Case presentation:
A 19 years old male, student, with no history of trauma, complaining of
left proximal tibial pain, gradual onset, not radiated to any site,
aggravated by movement and relieved partially by analgesia and
associated with swelling for three months. He sought traditional
treatment several times. After six months of his complained he came to
our orthopaedic clinic with fungating limb, offensive odor. Systemic
review was unremarkable, no history of similar condition, chronic
diseases or hospital admission. No family history of similar condition
and he was not smoker or alcoholic. Not known allergic to any
medication, no chronic medication.
On physical examination patient looks ill, there was left knee discharge
sinus, left quadriceps muscle wasting comparing to other site, patient
demonstrate abnormal gait. The left knee temperature was high and the
knee was tender. The left knee movement was restricted compared to other
side.
Some investigations were requested. General investigations include CBC
low Hg 8 gm/dl, ESR 83, CRP = 10, RFT (normal), LFT (increase ALP and
LDH). Specific investigations include X-ray shows mixed lytic and
plastic lesion and periosteal reaction, MRI shows heterogeneous proximal
tibial lesion, soft tissue involvement, no skin lesion and no nerve
involvement, CT chest revealed single right basal lung nodule
approximately 1.3 cm and bone scan revealed right proximal tibial and
right single basal lung nodule. Also biopsy was obtained and sent to
histopathology study which revealed osteosarcoma. The patient planned to
follow treatment protocol of osteosarcoma neoadjuvant chemotherapy,
surgery and adjuvant chemotherapy. Patient received three cycle
neoadjuvant chemotherapy and then planned for surgery.
Patient was planned for proximal tibia resection and applied in liquid
nitrogen to eradicate the malignant cells. Then proximal tibia was
recycled and filled with bone cement. Medial and lateral gastrocnemins
flap, skin graft and internal fixation with plate and screws were done.
Infection occurred and skin sloughed, so debridement and full thick skin
graft was done two times.
Patient became well and continued the chemotherapy. Two years later on
the follow up he came with single lung nodule about 0.4 * 0.5 cm at the
lower left loop and inguinal lymphadenopathy.
Patient was fit and no comorbidities, leg was saved and TNR was 10%.
Now the patient was 5 years on follow up and he was stable, near normal
knee range of movement and patient completed his university study and
graduated as Accounter. Now he is officer in private institute.