Osteolytic lesion 1st MT

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dear all,

here with 36 yrs old female patient attended my OPD with
1 yr duration swelling with paint started after 6 months in her left foot.

radiology shows well defined lytic lesion in the 1st MT, with ballooning of
cortex, with spiculation.

i need opinion regarding this .

my plan is do
MRI
needle biopsy
then curettage and bone grafting.



suresh,
Chennai.

 

How come you get all the easy cases?

Steven

 

Dear Dr.:
I think your approach to treatment is very successful.
Sincerely

 

Dr. Gandhi
You do seem to get your share of bone lesions.
How did the Os Calcis cyst turn out?
Looks to me like another benign lesion.
May be easier to fill with a bone paste after exposure.

Steve

 

dear Dr.Steve

I am awaiting pathological diagnosis from your reply

as you diagnosed BFH of calcaneum from x ray.

 

HAHA
Maybe I just got lucky?
As you know, the pathologist always has the final word in these things.

But....since you asked...

You didn't mention any signs or symptoms other than pain, so I'll go out on a limb and suggest a simple Osteoid Osteoma. Second choice...Giant cell tumor.

Let us know

Steve

 

still we have problem to proceed with this pt.

our pathologist has given a two possibilities of '

diagnosis, after needle biopsy. Enchondroma, Fibrosarcoma..

if it s a malignant one what are the options to proceed.

resection and fibular graft?

 

Interesting.
Lots of similarities between osteoid osteoma and enchondromas.... one should be able to differentiate these from a sarcoma though. Any soft tissue involvement?

Treatment plan begins with a diagnosis.

I would get a second opinion on the path reading as well as MRI and / or PET. I would also call the pathologist. As you know they will frequently "cover themselves" by stating they cannot rule out such and such although they are fairly certain of the Dx. After this, if you're still unsure I would seek out an orthopedic oncologist.

Good luck

Steve

 

open biopsy was reported as grade 1 chondrosarcoma .


options are ,1st ray amputation/ resection and fibula grafting ,

curettage and bone grafting ( For Grade 1 chondrosarcoma, curettage with bone grafting has been reported to be an acceptable procedure.)
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I am planning to do ray amputation as have to give 5 cm clearance.

any suggestion.

 

Hi Suresh
Sorry to see the path report.
I don't recall ever having a chondrosarcoma and only one fibrosarcoma.

Your surgical approach seems appropriate (first ray amp). What is your plan for follow up care?

Best of luck

Steve

 

dear steve,

i am thinking of preservation or reattach(navicular) the tib ant. and peroneus longus after excision of 1st MT?

what will happen if i do only tenotomy.

 

Hi Dr. Gandhi:
A bit of a situation. Normally you'd like to leave as much of the metatarsal base as possible with a ray resection for obvious reasons. You will not have that luxury due to the etiology.

If you are taking part of the cuneiform (I assume you are) it may be possible to leave the proximal third or so and utilized the distal aspect for suturing the PL, TA and possibly the FHL tendons to. A simple 2 or 3x0 bone anchor (s) should suffice and the "raw" bone surface should help with biological anchoring. You will be able to push the anchors in manually.

It will be a biomechanical challenge post operatively either way.

At least with the Dx of chondrosarcoma the possible involvement of the surrounding soft tissue is not as likely as with a fibrosarcoma.

Good luck

Steve

 

Dr. Gandhi.

What did you end up doing with this patient?
Steve