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hip and proximal femur

A 25 year old nanny with a right hip mass

Case Identification
Case ID Number: 
20120112NA
Benign/Malignant: 
unknown
Clinical case information
Case presentation: 

The patient is a healthy 25-year-old woman. She had a bump discovered near her right hip several years ago, that she thought was cellulite. It was not painful then. Recently the bump seems bigger, and it is now symptomatic.

Radiological findings:: 
There is a pedunculated surface lesion on the posterior aspect of the right proximal femur, which measures about 50 x 40 mm in size. It projects into the muscular tissues posterior and lateral to the lesser trochanter. Portions of the lesion are densely ossified. There are some ring and arc patterns of calcification. The lesion has a cap of tissue with high signal intensity on T2 weighted images consistent with cartilage. The maximum thickness of the cap is less than 2 cm.
Laboratory results:: 
none requested
Differential Diagnosis: 
Osteochondroma versus chondrosarcoma, secondary
Further Work Up Needed:: 
Due to the appearance and history of this lesion, combined with the thickness of the cartilage cap, excisional biopsy appears to be a reasonable approach.
Special Features of this Case:: 
When a lesion that has features consistent with osteochondroma has been growing or increasing in symptoms in an adult, secondary chondrosarcoma must be considered. However, the patient's history of a bump in the area several years ago helps establish that the lesion has probably been present for some time. Large deep osteochondromas around the proximal femur may be asymptomatic until some sort of bursitis or degenerative change begins causing inflammation or pain. Patients typically will present with these in their mid-20s or even in their 30s or 40s. The symptoms are not from growth of the lesion, but rather from the tissues that are in contact with the lesion becoming symptomatic due to advancing age.

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.

A 73-year-old man with right hip pain and prostate cancer

Case Identification
Case ID Number: 
20090708NB
Benign/Malignant: 
Benign
Clinical case information
Case presentation: 

The patient is a generally active 73-year-old gentleman who is retired. He has prostate cancer that has been well controlled. Now, he has right hip pain and lesions in the acetabulum and proximal femur.

Radiological findings:: 
On both sides of the right hip, along with joint space narrowing and bone-on-bone contact, there are well defined cystic lesions, with sclerotic rims, which abut the joint on both sides. MRI scan the scan shows extensive abnormality in the right hip and acetabulum and supraacetabular region as well as the right femoral head. There was a cystic focus, joint space narrowing, and perilesional edema. The cystic lesions have a well defined dark rim.
Laboratory results:: 
The patient's prostate cancer is currently staged T3, N0, with suspicion of metastatic disease. PSA 19 at the time of treatment. Current PSA is 1.3.
Differential Diagnosis: 
Subchondral cyst versus metastasis or new primary malignancy.
Treatment Options:: 
Please see our page on subchondral cyst.
Special Features of this Case:: 
To differentiate between subchondral cyst and a true bone tumor or a metastatic cancer deposit in bone, look for the following features: 1) The lesion is right next to the joint. Careful examination of the radiographs may reveal an actual communication between the joint space and the cyst cavity. If doubt about the nature of the lesion exists, a fine cut CT scan on the area may allow this communicating opening to be seen and help establish the true diagnosis. 2) There are radiographically visible signs of osteoarthritis, usually moderate but sometimes mild, seen in the adjacent joint. If these are entirely absent, the diagnosis should be reconsidered. In the hip, these lesions occur the acetabulum in women with "shallow hips" which can be determined by calculating the center-edge angle. The shallow hip is prone to early degenerative changes and cysts are common in these patients. 3)There is usually a sclerotic rim around some areas of the lesion. The zone of transition is narrow, whereas in a metastatic lesion a sclerotic rim is absent and the zone of transition may be poorly defined. 4) The lesion should be fluid filled, and this may be seen best on MRI images. 5) These lesions are rarely progressive, and pathological fractures are rare.
Image Reference: 

A machinist with pain at work

Case Identification
Case ID Number: 
20090721AM
Periosteal Reaction: 
absent
Benign/Malignant: 
unknown
Clinical case information
Case presentation: 

The patient is a 44-year-old machinist who has had pain in the right hip for approximately one year. It is exacerbated by standing, walking and heavy activity, and somewhat relieved by rest.

Radiological findings:: 
There is no significant night pain but there may be a dull ache. Motrin does not relieve the pain. There is no significant past history or family history. On examination of the right hip there is an excellent full range of motion without apparent pain. There is some anterior irritability to deep palpation but no mass can be appreciated. There is no skin abnormality, no ecchymosis, no warmth. No other pertinent findings are noted on the exam. Plain radiographs, CT scan, bone scan are available for review. There is a mixed lytic and sclerotic lesion in the proximal femur, centrally located in the intramedullary space, just above the lesser trochanter. The cortex does not appear to be violated. The area in the center of the lesion is lucent without matrix. Surrounding this is a very dense area of sclerosis which is somewhat irregular. The CT scan shows essentially similar findings but shows that the lesion is larger when seen on CT that when seen on radiographs. The central area is actually two lobulated central lucent defects in the bone. The lesion is very slightly increased uptake on bone scan. No other areas of abnormality on the bone scan are appreciated.
Differential Diagnosis: 
The differential diagnosis of this lesion should include fibrous dysplasia, fibroxanthoma (non-ossifying fibroma), polymorphic fibro-osseous tumor of bone, liposclerosing myxofibrous tumor of bone, myxofibroma, lipoma, cyst, bone infarct, Paget's disease, and, chondroma. The lesion is too large for an osteoid osteoma but might be an osteoblastoma. The lesion does not have aggressive features so osteosarcoma is unlikely. No orthopedic surgeon considering a bone-forming lesion in the femur should fail to at least consider osteosarcoma, regardless of the age of the patient.
Special Features of this Case:: 
The tumor is a polymorphic fibro-osseous tumor of bone, also called a liposclerosing myxofibrous tumor of bone. On pathology, the lesion is composed of crudely woven bone that may have a pagetoid appearance. surrounded by fibrous tissue. Fat and myxoid change may also be present. The lesion may mimic fibrous dysplasia. This tumor is usually in the proximal femur.. A diagnosis must be based on the combination of the location and appearance with the predominant histological pattern. These lesions are usually incidental findings. The age range is broad, usually adults, The tumors probably arise in childhood. Their appearance may evolve slowly over time. The tumor may not have features that allow diagnosis without careful biopsy, thus observation only is not appropriate management of this tumor. After biosy, this tumor does not require aggressive resection. Treatment by curettage is sufficient. The patient should be followed to check for progression. In parallel with some enchondromas and bone infarcts, a minority of lesions undergo malignant transformation. References: Hum Pathol. 1993 May; 24(5): 505-12. Polymorphic fibro-osseous lesions of bone: an almost site-specific diagnostic problem of the proximal femur. Ragsdale BD. This lesion was biopsied by minimally invasive means, with an approach calculated to minimize the risk of biopsy-induced pathologic fracture as well as to minimize the risk of contamination of uninvolved structures which might complicate limb salvage if it became necessary. The tumor is a polymorphic fibro-osseous tumor of bone, also called a liposclerosing myxofibrous tumor of bone. This tumor does not require aggressive resection. Treatment by curettage is sufficient. In in this case the patient will be followed to check for progression.
Image Reference: 
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