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.