Limits...
An unusual case of persistent groin pain after total hip arthroplasty: a case report.

Konala P, Schaefer TK, Iranpour F, Friederich NF, Hirschmann MT - J Med Case Rep (2011)

Bottom Line: Further radiological examination revealed multiple metastatic lesions throughout the pelvis due to a pyeloureteral carcinoma.Often subtle radiological changes are classed as normal, especially if they are bilateral.Further radiological imaging should be recommended in all cases where unexplained clinical features or radiological findings are present.

View Article: PubMed Central - HTML - PubMed

Affiliation: Musculoskeletal Surgery Department, Imperial College, London, UK. Michael.Hirschmann@ksbh.ch.

ABSTRACT

Introduction: Arthroplasty is a well-established routine elective surgical procedure in orthopaedics. To a great extent, diagnosis, treatment and post-operative rehabilitation in these patients is standardised. In a busy clinic, surgeons from time to time tend to focus their attention on common causes of joint pain, but it may lead them to overlook sinister but less common pathologies. Here we report a case of a patient with groin pain due to pre-operatively undetected pelvic metastases from a pyeloureteral carcinoma who underwent total hip arthroplasty. There are several case reports which deal with primary or secondary tumours which were either discovered at the time of replacement surgery or developed at the site of prosthesis years after total hip or knee replacement. To the best of our knowledge, this is the first case report in which a metastatic cancer was missed pre-operatively and intra-operatively both by the radiologist and by the orthopaedic surgeon and should be reported so that surgeons are reminded to be careful when dealing with seemingly routine cases.

Case presentation: A 79-year-old Caucasian woman presented to the arthroplasty clinic with groin pain. Initial radiographs showed subtle bilateral abnormalities in the pelvis. Neither the radiologist nor the orthopaedic surgeon recognized it. A diagnosis of osteoarthritis of the hip was established, and she underwent total hip arthroplasty. Despite initial improvement, the patient came back with worsening hip pain three months later. Further radiological examination revealed multiple metastatic lesions throughout the pelvis due to a pyeloureteral carcinoma.

Conclusions: This case report emphasizes the importance of meticulous, unbiased pre-operative assessment of patients and their radiographs, even in so-called routine clinical cases. Often subtle radiological changes are classed as normal, especially if they are bilateral. Further radiological imaging should be recommended in all cases where unexplained clinical features or radiological findings are present.

No MeSH data available.


Related in: MedlinePlus

Comparison of anteroposterior pelvic hip radiographs preoperatively and six weeks and three months post-operatively (from left to right).
© Copyright Policy - open-access
Related In: Results  -  Collection

License
getmorefigures.php?uid=PMC3049745&req=5

Figure 3: Comparison of anteroposterior pelvic hip radiographs preoperatively and six weeks and three months post-operatively (from left to right).

Mentions: A 79-year-old, active Caucasian woman with left groin pain was referred to the orthopaedic clinic by her general practitioner to undergo THA. She complained about progressive left groin pain for 12 months that was worst in the morning and exacerbated by physical activity and prolonged sitting. Clinical examination revealed left-sided antalgic gait and tenderness in her left groin. Left hip internal rotation was limited to 10°. Anteroposterior pelvic and true lateral hip radiographs revealed typical signs of osteoarthritis (Figure 1). In addition, there was a 25-mm-diameter calcification in the lesser pelvis, which was reported by the radiologist to be a calcified uterine myoma. Finally, the patient was scheduled for elective left THA. At the preadmission clinic, a routine urine dipstick test revealed 3 to 20 erythrocytes and no leucocytes or nitrites. On the basis of the urine dipstick stick, a diagnosis of urinary tract infection (UTI) was made, although the patient was asymptomatic and urine was sent for culture. The patient was empirically treated with oral antibiotics, and the surgery was postponed. Urine cultures showed no bacterial growth, and no further tests or referral to other specialties were done. Four weeks later she underwent a THA with satisfactory recovery. At the first follow-up six weeks postoperatively, the patient was almost pain-free and was using two crutches for stability. Her examination was unremarkable at that time. Standard radiographs showed an acceptable implant position (Figure 2). The orthopaedic surgeon and the radiologist did not report any other abnormality. Further physiotherapy was recommended, and routine follow-up was recommended six months from the time of surgery. Unexpectedly, the patient presented to us four months after surgery complaining of worsening left hip pain. Because she was still on crutches, she noted weakness, loss of appetite and weight loss of 5 kg. Further examination revealed generalized tenderness of the left iliac crest, gluteal region and groin. The radiographs then showed bilateral cloudy bone formation in the pelvis (Figure 3). Further investigation with a technetium-99 m bone scan and computed tomography (CT) revealed widespread osteolytic and osteoblastic lesions bilaterally in the superior and inferior pubic ramii, sacrum, iliac wings, acetabula and left transverse process of the L4 and L5 vertebrae, which were most likely metastatic (Figures 4 and 5). Screening for the primary tumor (CT of the chest abdomen and pelvis) revealed a left pyeloureteral carcinoma. No further invasive tests or histopathological examinations were done because of the advanced stage of the disease, and a decision was made to provide palliative treatment to the patient. The patient received palliative chemotherapy and radiotherapy and died one year after diagnosis.


An unusual case of persistent groin pain after total hip arthroplasty: a case report.

Konala P, Schaefer TK, Iranpour F, Friederich NF, Hirschmann MT - J Med Case Rep (2011)

Comparison of anteroposterior pelvic hip radiographs preoperatively and six weeks and three months post-operatively (from left to right).
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC3049745&req=5

Figure 3: Comparison of anteroposterior pelvic hip radiographs preoperatively and six weeks and three months post-operatively (from left to right).
Mentions: A 79-year-old, active Caucasian woman with left groin pain was referred to the orthopaedic clinic by her general practitioner to undergo THA. She complained about progressive left groin pain for 12 months that was worst in the morning and exacerbated by physical activity and prolonged sitting. Clinical examination revealed left-sided antalgic gait and tenderness in her left groin. Left hip internal rotation was limited to 10°. Anteroposterior pelvic and true lateral hip radiographs revealed typical signs of osteoarthritis (Figure 1). In addition, there was a 25-mm-diameter calcification in the lesser pelvis, which was reported by the radiologist to be a calcified uterine myoma. Finally, the patient was scheduled for elective left THA. At the preadmission clinic, a routine urine dipstick test revealed 3 to 20 erythrocytes and no leucocytes or nitrites. On the basis of the urine dipstick stick, a diagnosis of urinary tract infection (UTI) was made, although the patient was asymptomatic and urine was sent for culture. The patient was empirically treated with oral antibiotics, and the surgery was postponed. Urine cultures showed no bacterial growth, and no further tests or referral to other specialties were done. Four weeks later she underwent a THA with satisfactory recovery. At the first follow-up six weeks postoperatively, the patient was almost pain-free and was using two crutches for stability. Her examination was unremarkable at that time. Standard radiographs showed an acceptable implant position (Figure 2). The orthopaedic surgeon and the radiologist did not report any other abnormality. Further physiotherapy was recommended, and routine follow-up was recommended six months from the time of surgery. Unexpectedly, the patient presented to us four months after surgery complaining of worsening left hip pain. Because she was still on crutches, she noted weakness, loss of appetite and weight loss of 5 kg. Further examination revealed generalized tenderness of the left iliac crest, gluteal region and groin. The radiographs then showed bilateral cloudy bone formation in the pelvis (Figure 3). Further investigation with a technetium-99 m bone scan and computed tomography (CT) revealed widespread osteolytic and osteoblastic lesions bilaterally in the superior and inferior pubic ramii, sacrum, iliac wings, acetabula and left transverse process of the L4 and L5 vertebrae, which were most likely metastatic (Figures 4 and 5). Screening for the primary tumor (CT of the chest abdomen and pelvis) revealed a left pyeloureteral carcinoma. No further invasive tests or histopathological examinations were done because of the advanced stage of the disease, and a decision was made to provide palliative treatment to the patient. The patient received palliative chemotherapy and radiotherapy and died one year after diagnosis.

Bottom Line: Further radiological examination revealed multiple metastatic lesions throughout the pelvis due to a pyeloureteral carcinoma.Often subtle radiological changes are classed as normal, especially if they are bilateral.Further radiological imaging should be recommended in all cases where unexplained clinical features or radiological findings are present.

View Article: PubMed Central - HTML - PubMed

Affiliation: Musculoskeletal Surgery Department, Imperial College, London, UK. Michael.Hirschmann@ksbh.ch.

ABSTRACT

Introduction: Arthroplasty is a well-established routine elective surgical procedure in orthopaedics. To a great extent, diagnosis, treatment and post-operative rehabilitation in these patients is standardised. In a busy clinic, surgeons from time to time tend to focus their attention on common causes of joint pain, but it may lead them to overlook sinister but less common pathologies. Here we report a case of a patient with groin pain due to pre-operatively undetected pelvic metastases from a pyeloureteral carcinoma who underwent total hip arthroplasty. There are several case reports which deal with primary or secondary tumours which were either discovered at the time of replacement surgery or developed at the site of prosthesis years after total hip or knee replacement. To the best of our knowledge, this is the first case report in which a metastatic cancer was missed pre-operatively and intra-operatively both by the radiologist and by the orthopaedic surgeon and should be reported so that surgeons are reminded to be careful when dealing with seemingly routine cases.

Case presentation: A 79-year-old Caucasian woman presented to the arthroplasty clinic with groin pain. Initial radiographs showed subtle bilateral abnormalities in the pelvis. Neither the radiologist nor the orthopaedic surgeon recognized it. A diagnosis of osteoarthritis of the hip was established, and she underwent total hip arthroplasty. Despite initial improvement, the patient came back with worsening hip pain three months later. Further radiological examination revealed multiple metastatic lesions throughout the pelvis due to a pyeloureteral carcinoma.

Conclusions: This case report emphasizes the importance of meticulous, unbiased pre-operative assessment of patients and their radiographs, even in so-called routine clinical cases. Often subtle radiological changes are classed as normal, especially if they are bilateral. Further radiological imaging should be recommended in all cases where unexplained clinical features or radiological findings are present.

No MeSH data available.


Related in: MedlinePlus