Supercharged free fibula for complex ankle arthrodesis: a case report

We report the successful use of a supercharged free fibula for tibial reconstruction and ankle arthrodesis. A 28-year-old woman underwent resection of a giant cell tumor of the distal tibia and reconstruction using a methyl methacrylate cement spacer 12 years prior. The spacer eroded into her ankle joint causing significant pain with ambulation. Therefore, she required ankle arthrodesis but lacked distal tibia bone stock. The ipsilateral fibula was harvested for reconstruction and transferred on its distal blood supply into the bony tibial defect. The proximal blood supply of the fibula flap was then anastomosed to the posterior tibial vessels to supercharge the blood supply. An Ilizarov was placed for external fixation. The combination of a supercharged free fibula and stable external fixation for tibial reconstruction led to timely bony union and ambulation, as well as avoiding the potential complications that can occur with other reconstructive options.     

The use of fibular autograft and ankle arthrodesis for aggressive giant cell tumor in the distal tibia: a case report

The case describes successful distal tibial resection, fibular autograft, and ankle arthrodesis in two patients who had giant cell tumor in the distal tibia. At long-term followup, the patients had no pain and no limitation in daily or low-impact recreational activities. In conclusion, due to the large resection that is often necessary for aggressive tumors, fibular autograft and ankle arthrodesis may be a useful method in the distal tibia.     

外科治疗肢体骨巨细胞瘤43例

目的探讨外科手术治疗肢体骨巨细胞瘤（giant cell tumor of bone, GCT）的临床疗效。方法回顾性分析2007年1月至2013年7月于我院应用外科手术方法治疗的43例GCT患者,年龄20~66岁（平均32岁）;发病部位：股骨远端17例,胫骨近端16例,桡骨远端5例,腓骨近端2例,股骨近端2例,肱骨近端1例;治疗方法：病灶扩大刮除骨水泥填充并（或不并）内固定及并（或不并）植骨术,瘤段骨切除特制肿瘤关节置换术,瘤段骨切除腓骨小头移植术,瘤段骨切除关节融合术,瘤段骨切除稳定结构重建术。分析本组患者的手术相关资料、术后恢复情况及复发率。结果43例患者均获得随访,随访时间8~64个月,平均28个月。本组患者的总复发率为7.0%（3/43）,其中采用扩大刮除术患者复发率为7.7%（2/26）,瘤段切除术患者的复发率为5.9%（1/17）,复发患者均经二次手术治疗。2例合并感染,发生率为4.7%。结论通过术前认真设计,选择恰当的手术方式和重建方式,肢体GCT可获得良好的治疗效果。     

Operative technique of distal radius resection and wrist fusion with iliac crest bone graft

Malignant lesions of distal radius and appropriately selected cases of benign aggressive lesions (giant cell tumor) of distal radius require resection for limb salvage. Post resection, reconstruction of that defect can be accomplished by either arthrodesis or arthroplasty both having their own pros and cons. In cases undergoing arthrodesis as modality of reconstruction, small defects (≤6 cm) can be reconstructed using autologous iliac crest bone graft which results in good cosmetic appearance and functional outcome. We have described in detail, the preoperative planning, surgical steps and rehabilitation of wrist fusion with iliac crest bone grafting post distal radius resection.     

膝关节周围骨巨细胞瘤的手术治疗

目的:回顾性分析膝关节周围骨巨细胞瘤行手术治疗的病例,探讨骨巨细胞瘤手术病灶刮除与功能重建的方法与疗效。方法:膝关节周围骨巨细胞瘤21例,男15例,女6例;年龄6～72岁,平均43岁。股骨下端骨巨细胞瘤14例,胫骨上端骨巨细胞瘤7例。无症状偶然发现者2例,膝关节周围疼痛肿胀伴活动障碍者19例。除1例采用截肢术外,对8例儿童及青少年采用瘤体扩大刮除、灭活、植骨治疗;对12例18岁以上成年人采用肿瘤扩大刮除、灭活、植骨及骨水泥充填,钢板内固定治疗。结果:20例获随访,随访时间6～48个月,平均42个月。术后肿瘤复发3例,切口液化坏死1例。膝关节功能按李强一等标准评价:优11例,良6例,差3例。结论:对膝关节周围骨巨细胞瘤采用肿瘤扩大刮除、灭活、植骨或骨水泥充填重建功能,降低了肿瘤的复发率,并最大程度地保留了肢体功能。     

Distal tibial aneurysmal bone cyst treatment by using a proximal fibular autologous bone graft: a case report

A case of an aneurysmal bone cyst that involved the distal tibia and medial malleolus with erosion of the medial cortex in a 22-year-old woman is presented. The patient was surgically treated by curettage and bone grafting along with reconstruction of the distal tibia by using ipsilateral proximal fibula. At the 2-year follow-up, the patient had full, painless range of motion and complete incorporation of the fibular graft. The authors discuss the different treatment options for benign tumors of the distal tibia and the advantages of using proximal fibula as an autologous bone graft in the reconstruction of medial malleolus.     

Giant cell tumors of the distal radius: resection: reconstruction by long avascular fibular graft (a case report)

Giant cell tumors (GCT) are locally aggressive tumors with a preference for epiphyses and metaphyses of long bones. They represent 5%-10% of all primary bone tumors. They affect mostly young adults between 20 and 40. Their origin remains uncertain. GCT is a purely lytic tumor, recurrent and can even lead to fracture. The distal radius is the third location after the distal femur and proximal tibia. Tumors are benign on histopathology, but "benign" lung metastases can sometimes be seen. Their treatment remains controversial because of the high rate of recurrence; oncological resection of the diseased bone segment with reconstruction reduces the rate of recurrence. Several techniques of resection and reconstruction of the wrist have been proposed. We report a case of giant cell tumor of the distal radius treated by resection and reconstruction by avascular fibular graft to a length of 12cm, and we evaluate the use of this reconstruction to salvage the wrist with this pathology.     

Allograft arthrodesis of the knee for giant cell tumors

Giant cell tumors of bone are aggressive benign tumors. Wide resection is reserved for a small subset of patients with biologically more aggressive, recurrent, and extensive tumors. For patients with giant cell tumors who are young or middle-aged adults with normal life expectancies and high levels of activity, arthrodesis is an option for reconstruction after resection. We retrospectively studied 40 patients (mean age, 33.1 years) with Campanacci grade III giant cell tumors around the knee (12 distal femoral and 28 proximal tibial) that were treated with wide resection and allograft arthrodesis using compression plating between January 1998 and January 2008. At an average follow-up of 4.3 years (range, 2-10 years), no patient had local recurrence, malignant transformation, or pulmonary or distant metastases. The grafts united proximally and distally in 35 (87.5%) patients. Average limb-length shortening was 2 cm (range, 1.5-5 cm). No patient needed a lengthening procedure. Functional outcomes according to the Musculoskeletal Tumor Society measure were successful, with an average score of 26.3 points (range, 22-30 points). Wide resection with allograft arthrodesis of the knee is a treatment option in young, active patients with Campanacci grade III giant cell tumors around the knee. Wide resection and reconstruction with knee allograft arthrodesis for giant cell tumors can achieve excellent control of disease, high fusion rates, acceptable functional results, and low complication rates.     

Is Intralesional Treatment of Giant Cell Tumor of the Distal Radius Comparable to Resection With Respect to Local Control and Functional Outcome?

Background

A giant cell tumor is a benign locally aggressive tumor commonly seen in the distal radius with reported recurrence rates higher than tumors at other sites. The dilemma for the treating surgeon is deciding whether intralesional treatment is adequate compared with resection of the primary tumor for oncologic and functional outcomes. More information would be helpful to guide shared decision-making.

Questions/purposes

We asked: (1) How will validated functional scores, ROM, and strength differ between resection versus intralesional excision for a giant cell tumor of the distal radius? (2) How will recurrence rate and reoperation differ between these types of treatments? (3) What are the complications resulting in reoperation after intralesional excision and resection procedures? (4) Is there a difference in functional outcome in treating a primary versus recurrent giant cell tumor with a resection arthrodesis?

Methods

Between 1985 and 2008, 39 patients (39 wrists) were treated for primary giant cell tumor of the distal radius at two academic centers. Twenty patients underwent primary intralesional excision, typically in cases where bony architecture and cortical thickness were preserved, 15 underwent resection with radiocarpal arthrodesis, and four had resection with osteoarticular allograft. Resection regardless of reconstruction type was favored in cases with marked cortical expansion. A specific evaluation for purposes of the study with radiographs, ROM, grip strength, and pain and functional scores was performed at a minimum of 1 year for 21 patients (54%) and an additional 11 patients (28%) were available only by phone. We also assessed reoperations for recurrence and other complications via chart review.

Results

With the numbers available, there were no differences in pain or functional scores or grip strength between groups; however, there was greater supination in the intralesional excision group (p = 0.037). Tumors recurred in six of 17 wrists after intralesional excision and none of the 15 after en bloc resection (p = 0.030). There was no relationship between tumor grade and recurrence. There were 12 reoperations in eight of 17 patients in the intralesional excision group but only one of 11 patients (p = 0.049) who underwent resection arthrodesis with distal radius allograft had a reoperation. There were no differences in functional scores whether resection arthrodesis was performed as the primary procedure or to treat recurrence after intralesional excision.

Conclusions

Resection for giant cell tumor of the distal radius with distal radius allograft arthrodesis showed a lower recurrence rate, lower reoperation rate, and no apparent differences in functional outcome compared with joint salvage with intralesional excision. Because an arthrodesis for recurrence after intralesional procedures seems to function well, we believe that intralesional excision is reasonable to consider for initial treatment, but the patient should be informed about the relative benefits and risks of both options during the shared decision-making process. Because arthrodesis after recurrence functions similar to the initial resection and arthrodesis, an initial treatment with curettage remains a viable, and likely the standard, mode of treatment for most giant cell tumors of the distal radius unless there is extensive bone loss.

Level of Evidence

Level III, therapeutic study.     

Ankle arthrodesis with bone graft after distal tibia resection for bone tumors

BACKGROUND: Treatment of distal tibial tumors is challenging due to the scarce soft tissue coverage of this area. Ankle arthrodesis has proven to be an effective treatment in primary and post-traumatic joint arthritis, but few papers have addressed the feasibility and techniques of ankle arthrodesis in tumor surgery after long bone resections. MATERIALS AND METHODS: Resection of the distal tibia and reconstruction by ankle fusion using non-vascularized structural bone grafts was performed in 8 patients affected by malignant (5 patients) or aggressive benign (3 patients) tumors. Resection length of the tibia ranged from 5 to 21 cm. Bone defects were reconstructed with cortical structural autografts (from contralateral tibia) or allografts or both, plus autologous bone chips. Fixation was accomplished by antegrade nailing (6 cases) or plating (2~cases). RESULTS: All the arthrodesis successfully healed. At followup ranging from 23 to 113 months (average 53.5), all patients were alive. One local recurrence was observed with concomitant deep infection (a below-knee amputation was performed). Mean functional MSTS score of the seven available patients was 80.4% (range, 53 to 93). CONCLUSION: Resection of the distal tibia and arthrodesis of the ankle with non-vascularized structural bone grafts, combined with autologous bone chips, can be an effective procedure in bone tumor surgery with durable and satisfactory functional results. In shorter resections, autologous cortical structural grafts can be used; in longer resections, allograft structural bone grafts are needed.     

Iatrogenic implantation of giant cell tumor at bone graft donor site and clinical recommendations to prevent “A Rare Avoidable Complication”

The treatment of giant cell tumor of bone is directed toward local control without sacrificing joint function. This is achieved by intralesional curettage. When autograft is used for the reconstruction of the curetted cavity, there is always a theoretical risk of contamination of graft donor site. We report a case of iatrogenic implantation of giant cell tumor at the bone graft donor site after intralesional curettage and bone grafting of giant cell tumor of distal femur. Patient was treated with repeat intralesional curettage and excision of implantation lesion at bone graft donor site. We recommend precautionary measures to prevent this avoidable complication.     

Giant cell tumor of bone: Multimodal approach

Background:

The clinical behavior and treatment of giant cell tumor of bone is still perplexing. The aim of this study is to clarify the clinico-pathological correlation of tumor and its relevance in treatment and prognosis.

Materials and Methods:

Ninety -three cases of giant cell tumor were treated during 1980-1990 by different methods. The age of the patients varied from 18-58 yrs with male and female ratio as 5:4. The upper end of the tibia was most commonly involved (n=31), followed by the lower end of the femur(n=21), distal end of radius(n=14), upper end of fibula (n=9), proximal end of femur(n=5), upper end of the humerus(n=3), iliac bone(n=2), phalanx (n=2) and spine(n=1). The tumors were also encountered on uncommon sites like metacarpals (n=4) and metatarsal(n=1). Fifty four cases were treated by curettage and bone grafting. Wide excision and reconstruction was performed in twenty two cases. Nine cases were treated by wide excision while primary amputation was performed in four cases. One case required only curettage. Three inaccessible lesions of ilium and spine were treated by radiotherapy.

Results:

19 of 54 treated by curettage and bone grafting showed a recurrence. The repeat curettage and bone grafting was performed in 18 cases while amputation was done in one. One each out of the cases treated by wide excision and reconstruction and wide excision alone recurred. In this study we observed that though curettage and bone grafting is still the most commonly adopted treatment, wide excision of tumor with reconstruction has shown lesser recurrence.

Conclusion:

For radiologically well-contained and histologically typical tumor, curettage and autogenous bone grafting is the treatment of choice. The typical tumors with radiologically deficient cortex, clinically aggressive tumors and tumors with histological Grade III should be treated by wide excision and reconstruction.     

骨水泥填充内固定联合二磷酸盐治疗邻膝关节骨巨细胞瘤

[目的]探讨采用病灶内肿瘤扩大刮除、骨水泥填充并钢板内固定联合二磷酸盐治疗邻膝关节骨巨细胞瘤的临床应用可行性.[方法]回顾分析2008年1月～2010年6月本科治疗的16例邻膝关节骨巨细胞瘤.男7例,女9例,平均年龄38岁(27～78岁).发病部位:股骨远端10例,胫骨近端6例.所有患者术前均经仔细评估确定肿瘤腔的完整性,术中仔细刮除肿瘤组织,应用磨钻及电刀处理瘤腔壁,骨水泥填充修复骨缺损,同时给予钢板内固定.术后均应用二膦酸盐类药物.[结果]本组患者全部获得随访,中位随访15个月,无局部复发及转移发生.参照Enneking肢体功能评分标准,本组患者平均得29分(27～30)分.复查X线片示所有患者内固定均牢靠,无软骨下骨骨折.[结论]对于膝关节周嗣骨巨细胞瘤可以选择病灶扩大刮除、骨水泥充填内固定联合二膦酸盐类药物治疗,该方法具有操作简单、肢体功能恢复理想、近期复发率低、病人易于接受等优点.远期疗效有待进一步观察.     

Alumina ceramic prostheses for bone tumor surgery

Summary Between 1979 and 1990 reconstruction using a ceramic prosthesis with a polycrystal alumina segment and a monocrystal alumina stem was carried out in 65 patients after the resection of malignant or benign aggressive bone tumors. Resection of 18 osteosarcomas, 5 chondrosarcomas, 9 other sarcomas, 10 giant cell tumors, 20 metastatic bone tumors, and 3 other bone tumors was followed by replacement of 17 proximal femurs, 12 distal femurs, 12 proximal tibia, 11 proximal humeri, 3 distal radii, 5 midshafts of the long bone, 2 pelvises, and 3 other parts. Results were rated excellent in 4 cases, good in 43, fair in 13, and poor in 4. In the cases with benignly aggressive or low-grade malignant tumors and those with tumors of the proximal femur, proximal tibia, or midshaft, satisfactory results can be obtained. Four skin ulcers, three dislocations, three loosenings, two infections, and two breaks were noted. Close interfacing between the ceramic prosthesis and the bone was observed radiologically in all cases with cementless fixation except in cases with high-grade malignancies in the knee joint. These results demonstrate that the ceramic prosthesis can be beneficial for the management of patients with benignly aggressive or low-grade malignant bone tumors who have retained adequate muscle strength around the joint even after tumor resection.     

Resection arthrodesis for the management of aggressive giant cell tumor of the distal femur

Background:

Giant cell tumors (GCTs) of bone are aggressive benign tumors. Wide resection is reserved for a small subset of patients with biologically more aggressive, recurrent, and extensive tumors. Wide resection and mobile joint reconstruction are preferable for treating tumors around the knee. In certain situations, resection arthrodesis or an amputation is suggested. In this prospective study we report the outcome of 8 patients of aggressive GCT of lower end of femur treated with resection arthrodesis.

Materials and Methods:

Eight patients with mean age of 37.25 years (range 30–45 years) with Campanacci Grade III (Enneking stage III) giant cell tumors at the distal femur were treated with wide resection and arthrodesis using dual free fibular graft and locked intramedullary nail from January 2003 to January 2008. There were four males and four females patients. The mean follow-up was 48.75 months (range 30–60 months). The functional evaluation was done using the standard system of musculoskeletal tumor society with its modification developed by Enneking et al.

Results:

At the final follow up the functional score ranged from 20 to 27 out of total score of 30. Graft union was achieved in all cases in a duration mean of 14.5 months (range 12-20 months).One case required secondary bone graft due to delayed union, and one case had superficial wound infection which healed on systemic antibiotics. At final followup, all the patients were disease free.

Conclusion:

Wide resection and arthrodesis in aggressive GCTs of the distal femur with involvement of all muscle compartments is a good treatment option. Resection arthrodesis offers a biological reconstruction alternative to amputation in a special group of patients when extensive resection precludes mobile joint reconstruction.     

膝关节融合治疗股骨远端侵袭性骨巨细胞瘤

目的：探讨应用自体腓骨移植联合膝关节融合治疗股骨远端侵袭性骨巨细胞瘤的应用及临床效果。方法：自2007-2009年对5例股骨远端侵袭性骨巨细胞瘤（Campanacci Ⅲ级）行整块切除术后骨缺损,采用游离腓骨移植联合钢板内固定行膝关节融合术重建下肢功能。结果：所有患者随访20～80个月,疼痛症状消失,MSTS评分21～27分,骨愈合时间6—18个月,无移植骨吸收和骨折,恢复正常工作劳动。所有患者均未出现病变复发及肺转移。结论：肿瘤整块切除联合腓骨移植膝关节融合术是治疗股骨远端侵袭性骨巨细胞瘤的一种良好选择。     

四肢骨巨细胞瘤的手术治疗

目的比较不同手术方法治疗四肢骨巨细胞瘤的疗效。方法自1998年5月至2006年5月收治骨巨细胞瘤48例,男28例,女20例;年龄16～59岁,平均31岁。股骨远端19例,胫骨近端18例,股骨近端5例,肱骨近端5例,肱骨远端1例。按Campanacci分级,Ⅰ级7例,Ⅱ级30例,Ⅲ级11例。根据肿瘤部位、Campanacci分级及患者年龄,采取不同的手术治疗方法,其中单纯刮除植骨或骨水泥填充17例,刮除植骨内固定19例,瘤段切除＋人工关节置换12例。结果随访时间3～11年,平均6.8年,刮除植骨组有4例复发,复发率为11.1%,瘤段切除＋关节置换组有1例复发,复发率为8.3%,术后患者Enneking功能评定优25例,良12例,可6例,差5例,总体满意率为89.6%。结论病灶刮除植骨是骨巨细胞瘤基本的外科治疗方法,局部辅助处理措施如高速磨钻磨削、蒸馏水浸泡可达到安全的外科治疗边界,从而大大降低病灶刮除术后的复发率,且术后肢体具有良好的功能;瘤段切除适用于CampanacciⅢ级骨巨细胞瘤,虽复发率较低,但重建后的并发症相对较多。     

Complications associated with bone cementing for the treatment of giant cell tumors of bone

A retrospective review was conducted of giant cell tumors treated between 1984 and 1998 using the technique of aggressive curettage through a large bone window followed by acrylic cement reconstruction. Fifteen patients with a mean follow-up time of 46 months (range, 24–188 months) were identified. One patient had a local recurrence 24 months postoperatively. All the patients showed a radiolucent zone at the bone–cement interface up to 2.5 mm in width during the first 6 months after operation. However, the radiolucent zones were nonprogressive and did not affect the stability of the bone cement. Osteoarthritis of the knee joint occurred 14 years postoperatively in one patient with an intraarticular fracture at presentation. A stress fracture occurred in one patient who had the largest tumor in the distal femur. Acrylic cement reconstruction is a safe and effective procedure that provides local adjuvant therapy. Giant cell tumors with an associated intraarticular fracture remain a challenging problem to treat. Received: August 31, 2001 / Accepted: November 30, 2001