Case 13
A 31-year-old male presented with a 4 months history of pain along the lateral thigh.
A: AP radiograph at presentation. The medullary canal has a long radiolucent lesion containing a long slender area of dense cortical bone. On the medial surface of the femoral shaft is an area of mature reactive bone.
B: Magnification of the same radiograph. Magnification brings out the laminated appearance of the reactive bone.
C: Magnified lateral radiograph at presentation. This view shows the long spicule of cortical bone that appeared to be in the medullary canal on the AP view is actually in the posterior cortex.
The radiographs show a lesion in the medullary canal and posterior cortex containing a long slender area of radiodense bone surrounded by a radiolucent zone. The surface of the process is limited by layers of reactive bone. These features are characteristic of either osteomyelitis or a round cell neoplasm such as Ewing's sarcoma.
D: Regional isotope scan. There is intense focal uptake that closely corresponds to the area of reactive bone seen radiographically. This is more suggerstive of infection than neoplasm as that is usually more diffuse and extends well beyond the radiographic limits of involvement.
A biopsy was done obtaining tissue from both the surface of the lesion and within the medullary canal.
E: A low-power field from the periphery of the lesion. The upper portion of the field contains active proliferating reactive bone. The free edges are everywhere lined by plump osteoblasts. The bottom half is composed of proliferations of immature mesenchymal cells.
F: Higher magnification from the same field. A close look at a reactive trabeculae. The large plump osteoblasts and osteocytes are testimonials to its' immaturity.
G: Low power field from the tissue in the medullary canal. The diaganol central portion is packed with small round cells. The cortical bone above and below is acellular and in many areas has a scalloped margin where it has recently undergone resorption.
H: Another low-power field from the tissue in the medullary canal. A heavyily baspophilic band of cellular tissue extends across the field. Again the remnants of cortical bone are acellular and undergoing resorption.
I: High power field from the basophilic tissue in the medullary canal. The tissue is a mass of chronic inflammatory cells - the majority are lymphocytes with a few scattered plasma cells.
Cultures of these tissues grew out staphylococcus.
Diagnosis: Chronic osteomyelitis
The treatment was sequestrectomy, curettage, and prolonged antibiotics.
A 31-year-old male presented with a 4 months history of pain along the lateral thigh.
