Konala et al. Journal of Medical Case Reports 2011, 5:67 http://www.jmedicalcasereports.com/content/5/1/67 received palliative chemotherapy and radiotherapy and died one year after diagnosis. Discussion Many case reports have been published with regard to tumours developing at the site of arthroplasty [4-9]. It may be assumed that in these cases, the tumour was already pre- sent pre-operatively and could have been detected by more extensive clinical and radiological investigation. In our case, even retrospectively it is hard to pick up the pathology on the initial pelvic radiographs, but a closer look reveals an abnormal texture of both pubic bones. This was considered normal, however, as it appeared bilaterally. In addition, the calcified myoma distracted the surgeons’ and radiologists’ attention. A comparison with a normal pelvic radiograph from another patient could have been helpful and might possibly have resulted in an earlier diagnosis. Interestingly, the patient’s surgery was postponed because of microscopic haematuria, which was inter- preted as a lower UTI. However, haematuria is one of the most common findings in urothelial carcinoma, although it is not specific and is also present in cases of UTI [14]. The question whether our patient’s preo- perative symptoms were caused in total or at least in part by the osteoarthritis is difficult to answer, but the initial clinical presentation as well as the fact that the patient was temporarily pain-free after THA points in that direction. During surgery, no abnormal bone pre- sentation was detected in the hip joint, which further supports this theory, although it is highly likely that the metastases were present at the time of initial pre- sentation. Whether the surgery may have led to a more rapid progression of the metastatic disease because of compromise of the immune system remains unclear. On this issue, no evidence is available in the literature. Conclusion This case report is of particular importance to all radiol- ogists and any surgeon involved in elective orthopaedic surgery. It highlights the importance of avoiding the pigeon-holing of patients with specific symptoms into specific diagnostic categories to correctly diagnose the outliers. Further, radiographs should be analyzed in a systematic, standardized and complete manner, taking every visible structure into account. In the presence of bilateral subtle abnormalities, further radiological ima- ging such as magnetic resonance imaging or single photon emission tomography should be recommended. In conclusion, the importance of an unbiased assess- ment of patients and their radiographs is a sine qua non for the establishment of the correct diagnosis. Page 5 of 5 Author details 1Musculoskeletal Surgery Department, Imperial College, London, UK. 2Department of Orthopaedic Surgery and Traumatology, Kantonsspital Bruderholz, CH-4101 Bruderholz, Switzerland. Authors’ contributions PK reviewed the case and drafted the manuscript. FI participated in drafting the manuscript and case review. TS participated in drafting the manuscript and literature review. NFF participated in drafting the manuscript and case review. MTH reviewed the case and drafted the manuscript. All authors read and approved the final manuscript. Competing interests The authors declare that they have no competing interests. Consent Written, informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal. Received: 11 February 2010 Accepted: 15 February 2011 Published: 15 February 2011 References 1. Recommendations for the medical management of osteoarthritis of the hip and knee: 2000 update. American College of Rheumatology Subcommittee on Osteoarthritis Guidelines. Arthritis Rheum 2000, 43:1905-1915. 2. 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