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276 Medicinski Glasnik, Volumen 6, Number 2, August 2009 This patient lived in a rural area, worked in agricultural environment and was exposed to pesticides for many years. The diagnosis of lymphoma cannot be made from clinical findings solely and thus biopsy and imaging of the lesions is mandatory prior to any treatment (9). During the diagnostic procedure adequate tissue biopsy must be taken to differentiate lymphoma from destructive inflammatory diseases or malignant tumors (9). Biopsy must be adequate, not too small or too superficial because sinusonasal lymphomas are subepithelial lesions, often with perfectly normal overlying mucosa, unlike carcinoma, which are usually ulcerative (9). Repeated biopsy may sometimes be needed. Cross-sectional imaging findings like pathologic contrast enhancement or bone changes may reveal the malignant nature of the disease but there is significant overlapping between those possible pathologies that can arise in this region (9). Physiologic imaging, like perfusion CT and proton MR spectroscopy, in the extracranial head and neck can be implemented in any CT or MRI survey, provide functional information of the lesion, and may be helpful to differentiate benign from malignant disease as well as guide therapeutic decisions (10). The optimal treatment for primary nasal lymphoma remains unknown (11). Surgical resection of paranasal sinusal lymphoma is not recommended unless the tumor spreads to critical locations resulting in impending death (11). Complete response rate after radiotherapy is much higher as compared to chemotherapy although radiothera- Figure 3. Immunohistological section of the lymphoma showing strong positive staining for cytoplasmic CD56 (CD56; x40) (I. Mahovne, 2007.) py planning for primary nasal lymphomas may be difficult because these lymphomas often encroach on such radiosensitive critical structures as the optic chiasm, optic nerve and eyeballs and exact dose-tumor response relationship is unknown (11). Addition of chemotherapy to radiotherapy did not improve survival rate with early stage NK/T cell lymphoma (12). Ocular manifestation prior to systemic ones may be useful to monitor the response to therapy (12). Prognosis associated with sinonasal NK/T cell lymphomas varies. Dissemination is infrequent, but when it occurs it typically involves other extranodal sites (12). In conclusion, this case highlights the importance of adequate tissue biopsy and patohistological examination in patients with chronic sinusitis or orbital cellulitis that fail to respond to traditional management. ACKNOWLEDGMENT / DISCLOSURE Competing interests: none declared. REFERENCES 1. 2. 3. 4. 5. 6. 7. 8. McBride P. Photographs of a case of rapid destruction of the nose & face. Laryngol 1987;12:64–6. Kassel S, Echevaria RA, Guzzo FP. Midline malignant reticulosis (so-called lethal midline granuloma). Cancer 1969;23:920–35. Aozasa K, Takakuwa T, Hongyo T, Yang WI. Nasal NK/T-cell lymphoma: epidemiology and pathogenesis. Int J Hematol 2008; 87:110-7. Swerdlow SH, Campo E, Harris NL, Jaffe ES, Pileri SA, et al. WHO Classification of Tumours, Volume 2 [IARC WHO Classification of Tumours, No 2], 2008. Vidal RW, Devaney K, Farkiti A, Rinaldo A, Carbone A. Sinusonasal malignant lymphomas: a distinct clinicopathological category. Ann Otol Rhinol Laryngol 1999; 108:411-449. Van de Rijin M, Bhargava V, Molina-Kirsc H, Carlos-Bregni R, Warnke RA, Cleary ML. Extranodal head and neck lymphomas in Guatemala: high frequency of Epstein-Barr virus associated sinusonasal lymphomas. Hum Pathol 1997; 28:834-9. Charton J, Witherspoon SR, Itani K, Jones FR, Marple B, Morse B. Natural Killer/T –cell lymphoma masquerading as orbital cellulitis. Ophtal Plast Reconst Surg 2008; 24:143-5. Hardell L, Erickson MA. A case-control study of non-Hodgkins lymphoma and exposure to pesticide. Cancer 1999; 85:1353-60.
9. Chen SH, Wu CS, Chan KH, Hongh YT, Shun CT, Liu CM. Primary sinusonasal non-Hodgkins lymphoma masquerading as chronic rhinosinusitis: an issue of rutine histopathological examination. J Laryngol Otol 2003; 117:404-7. 10. Bisdas S, Fetscher S, Feller AC, Baghi M, Knecht R, Gstoettner W, Vogl TJ, Balzer JO. Primary B cell lymphoma of the sphenoid sinus: CT and MRI characteristics with correlation to perfusion and spectroscopic imaging features. Eur Arch Otorhinolaryngol 2007; 264:1207-13. 11. Yu K. Primary nasal lymphoma. J HK Coll Radiol 2001; 4:128-32. 12. Yao B, Song YW, Jin J, Wang WH,Wang SL Sun YT et al. Treatment option and outcome for patients with primary non-Hodgkins lymphoma of the nasal cavity. Zhonguhua Zhong Liu Za Zhi 2006; 28:58-61. CASE REPORT Knee disarticulation Ognjen Živković¹, Antun Muljačić², Renata Poljak- Guberina³ ¹Institute for Rehabilitation and Orthopaedic Aids of the University; Hospital Center, Zagreb, ²University Hospital of Traumatology, Zagreb, ³Private Practice, Zagreb; Croatia Corresponding author: Renata Poljak–Guberina Private practice Rockefellerova 23a, 10000 Zagreb, Croatia Phone: +385 1 481 7705 E-mail: renata.poljak@zg.t-com.hr Original submission: 16 September 2008; Revised submission: 29 December 2008; Accepted: 04 February 2009. Med Glas 2009; 6(2): 277-279 ABSTRACT In this paper we presented three patients with knee disarticulation performed according to Baumgartner. The Baumgartner tehnique and the application of knee disarticulation prosthesis appeared to be superior in comparisson with other methods. Key words: knee, disarticulation, Baumgartner tehnique INTRODUCTION Knee disarticulation is a rarely used method in amputation surgery, primarily due to the operative technique itself and secondly, due to poor Case report understanding of prosthetic replacement possibilities (1). Technological progress and new developments in the prosthetics have opened new possibilities of amputation methods and consequently in the choice of the amputation level (1). A prosthesis for patients with knee disarticulation has been designed, with construction being based on the operative method of knee disarticulation according to Baumagartner (2). The energy expenditure during walking with knee disarticulation prosthesis is a little more than 40%, the same as for below-knee prosthesis (3). Disarticulation of a knee is recommended for high traumatic amputation of the below-knee, crush injury, complex injuries and tumors of the belowknee (1). Surgeons have been in dilemma between the method of transcondylar amputation and knee disarticulation (2). Knee disarticulation proves to be superior due to the possibilities of prosthetic replacement. The advantages are: a long and strong stump with a tip that can endure full-weight bearing and is suitable for a knee disarticulation prosthesis, the energy expenditure during walking equal to walking with below-knee prosthesis, normal function of the abbove-knee muscles (2). Unpopularity of knee amputation over many years was caused by bad experience with primary wound healing and the resulting stump of poor quality with regard to its function (2). In order to prevent these complications some surgeons introduced modifications in operative method (4-6). These methods are surgically more demanding and associated with a higher risk of complications (7). Baumgartner 1971 describes the method of knee disarticulation as a surgically simple procedure that creates a functionally satisfactory stump with regard to further prosthetic fitting (2). The simplicity of the technique is reflected in every aspect - skin, cartilage, bone, muscles (2). During the last 10 years the Clinic of Traumatology Zagreb has been using the technique of knee disarticulation described by Baumgartner. However, we have introduced some minor modifications. Instaed of sutturing the patellar ligament as Baumagartner was practising, we cut ligament at the top of the patella. So we additionally increas the contact and weight-bearing surface 277
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