Case Introduction] Liu, male, 10 years old, with “left upper calf lateral swelling and pain for more than 3 months, accompanied by claudication for more than 2 months”. The patient in March after a fall on a bicycle found that the upper left calf anterolateral swelling, local pain on palpation, local hospital radiographs did not find bone lesions, given traditional Chinese medicine, plasters, massage and other conservative treatment for about 2 weeks, the symptoms gradually aggravated, 2 months ago, began to limp with the affected limb, the local swelling further aggravated. Specialized examination: malnutrition, left lower limb claudication, bilateral inguinal lymph node enlargement. The left knee joint is swollen and elevated in the anterior and lateral aspect, the surface skin is normal, soft to touch, pain is obvious, there is a sense of fluctuation, the left knee joint extension activities are limited, about 15 degrees of flexion contracture, passive activities, pain, flexion contracture can not be fully recovered, compared with the right side of the left side of the lower limb circumference of the thin 2cm. X-ray: the left tibia upper end of the lateral bone destruction of about 4cm x 4cm x 4cm, reduced density, border is unclear. CT: anterolateral osteolytic destruction of the upper end of the left tibia, low density in the lesion area (comparable to the density of soft tissues), with patchy high-density shadows inside, and only a thin layer of the anterolateral cortex remained, which was eggshell-like with sieve-like changes, and the soft tissues around it were swollen (Fig. 3).MRI: lateral osteolytic destruction of the upper end of the left tibia, with T1 low signal, T2 high signal, and spreading to the articular surface, bone surface, and bone marrow, and the joints. signal, spreading to the articular surface, metaphysis and epiphysis, uneven enhancement, adjacent soft tissue edema (Figure 3). Preliminary diagnosis: 1, bone destruction of the upper end of the left tibia (nature to be determined); 2, left knee joint effusion; 3, left knee flexion contracture deformity. Treatment: After admission, skin traction braking was given, and local biopsy biopsy was performed to support chondroblastoma. The pathology section was diagnosed by the First Hospital of Henan University of Medical Sciences, which was the same as the report of the hospital, and the Provincial Hospital of Traditional Chinese Medicine diagnosed epiphyseal inflammation, and the opinions of each hospital were different. In view of the fact that the tumor tissues were too little, in order to arrive at the exact diagnosis, with the consent of the family members, the second CT-guided biopsy was performed, and the pathology report showed that the chondroblastoma was chondroblastoma (the osteoblastoma failed to be ruled out). Under epidural anesthesia, the tumor was scraped and the allograft bone was implanted, and the operation went smoothly. During the operation, the tumor tissue was gray-red, tender, and there were a lot of dark red blood clots, and all the lesion tissue was scraped, and there was not much bleeding in the residual cavity, and the cystic wall of the anterior and lateral part of the lesion was resected, and the window of opening was enlarged, and the lesion was further scraped, and the residual cavity wall was cleared by inactivation of carbolic acid for three times, and a sufficient amount of allograft bone was implanted and compacted, and was fixed by plaster casts after the operation. Reaction, two wounds red and swollen with secretion, no bacterial growth by culture, symptomatic treatment, delayed healing, discharged from the hospital after 6 weeks of removal of the plaster fixation, the left lower limb claudication. Postoperative pathological return diagnosis: chondroblastoma, bone giant cell tumor could not be excluded, the tumor invaded the surrounding soft tissue, which was consistent with the preoperative diagnosis. Postoperative radiographs suggested that the tumor was scraped thoroughly and the bone graft was adequate (Figure 4). Nine months after the operation, the patient was admitted to the hospital with “pain and swelling at the lateral side of the upper end of the left calf for more than 1 week after being kicked by someone”. Radiographs showed that the bone of the lower part of the original lesion was destroyed, and the original tumor had recurred (Figure 5). Under epidural anesthesia, the patient was given tumor scraping and filling with bone cement, and the operation went smoothly. During the operation, we saw that the tumor tissue was grayish-red in color and tender in texture, and the tumor had destroyed the outer epiphysis and metaphysis, and the original implant had been replaced by the tumor. The residual cavity wall was inactivated and removed with carbolic acid three times, rinsed with saline, a layer of allograft bone was placed under the cartilaginous surface of the upper end of the residual cavity, the rest of the residual cavity was filled with bone cement, and two drainage strips were placed in the wound. Postoperative swelling of the left lower limb was treated with Chinese herbal medicine to promote blood circulation and dissipate blood stasis. The formula of anti-inflammatory and swelling reduction soup was: Angelica sinensis, Radix et Rhizoma Sengdi, Radix Paeoniae Alba, Papaver somnifera, Zelenyphus, Dicotyledonous bark, Forsythia, Cortex Eucommiae, 6 grams of each, Ligustici Chuanxiong, Frankincense, Myrrh 3 grams each, Serratia officinalis, Licorice 3 grams of each, and was taken for 10 days, with a one-stage healing. Postoperative radiographs showed that after the operation of chondroblastoma in the upper part of the left tibia, the tumor segment was filled with bone cement, and there seemed to be a small cystic area under the joint capsule (Figure 6). The tumor did not recur and the bone cement was in a good position (Figure 7). The characteristics of this case are as follows: ① male, 10 years old, admitted to the hospital with “swelling and pain on the lateral side of the upper left calf for more than 3 months, accompanied by claudication for more than 2 months”; ② examination showed: malnutrition, left lower limb claudication, bilateral inguinal lymph node enlargement. The left knee joint can be seen below the anterolateral swelling bulge, the surface of the skin is normal, soft to the touch, pain is obvious, there is a sense of fluctuation, the left knee joint extension activities are limited, about 15 degrees of flexion contracture, passive activities, pain, flexion contracture can not be fully recovered, and the right compared to the left side of the lower limb circumference of the thin 2 cm; ③ imaging performance: the left tibia upper end of the anterolateral osteolytic destruction, lesion area hypodensities (comparable to the density of the soft tissue), there are patches of high density shadows, and the left lower extremity of the anterior tibia. There were patchy high-density shadows within the lesion area, and only a thin layer of anterior and lateral cortex remained, which was eggshell-like and had sieve-like changes, and the surrounding soft tissues were swollen; (4) the diagnosis of chondroblastoma of the upper end of the left tibia was made by puncture; (5) the first treatment was tumor scraping and inactivation of the allograft bone grafting; (6) the tumor recurred 9 months after the operation, and the tumor was filled with bone cement. This case was diagnosed as chondroblastoma. This case was diagnosed as chondroblastoma on the basis of: (1) the age of onset was 10 years old; (2) the site of onset was at the upper end of the left tibia, affecting the articular surface, metaphysis and epiphysis; (3) eccentric and osteolytic destruction, with a fair boundary, with calcified foci inside, spreading to the soft tissues, without periosteal reaction; (4) preoperative and postoperative pathology suggested that the tumor was a chondroblastoma. Chondroblastoma is divided into benign chondroblastoma and malignant chondroblastoma. Benign chondroblastoma, also known as chondroblastoma, is rare, accounting for about 2% of benign tumors, and it is common in adolescents aged between 10 and 25 years old, with a male-to-female ratio of about 2:1. It can occur in any part of epiphyseal cartilage, and it is more common in the epiphyses of long bones of the limbs, and also in the epiphyseal ends of the metaphyses. The clinical course of the disease is slow, and may be shorter in younger patients, mainly manifested in localized pain or discomfort. Imaging shows a centrally or eccentrically located osteolytic destruction at the epiphysis or metaphyseal process of the long bones, with a slightly swollen bone cortex, usually 2-4 cm in size, well defined, round or ovoid, surrounded by a very fine sclerotic ring separated from normal tissue, with foci of calcification. In advanced stages, the tumor is invasive and can enter the soft tissues but has no reactive bone. In the gross specimen the tumor tissue is bluish-gray to grayish-white with gritty yellow foci of calcification and areas of necrosis. Treatment consists of surgical scraping and grafting, with wide excision of lesions in the mid-shaft skeleton, and amputation may be considered for those with aggressive or malignant tendencies. The prognosis of this disease is good, a few have recurrence or lung metastasis, radiation therapy can be considered. Malignant chondroblastoma, also known as chondroblast sarcoma, chondroblast sarcoma, malignant chondroblastoma, is extremely rare, and is a low-grade malignant and easily recurring tumor, which occurs in the epiphyseal plates of the long bones, and can also be seen in the foot bones, scapulae, ribs, and other parts of the body. Imaging shows from limited osteoporosis to extensive bone destruction, with irregular calcification, which occurs along the cartilage matrix in the interstitial space of the tumor cells in the form of lines or reticulation. The tumor has an irregular contour with blurred margins, and soon encroaches on the diaphysis after epiphyseal destruction, with clear boundaries but no sclerotic ring, and periosteal reaction, which can be accompanied by a large soft-tissue mass. This disease requires early and thorough surgery, and the prognosis is better than chondrosarcoma. Differential diagnosis In this case, the nature of bone destruction of the upper end of the left tibia had the following tendency to diagnose: ① tuberculosis or common infection, from the site of onset, clinical manifestations, imaging manifestations have the possibility of inflammation, and the affected limb appeared to reactive joint effusion and articular contracture, the possibility of infection should be firstly considered, but the patient’s blood picture was normal, there was no local redness, swelling, heat and pain, which could exclude common infection, and consider tuberculosis, but the sedimentation rate did not obviously accelerate, and the patient had no low fever, pyrexia, and pain. Accelerate, the patient has no low fever, night sweating clinical manifestations, puncture biopsy results also do not support, tuberculosis is also basically excluded. ② chondroblastoma, the patient is in the growth period, the onset of epiphysis before epiphyseal closure, epiphyseal destruction, the image shows invasive, but the lesion is still relatively limited, no periosteal reaction, tend to be benign lesions, firstly, consider the chondroblastoma, the disease occurs in the pro-articular part, the proximal joint cavity reactive effusion, due to the epiphyseal destruction, the joint force line is unstable, the protective contracture of soft tissues, deformity and limp is explained, puncture biopsy results also do not support, tuberculosis also basically excluded. The pathologic report of puncture biopsy also supports chondroblastoma. (3)Giant cell tumor of bone, the most common age is 20-40, mostly occurring after epiphyseal closure, but there are reports that the minimum age is 1 year old; it occurs at the bone ends of long tubular bones of the limbs, and it is common to see single occurrence, and the spine is common to the sacrum, and the short bones of the hands and feet are common and rare; the clinical manifestations are localized swelling, pain, and limitation of the joint activities; the imaging manifestation is the “soap bubble-like” osteolytic destruction of the bone ends, and it can be explained by the pathological report of puncture biopsy. The image shows “soap bubble-like” osteolytic destruction of bone ends, eccentric expansion growth, thinning of bone cortex, and the tumor can penetrate the cortex into soft tissues, with clear boundary and no periosteal reaction. Giant cell tumor of bone has a certain aggressiveness, high recurrence rate, and the clinical diagnosis tends to be a low-grade malignant tumor. The biopsy in this case suggests that giant cell tumor of bone is not excluded, based on clinical and imaging manifestations, it can be basically excluded, and other tumors are very unlikely. Tumor diagnosis is highly dependent on pathology, and the only ambiguity in the diagnosis of this case is precisely the biopsy pathology. The only ambiguity in the diagnosis of this case is the biopsy pathology. The percutaneous puncture sampling has a great influence on the correct diagnosis of the pathology because of too little tissue, which suggests that more material should be sampled as much as possible, and the pathology slides should be routinely consulted by several departments, and the biopsies should be re-punctured if necessary, and then the pathology should be determined after the operation, in order to prevent misdiagnosis. The most appropriate surgery for chondroblastoma occurring in children is scraping and bone grafting if the border is still good and the tumor is benign. In patients with damaged medial growth plates, the ideal approach would be to resect the tumor segment and implant a bone with a similar growth plate on the healthy side or a residual portion of the growth plate, but this is not yet possible with current medical technology. Currently, the main therapeutic options are implantation of own iliac bone, allograft bone, or a combination of own and allograft bone after tumor resection. None of these three surgical options can prevent deformities such as inversion of the knee joint and shortening of the affected limb. In order to have as little deformity as possible, we should try to preserve as much growth plate as possible, but in order to reduce the postoperative recurrence, we should try to scrape the tumor tissue as widely as possible, which is a contradictory principle, and the treatment is based on our most fundamental principle, which is to minimize the recurrence. In this case, the surgical process of scraping was more extensive, and the carbolic acid inactivation was performed 3 times after scraping, and the implanted allograft bone was also compacted sufficiently, which were the means to reduce the recurrence. However, the tumor still recurred 9 months later, and the site of recurrence was in the lower part of the tumor, and the possible reasons for the recurrence were as follows: (1) chondroblastoma itself tends to be malignant, and it is easy to recur; (2) the scraping of the tumor tissues did not remove the lower part of the tumor that met with the normal bone marrow extensively, and the tissues planted in the bone marrow were localized, because of the fact that the tumor was not removed from the bone marrow. The tissue was planted in the bone marrow and recurred due to rich local blood nutrition; ③ Insufficient compaction of the lower end of the residual cavity in the implanted allograft bone; ④ Trauma in the lower part of the original lesion, the local hematoma and the impact of external force led to the proliferation of the latent tumor cells again and recurrence. In this case, the secondary surgery was performed by scraping and cement filling, in which the upper end of the residual cavity was padded with a layer of allograft bone under the cartilaginous surface, and the rest of the residual cavity was filled with bone cement. This surgical plan belongs to palliative surgery, for 10-year-old children, bone cement filling is not the best choice, but this case is a case of tumor recurrence, further bone grafting is obviously not appropriate, and the heat process of the bone cement itself can kill some of the tumor cells, and the non-biological implant, which does not have the possibility of recurrence, plays a better delaying role in controlling the recurrence of tumor tissues. Intraoperatively, a layer of allograft bone was placed under the cartilage surface, aiming to protect the cartilage surface from being burned by the bone cement and to play a skeleton role in the remodeling of the medial surface of the joint. In this case, healing was not uneventful after both surgeries, with rejection, wound discharge, and delayed healing occurring after the first surgery. After the second surgery, there was deep vein embolism of the left lower limb, swelling and pain, and the herbal medicine Anti-inflammatory and Swelling Decongestion Tang was given, in which Angelica sinensis, Radix Rehmanniae Praeparata, Paeonia lactiflora, Rhizoma Ligustici Chuanxiong, Frankincense, and Myrrh play the role of activating the blood and clearing up collaterals, papaya, Ze Xerophthalmus, Dictyostelium, Hippocastanum, Forsythia, play the role of diuretics to reduce swelling, detoxification and clearing away heat, and Serratia officinalis, Radix glycyrrhizae, strengthens the spleen and the medicinal herbs in a light and gentle way, so that it is useful to be taken, suitable for children who have implanted a foreign body in the surgery, and who experience postoperative swelling. Although there was a foreign body in the second operation, the wound did not have delayed healing and was discharged from the hospital on schedule, indicating that the combination of traditional Chinese and western medicine, evidence-based treatment and comprehensive use of medicines can promote early healing of the wound. This case still needs long-term follow-up, postoperative radiographs found that there seems to be a small cystic area under the joint capsule, it is more necessary to closely observe the changes of the disease, if the disease can be controlled to the epiphyseal closure, and then carry out the resection of the tumor segment artificial prosthetic joint replacement and the affected limb compression lengthening surgery, in order to cure the disease and correct the deformity as much as possible, and to restore the normal function of the left lower limb.