OCAD – orthopedist wants to amputate. Vascular surgeon not

Thank you for everyone’s collaboration.

I was scared when the internal medicine resident came to my room and told me that the orthopedist wants to amputate the leg, even though it is functional! People exaggerate their claims, but the responsibility was in my diagnosis!

The responses I received are as follows:

Pagetoid wonder if it was treated?

Pachydermoperiostosis suggests chronic veno lymphatic changes primary or secondary. Low grade infiltrative skin neoplasm or T cell lymphoma a consideration. But it sure looks like complicated skin process overlying Pagets.

3 reasons for amputation: Dead, Dead useless: Deadly no clear indication for me.

Paget’s comes to mind but it seems too peculiar to realistically consider given the history. I favor old osteomyelitis…given the lack of edema signal on the MR and normal labs, it seems like active osteomyelitis is not likely.

The decision to amputate or not seems like it should hinge on clinical data…not our call anyway…pain, function of the limb, systemic illness.

It looks like Paget’s disease to me.

I think there is gelatinous transformation, which is the marrow is so bright. I don’t see any reason to amputate.

Paget.

Is it possible it’s unrelated to the old cutaneous injury?

Looks alot like Pagets.

Chronic stasis leads to periostitis- some here

but underlying- its Pagets of tibia.

Looks chronic infectious to me.

If venous stasis would expect thick wavy periosteal reaction.

CT doesn’t look like fibrous dysplasia although X-ray is slightly suggestive.

Would it not be a good idea to get a bone biopsy before the decision to amputate is made? Just a thought!

68M, orthopedist wants to amputate. Vascular surgeon not.
Chemical burn on the skin 28 years ago, with skin ulcer.
Venous stasis, periosteal reactions and dystrophic calcifications.
Laboratory tests for infection are normal.
Do not have sequestration or cloaca.
Chronic osteomyelitis?
Dx?
I wonder if chronic venous stasis could result in a diffuse bony change in the tibia as in this case.

what do you think?

Ciro

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