Orthopaedic Case of the Month: A 72-year-old Man With a Painful Flexion Contracture of the Left Thigh

Abstract

A 72-year-old man presented with a 48-hour history of increasing left posterior thigh pain and a progressive left knee flexion contracture. Physical examination revealed that he recently had a left below knee amputation. The stump was healing well. He had a firm posterior thigh with a woody consistency extending from the popliteal fossa proximally to the midposterior left thigh. On attempted passive extension of the left knee, there was exquisite pain in the posterior thigh.Four weeks before his current presentation for the left posterior thigh pain, he had been admitted to our institution with a 1-week history of worsening abdominal pain, nausea, and vomiting. The patient had general surgery and gastroenterology consultations. Physical examination of his abdomen revealed a soft, nondistended abdomen with hyperactive bowel sounds. He had tenderness in the epigastrium, umbilical region, and right lower quadrant. There were no palpable masses or organomegaly. Imaging of the abdomen revealed a high-grade small bowel obstruction with a transition point seen in the right lower quadrant. The patient was treated with a small bowel follow-through and colonoscopy that led to an exploratory laparotomy with resection of a mass in the distal ileum. Pathologic examination of the small bowel mass showed a metastatic Stage IV carcinoma. Further immunohistochemical and tumor marker analyses suggested a primary neoplasm of gastric or esophageal origin. Staging with a CT of the chest, abdomen, and pelvis showed no other lesions of the viscera.During the same hospital admission for his small bowel obstruction, orthopaedics was consulted for a chronic 4-cm 9 2-cm wound of the left heel that had been present for 6 months. On evaluation, he also had chronic osteomyelitis of the left calcaneus and a left knee flexion contracture of 30°with mild tenderness to palpation about the knee. Radiographs of the left knee showed chronic degenerative changes. No additional or advanced imaging of his left knee or thigh was obtained at that time, as he had a relatively painless knee flexion contracture. His surgical history revealed that 2 years before his current presentation he had undergone a left Chopart amputation for dysvascular forefoot wounds. Although he did not have a diagnosis of diabetes, he had a history of peripheral vascular disease with neuropathy secondary to heavy tobacco use. As treatment for his chronic heel wound, the patient underwent a left below knee amputation 5 days after his exploratory laparotomy. Intraoperatively after the below knee amputation, he was treated with an intraarticular