Blog Elements

Half Sized Blog Element (Single Author Style)

Half Sized Blog Element (Multi Author Style)

The “ODYSSEY”: “Orthopaedic Oncology” My journey thus far!

May 10, 2015

Vol 1 | Issue 1 | May – August 2015 | page:3-5 | Dr Ajay Puri. Author: Dr Ajay Puri. Chief – Orthopaedic Oncology. Professor & Head – Surgical Oncology, Tata Memorial Centre. President – Indian Musculo Skeletal Oncology Society, Chairman – Indian Orthopaedic Association (Oncology) President Elect – Asia Pacific Musculo Skeletal Oncology Society. Address […]

Intractable Knee pain….it could be Glomus!

May 10, 2015

Vol 1 | Issue 1 | May – August 2015 | page:48-50 | Umesh M Kulkarni[1], Vijay Zavar[2], Sudhir Sankalecha[3], Ameya Kulkarni[1]. Author: Umesh M Kulkarni[1], Vijay Zavar[2], Sudhir Sankalecha[3], Ameya Kulkarni[1]. [1]Sanjivan Hospital, India Security Press Hospital, Nashik, Maharashtra, India. [2]Skin Diseases Center, Nashik, Maharashtra, India. [3]Sankalecha Labs, Nashik, Maharashtra, India. Address of Correspondence Dr. […]

The “ODYSSEY”: “Orthopaedic Oncology” My journey thus far!

May 10, 2015

Intractable Knee pain….it could be Glomus!

May 10, 2015

Full Sized Blog Element (Big Preview Pic)

The “ODYSSEY”: “Orthopaedic Oncology” My journey thus far!

May 10, 2015

Vol 1 | Issue 1 | May – August 2015 | page:3-5 | Dr Ajay Puri.

Author: Dr Ajay Puri.

Chief – Orthopaedic Oncology.
Professor & Head – Surgical Oncology, Tata Memorial Centre.
President – Indian Musculo Skeletal Oncology Society,
Chairman – Indian Orthopaedic Association (Oncology)
President Elect – Asia Pacific Musculo Skeletal Oncology Society.

Address of Correspondence
Dr. Ajay Puri.
Email: docpuri@gmail.com

Guest Editorial:The “ODYSSEY”: “Orthopaedic Oncology” My journey thus far!

“The Odyssey is one of two major ancient Greek epic poems attributed to Homer. It centres on Odysseus and describes his journey home after the fall of Troy. It takes Odysseus ten years and multiple trials and tribulations as he seeks to return after the ten-year Trojan War.”

Circa 1999. Well ensconced as Associate Professor in one of Mumbai’s premier teaching University Hospitals living life in my “comfort zone” I was unaware of the cosmic forces building up that were soon to bring about a major upheaval in my professional career. An advertisement brought to my notice by a colleague for an “orthopaedic oncologist” in India’s premier oncology centre triggered a chain of events that I could have little foreseen. To most of us “routine” orthopaedic surgeons, orthopaedic oncology in the last millennium was a dark and forbidding battleground littered with countless mines all waiting to explode in the faces of those who were foolish enough to walk down that path. Besides the occasional giant cell tumor seen infrequently, the little I knew of this “unexplored specialty” was from the lectures heard at meetings where the wise man from the North propounded the theory of “God’s foresight that gave us two fibulae for reconstruction”, equally forcefully countered by the “mega” surgeon from the South who emphatically put forward the benefits of huge metallic monsters for reconstruction that functioned in lieu of our God given bones. [1, 2] To me as a youngster all this was as fascinating and farfetched as “Star Wars” because I never expected to walk down this road where “few men had gone before”.
Having had this “fateful” advertisement brought to my notice and more for lack of an alternate opportunity at adventure rather than a belief in choosing this as “the” career option I ventured to appear for this interview. Sports psychologists will go blue in the face trying to drill into their wards theories about “just enjoy the game” and “don’t let the pressure get to you and you will perform better”. With no pressure to perform, secure in the knowledge that I had a faculty position already and buoyed by the cockiness that was inherent in most young orthopaedic surgeons of my generation, the “enjoyable” interview went like a breeze. Lo and behold, “unexpectedly” I had an appointment letter in my hand to venture into this minefield.
Then is when the “pressure” set in. Should I leave my “comfort” zone to try and navigate this minefield? “Fools rush in – where angels fear to tread”. Angel I definitely was not, but a fool…….?
…………And I became the first orthopaedic oncologist to be appointed as full time faculty by Tata Memorial Hospital. I was joined a few months later by a colleague, a lecturer from the adjoining KEM hospital – Dr. MG Agarwal and together we set about navigating these stormy seas. Apart from the complexity of these “first time” surgeries one of the main obstacles that we encountered was the lack of a credible prosthesis for reconstructing large defects after resection. Though individual surgeons earlier had their prosthesis manufactured by local fabricators no national implant company had envisaged interest in these previously, either because of lack of numbers or the absence of an opportunity to develop a prosthesis with surgeon inputs. Armed with little more than the enthusiasm of the “new convert” we set up a collaboration with Sushrut, an implant manufacturer with whom I had the opportunity earlier to help develop their spine and trauma implants while working at “Sion” hospital. The absence of stringent regulatory requirements facilitated rapid development which would otherwise have been a lot slower in today’s era. The TMH –NICE (Tata Memorial Hospital – New Indigenous Customised Endoprosthesis) a custom prosthesis, individually manufactured for each patient was the result of this collaboration.[3] Over a decade, based on our clinical experience and increasing understanding of biomechanics the TMH –NICE metamorphosed into the “ResTOR”. This “off the shelf” modular prosthesis can now reconstruct whole bones and offers a cost effective alternative in many Asian and African countries.[4, 5] Along the way we also practised and refined numerous biological reconstructions.[6, 7] These offered alternative options that were more durable, universally applicable and easier to implement in financially constrained situations. The adrenaline pumping pelvis surgeries; fearful bloodbaths initially, gradually transformed into more controlled battles. We learned to reconstruct these large pelvic resections with options more suited for squatting and sitting cross legged, “activities of daily living” inherent to our patients.[8] Yes, there were complications and disasters. While we hopefully learned from these we did not allow them to overshadow our enthusiasm and possibly were the first believers of the “acche din aayenge” philosophy which encouraged us to keep moving ahead. While benefiting from the published experience of “western” literature we learned to innovate and develop methods and techniques more suited to our own our local socio-economic milieu.
We were fortunate that the environment of the institution we worked in was steeped in the culture of “multi-disciplinary” management, the essence of successful treatment of any cancer. We were easily able to implement “joint clinics” where patients benefited from a “one stop window” where all specialties pooled in their expertise to decide the optimum treatment of a particular case. The concept of our weekly ORP “ortho – radio – path” diagnostic meeting to discuss difficult diagnostic lesions has been the genesis of the hugely popular musculo skeletal oncology ORP gatherings that have been organised all across the country over the last decade or so.
Besides service, “education” has been a core component of the philosophy of the institute that gave me this opportunity to practise the art and science of musculoskeletal oncology. We began by training post M.S. “fellows”. As there was no formal program or rigid curriculum they spent varying amounts of time with us based on their endurance and ability to last the course and tolerate my idiosyncrasies. It is a matter of great pride now to see most of them as well established proponents of “orthopaedic oncology” in various parts of the country. Publishing our results in international peer reviewed journals and presentations at various international meetings helped establish the unit as a credible centre for bone and soft tissue tumors. This drew various international visitors all keen to experience the “large volumes” unlikely to be seen in most other global centres, further enhancing the exposure of the Indian musculoskeletal oncology fraternity on a global platform.[9] The earlier informal training has now formalised into a 2 year recognised “orthopaedic oncology fellowship” program, the only one of its kind in the country.
In ancient Roman religion and myth, Janus is the god of beginnings and transitions. He is usually depicted as having two faces, since he looks to the past and to the future. While certainly no Janus I think this is an appropriate moment to dwell on the future challenges we as a specialty must now try and overcome?[10] We must embrace the responsibility of increasing awareness about these uncommon lesions both in the public and professional domain. We must enhance our ability to disseminate and propagate current information and techniques, continue to train surgeons in larger numbers and help set up collaborative networks to gain further insight into these rare lesions. There is increasing pressure for medical technology assessment to include cost-effectiveness analyses to help determine difficult resource allocation decisions.[11] While the importance of clinical expertise and experience is unquestionable we do need to combine this with the judicious integration of best available scientific evidence to facilitate rational “informed” clinical decision making and help develop evidence based protocols that would be both effective and applicable in our settings.
The Indian Musculo Skeletal Oncology Society (IMSOS) is a step in this direction.[12] It aims to “promote scientific, evidence based, comprehensive multidisciplinary management of bone and soft tissue sarcomas and encourage basic and clinical research.” IMSOS seeks to provide a common forum for interaction and mutual collaboration between different specialists and institutes involved in the treatment of sarcomas. It will help foster training and education opportunities, promote dissemination of knowledge and aid in the development of treatment guidelines suitable for our socio cultural environment. Together we must strive to develop this society to ultimately provide the best possible care to the maximum number of patients. The launch of the “Journal of Bone and Soft Tissue Tumors” cannot have come at a more opportune time. It will provide a fillip to surgeons seeking to share their experience who may have otherwise been intimidated by the “established” journals which currently look askance at individual case reports and series with relatively small numbers.
The “Odyssey” continues…….. , Indian orthopaedic oncology while having successfully navigated its nascent and adolescent period is successfully maturing into a vibrant specialty seeking to stamp its own unique impression globally. It is heartening to see an ever increasing number of practitioners venturing into these seas, now armed with navigational aids and charts that could help make the journey less turbulent, yet as exciting and exhilarating as it has always been.

Ajay Puri.

References

1. Natarajan MV, Sivaseelam A, Ayyappan S, Bose JC, Sampath Kumar M. Distal femoral tumours treated by resection and custom mega-prosthetic replacement. Int Orthop 2005;29: 309-13.
2. Yadav SS. Dual-fibular grafting for massive bone gaps in the lower extremity. J Bone Joint Surg Am 1990;72: 486-94.
3. Agarwal M, Anchan C, Shah M, Puri A, Pai S. Limb salvage surgery for osteosarcoma: effective low-cost treatment. Clin Orthop Relat Res. 2007 Jun;459:82-91.
4. Puri A, Gulia A. The results of total humeral replacement following excision for primary bone tumour. J Bone Joint Surg Br 2012;94: 1277-81.
5. Puri A, Gulia A, Chan WH. Functional and oncologic outcomes after excision of the total femur in primary bone tumors: Results with a low cost total femur prosthesis. Indian J Orthop 2012;46: 470-4.
6. Puri A, Subin BS, Agarwal MG. Fibular centralisation for the reconstruction of defects of the tibial diaphysis and distal metaphysis after excision of bone tumours. J Bone Joint Surg Br 2009;91: 234-9.
7. Puri A, Gulia A, Jambhekar N, Laskar S. The outcome of the treatment of diaphyseal primary bone sarcoma by resection, irradiation and re-implantation of the host bone: extracorporeal irradiation as an option for reconstruction in diaphyseal bone sarcomas. J Bone Joint Surg Br 2012;94: 982-8.
8. Puri A, Pruthi M, Gulia A. Outcomes after limb sparing resection in primary malignant pelvic tumors. Eur J Surg Oncol 2014;40: 27-33.
9.http://www.indianorthopaedicsociety.org.uk/wp-content/uploads/2012/11/Report-3-Rej-bhumbra.pdf.
10. Puri A. Orthopedic oncology – “the challenges ahead”. Front Surg 2014;1: 27.
11. Brauer CA, Neumann PJ, Rosen AB. Trends in cost effectiveness analyses in orthopaedic surgery. Clin Orthop Relat Res 2007;457: 42-8.
12. http://www.imsos.org.

How to Cite this article: Puri A. The “ODYSSEY”: “Orthopaedic Oncology” – My journey thus far! Journal of Bone and Soft Tissue Tumors May-Aug 2015;1(1):3-5

Dr Ajay Puri

(Abstract) (Full Text HTML) (Download PDF)

Intractable Knee pain….it could be Glomus!

May 10, 2015

Vol 1 | Issue 1 | May – August 2015 | page:48-50 | Umesh M Kulkarni[1], Vijay Zavar[2], Sudhir Sankalecha[3], Ameya Kulkarni[1].

Author: Umesh M Kulkarni[1], Vijay Zavar[2], Sudhir Sankalecha[3], Ameya Kulkarni[1].

[1]Sanjivan Hospital, India Security Press Hospital, Nashik, Maharashtra, India.
[2]Skin Diseases Center, Nashik, Maharashtra, India.
[3]Sankalecha Labs, Nashik, Maharashtra, India.

Address of Correspondence
Dr. Umesh M Kulkarni
Sanjivan Hospital, India Security Press Hospital, Nashik, Maharashtra, India.
Email : umesh_kulkarni76@yahoo.com

Abstract

Introduction: Glomus tumors are areteriovenous anastomoses mostly found on flexor surfaces of fingers and nail beds. Occurrences in lower extremity is rarity and requires high index of suspicion.
Case Report: Thirty eight year old housewife presented with severe knee pain and swelling on the medial side of the knee since last two years. She had taken multiple opinions and was on analgesics and anti inflammatory medications for an extended duration. On examination an ill defined tender nodule was palpable on superolateral aspect of patella. MRI showed hypointense nodule with uniform contrast uptake. Excision biopsy was done to remove the lesion in total. Patient has complete relief of symptoms. Histopathology confirmed the diagnosis of glomus tumor
Conclusion: Glomus tumors can rarely occur in unusual locations. Clinical presentation and MRI help to narrow down the diagnosis. Excision leads to complete relief of symptoms.
Keywords: Glomus tumor, Knee, excision biopsy.

Introduction

The glomus body is a specialised form of arteriovenous anastomosis localised in the dermal soft tissue and acts as a thermoregulator. A glomus tumour (glomangioma, tumors of Popoff, or Barré-Masson syndrome) is a benign mesenchymal neoplasm composed of cells which resemble the modified smooth muscle cells of the normal glomus body (glomocytes) [1]. Extra-digital location of glomus tumour is uncommon [2]. Considering the rarity of this site, we present this case of Glomus tumour (GT) of the knee.

Case Report
A 38-yr-old housewife presented with severe right knee pains, supero-laterally to the patella, progressive since 2 years. Even the gentle touch would result in disproportionate shooting or stabbing type of pains, sometimes associated with paraesthesia. At times, the touch of clothing was unbearable. There was no seasonal exacerbation of the pains, which increased on extreme flexion of the knee or sitting cross-legged, compromising her daily work. She had abnormal apprehensive behaviour towards any person or object near her knee. There was no history of trauma or any inflammatory episode of the knee. She had received a number of analgesics, anti-inflammatory and anti-psychotic agents without much relief. She was even advised a psychiatric consultation prior to coming to us. On examination, an ill-defined soft nodule was palpable at the point of maximum tenderness only on extreme flexion of the knee (Fig.1). It was exquisitely tender on deep palpation. Movements of knee were painful in terminal flexion. There was no increase in local temperature. Swelling was mobile in the transverse direction, indicating adherence to deeper fibrous layers.

MRI revealed a hypointense nodule with in supero-lateral area of right knee on T1(Fig 2a). Gadolinium contrast showing enhanced and uniform uptake of the contrast (Fig. 2b). This confirmed the vascular nature of the lesion. The authors had earlier treated a similar case of GT of the knee joint and thus a high index of suspicion was present for GT. Excision biopsy was planned for the lesion. Open mini- excision biopsy of the lesion was preferred over arthroscopic shaving so that the lesion could be obtained in toto. The discrete lesion was found to be arising from the capsule of the suprapatellar region of the right knee and was fully excised. The patient had a miraculous recovery from the pain and unusual behaviour pattern. Histological examination revealed a well-circumscribed benign lesion with several vascular spaces (Fig. 3a) and solid aggregates of regular round glomus cells with darkly staining basophilic nucleus in a hyaline stroma.(Fig. 3b). On follow up the patient was completely relieved of all her symptoms. A consent for publication was taken before submitting the case report

Discussion
Histologically GT arises from glomus bodies that are specialised form of arteriovenous anastomosis involved in temperature regulation. Structurally plump endothelial cells line a centrally coiled canal which is surrounded by longitudinal and circular muscle fibres containing rounded epithelial appearing glomus cells (glomocytes) [1,2]. Histologically, GT are divided into 3 subtypes: The classical glomus tumour, glomangiomas and glomangiomyomas, the last being least common. Rarely, glomus tumours may have a malignant potential [3].
Though GT occur more commonly on digits below the nails, they may appear in other anatomical areas. Cutaneous lesions appear as small bluish-red tender nodules in the dermis or sub dermal skin. Pinpoint exquisite tenderness is characteristic. Pain from GT is so severe that at times a patient may even demand an amputation of the limb. The symptoms are generally worse in winter. Extra-digital GT commonly get misdiagnosed for a significant time period before the final diagnosis.4,5,6 In our case too there was a delay of more than a year in diagnosis. GT around the knee are reported infrequently [2,4-22]. In a review of cases GT of mayo clinic, tumors around the knee were 17.8% of all the cases of extradigital GT [2]. The structures around the knee that may be involved can be varied and GT is reported to arise from patellar ligament [9,22], quadriceps muscle [10], vastus lateralis [11], hoffa’s fat pad [13-18], plica synovialis [17]. In our case the lesion was arising from the joint capsule and did not involve muscles or tendons.
We had a very high index of suspicion of GT because of our earlier experience in treating such patients of GT along the knee joint. Often the tumour may not appear for a long time after the pain has begun [23] or may be neglected by the patient [8] or delayed diagnosed [6]. In our case the patient had taken medications from multiple consultants and presented to us with no specific diagnosis. According to Shugart et al, “almost diagnostic is the fact that the patient is reluctant, and often refuses palpation during examination [24]. In our case there was tenderness on deep palpation on complete flexion. This may be because the lesion was deep seated in the capsule and was covered laterally by vastus musculature. The clinical diagnosis needs to be confirmed with MRI and histopathology of the excised tissue. It is important to diagnose glomus tumour because the condition is potentially curable by surgical excision [2,3,4,5]. It however remains intriguing as to why a glomus appeared at this uncommon location.
In conclusion, intractable knee pain with focal exquisite tenderness may be due to glomus tumour and should be suspected early to minimize painful endurance by the patient.

References

1. GombosZ, ZhangPJ. Glomus tumor. Arch Pathol Lab Med 2008;132:1448-52.
2. Schiefer TK, Parker WL, Anakwenze OA, Amadio PC, Inwards CY, Spinner RJ. Extradigital glomus tumors: a 20-year experience. Mayo Clin Proc. 2006 Oct;81(10):1337-44
3. Hiruta N, Kameda N, Tokudome T, Tsuchiya K, Nonaka H, Hatori T, Akima M, Miura M. Malignant glomus tumor: a case report and review of the literature. Am J Surg Pathol. 1997 Sep;21(9):1096-103..
4. Clark ML, O’Hara C, Dobson PJ, Smith AL. Glomus tumour and knee pain: a report of four cases. Knee. 2009; 16: 231-4.
5. Puchala M, Kruczynski J, Szukalski J, Lianeri M. Glomangioma as a rare cause of knee pain. J Bone Joint Surg Am. 2008; 90: 2505-8.
6. Panagiotopoulos E, Maraziotis T, Karageorgos A, Dimopoulos P, Koumoundourou D. A twenty-year delay in diagnosing a glomus knee tumor. Orthopedics. 2006 May;29(5):451-2.
7. Caughey DE, Highton TC. Glomus tumour of the knee. Report of a case. J Bone Joint Surg Br. 1966 Feb;48(1):134-7.
8. Davenport D, Colaco HB, Edwards MR. The 30-year wait for treatment of an acutely painful knee. BMJ Case Rep. 2014 Sep 29;2014.
9.Mabit C, Pecout C, Araud JP. Glomus tumour in the patellar ligament: A case report. J Bone Joint Surg [Am] 1995; 77: 140-141.
10.Negri G, Schulte M, Mohr W. Glomus tumour with diffuse infiltration of the quadriceps muscle: A case report. Hum Path 1997; 28: 750-752.
11.Amillo S, Arriola FJ, Munoz, G. Extradigital glomus tumour causing thigh pain. J Bone Joint Surg [Br] 1997; 79B: 104-106.
12.Oztekin HH. Popliteal glomangioma mimicking baker’s cyst in a 9-year-old child: an unusual location of a glomus tumour. Arthroscopy 2003; 19(7); 1-5.
13.Hardy P, Muller GP, Got C. Glomus tumour of the fat pad. Arthroscopy 1998; 14: 325-328.
14.Waseem S, Jari S, Paton R. Glomus tumour, a rare cause of knee pain: a case report. Knee 2002; 9:161-163.
15. Clark ML, O’Hara C, Dobson PJ, Smith AL. Glomus tumor and knee pain: a report of four cases. Knee. 2009 Jun;16(3):231-4.
16. Gholve PA, Hosalkar HS, Finstein JL, Lackman RD, Fox EJ. Popliteal mass with knee pain in a 57-year-old woman. Clin Orthop Relat Res. 2007 Apr;457:253-9.
17. Kato S, Fujii H, Yoshida A, Hinoki S. Glomus tumor beneath the plica synovialis in the knee: a case report. Knee. 2007 Mar;14(2):164-6.
18. Prabhakar S, Dhillon MS, Vasishtha RK, Bali K. Glomus tumor of Hoffa’s fat pad and its management by arthroscopic excision. Clin Orthop Surg. 2013 Dec;5(4):334-7.
19. Gonçalves R, Lopes A, Júlio C, Durão C, de Mello RA. Knee glomangioma: a rare location for a glomus tumor. Rare Tumors. 2014 Dec 18;6(4):5588.
20. Sraj SA, Khoury NJ, Afeiche NE, Abdelnoor J. Thigh pain of 5 years’ duration in a 48-year-old man. Clin Orthop Relat Res. 2008 Sep;466(9):2291-5.
21. Okahashi K, Sugimoto K, Iwai M, Kaneko K, Samma M, Fujisawa Y, Takakura Y. Glomus tumor of the lateral aspect of the knee joint. Arch Orthop Trauma Surg. 2004 Nov;124(9):636-8.
22. Akgün RC, Güler UÖ, Onay U. A glomus tumor anterior to the patellar tendon: a case report. Acta Orthop Traumatol Turc. 2010;44(3):250-3.
23. King ESJ. Glomus Tumour. Australian and New Zealand Journal of Surgery, 1954:23(4); 280-295.
24. Shugart RR, Soule EH, Johnson EW. Glomus tumor. Surgery, Gynecology & Obstetrics. 1963;117:334–340.

How to Cite this article: Kulkarni UM, Zavar V, Sankalecha S, Kulkarni A. Intractable Knee pain….it could be Glomus! Journal of Bone and Soft Tissue Tumors May-Aug 2015; 1(1):48-50.

Dr.Umesh M Kulkarni

Dr.Vijay Zavar

Dr.Sudhir Sankalecha

Dr.Ameya Kulkarni

Half Sized Blog Element (Single Author Style)

Half Sized Blog Element (Multi Author Style)

The “ODYSSEY”: “Orthopaedic Oncology” My journey thus far!

Like this:

Intractable Knee pain….it could be Glomus!

Like this:

The “ODYSSEY”: “Orthopaedic Oncology” My journey thus far!

Like this:

Intractable Knee pain….it could be Glomus!

Like this:

Full Sized Blog Element (Big Preview Pic)