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Case Report: Fibroxanthoma: A Complication of a Biodegradable Screw

Sadat-Ali, Mir, MD, PhD, FRCS, D Orth1, 2, a; Azzam, Quamar, MBBS, MS1, 2; Bluwi, Mohammed, MBBS, SSC (Ortho)1, 2; Al-Umran, Abdallah, S., MBBS, SSC (Ortho)1, 2

Clinical Orthopaedics and Related Research: August 2010 - Volume 468 - Issue 8 - p 2284–2287
doi: 10.1007/s11999-009-1170-6
CASE REPORT
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Background Biodegradable interference screws in anterior cruciate ligament (ACL) reconstruction have gained popularity because of their similar or superior fixation strength in comparison to metallic interference screws and because they do not cause imaging artifacts and do not need to be removed.

Case Description We report the case of a 23-year-old man who presented with slowly progressive firm swelling of 2 months' duration at the site of the tibial tunnel 3 years after ACL reconstruction using a biodegradable interference screw. After curettage and débridement, the material was sent for histopathologic examination, which was reported as a fibroxanthoma.

Literature Review Reported complications are osteolysis around the screw, allergic reaction, sterile abscess formation, ganglion cyst formation, and intraarticular migration. A fibroxanthoma consists of fibroblasts and mononuclear or multinucleated cells with large lipid-filled histiocytes (foam cells). The cells are negative for S-100 and keratin and positive for anti-human macrophage marker HAM-56.

Purposes and Clinical Relevance Use of biodegradable screws is associated with high healing rates and low complication rates; however, awareness of their potential complications may help in early recognition and prevention of associated morbidity.

1The University Department of Orthopaedic Surgery, College of Medicine, King Faisal University, Dammam, Saudi Arabia

2King Fahd University Hospital, PO Box 40071, 31952, AlKhobar, Saudi Arabia

ae-mail; drsadat@hotmail.com

Received: June 25, 2009/Accepted: November 4, 2009/Published online: November 21, 2009

Each author certifies that he or she has no commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article.

Each author certifies that his or her institution approved the reporting of this case report, that all investigations were conducted in conformity with ethical principles of research, and that informed consent for participation in the study was obtained.

This work was performed at King Fahd University Hospital.

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Introduction

Biodegradable screws have gained wide acceptance by arthroscopic surgeons [7, 11, 22] because they do not cause imaging artifacts and graft lacerations and do not need to be removed. They have similar or superior fixation strength in comparison to metallic interference screws [11, 21]. However, they have complications such as cyst and abscess formation [4, 7, 19, 20], breakage, and intraarticular migration [2, 18]. Although no fibroxanthoma as a complication of biodegradable screws has been reported in the English literature, a literature search shows sarcoma [9] and malignant fibrous histiocytoma [1, 8] in response to other orthopaedic implants.

We report the case of 23-year-old man who presented with slowly progressive firm swelling of 2 months' duration at the site of the tibial tunnel 3 years after anterior cruciate ligament (ACL) reconstruction using a biodegradable interference screw. After curettage and débridement, the material was sent for histopathologic examination, which resulted in a diagnosis of fibroxanthoma.

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Case Report

A 23-year-old man presented to our outpatient clinic with an 18-month history of instability and recurrent giving way of his right knee, especially when trying to change direction. His history revealed he sustained a twisting injury to the same knee approximately 2 years earlier while playing football. He had pain and swelling and was unable to weight bear. His doctor recommended a cylinder cast for 3 weeks followed by physiotherapy. The pain and swelling improved over 6 months; however, he noticed instability, especially when running or climbing stairs.

At the time we saw the patient 2 years after the initial injury, examination showed a positive Lachman test and a positive pivot shift test. MRI showed a complete tear of the ACL with an oblique tear of the lateral meniscus (Type II). ACL reconstruction was performed using a hamstrings (gracilis and semitendinosus) graft, and a biodegradable interference screw (Bionix Implants, Tampere, Finland) was used for fixation of the graft at the tibial tunnel. After 3 months of supervised physiotherapy, he regained full range of movements and resumed preinjury level of activities by 6 months after surgery.

Three years after the index surgery, he presented with slowly progressive bony swelling at the site of the tibial tunnel of 2 months' duration. He had intermittent pain and an unusual itching sensation at the site of the swelling. On examination, an irregular firm swelling approximately 1 × 1.5 cm was found near the entry portal of the tibial screw. The clinical impression was ectopic bone formation, delayed allergic reaction to the screw, or disengagement and backing out of the screw. The plain radiograph was normal (Fig. 1). The sedimentation rate and C-reactive protein were normal. The patient was given nonsteroidal antiinflammatory drugs for 3 weeks without relief.

Fig. 1A-B

Fig. 1A-B

Owing to the progressive symptoms and size of the mass, the region was explored. We observed an irregular mass localized around the tibial entry portal. The bioscrew was partially degraded and in its original position. The tunnel was obliterated with bone. The mass was curetted and the tunnel débrided and irrigated. Material obtained was sent for biopsy. Histopathologic examination showed large areas of foam cells, lipid-filled cells with abundant vacuolated cytoplasm, interspersed with fibrovascular septations. The cells were negative for S-100 and positive for anti-human macrophage marker HAM-56, which was consistent with the diagnosis of fibroxanthoma (Figs. 2, 3).

Fig. 2A-B

Fig. 2A-B

Fig. 3

Fig. 3

A plaster cast was applied for 3 weeks after surgery; the patient did not need any walking aid. Physiotherapy was started after cast removal. The patient's pain was relieved within 4 postoperative days. At 9 months' followup, his symptoms and the mass had completely disappeared.

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Discussion

The use of biodegradable interference screws in ACL reconstruction has gained popularity [7, 13]. They typically are made from poly-L-lactic acid and offer similar or superior fixation [11, 21] in comparison to that of similarly designed metal screws for ACL reconstruction [16, 17]. Comparative studies between biodegradable and metallic screws have shown no superiority of one over the other in terms of pain, Lachman and pivot shift tests, Tegner activity level, and Lysholm score [12, 13, 15, 17]. Biodegradable screws have several advantages over metallic screws: they do not have to be removed, they may avoid the damage metallic screws can cause to the patellar bone/tendon graft in the tunnel, and they avoid metal artifacts with imaging. The benefits of biodegradable screws, however, come with more complications. The reported complications of biodegradable screws are osteolysis around the screw [17], allergic reaction [15], and extraarticular pretibial sterile abscess [4]. Other reported complications are transcutaneous [18] and intraarticular migration [2], recurrent pretibial ganglion cyst formation [19], and intraarticular granuloma formation [7].

There is disagreement among pathologists regarding whether a fibroxanthoma represents a true neoplasm [3, 6], developmental defect [5], or reactive process [14]. Radiographic findings generally are nondiagnostic. Histologic findings of fibroblasts and mononuclear or multinucleated lipid-filled cells having the appearance of histiocytes with abundant vacuolated cytoplasm interspersed with fibrovascular septations and masses of cholesterol suggest the diagnosis [3]. Cells are negative for S-100 protein and positive for anti-human macrophage marker HAM-56, which indicates histiocyte lineage [3, 5, 10].

Use of bioabsorbable screws for fixation of graft in ACL reconstruction is effective in terms of fixation strength [7, 21] and safe with overall low complication rates [2]; however, we need to be aware of potential complications, early recognition of which may prevent associated morbidity.

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References

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