathology should be performed to evaluate for malignant features since benign appearing histology can present diagnostic difficulty.2 In this case, thyroglobulin level was lower than reported in previous cases; however, sites of metastases were responsive to radioactive iodine therapy indicating well differentiated disease and a favorable prognosis.

Evaluation of skeletal muscle perfusion in canine hind limb ischemia model using color-coded digital subtraction angiography

ObjectiveTo evaluate perfusion alterations in skeletal muscle in a canine hind limb ischemia model using color-coded digital subtraction angiography (CC-DSA). MethodsTwelve beagles underwent embolization at the branch of their left deep femoral artery. Right hind limbs were used as the control group. Angiography was performed before and immediately after embolization. Upon CC-DSA analysis, time to peak (TTP) was measured before embolization in both sides of the beagles' hind limbs at the middle iliac artery, and the distant, middle and proximal femoral artery. Regions of interest (ROI) peak and ROI peak time were symmetrically computed in proximal and distal thigh muscles before and immediately after embolization. The data were analyzed and compared using the Wilcoxon signed rank test. ResultsBefore embolization, ROI peak in the proximal thigh was lower than in the ipsilateral distal thigh, whereas ROI peak time in the proximal thigh was longer than in the distal thigh. In the iliac femoral artery, there was no significant difference in ROI peak, ROI peak time, or TTP between right and left sides. After embolization, ROI peaks in proximal and distal skeletal muscles of the left hind limb were significantly lower than on the contralateral side. ROI peak time was significantly longer in the left proximal and left distal thigh compared to the contralateral side. There were no significant changes in ROI peak or ROI peak time in the right proximal and right distal thigh compared to pre-embolization values. Changes in ROI peak and ROI peak time were larger in the left proximal than in the left distal thigh. ConclusionCC-DSA provided real-time measurement of changes in vascular hemodynamics and skeletal muscle perfusion without increasing X-ray usage or contrast agent dose.

Bizarre parosteal osteochondromatous proliferation of the femur: A case report

A 54-year-old man initially presented with left distal thigh pain during walking. Imaging analysis revealed a diffuse calcified or ossified mass adjacent to the medial cortex of the distal femur and absence of continuity with the medulla. We performed resection biopsy. Histological examination revealed a large amount of hypercellular cartilage showing transformation to trabecular bone and BPOP was diagnosed. Postoperative course was uneventful and he remained free of recurrence. The method of resection should depend on the stage of reactive proliferation and whether the lesion is pathologically immature or mature. We also provide a brief review of the literature.

Treatment of severe oral mucositis in a pediatric patient undergoing chemotherapy

This article reports the resolution of a case of severe oral mucositis and the treatment protocol that promoted complete remission of the lesions. A male 13-year-old patient with chondroblastic osteosarcoma in the left distal thigh and acute lymphoblastic leukemia undergoing cancer treatment with methotrexate presented with severe oral mucositis. The treatment protocol included the use of 10ml of a mucositis mouthwash and low-level laser therapy. The lesions remitted after five days of gargling with the mucositis mouthwash and two sessions of low-level laser therapy on the lesions. The use of a treatment protocol consisting of a mucositis solution associated with low-level laser therapy effectively resolved a case of severe chemotherapy-induced oral mucositis. The monitoring and treatment of oral mucositis lesions in children and adolescents undergoing chemotherapy are necessary to prevent the patient from suffering from induced comorbidities.

Cushing’s Syndrome due to a non-adrenal ectopic adrenocorticotropin-secreting ewing sarcoma in a child

Ectopic ACTH Syndrome (EAS) is extremely rare in pediatric age group. Sarcomatous tumors causing EAS are even rarer. A nine year and 4 months old male Filipino presented with a 6 months history of gradually enlarging mass on the left distal thigh. He experienced increasing appetite, rapid weight gain of about 27kgs in 5 months, recent onset of widespread acne and darkening of skin around the neck. Physical Examinations revealed cushingoid face, widespread acne, facial hair, phlethora, buffalo hump, truncal obesity, purple abdominal striae and severe acanthosis nigricans on the neck and axilla. Non-inflamed mass and slight tenderness over the left distal thigh were noted. Patient was hypertensive. Weight & height for age were at Z score above 3 and -1, respectively. Body Mass Index at Z score above 2. His pubertal development was classified as Tanner stage 1 testicular and pubic hair development. Work ups revealed hypernatremia, hypokalemia, metabolic alkalosis and elevated levels of serum cortisol and ACTH. Low and high dose dexamethasone suppression tests failed to suppress serum and urine free cortisol levels, findings which were consistent with ectopic ACTH secreting tumor. Radiological findings were normal skull and chest roentgenograms and normal computed tomographic scan of chest and abdomen. Magnetic resonance imaging of Hypothalamo-pituitary was also normal. An Immunohistochemistry result of left distal thigh mass was consistent with Ewing Sarcoma. The patient received chemotherapy with Vincristine, Doxorubicin and Cyclophosphamide. Unfortunately, patient succumbed to death 5 days post chemotherapy due to severe sepsis.

Fibrocartilaginous Intramedullary Bone Forming Tumor of the Distal Femur Mimicking Osteosarcoma

Fibrocartilaginous dysplasia (FCD) has occasionally led to a misdiagnosis and wrong decision which can significantly alter the outcome of the patients. A 9-yr-old boy presented with pain on his left distal thigh for 6 months without any trauma history. Initial radiographs showed moth eaten both osteolytic and osteosclerotic lesions and biopsy findings showed that the lesion revealed many irregular shaped and sclerotic mature and immature bony trabeculae. Initial diagnostic suggestions were varied from the conventional osteosarcoma to low grade central osteosarcoma or benign intramedullary bone forming lesion, but close observation was done. This study demonstrated a case of unusual fibrocartilaginous intramedullary bone forming tumor mimicking osteosarcoma, so that possible misdiagnosis might be made and unnecessary extensive surgical treatment could be performed. In conclusion, the role of orthopaedic oncologist as a decision maker is very important when the diagnosis is uncertain.

Primary subcutaneous hydatid cyst in the left distal thigh.

Human cystic echinococcosis, a zoonotic infection caused by Echinococcus granulosus, remains a largely extended public health problem in endemic regions. Hydatid cyst disease can occur in all viscera and soft tissues, although the liver and the lungs are the most commonly involved organs. Primary hydatid disease of the soft tissue is extremely rare, even in endemic areas, and accounts for 0.5-5.4% of all hydatid disease cases, with very little data on the incidence of subcutaneous echinococcosis. The paper will be focused on analyzing this extremely rare disease. A 14-year-old girl came to our Department of pediatric Surgery with a painless, round, palpable mass in the subcutaneous tissue of the distal anteromedial side of the left thigh. Based on clinical and laboratory findings and imaging techniques, we suspected a hydatid cyst. She was treated successfully with complete cyst excision. The macroscopic appearance suggested a hydatid cyst. Histopathologic examination of the specimen revealed a hydatid cyst. No other organ involvement has been detected. Hydatid disease should be considered in the differential diagnosis of all cystic masses in all anatomic locations, especially in regions where the disease is endemic.

Collagenous vasculopathy: a report of three cases

Cutaneous collagenous vasculopathy (CCV) is an idiopathic microangiopathy involving the superficial blood vessels that was initially reported in a 54-year-old male. We recently have identified this rarely reported entity in three Caucasian males. The first patient was a 59-year-old male with diabetes, hypertension and hypercholesterolemia who presented with multiple, red, blanchable, asymptomatic telangiectasias covering the extensor surface of the forearms, the lower abdomen and parts of the chest. The second patient was a 62-year-old male with psoriasis and extensive arthritis who presented with prominent telangiectasias on the left lateral distal thigh with mild overlying epidermal atrophy. The third patient was an 80-year-old male with atrial fibrillation who presented with blanching, telangiectatic areas on the abdomen, thighs and back. Histologically, the skin lesions showed ectatic superficial small blood vessels with laminated, hyalinized concretions around vessels that were highlighted with periodic acid-Schiff staining following diastase digestion and reactive by immunohistochemical staining with an antibody to collagen type IV. CCV is a rare and poorly understood entity with distinct histopathological features that may clinically resemble generalized essential telangiectasia (GET), yet which may affect a different demographic population than GET. Awareness of this uncommon entity may further help to elucidate its etiology.

Iliopsoas bursitis-associated femoral neuropathy exacerbated after internal fixation of an intertrochanteric hip fracture in rheumatoid arthritis: a case report

We present the case of a 63-year-old woman with a six-year history of rheumatoid arthritis (RA) and a left iliopsoas bursitis. Radiography had detected destructive changes in her hip joint associated with her bursitis, and she had reported some paresthesia along the left anterior distal thigh. Her pain and numbness remained tolerable, and her disease activity was well controlled until she accidentally fell on the floor, which resulted in an unstable intertrochanteric fracture of left femur with displacement of the proximal portion. The fracture was successfully treated with open reduction and internal fixation, but after the surgery, her femoral nerve palsy worsened. She subsequently underwent bursa excision after the failure of conservative treatment. Accordingly, after bursa excision, the postoperative course was uneventful, and her neurological symptoms gradually disappeared. We would recommend that bursa excision be considered even in cases of iliopsoas bursitis associated with mild femoral neuropathy when destructive changes in the hip joint are also present.

Nonossifying Fibroma Accompanied by Pathological Fracture in a 12-Year-Old Runner

Resident's case problem. Nonossifying fibroma (NOF) is the most common fibrous bone lesion in children. The lesion is usually asymptomatic, and rarely leads to pathological fractures. We present the case of a 12-year-old boy who appeared to be normally developed but had a pathological insufficiency fracture associated with NOF in the distal femur. He was a member of a track athletics club and ran more than 5 km every day. Seven weeks prior to the initial evaluation he felt discomfort in the left distal thigh when running and felt pain upon knee flexion. The amount of discomfort increased gradually and he began to experience pain while running 4 weeks prior to his initial evaluation. At the time of the initial evaluation, he had tenderness over the distal thigh region and there was increased pain with weight bearing. Plain radiographs showed an irregular, well-defined cortical bone lesion, suggesting NOF, with vague increased density in the bone marrow across the femur and periosteal new bone, suggesting a fracture. Computed tomography confirmed a linear fracture with increased density across the femur leading to the cortical lesion. In the process of differential diagnosis osteosarcoma, or Ewing sarcoma, and bone/joint infection were ruled out using magnetic resonance imaging. The final diagnosis based upon the images and clinical course was pathological insufficiency fracture associated with NOF. The patient was treated with initial avoidance of weight bearing using 2 crutches for ambulation, followed by progressive weight bearing over a period of 5 weeks. Active range of motion of the knee joint was allowed. Three months after onset (5 weeks after the initial evaluation), the patient had normal gait without pain, whereupon the patient resumed his sport activities, beginning with jogging. Although pathological fractures secondary to NOF in the femur are rare, NOF can cause pathological insufficiency fractures in athletes, even if the lesion is confined and small. The current case is a reminder of such a possibility. This case also provides a time course as a reference for the rehabilitation of patients in similar cases. Diagnosis, level 4.

Dedifferentiated Liposarcoma of Soft Tissue with High-Grade Osteosarcomatous Dedifferentiation

History A 59-year-old white woman presented with a painless soft-tissue mass of the left thigh that had been progressively enlarging for about 6 months. At physical examination, the left distal thigh was markedly larger than the right. The large firm mass was noted along the medial aspect of the left distal femur. The remainder of the physical examination findings were fairly unremarkable. Her medical history was significant for breast cancer, seizure disorder, diabetes mellitus, hypertension, and hypercholesterolemia. Results of laboratory evaluation including white blood cell count, electrolyte level, hemoglobin and hematocrit levels, platelet count, and liver function studies were all within normal limits.

Femoral Artery Pseudoaneurysm Caused by an Osteochondroma of the Femur: A Case Report

Introduction The osteochondroma is the most common benign tumor of bone. Typically asymptomatic bony protuberances are discovered in childhood or adolescence. Although vascular complications are rare, these bony spikes can course along an artery and cause severe arterial complications. Reported here is a case involving the use of color duplex ultrasonography (CDU) to identify a superficial femoral artery (SFA) pseudoaneurysm as a result of an osteochondroma. Case Report A 12-year-old girl had been experiencing left lower extremity pain for approximately 2 months. The pain became progressively severe, and her parents noticed that she was limping. Magnetic resonance imaging (MRI) demonstrated a mass in the left thigh, suggesting the possibility of a femoral aneurysm. A bony spicule was noted on x-ray at the distal femur, projecting posteriorly. Clinical evaluation revealed an impressive pulsatile mass in the left distal medial thigh. The left thigh was noticeably larger than the right with poor pedal pulses compared with the asymptomatic limb. CDU was performed and identified an aneurysm of the SFA at the adductor canal. There was unusual oscillatory flow in the SFA proximal to the aneurysm with monophasic signals distally. The large aneurysm size displaced the normal anatomic course of the SFA and vein. Ankle-brachial indices (ABI) were 0.72 and monophasic in the affected limb and >1.0 and triphasic in the contralateral limb. Angiography confirmed the CDU and MRA findings, demonstrating a large pseudoaneurysm at the adductor canal caused by an osteochondroma of the femur. At time of surgical repair, the bony spicule was noted to have eroded into the femoral artery. Conclusion Vascular complications as a result of an osteochondroma are rare. Rapid diagnosis is necessary to prevent serious arterial compromise in these young patients. CDU can quickly and accurately confirm the presence of a pseudoaneurysm when an osteochondroma is suspected.

A case of malignant tumor in the knee; reconstruction with Stanmore resection prosthesis

A 15 year-old female patient was admitted with pain and swelling in her left knee and distal thigh. The knee had a 35 degrees flexion range, painful when attempted. Radiologically, a Iytic tumor in the distal third of the left femur which had expanded the bone entirely, containing the femoral condyles, invasing the subchondral bone, and sometimes destructing the cortex, was seen Histologic diagnosis was fusiform celled tumor with a low grade of malignancy. We decided to perform local resection and reconstruction in two stages. Local resection was perforrned and an intramedullary Kuntscher nail was inserted into the proximal femur and tibia. Mthylmethacrylate was used as spacer at the first satge. At the second stage, the Kuntscher nail and the spacer was removed and the Stanmore resection type total knee prosthesis was applied.