Surgical Grand Rounds 12/9/13 ‘Nail the diagnosis before the bone’

History of Presenting Complaint April ‘13: Pain in right calf, some heaviness in limb. Otherwise well GP: Px anti-inflammatories Over next 2/52 pain gradually moves up leg from calf to thigh, causing pain and tightness in anterior aspect of thigh. Also had some lower back pain at this time; attributed this to limp associated with leg pain

Back to GP Concerned patient may have DVT ED: D-dimers normal, referred for physiotherapy Physio: No progress after two sessions, referred for hip x-ray, concerned about possible hip pathology

OPD XX/XX/13 X-rays and bone scans reviewed Bloods: Hb – 12.7 Na – 142 ESR – 25 WCC – 6.42 K – 3.5 CRP - 13 PLT – 250 Corr Ca – 2.59 Creat - 65 Admitted for investigation: CT TAP MRI Spine Skeletal survey Mammogram Dermatology & oncology consults Bone marrow biopsy

MRI Thigh

Skeletal Survey

Investigations Mammogram: NAD Dermatology Review: No suspicious lesions SPEP: IgG – 6.4, IgA – 0.56, IgM – 0.27 Small free kappa light chain monoclonal protein band present Bone Marrow: Atypical plasma cells maje up 20% of total nucleated cells; suggestive of myeloma

Myeloma Most common primary bone tumour Malignancy of plasma cells 1% of all cancers Males, 60yrs+ Less than 3% of cases occur in patients <40yrs 80% of patients will have bone pain at diagnosis Other symptoms are those associated with pancytopenia; fatigue, recurrent infection, bruising etc Investigations: FBC, SPEP, calcium, marrow bx, skeletal survey, urinalysis for BJ proteins

Surgery? Decision made to internally fix femur Patient advised to remain completely NWB until date of surgery

XX/XX/XX: However…

Taken to T9

Bone lesions Must have diagnosis prior to fixation: IM nailing of a sarcomatous lesion will cause ‘millary sarcomatous mets’ Urgent diagnosis, not urgent treatment

Bone lesions Primary: Myeloma, osteosarcoma, chondrosarcoma, Ewing’s sarcoma etc Secondary: Most commonly breast, prostate, lung, renal, thyroid. Can by lytic or blastic (sclerotic)

When & Who To Fix?

Harrington’s Criteria >50% destruction of the diaphyseal cortices >50-75% destruction of the metaphysis Permeative destruction of the subtrochanteric femoral region Persistant pain following irradiation

Surgical management Goals: Maximise ability for immediate mobilisation Allow full weight bearing Optimise implant choice in the context of prognosis Type of fixation depends on location and type of lesion, however most common fixation method is with IM nailing

Questions