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. 2005 Jun;17(1):21–28. doi: 10.4314/mmj.v17i1.10867

Giant cell tumour of the neck of femur treated by total hip replacement

NC Mkandawire 1
PMCID: PMC3346041  PMID: 27528994

A 49-year old accountant presented with a two-week history of left hip pain which came on after tripping and falling in his bathroom. He had no other significant past medical history. He was initially treated with simple analgesics by his local doctor. Due to continuing pain on weight bearing an x-ray was taken 2 weeks after the fall showed a large lytic lesion involving the head and neck region of the femur (figures 1a and 1 b). Routine blood tests including FBC, ESR, and bone chemistry were normal. A chest x-ray was normal. Based on the x-ray appearance a giant cell tumour was suspected as the diagnosis. A CT scan of the lesion (figure 2) was done which confirmed a large lytic lesion of the head and neck region of the femur, the extent of which was far greater than appreciated on plain x-rays. During the CT scan, a guided needle biopsy was performed. Blood stained fluid was aspirated. The aspirate was sent for cytology but was not diagnostic as it showed only fibrin with no malignant cells.

Figure 1a; 1b.

Figure 1a; 1b

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Antero-posterior and lateral x-rays of the left hip showing a well defined lytic lesion in the region of the femoral head and neck.

Figure 2.

Figure 2

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CT scan image showing the extent of the lesion

Based on the CT and x-ray findings, he underwent a wide excision of the lesion and reconstruction with a Charnley type total hip replacement. The wound healed satisfactorily (figure 3). On the third post-operative day the patient started mobilising with a frame. He was discharged on the 14th postoperative day mobilising with a single crutch.

Figure 3a: 3b.

Figure 3a: 3b

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Antero-posterior and lateral x-rays of the hip following total hip replacement.

Histology of the surgical specimen was consistent with the diagnosis of giant cell tumour.

Introduction

Giant cell tumour of the bone is a relatively rare benign tumour whose true incidence and patho-aetiology are not fully established. The tumour is usually located in the epi-metaphysis of the long bones, predominantly in the distal femur, proximal tibia and distal radius with 50% occurring around the knee joint. The age group at presentation is commonly between 20 and 50 years with the peak in the 30 to 40 year age group. Although benign, the tumour is locally aggressive with tendency for local recurrence after excision. A very small proportion of giant cell tumours can have malignant cells in the lesion. Irradiation of the tumour has been associated with malignant transformation and must be avoided. Rarely the giant cell tumour can metastasise and still maintain the ‘benign’ histological pattern in the metastases.

The proximal femur is an uncommon location for the occurrence of Giant Cell Tumour. The incidence at this site has been reported as less than 4%.1,2 Treatment of a locally aggressive giant cell tumour of the neck of femur is difficult because of the location and the high local recurrence.

Discussion

Pathology

Giant cell tumour has a typical appearance of multi nucleated giant cells diffusely distributed on a background of mononuclear cells. Some giant cells resemble osteoclasts and indeed this tumour is often called an osteoclastoma. Mitotic figures are common in the mononuclear cell population. It is a locally aggressive tumour with a high recurrence rate if not completely excised.

The local recurrence rate is correlated to the Enneking surgical staging and the type of surgical excision undertaken. The rate of local recurrence rates after intralesional excision are quoted in the literature as ranging from 29% to 75% Recurrence rates after wide excision range from 0% to 6%.3,4 Surgical stage of disease is correlated to the incidence of local recurrence (Stage 1, 0%; Stage 2, 53%; Stage 3, 70%). Phenol cauterisation after curetting out the lesion and packing with bone cement has been shown to decrease the incidence of local recurrence.5

Treatment methods

The aim of treatment is to excise the tumour completely. Minimise the risk of local recurrence; and maintain functional capacity. The reconstruction of the hip joint following excision for tumours is essential for maintenance of stability and normalisation of gait patterns. Because the tumour is usually located in the neck and at the juxta-articular region of the bone, reconstruction of the defect to preserve the head of the femur is difficult. The treatment options available for such a lesion are excision arthroplasty (Girdlestone procedure); intralesional curetting and bone grafting or packing with bone cement; excision and reconstruction with cortical cancellous bone graft and internal fixation; hemiarthroplasty; and total hip replacement.

Girdlestone Procedure

Excision arthroplasty in the form of a Girdle stone procedure results in a functional disability that may not be acceptable to some patients.

Intralesional Curetting And Cancellous Bone Grafting Or Packing With Bone Cement

Curettage and bone grafting or packing with bone cement without additional internal fixation may not provide adequate stability at the neck of femur to withstand the large shear type mechanical forces that are transmitted in this region.

Curettage, Vascularised Bone Grafting And I Or Internal Fixation

Use of a large vascularized bone graft from the iliac crest to reconstruct the defect after extensive excision has been reported. Applying such microsurgical reconstructive techniques allows a more aggressive excision of the lesion. Yip and Leung have reported a recurrence rate of 4.5% using this method.6

In the young patient, intralesional excision / curettage, bone grafting and internal stabilisation with devices such as dynamic hip screw has been advocated by some authors. This being an attempt to preserve the patient's head of femur. Total hip replacement in a young patient is seen risky due to the high probability of early revision surgery. Sim and Lang reported the case of a 20-year-old man with an unusually large giant-cell tumour of the proximal right femur complicated by a transcervical fracture.7 In view of the patient's age, curettage and bone grafting and stabilization with a dynamic hip screw combined with valgus osteotomy, was preferred to total hip replacement.

Hemiarthroplasty

This method would be suitable only in elderly low demand patients. Most patients with giant cell tumours are relatively young and therefore this method is not ideal as results of hemiarthroplasty in young patients are poor.8

Total Hip Replacement

Current evidence suggests that results of total hip replacement in the young patient are becoming more and more encouraging. The reconstruction by total hip replacement following excision for tumours is essential for maintenance of joint stability and a normal of gait pattern. A cemented prosthesis has the added beneficial local cauterising effect of bone cement to reduce the incidence of local recurrence.

In this particular case, the age of the patient; the sedentary nature of his job; the anticipated reconstructive difficulties if the head of femur was to be preserved (due to the size of the lesion); the relatively higher risk of local recurrence after intralesional excision and the desire to maintain a stable joint; favoured a wide excision followed by a total hip replacement as the treatment of choice.

References

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MMJ. 2005 Jun;17(1):21–28.

Paraduodenal hernias

A Sherry, EJ van Hasselt, ES Borgstein

CASE 1: C.M. 23 Years old female, Presented with abdominal pains and vomiting for a period of 2 months. She gave a history abdominal distension after eating which would gradually settle. She denied being constipated. Barium follow-through showed gastric stasis and a slow passage through the mid-gut. An elective operation revealed that the small bowel was in a sac of peritoneum within the peritoneal cavity below the transverse colon. The sac was opened and excised to free the small bowel trapped within.

CASE 2: L.M. 6 Years old female, Presented with a four days history of abdominal pains, constipation and vomiting. On examination she was dehydrated, had a distended, tense abdomen with visible bowel loops in the epigastrium. High pitched bowel sounds with a succussion splash were heard. Rectal exam was unremarkable.

Emergency laparotomy showed a malrotation of both small and large bowels. A right paraduodenal hernia with an ischemic loop of bowel near the ilealcaecal junction was also noted. Operation included mobilization, release of mal-rotation and resection of the non-viable bowel.

PARA-DUODENAL HERNIAS (PDH)

Incindence

Accounts for 0.2 – 0.9 % of all small bowel obstructions with a mortality of around 20%. Males are affected three times often than females1.

Aetiology

Paraduodenal hernias are an uncommon congenital cause of small bowel obstruction. There are three types as characterized by Wilworth et al., I, left; II, right; and III, transverse. They are classified in order of frequency as Left PDH accounting for approximately 75% and 25%. transverse hernias are exceedingly very rare2.

In 1923 Andrews proposed that these hernias were the result of errors of mid-gut rotation occuring between the 5th and 11th weeks of gestation in which the gut undergoes counterclockwise rotation bringing the mesentery in contact with the posterior abdominal wall

Presentation

PDHs are rare in clinical practice despite being the most common internal hernias, accounting for 53% of cases3. They may be discovered at the time of operation for an acute abdominal problem as in case 2 or chronic as in case 1 with vague abdominal pains. They may be found during surgery for an unrelated condition sometimes leading to confusion even to the experienced surgeon, or at autopsy, recurrent abdominal complaints in an adult should arouse suspicion of mid -gut mal-rotation

Investigations4

It may be suspected on pre-operative x-rays if the small bowel loops are all on the right or on the left of the midline. Barium enema may show the caecum in a normal position or it may be incompletely rotated. A Barium follow-thru enema may give the same findings. More recently CT scans without and then with contrast has been shown to be useful. All these investigations may be performed without any diagnostic yield and patients may may be assumed to have a psychosomatic illness.

Treatment

Sometimes it is necessary to close the herina orifice, otherwise the hernia sac is opened widely and made part of the peritoneal cavity5. See Fig 2 to 4.

Fig 2.

Fig 2

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Right PDH. Incise the sac along the dotted line.

Fig 4.

Fig 4

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Left PDH with the sac to the left of the inferior mesenteric artery. Open sac along the dotted line.

Fig 1.

Fig 1

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Sites for PDHs. 1 & 3 are sites for right PDHs. 2 is for left PDH.

Fig 3.

Fig 3

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Right PDH. The sac is opened widely so that it becomes part of the general peritoneal cavity.

Fig 5.

Fig 5

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The neck is opened by dividing the inferior mesenteric vessels and feeling the hernia contents

References

  • 1.Manji Rizwan, Warnock Garth. Left Paraduodenal Hernia: An unusual cause of SBO. Canadian Journal of Surgery. 2001 Dec;44(6) [PMC free article] [PubMed] [Google Scholar]
  • 2.Dristas E, et al. Paraduodenal Hernia: Report of two cases. The American Surgeon. 2001 Aug;67 [PubMed] [Google Scholar]
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MMJ. 2005 Jun;17(1):21–28.

Technique for prevention and treatment of abdominal compartment syndrome

K Chalulu 1, EJ van Hasselt 1

JP was a 19-year-old female referred to Queen Elizabeth Central Hospital from Nsanje District hospital. She presented with a five-day history of abdominal pains, distension and inability to pass stool or flatus. The pain was constant and not radiating. There was no history of vomiting. Past medical and drug histories were unremarkable. She was not married but was sexually active.

On examination she was in pain, febrile with temperature of 38.5°c, tachycardic with a pulse rate of 110 bpm of good volume, not cyanosed and with normal blood pressure (110/60 mmHg). Examination of head and neck, chest, heart and extremities was normal. The abdomen was distended, rigid, tense, and tympanic with high-pitched bowel sounds. Digital rectal examination revealed an empty rectum but there was a mass that could be felt anteriorly.

Haemoglobin was 7.7g/dl. Group and cross matching were done. Intravenous normal saline was given, and a nasogastric tube and an indwelling catheter inserted which initially drained 800mls of urine. After resuscitation, a laparotomy was performed. Intraoperatively, she was given intravenous Gentamicin 240mg and Metronidazole 500mg. The findings at laparotomy were:

  • 4 litres of pus spread over all four quadrants of the abdomen

  • oedematous small bowel

  • left ovarian abscess with an inflamed fallopian tube on the same side

All the pus was drained and a left oophorectomy was done. Four litres of tepid normal saline was used for washout after retrograde emptying of the small bowel. Intraoperatively, she had a stable blood pressure and pulse but oxygen saturations ranged from 80% and 93%. The abdomen was closed using the so-called “Bogota bag” technique (see below). The patient was then admitted to ICU for cardiovascular and respiratory support because of her low haemoglobin, sepsis and hypoxia. Antibiotic treatment with Gentamicin and Metronidazole was continued.

A planned relaporotomy was carried out 72 hours later. Upon removal of the Bogota bag, she was found to have less oedematous bowel and some serous fluid in the abdomen. Decompression of small bowel was done and washout with tepid normal saline done. A secondary fascial closure was then performed using PDS and the skin was closed with interrupted Ethibond 2/0. Apart from a minor wound infection warranting removal of two of the stitches, she made an uneventful recovery and was discharged two weeks later.

Discussion

After abdominal surgery, primary fascial closure is desirable but not always possible. This may be the case in severely injured patients requiring massive resuscitation and also in patients with oedematous bowel due to generalized peritonitis as was the case in this patient. Resuscitation, capillary leakage and reperfusion injury all contribute to tissue swelling; if combined with intraabdominal packing or retroperitoneal haematoma, this may render the abdomen impossible or difficult to close without undue tension 1,2,3. If in those circumstances, the abdomen is closed primarily, intra-abdominal pressure (IAP) will rise which may eventually lead to serious multiple organ dysfunction causing significant morbidity and mortality. A rise in IAP will compress the inferior vena cava reducing venous return and by Starling's law reducing cardiac output. The splintage of the diaphragm by this increase in abdominal pressure will lead to an increase in airway and intrathoracic pressure followed by a reduction of venous return to the heart, barotraumas and exacerbation of acute respiratory distress syndrome. Oliguria and anuria will follow due to compression of the renal vein and renal parenchyma.1,2,3 A rise in intrathoracic pressure also leads to a rise in central venous pressure because of compression of the superior vena cava and which may cause and increase in intracranial pressure. Abdominal compartment syndrome (ACS) will therefore result in organ damage and multiple organ dysfunction1.

Diagnosis of abdominal compartment syndrome

  • ACS should be suspected in any multiple trauma patient who has undergone a period of profound shock1.

  • Clinically ACS should be suspected when there is a fall in urinary output associated with a rise in central venous pressure

  • The diagnosis can be confirmed by measuring of the intra abdominal pressure. The technique involves inserting a Foley catheter in the bladder and connecting to a pressure transducer. The normal IAP is 0 mm Hg or subatmospheric. Readings of 20 mm Hg or more are considered diagnostic of ACS2,3,4.

  • ACS should be suspected in patients who have severe peritonitis with oedematous bowel and in those in poor condition with hypotension and/or oliguria due to trauma or an acute abdomen.

Management of ACS - the Bogota bag

It is better to anticipate development of ACS and therefore plan a wound covering technique that will not further exercebate the condition, especially when the abdomen cannot be closed without undue tension3. The open abdomen (laparostomy) is a large surface area for fluid loss, it exposes the viscera to trauma and will dry them out. It is also a route of infection. Management of the open abdomen is aimed at preventing these problems and one of the techniques of protecting the abdominal viscera is the use of the “Bogota Bag”. In this technique, a sterile intravenous bag is emptied and cut open. The edges are trimmed and sutured to the skin edges using a continuous suture. It thus provides a cheap, transparent and compliant sheath through which the abdominal cavity and bowels can be inspected visually.5.

A few holes are made to allow seepage of the fluid there in although some authors advocate use of a sterile absorbent drape inside the abdomen to soak up some of the fluid. An absorbent dressing is placed over the bag which will not conceal any fluid coming out. If the fluid is pus or bowel content then this will obviate an earlier relaparotomy. The main indication for applying a Bogota bag is to prevent the development of an ACS, but it can also be applied when a relaparotomy is planned in the next 72 hours.

Indications for relaparotomy and the use of a Bogota bag

The decision to do a relaparotomy is part of the initial management plan. The aim mainly should be to diminish the severity of systemic inflammatory response syndrome and multiple organ failure. Failure to obtain adequate source control during the index operation is also an indication. An example is typhoid perforation where subsequent perforations are expected.1 Faecal peritonitis or severe faecal contamination during the initial operation is another indication since a peritoneal toilet can be adequately achieved at the next operation 1. Patient instability during the initial operation should alert the surgeon to do a damage control type of procedure and a relaparotomy for a definitive procedure done later. Other relative indications may include suspicious looking bowel after initial surgery and high risk anastomoses, though others would argue that a colostomy would be a safer bet1.

If there is a likelihood of a re-operation and the patient is either at a centre that cannot deal with the problem, then the patient should be referred with a Bogota bag.

Conclusion

The use of the Bogota bag is a cheap and safe way to offer temporary cover in the management of the open abdomen. The main indications of a laparostomy are the prevention of abdominal compartment syndrome and a relaparotomy which has been planned in the next 72 hours. Prevention of the ACS also limits the progression of the systemic inflammatory response syndrome and multiple organ dysfunction syndrome. It may reduce morbidity and mortality and is a safe and easy procedure which can be done in a district hospital setting.

References

  • 1.Schein M. Surgical management of intra-abdominal infection: Is there evidence? Langenbeck's Arch Surg. 2002;387:1–7. doi: 10.1007/s00423-002-0276-z. [DOI] [PubMed] [Google Scholar]
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MMJ. 2005 Jun;17(1):21–28.

Unusual cause of acute painful scrotal swelling

T Chokotho 1

A 50year-old man presented with a two-day history of acute pain and swelling in the right scrotum. He previously had a reducible groin swelling on the same side. His last bowel motion was on the day of admission. He vomited twice on the same day. On examination he had a swollen, tender scrotum and groin. One could neither get above it, nor reduce it. The rectum was empty.

Questions

  1. What is the differential diagnosis?

  2. How would you manage this patient?

Differential diagnosis

Conditions which present as an acute scrotum and/or groin include testicular torsion, acute epididymo-orchitis and strangulated inguinal hernia.

Testicular torsion most commonly occurs between 10 and 15years of age, and is rare after 25years. It presents with severe acute pain in the testis and groin. Nausea and vomiting are common. The affected testicle hangs higher than the normal one and is exquisitely tender. Swelling is confined to the scrotum. Urgent surgery is required to derotate and fix the testicle (orchidopexy), the latter being done even on the other side.

Acute epididymo-orchitis is commonest in young and middle-aged men. The onset of pain is subacute. There may be malaise, anorexia, dysuria and frequency. Although very tender, gentle palpation may reveal that it is the epididymis that is tender. Clinically it may be impossible to distinguish from testicular torsion. Doppler ultrasound would show absence of blood flow in a case of torsion. Treatment is medical - gentamcin and doxycycline.

A tender, previously reducible swelling arising from an expected hernial orifice is likely to be a strangulated hernia.

Management and outcome

The pre-operative diagnosis was a strangulated inguinal hernia. At operation we found a grossly inflamed hernial sac and cord and a testicular abscess within which was a fish bone (Figures 1 and 2). Since he was under spinal anaesthesia we asked if he noticed being pricked in the scrotum. He denied. A herniotomy and orchidectomy were done. A corrugated drain was placed after irrigation. He made an uneventful recovery. Incidentally the testicular tissue contained Schistosomiasis mansoni ova on histological examination (Figure 3). Schistosomiasis haematobium has been described to occur commonly in the testicle before 1, but not S. mansoni.

Figure 1.

Figure 1

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Fishbone - compared to paper-clip

Figure 3.

Figure 3

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Schistosoma mansoni ova in testis

Common things occur commonly but we must never close our minds to other possibilities.

Figure 2.

Figure 2

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Testicular abscess

Acknowledgement

The histological specimens were examined by Dr. CP Dzamalala, consultant histopathologist at College of Medicine.

References

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Articles from Malawi Medical Journal : The Journal of Medical Association of Malawi are provided here courtesy of Kamuzu University of Health Sciences and Medical Association of Malawi

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