Femoral head

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The femoral head is a common ditzel in surgical pathology at centres which have orthopaedic surgeons.

Many of these can be "gross only".

Gross

Features to comment on:[1]

  • Laterality (on requisition).
  • Dimensions of head and neck.
  • Shape of head (round? deformed?).
  • Resection margin (irregular?).
  • Cartilage (thinning/eburnation? separation from the cartilage).
  • Bone (subchondral cysts? subchondral sclerosis?).
  • Presence of soft tissue.
  • Other (osteophytes? pannus?).

Notes:

  • Some advocate the use of cardboard when cutting[2] -- weird.

Criteria for gross only

Must be fulfilled:

More stringent - in addition to the above:

  • No history of cancer.

Diagnoses to consider

Specific diagnoses

Avascular necrosis of the femoral head

  • AKA avascular necrosis, abbreviated AVN.

General

Risk factors:

Gross

Features:[4]

  • Wedge-shaped pale yellow abnormality below cartilage.
  • +/-Cartilage separates from the bone.
  • +/-Deformation of femoral head.

Image:

Microscopic

Features:[5]

  • Empty lacunae (indicative of necrotic bone).

Sign out

FEMORAL HEAD, RIGHT, HIP ARTHROPLASTY: 
- AVASCULAR NECROSIS OF THE FEMORAL HEAD.

Remote AVN

FEMORAL HEAD AND JOINT CAPSULE, LEFT, HIP ARTHROPLASTY:
- FEMORAL HEAD WITH OSTEOARTHRITIS AND MARKED DEFORMATION CONSISTENT WITH HISTORY OF
AVASCULAR NECROSIS.
- JOINT CAPSULE WITH MINIMAL CHRONIC INFLAMMATION.
Micro

The sections show a femoral head with loss of cartilage and focal vertical cleft formation in the remaining thinned cartilage. Subchondral sclerosis is present. The underlying bone is viable. Bone marrow is present. The red blood cells have a sickled morphology.

Osteoarthritis

See Osteoarthritis.

Infection

See Osteomyelitis.

Rheumatoid arthritis

Fracture of bone due to metastatic carcinoma

  • AKA pathologic fracture.

General

  • Uncommon ~ 10 of 90 suspected cases.[6]
    • Usually in patients with a known malignancy and bony metastases.
  • Should not be missed.
  • Classically in older individuals.

Gross

Features:

  • Irregular resection margin.†
  • Focal, irregular, tan-white discolouration at the fracture site, i.e. margin, and in the marrow space.

Note:

  • † Non-fracture resections have a flat resection margin, as they were cut by the surgeon.

Image:

Microscopic

Features:

DDx:

Sign out

FEMORAL HEAD, LEFT, HIP ARTHROPLASTY: 
- METASTATIC SMALL CELL CARCINOMA.

Non-pathologic fracture of the femoral neck

Hip fracture, traumatic hip fracture and traumatic fracture of the femoral neck redirect here.

General

Gross

  • Irregular/jagged femoral neck margin.
  • Hemorrhage.

Microscopic

Features:

  • Non-vital bone.
    • Loss of osteocytes.

DDx:

Commonly concurrent pathology:

Sign out

FEMORAL HEAD AND SURROUNDING TISSUE, LEFT, HIP ARTHROPLASTY:
- NON-VITAL BONE CONSISTENT WITH FRACTURE.
- BENIGN FIBROADIPOSE TISSUE.
- NEGATIVE FOR MALIGNANCY.

See also

References

  1. Lester, Susan Carole (2005). Manual of Surgical Pathology (2nd ed.). Saunders. pp. 225. ISBN 978-0443066450.
  2. Dimenstein, IB. (Jun 2008). "Bone grossing techniques: helpful hints and procedures.". Ann Diagn Pathol 12 (3): 191-8. doi:10.1016/j.anndiagpath.2007.06.004. PMID 18486895.
  3. URL: http://www.merckmanuals.com/professional/musculoskeletal_and_connective_tissue_disorders/osteonecrosis/osteonecrosis.html. Accessed on: 30 April 2012.
  4. Lester, Susan Carole (2005). Manual of Surgical Pathology (2nd ed.). Saunders. pp. 224. ISBN 978-0443066450.
  5. Steffen, RT.; Athanasou, NA.; Gill, HS.; Murray, DW. (Jun 2010). "Avascular necrosis associated with fracture of the femoral neck after hip resurfacing: histological assessment of femoral bone from retrieval specimens.". J Bone Joint Surg Br 92 (6): 787-93. doi:10.1302/0301-620X.92B6.23377. PMID 20513874.
  6. Ramisetty, NM.; Pynsent, PB.; Abudu, A. (May 2005). "Fracture of the femoral neck, the risk of serious underlying pathology.". Injury 36 (5): 622-6. doi:10.1016/j.injury.2004.08.034. PMID 15826621.
  7. URL: http://www.path.utah.edu/casepath/ms%20cases/ms%20case%205%20comp/case%205.htm. Accessed on: 11 October 2012.
  8. Blain, H.; Chavassieux, P.; Portero-Muzy, N.; Bonnel, F.; Canovas, F.; Chammas, M.; Maury, P.; Delmas, PD. (Nov 2008). "Cortical and trabecular bone distribution in the femoral neck in osteoporosis and osteoarthritis.". Bone 43 (5): 862-8. doi:10.1016/j.bone.2008.07.236. PMID 18708176.