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

2. 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

3. 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

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

6. MRI Thigh

8. Skeletal Survey

11. 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

12. 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

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

14. XX/XX/XX: However…

16. Taken to T9

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

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

20. When & Who To Fix?

21. 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

22. 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

23. Questions