Left Proximal Tibia Research Articles

Perianal Lesion as the Leading Presentation of Langerhans Cell Histiocytosis: Report of a Case

Langerhans cell histiocytosis is a proliferative hematological disease with pleomorphic characters. Here, we present a very unusual case of Langerhans cell histiocytosis in a young male patient without a specific previous medical history, who had a perianal lesion as the leading symptom. This 17-year-old patient presented with perianal erythematous nodules for two months, unresponsive to topicals. Langerhans cell histiocytosis was suggested by histopathological examination after excisional biopsy. Thorough investigations revealed additional involvement of the left posterior temporal region of the cranium, and the left medial proximal tibia. However, these bone lesions caused no symptoms. Langerhans cell histiocytosis should always be included in the differential diagnosis list for patients with nonspecific perianal lesions. For any perianal mass in doubt, a simple biopsy examination is necessary.

Donor-Specific Anti-HLA Antibodies After Bone-Graft Transplantation. Impact on a Subsequent Renal Transplantation: A Case Report

Immunological evaluation by panel-reactive antibody (PRA) and determination of anti-HLA specificity are important phases in the evaluation of patients awaiting kidney transplantation. The main causes of immunization are previous solid organ transplantation, hemotransfusion, and pregnancy. It is also possible that immunogenicity can be triggered by vascularized tissue grafts. Immune induction by cryopreserved bone prostheses is not yet understood. A 19-year-old patient with osteosarcoma had undergone resection of the left proximal tibia with reconstruction using human bone in 1997. The donor HLA typing was as follows: A3, A29 (19); B44 (12), Bw4; DR13 (6), DR7, DR52, DR53. The patient was subsequently enrolled onto the waiting list for cadaveric donor kidney transplantation due to chronic kidney failure caused by cisplatin toxicity. Pretransplantation immunological screening using the complement-dependent cytotoxicity (CDC) technique revealed a PRA of 63%. IgG antibody specificities were detected against class I and class II donor antigens, specifically anti-A3, B44, DR7 antibodies, using flow cytometry (Tepnel Luminex). Further immunological studies using single HLA specificity analysis (LSA Class I°–II°, Tepnel-Luminex) showed direct antibodies against all donor antigen specificities. This case showed immune induction after the implantation of bone prosthesis in a kidney transplant candidate, underlining the importance of the availability of HLA typing data of donors of a human prosthesis.

Systemic levels of metallic ions released from orthodontic mini-implants

Orthodontic mini-implants are a potential source of metallic ions to the human body because of the corrosion of titanium (Ti) alloy in body fluids. The purpose of this study was to gauge the concentration of Ti, aluminum (Al), and vanadium (V), as a function of time, in the kidneys, livers, and lungs of rabbits that had Ti-6Al-4V alloy orthodontic mini-implants placed in their tibia. Twenty-three New Zealand rabbits were randomly divided into 4 groups: control, 1 week, 4 weeks, and 12 weeks. Four orthodontic mini-implants were placed in the left proximal tibia of 18 rabbits. Five control rabbits had no orthodontic mini-implants. After 1, 4, and 12 weeks, the rabbits were killed, and the selected tissues were extracted and prepared for analysis by graphite furnace atomic absorption spectrophotometry. Low amounts of Ti, Al, and V were detectable in the 1-week, 4-weeks, and 12-weeks groups, confirming that release of these metals from the mini-implants occurs, with diffusion and accumulation in remote organs. Despite the tendency of ion release when using the Ti alloy as orthodontic mini-implants, the amounts of metals detected were significantly below the average intake of these elements through food and drink and did not reach toxic concentrations.

Plain X-ray, computed tomography and magnetic resonance imaging findings of telangiectatic osteosarcoma: a case report

An 18-year-old male patient presented with chronic nonspecific pain of three months located at his left proximal tibia. The patient was admitted to our department for plain X-ray, computed tomography and magnetic resonance imaging examination. Plain X-ray and computed tomography revealed a geographic lytic lesion at the medial aspect of the proximal tibia. Biopsy of the lesion showed telangiectatic osteosarcoma. Image findings of all modalities are presented.

Multiple Leg Pains in a Collegiate Distance Runner

HISTORY: A 19 year old college sophomore distance runner presented with complaint of left lower leg pain for 2 weeks. Her pain began with running only, however progressed to pain with walking. Pain was in one spot on her left mid-posterior tibia and right femur. Denied low back pain, paresthesias, symptoms of compartment syndrome or disordered eating. Regular menses. History includes bilateral shin pain while competing in high school, but was never seen for it. Freshman year presented with bilateral shin pain. Radiographs revealed a small area of callus formation to the left proximal medial tibia. Bone scan revealed 4 areas of increased uptake: 1 to the proximal left tibia, 2 to the distal right tibia, and the last to the posterior right femur which was asymptomatic. She was placed in bilateral long leg air casts and restricted to pain free activities. She was pain free 2 months later and returned, through a month progression, to full activity. After 3 months of full activity she again developed right distal tibia pain and new left fibular pain. 2nd bone scan revealed increased uptake to the right distal tibia and the mid left fibula. Previous area of increased uptake to femur and left tibia had resolved. CBC, CMP, ionized calcium, 1,25-OH Vit. D, intact PTH, celiac sprue labs, 24 hour urine for calcium were all normal. 25-OH Vit. D was low normal so Vitamin D started. Patient was seen by a dietician and a formal physical therapy evaluation completed. Custom orthotics made. Recommended DEXA scan but patient declined. PHYSICAL EXAM: Exam revealed tenderness to the mid third of the left tibia posteriorly. No femoral tenderness. Negative fulcrum test. Pulses normal. Sensation normal. Normal arches. Good proprioception. Normal gluteus medius strength. Full hip ROM. Normal ankle strength. No ankle instability. DIFFERENTIAL DIAGNOSIS: Bilateral tibial stress fractures Medial tibial stress syndrome Chronic exertional compartment syndrome Bone contusion TESTS AND RESULTS: Bone scan (3rd): -Showed 3 areas of increased uptake: 1. midshaft of right femur, 2. midshaft of left femur, and 3. midshaft of left tibia. FINAL WORKING DIAGNOSIS: Multiple bilateral, recurrent, lower extremity stress fractures. TREATMENT AND OUTCOMES: Endocrinology consult initiated. F-scan & DEXA scan ordered. Previous treatments repeated.

Juvenile juxtacortical chondromyxoid fibroma of bone: a case report

Conventional intramedullary chondromyxoid fibroma (CMF) is a rare benign tumor of bone; juxtacortical lesions are rarer still, and juxtacortical lesions occurring in children are heretofore essentially unreported. We present a case of such a lesion in a 12-year-old boy. This patient, who was previously healthy, presented with a 1-week history of poorly defined pain and mild swelling in the region of the left proximal tibia. Magnetic resonance imaging and bone scan showed changes most consistent with an aggressive biological process. However, the permanent histologic sections showed a (pseudo) lobular pattern of spindle cells with minimal pleomorphism and other features consistent with CMF. A clonal abnormality was detected in 15% of tumor cells karyotyped, characterized by a break in the long arm of chromosome 6 and a balanced Robertsonian translocation involving chromosomes 14 and 21. The patient has remained well and free of recurrence for more than 4 years. In general, CMF needs to be distinguished from its mimicker low-grade chondrosarcoma, and it must be recognized as occurring on bone surfaces among a wide age range of individuals. Juxtacortical CMF has not proven to be unusually aggressive in adults nor in this child, and marginal (en-block) resection remains the treatment of choice.

Osteochondrosis Dissecans in a Juvenile Roan Antelope (Hippotragus equinus)

A 4-mo-old, juvenile roan antelope (Hippotragus equinus) presented for an acute and progressive lameness of the left hind limb, which was non-responsive to anti-inflammatory medication. The antelope was anesthetized for examination, radiography, and lab work. The left stifle joint had limited range of motion and was markedly swollen on physical examination. Radiography revealed thin cortices of the left distal femur and proximal tibia, as well as multiple lytic areas in the condyles. Euthanasia was performed due to the severity of the lesions and the animal's overall physical condition. Postmortem findings included a parasitic infection of the gastrointestinal tract. Cartilaginous erosions, associated with fibrotic connective tissue and viscous joint fluid, were identified in all appendicular joints. Perimortem lab work demonstrated anemia and hypoproteinemia. Joint fluid was inflammatory but non-infectious, and aerobic culture of the joint was negative for pathogens. Histologic examination identified focal, transmural necrosis of the articular cartilage with clefting. Osteochondrosis dissecans was diagnosed, which initiated an evaluation of the nutritional status and management of the herd. This is the first documented case of osteochondrosis dissecans in a roan antelope.

Right Lower Extremity Swelling

A 4-month-old male infant who was born at 24 weeks’ gestation with right lower extremity swelling. ### Prenatal and Birth Histories ### Medications The infant experienced hypercalcemia and hypophosphatemia for most of his hospital stay (Table). View this table: Table. Laboratory Values During Postnatal Hospital Stay On postnatal day 125, the infant had right lower extremity swelling. Skeletal survey showed fractures in the right distal femur, right and left proximal tibia (Fig. 1), left distal femoral epiphysis and proximal left humerus, left distal radius, right proximal humerus, right distal radius and ulna (Fig. 3 - seen later). Bilateral rib fractures also were present (Fig. 2). Associated findings included decreased bone density, minimal bowing of the lower extremities, metaphyseal widening, and significant soft-tissue swelling in the knees and shoulders. Figure 1. Portable left lower extremity radiograph demonstrates …

Infantile tibia vara: Treatment of Langenskiold stage IV

An eight year old girl presented with a progressively increasing deformity of the left proximal tibia since last 2 years. She had no history of trauma, fever and swelling of left knee. There were no obvious signs of rickets/muscular dystrophy. She had 25 degrees of tibia vara clinically with lateral thrust and a prominent fibular head. The radiograph of left knee revealed tibia vara with medial beaking and a significant depression of the medial tibial epiphysis and metaphysis. A computed tomography (CT) scan revealed significant depression of the medial tibial epiphysis but no bony bar in the physis or fusion of the medical tibial epiphysis. There was a posterior slope in addition to the medial one. She was treated with elevation of the medial tibial hemiplateau with subtuberosity valgus derotation dome osteotomy. She also underwent a lateral proximal tibial hemiphysiodesis (temporary stapling). A prophylactic subcutaneons anterolateral compartment fasciotomy was also performed. All osteotomies united in 2 months. All deformities were corrected and she regained a knee range of 0 to 130 degrees. At final followup (4 years), there was no recurrence of varus deformity, knee was stable, with 1cm of leg length discrepancy. In Langenskiold stage IV tibia vara, elevation of medial tibial plateau, a subtuberosity valgus derotation osteotomy and a concomitant lateral hemiephiphysiodesis has given good results.

Diamond-Coated Titanium Implants: The Future of Temporomandibular Joint Reconstruction

Statement: Total temporomandibular joint reconstruction is the last option for many patients with severe temporomandibular joint disease. We propose that a diamond coated implant articulation could lead to better wear properties of these devices. This animal study is one part of the biocompatibility testing of a new diamond coated biomaterial. Prior materials science and biomaterials development studies have shown diamondlike materials to be resistant to articulating wear and thereby debris generation. Development of this coating could lead to better designs, biocompatibility, and clinical longevity of these devices. Materials and Methods: Twelve round titanium discs were processed in a helium rich environment with a diamond coating along one side and titanium alloy on the other. These implants were surgically inserted into the left distal femur and proximal tibia of six rabbits, following animal resources protocols for surgery. The discs were oriented with the diamond coating posterior. After eight weeks of implantation, the rabbits were euthanized and the left leg disarticulated and preserved in formalin. Method of Data Analysis: Multiple sections were ground to 20 micrometer thickness along the implant discs. After staining with Sanderson bone stain, histomorphometric analysis was performed. Measurements taken included percent bone contact on the diamond coated side, the alloy side, and the ends, plus both quality and quantity of bone and the histological quality of the bone and marrow. Evaluation for any adverse clinical reactions was also considered. Results: A critical aspect of in vivo biocompatibility studies is the use of a standardized model with highly consistent and reproducible surgical methods. All aspects of the surgery and assessment were highly controlled. Analysis of the specimens revealed osseous integration along the diamond coated and titanium sides and no adverse reactions in the adjacent bone marrow or soft tissue. Previous studies using this model on a hydrogen processed diamond disc have demonstrated the same. Conclusion: Analysis of these specimens shows biocompatibility between the diamond coated titanium, bone, and soft tissues in the rabbit model. Direct comparison and statistical analysis of the amount of bone versus diamond coating in the hydrogen versus the helium treated discs will be performed. With proven biocompatibility, further development of this biomaterial and its use in temporomandibular joint reconstruction should proceed.

Histiocytosis X and renal insufficiency

Langerhans cell histiocytosis (LCH) is a rare disordershowing a wide spectrum of clinical manifestationsranging from single cutaneous lesions to multifocalsystemic disease [1,2]. The typical infiltration consistsof pathological monoclonal Langerhans cells togetherwith lymphocytes, eosinophilic granulocytes and non-dendritic histiocytes [3]. Langerhans cells are antigen-presenting cells with features of dendritic cells, stainingpositive for CD1a [4]. One of their original functions iscutaneous immunosurveillance. LCH is rare and theincidence in adults is 1–2 cases per million, with a meanage of 35 14 years, and is slightly more prevalent inmales [5,6]. Histological diagnosis is made if lightmicroscopic morphological characteristics of the dis-ease are found with positive staining for CD1a antigen[4,7]. In addition, Birbeck granules in the lesional cellthat are detected with electron microscopy are alsosuggestive of the disease [4,7]. Typical manifestationsof LCH in adults are central diabetes insipidus, bone,pulmonary, skin disease and dental involvement.We report a case of a patient with progressive renalinsufficiency due to multi-systemic manifestation ofLangerhans cell histiocytosis including involvement ofthe kidneys. Treatment of LCH with chemotherapyresulted in stabilization of renal function.CaseA 46-year-old male patient was admitted to ournephrology clinic in May 2006, with a 1-year historyof impaired renal function with moderate proteinuriaand glomerular erythrocyturia. In 1991, the patientwas successfully treated for fibrous alveolitis withprednisolone. Two years later, the patient developedcentral diabetes insipidus. In 1999, Histiocytosis X(Langerhans cell histiocytosis, LCH) was diagnosed ina skin biopsy obtained from an axillary erythema(histological findings: cellular infiltration of the epi-dermis with histiocytes, co-expression of S100 andCD1a; negativity for lymphocytic markers and KL-1;positive PG-M1; epitheliotropism; highly-positive toMiB1). In the follow-up, he also developed bilaterallyrelapsing therapy-resistant external otitis and swollencervical and submandibular lymph nodes. CT thoraxrevealed disseminated micronodular pulmonal opaci-ties. Skeletal scintigraphy showed a suspicious focus inthe proximal left tibia, and foci in the left mandible andleft mastoid could be localized. Thin-layer magneticresonance tomography of the sella turcica providedevidence for granuloma, with contrast enhancement inthe area of the hypophyseal stalk. An intravenousprednisolone therapy with 100mg was performed andthe cutaneous focus showed a rapid diminution.Therefore, methylprednisolone (60mg/day for 4weeks) and vinblastine (7mg/m

Distal Leg Wear Debris Mass from a Rotating Hinged Knee Prosthesis

An 18-year-old woman presented with a gradually increasing distal leg mass 8 years after wide resection for an osteosarcoma and reconstruction of the proximal left tibia with a rotating hinged knee megaprosthesis. Open biopsy of the distal leg mass showed necrobiotic tissue, metallosis, fibroblasts, osteoblasts, histiocytes, and multinucleated giant cells. The patient underwent debridement of the distal leg mass, metallosis, and wear debris surrounding the tibial component, followed by revision of the destructed polyethylene-bearing components. At the latest follow-up, 4 years after the revision surgery, the patient is alive and tumor-free, asymptomatic, and has no clinical or imaging evidence of wear and metallosis.

Traitement palliatif pour métastases proximales du tibia par enclouage centro-médullaire fémoro-tibial

We report the case of an 80-year-old woman treated by palliative knee arthrodesis for metastasis of the proximal left tibia secondary to bladder carcinoma, using percutaneous femoro-tibial intramedullary arthrodesis nailing.

Intraosseous pilomatricoma: a possible rare skeletal manifestation of Gardner syndrome

Here we report a case of intraosseous pilomatricoma in a patient with Gardner syndrome. A 17-year-old boy with a family history of Gardner syndrome and multiple cutaneous epidermoid cysts presented with pain in the region below the knee of the left leg. Plain radiographs displayed a well-circumscribed eccentric lesion of mixed radiolucent and radiopaque density within the diaphysis of the left proximal tibia. By magnetic resonance (MR) imaging, the lesion appeared as a low intensity lesion in T1-weighted images and a heterogeneous high intensity lesion with a low-signal radiation pattern on T2-weighted images. Gadolinium enhancement was observed partially within the lesion and intensely in the lesion rim. After curettage, histological examination revealed a massive accumulation of keratinous material with epithelial nests that displayed both epidermal and trichilemmal keratinization with basaloid and shadow cells and with metaplastic ossification. These features confirmed a pathological diagnosis of intraosseous counterpart of pilomatricoma. In the context of this patient's skin lesions, intraosseous pilomatricoma may be a rare skeletal manifestation of Gardner syndrome.

Bilateral multiple malignant transformation of Ollier’s disease

We treated a 26-year-old man with a 19-year history of Ollier's disease. Secondary chondrosarcomas developed metachronously at four separate locations: both femora, left proximal tibia and fibular head. All four lesions were surgically excised, and each specimen was histologically identified as grade 1 or 2 chondrosarcoma. Clinical follow-up for 20 years beginning at the time of first tumor surgery has shown no evidence of local recurrence or metastasis. This is the first report of multiple bilateral metachronous malignant transformation of multiple chondromatoses in a patient with Ollier's disease.

人工膝関節置換術後１０年以上を経て両側けい骨にｉｎｓｕｆｆｉｃｉｅｎｃｙ ｆｒａｃｔｕｒｅを来たした１例

Insufficiency fracture of the proximal tibia after total knee arthroplasty (TKA) is a rare complication. We report the case of a 65-year-old woman who sustained insufficiency fractures of both proximal tibia without trauma more than 10 years after TKA. The patient was unable to walk for three years because of bilateral severe knee pain due to rheumatoid arthritis. At our hospital, she underwent total arthroplasty of the right knee in 1991, and underwent total left knee arthroplasty in 1992. After TKA, her knee pain was relieved and she could walk with a crutch. In 2001, she felt pain in the right proximal tibia during gait without trauma, and visited our hospital three weeks later. Roentgenography showed a fracture line at the proximal tibia and fibula. In 2003, the patient sustained an insufficiency fracture of the left proximal tibia without trauma. Both tibial fractures were healed conservatively. The cause of these fractures may include generalized osteoporosis and malalignment of the tibial components. When a patient who has undergone TKA and has generalized osteoporosis complains of pain in the surrounding leg, the possibility of tibial insufficiency fracture should be considered, not only in the early post-operative phase (during which activity is increased due to rehabilitation) but also in the late post-operative phase, even in cases with no history of trauma.

Solitary intraosseous neurofibroma of the tibia

A solitary intraosseous neurofibroma is rare and mostly occurs in the mandible. We report a case of a solitary intraosseous neurofibroma of the tibia. The radiographic findings were nonspecific and showed an eccentrically located, osteolytic lesion with a thin sclerotic border in the diaphysis of the left proximal tibia. The entity of intraosseous neurofibroma is briefly reviewed.

Calcified brain metastasis of osteosarcoma: CT findings

Brain metastasis of osteosarcoma is uncommon. In this report, we present a 21-year-old man with calcified brain metastasis of the osteosarcoma of the left proximal tibia following pulmonary relapse. Cranial computed tomography (CT) scan demonstrated a single calcified mass lesion involving the right temporal, parietal and occipital lobes with surrounding vasogenic edema and significant mass effect on the midline structures.

An Unusual Case of Juxtacortical Osteosarcoma Presenting on Tc-99m MDP Bone Scan With Central Photopenia

A 26-year-old man presented with a 2-year history of a slowly enlarging, nontender left lower-extremity mass. He denied any history of trauma. Initial plain films showed a subtle, well-circumscribed, calcific mass adherent in the left anteromedial proximal tibia. Subsequent computed tomography and bone scans were performed. Both studies demonstrated a mass with increased peripheral calcification. This pattern of distribution in an exophytic lesion has been reported to be highly suggestive of heterotopic ossification. Biopsy provided a diagnosis of juxtacortical osteosarcoma. This case demonstrates a disparity between the scintigraphic findings and histologic diagnosis in a patient with suspected heterotopic ossification. A photopenic center in an exophytic lesion on bone scan might not always indicate a benign lesion.

LEG INJURY-RUNNING

HISTORY Patient is a 14-year-old high school cross-country runner, who began running at the end of August. There was no other preseason training prior to that. While running his first meet, he developed left knee pain. He had to finish the race limping. He reported no history of trauma during the race. Initially he tried treatments of ice and ibuprofen. He tried to resume running, but wasn't able to run pain free. He continued to cross-train on a bicycle. Approximately three weeks later, he sought care from his family doctor. X-rays were done and revealed a metaphyseal fracture. He was referred to sports medicine and was seen about one month from the onset of pain. By this time he was pain-free during activities of daily living. PHYSICAL EXAMINATION Appearance was normal with no deformity. Palpation revealed moderate tenderness over the medial tibial proximal metaphysis. Knee exam showed full active range-of-motion. Lachman's, varus and valgus stress testing and McMurray's were negative. His gait showed only a mild limp. Plain film x-rays showed proximal metaphyseal fracture with some sclerosis and evidence of healing. DIFFERENTIAL DIAGNOSIS Acute tibial fracture. Pathologic fracture. Chronic stess injury with fracture. TEST AND RESULTS MRI Left knee and proximal tibia: -pathologic stress fracture and a bone cyst measuring 1 × 2 × 2 cm with several small septations. No malignant bone destruction. FINAL/WORKING DIAGNOSIS Left proximal tibial metaphyseal stress fracture with bone cyst. TREATMENT AND OUTCOMES Partial weightbearing. Hold from athletics. Repeat radiographs in two weeks.