PMC7672249_01
AP pelvis x rays from 9/11/2017 demonstrating advance right sided femoral head AVN with associated deformity and secondary osteoarthritic changes. Mild sclerosis of the left femoral head suggestive of early AVN.
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Early on October 2016, he was evaluated for right hip pain and diagnosed with avascular necrosis (AVN) of right hip (Fig. 1).
MRI obtained 22/01/2018 shows serpiginous bone infarctions involving the right proximal femur as well as left femoral head and intertrochanteric region.
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During his follow up MRI with contrast on January 2018 indicated serpiginous bone infarcts involving the right proximal femoral shaft as well as left femoral head and intertrochanteric region demonstrating high T2 signal intensity and low T1 signal intensity (Fig. 2).
AP pelvis x rays obtained 01/11/2019 showing no significant interval change in bilateral avascular necrosis with the finding of new osteolytic lesion involving the left femoral subtrochanteric region with involvement of the lateral cortex.
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X-ray showed osteolytic lesion, involving the left femoral sub-trochanteric area and the lateral cortex, with a picture of an impending fracture (Fig. 3).
MRI pelvis obtained 05/11/2019 demonstrated.. Background of bone osteonecrosis superimposed by an aggressive intramedullary lesion involving the left intertrochanteric region with cortical destruction.
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These imaging features highly indicate malignant transformation of the osteonecrosis (Fig. 4).
Bone scan showing.. 1- Heterogeneous radiotracer uptake seen in the distal femur and proximal left and right tibia consistent with osteonecrosis.. 2- Heterogeneous radiotracer uptake seen in the left intertrochanteric region consistent with patient known aggressive lesion in the prior MRI.
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Radio Tracer uptake was also observed at the left distal femur, left proximal tibia and right proximal tibia, all of which represent bone infarcts (Fig. 5).
Intra-operative image of the resected tumor in the left proximal femur.
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Open biopsy of the left proximal femur lesion displayed malignant spindle/epithelioid neoplasm consistent with high-grade sarcoma, undifferentiated pleomorphic sarcoma (Fig. 6).
Left hip x rays described status post resection of the proximal femur with placement of hip prosthesis.
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After adequate preparation, the patient was taken for resection of the proximal femur and reconstruction with mega-prosthesis (Fig. 7).