since about a year ago visiting our hospital , a 73-year - old female patient visited our clinic with both hip pain more severe on the right side . the patient experienced pain while walking and the pain was getting more serious , she did not have a history of trauma . the patient has been taking drugs for diabetes and hypertension for the past 10 years . approximately 8 years ago , she underwent percutaneous coronary intervention and total thyroidectomy for angina pectoris and thyroid cancer , respectively . five years ago , the patient was also diagnosed with end stage renal disease ( esrd ) and taking the required drugs . after the onset of symptoms , a simple pelvis x - ray image taken by another institute indicated osteolytic lesions on the right femoral head and neck ( fig . 1 ) , computed tomographuy ( ct ) images of the pelvis also showed similar osteolytic lesions ; both hip joints were swollen and the joint cavities were invaded ( fig . 2 ) . in order to confirm the presence of lesions , non - enhanced magnetic resonance images ( mri ) were taken of both hip joint and the right femoral head and neck showed osseous lesions . in both joint cavities , low signal intensity of lesion deposition were observed ( fig . , the patient was subjected to simple x - ray and enhanced mri and we identified subchondral inflammation and that the femoral head and neck cysts were enlarged . further , amount the lesion which shows low signal intensity in mri that means deposition in cavities increased as well ( fig . 4 , 5 ) . the range of motion of the right hip joint , the flexion contracture , further flexion , internal rotation , and external rotation were measured and determined to be 10 , 90 , 10 , and 40 , respectively . in addition , adduction and abduction were 50 , and 30 , respectively . to make a more accurate diagnosis , ultrasound - guided biopsy was performed and amyloidosis was confirmed based on apple - green birefringence with congo red stain and the presence of amyloid p positive cells when immunohistochemical analysis was conducted . when hospitalized , hematological analyses were conducted ; erythrocyte sedimentation rate was 110 mm / hr and c - reactive protein was 2.95 mg / dl . in addition , it was suggested that the patient may have anemia ( hemoglobin 9.5 g / dl ) . despite of conservative treatment , the patient still complained of serious pain , thus total hip arthroplasty of the right hip was performed to relieve pain , prevent femoral neck fracture and the enlargement of lesions ( fig . 6 ) . while performing surgery , the authors confirmed cystic formation of the femoral neck and head and massive joint effusion , synovial hypertrophy , and amyloid deposition throughout the joint muscles ( fig . according to the biopsy , apple - green birefringence with congo red stain and amyloid p positive cells were observed and amyloid fibrils were visible with an electron microscope ( fig . no microbial contamination was observed with ultrasound - assisted biopsy and culture examination . to further test if amyloidosis invaded toward other tissues , esophagogastroduodenoscopy , sigmoidscopy , chest ct , and abdomen ultrasonic wave examinations were performed and the results suggested no additional amyloidosis . serum and urinary protein immune electrophoresis were performed to elucidate the primary cause of amyloidosis ; in this , lambda light chain ( monoclonal gammopathy , lambda type ) was found to be high and the bone marrow aspiration examination indicated increase in plasma cells ( 19.4% ) . therefore , the patient was diagnosed with secondary multiple local amyloidosis due to multiple myeloma . amyloidosis - a disease first described by wilks in 1856-is characterized by the extracellular deposition of amyloid protein in various tissues and organs6 ) . depending upon the clinical phase , amyloidosis can be classified as ( 1 ) primary amyloidosis , ( 2 ) secondary amyloidosis , ( 3 ) local amyloidosis , ( 4 ) genetic familial amyloidosis , or ( 5 ) degenerative amyloidosis . in 1990 , the international nomenclature committee for amylodosis suggested to classify amyloidosis based on amino acid sequences of fibril proteins such as aa , al , ah , attr , and a2 m . the cause of primary amyloidosis can be classified to primary amyloidosis without other diseases and amyloidosis with multiple myeloma . immunoglobulin kappa and lambda light chain act as a precursor protein , thus it is called al amyloidosis . secondary amyloidosis which is caused by infectious diseases ( e.g. , tuberculosis , leprosy , and chronic osteomyelitis ) , chronic inflammatory diseases ( e.g. , rheumatoid arthritis , and ankylosing spondylitis ) , and malignant tumors ( e.g. , renal cell carcinoma , and hodgkin 's disease ) is called aa amyloidosis . this is because serum amyloid a ( saa ; an acute phase reactant ) is increased in the serum . amyloid deposits can invade various tissues including the kidneys , heart , lung , liver , skin and joints thus it represents variable clinical patterns . typically al type protein deposits on the heart , tongue , gastro - intestinal tract , neuronal system , and skin whereas the aa type is typically found in the liver , spleen , and kidneys . the major differences between the al and aa type includes not only the structure of precursor amyloid protein but also clinical patterns . in particular , arthropathy is known as a disease specific finding of al type7 ) . amyloid arthropathy can be divided into two types . if amyloid is deposited around joint tissues and synovia , the affected joint experiences edema and swelling which can lead to misdiagnosis of rheumatoid arthritis . when bone marrow is replaced with amyloid it usually affect bigger joints ( e.g. , hip joint ) and fractures can frequently occur . in the simple x - ray , approximately 71% images are found to be normal , but when multiple myeloma is present pathological fracture , osteoporosis , and osteolytic lesions are observed and only 31% are found normal8 ) . osteolytic lesions due to myeloma , abscence of fever , no tenderness or inflammation are characteristic differences of amyloid arthropathy to rheumatic arthritis . amyloid arthropathy tends to be found in older patients , thus distinguishing it from rheumatoid arthritis . many researches indicate that amyloid arthropathy commonly occurs in the shoulder , hip , knee , and carpal bone . agents are used based on the fact that immunoglobulin light chain forms amyloid and is synthesized in plasma cells . nonsteroidal anti - inflammatory drugs , intra - articular - corticosteroid , muscular relaxants and physiotherapy ( as a conservative therapy ) are treatments for amyloid arthropathy associated with multiple myeloma . a case about a cyst of the femur neck was treated by a combination of curettage and autologous iliac crest bone graft and another case which was treated by iliac crest bone graft with internal fixation and total hip arthroplasty is reported910 ) . amyloidosis can be triggered by variable causes and the clinical manifestation and affected organ , treatment options , prognosis depends on the characteristics of deposited proteins . medical tests for screening the disease , differential diagnosis , searching for the primary disease should be properly done before treating patients with amyloidosis around their joints .
amyloidosis is a disease characterized by the deposition of non - soluble fibrous protein in multiple tissues with a number of possible causes . 
 this protein deposition can occur in any tissue , yet is most commonly seen in kidneys , heart , and gastrointestinal tracts . 
 however , invasion to bone tissues is not often reported . 
 the deposition of amyloid proteins in bone tissues may result in joint pain and pathological fractures ; it is important to elucidate the causes and detect early to determine prognosis and treat optimally . in the present case report , with relevant literature review 
 , the authors report a case of total hip arthroplasty in an amyloidosis patient .