TECHNIQUE TIP and ON-LINE CMEs
ON-LINE CMEs
ASOPA members with an active OPA-C credential can earn CME credits toward recertification just by reading the “Technique Tip” contained in each issue of the ASOPA Update and answering a few short questions at the conclusion of the article. Members can either answer the questions in the print version of the newsletter and return them via fax or mail to the ASOPA office or submit answers on-line by clicking on the link at the end of each article and completing the on-line questionnaire.
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TECHNIQUE TIP
Summer 2009 Update
KNEE PAIN IN THE ADULT RUNNER
Case Study of Chadwick Smith, MD
Article by Michael Craig, OPA-C, SA-C
A 48-year-old female, school teacher and an avid runner presented as a new patient in our office.
Chief Complaint: right knee pain
Right Knee History: Symptoms began years ago. The patient is complaining of aching, sharp pain and soreness. She also describes the level as being moderate in nature. The symptoms are made worse with kneeling, standing, squatting down and then attempting to stand up. She states that symptoms have increased to the point that she has stopped running.
Right Knee Exam:
--Tenderness: Anterior and Extensor mechanism at the lateral facet
--Swelling: no swelling noted
--Ecchymosis: none
--Range of motion: normal
--Patello-Femoral: compression pain and crepitus
--Compartment testing: positive medial McMurray’s test
--Effusion: moderate
--Nero Vascular: normal
X-ray: 3 views of knee, normal
Plan: MRI return after test
Return Visit:
--MRI Right Knee Impression: 1) 2.5 x 2.6 x 4.6 cm infrapatellar mass. The mass appears to arise intra-articular and extend into Hoffa’s fat pad.
--Impression: Benign tumor of the right knee joint.
--Recommended Right Knee Surgery: Incision of mass
--Plan: Instructed patient to return to office in 10 to 12 days.
As you can see from the surgical pictures below (Figure 1), there was an arthrotomy made and a large tumor (Figure 2) resected from the posterior patella tendon. The specimen was sent to pathology.
Post Op Visit: Incision healed well
ROM: Extension = 0 Flexion = 95°
Pathology Report: Received in formalin is an ovoid gray cystic appearing mass, 4.8 x 4.0 x up to 2.1 cm. The specimen superficially displays adherent yellow and gray fibrous and fibrofatty tissue. Cutting reveals yellow-orange rubbery tissue. There is a central cavity, 1.3 cm in greatest dimension with no grossly evident contents. Representative sections are processed.
Diagnoses: Giant cell tumor of the tendon sheath, which is consistent with a large multinucleated giant cell.
Quote: Giant cell tumors of the tendon sheath are the second most common tumors of the hand, with simple ganglion cysts being the most common. Chassaignac first described these benign soft-tissue masses in 1852, and he overstated their biologic potential in referring to them as cancers of the tendon sheath.
Giant cell tumors of the soft tissue are classified into 2 types: the common localized type and the rare diffuse type. The rare diffuse form is considered the soft tissue counterpart of diffuse pigmented villonodular synovitis ( PVNS) and typically affects the lower extremities. Its anatomic distribution parallels that of PVNS, with lesions most commonly found around the knee, followed by the ankle and foot: however, the diffuse form occasionally affects the hand. Typically, these lesions, like those of PVNS. Occur in young patients; 50% of cases are diagnosed in patients younger than 40 years. The diffuse form is often locally aggressive, and multiple recurrences after excision are common.
In this case, we believe that it is the common localized type of giant cell tumor and not PVNS.
As of nine months post op, patient is doing well and no recurrence.
REFERENCES
Author: James R. Verheyden MD, Consulting Surgeon, Department of Orhtopaedic Surgery, The Orthopedic and Neurosurgical Center of the Cascades. Coauthor(s): Timothy A. Damron, MD, David G. Murray Endowed Professor, Department of Orthopedic Surgery, Professor, Orthopedic Oncology and Adult Reconstruction, Vice Chair, Department of Orthopedics, State University of New York Upstate Medical University at Syracuse.
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| Figure 1 |
Figure 2 |
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