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   2007| April-June  | Volume 41 | Issue 2  
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Treatment of giant cell tumor of bone: Current concepts
Ajay Puri, Manish Agarwal
April-June 2007, 41(2):101-108
DOI:10.4103/0019-5413.32039  PMID:21139760
Giant cell tumor (GCT) of bone though one of the commonest bone tumors encountered by an orthopedic surgeon continues to intrigue treating surgeons. Usually benign, they are locally aggressive and may occasionally undergo malignant transformation. The surgeon needs to strike a balance during treatment between reducing the incidence of local recurrence while preserving maximal function. Differing opinions pertaining to the use of adjuvants for extension of curettage, the relative role of bone graft or cement to pack the defect and the management of recurrent lesions are some of the issues that offer topics for eternal debate. Current literature suggests that intralesional curettage strikes the best balance between controlling disease and preserving optimum function in the majority of the cases though there may be occasions where the extent of the disease mandates resection to ensure adequate disease clearance. An accompanying treatment algorithm helps outline the management strategy in GCT.
  17 19,373 1,785
Imaging of giant cell tumor of bone
Shaligram Purohit, Dinshaw N Pardiwala
April-June 2007, 41(2):91-96
DOI:10.4103/0019-5413.32037  PMID:21139758
Giant cell tumor (GCT) of bone is a benign but locally aggressive and destructive lesion generally occurring in skeletally mature individuals. Typically involving the epiphysiometaphyseal region of long bones, the most common sites include the distal femur, proximal tibia and distal radius. On radiographs, GCT demonstrates a lytic lesion centered in the epiphysis but involving the metaphysis and extending at least in part to the adjacent articular cortex. Most are eccentric, but become symmetric and centrally located with growth. Most cases show circumscribed borders or so-called geographical destruction with no periosteal reaction unless a pathological fracture is present. There is no mineralized tumor matrix. Giant cell tumor can produce wide-ranging appearances depending on site, complications such as hemorrhage or pathological fracture and after surgical intervention. This review demonstrates a spectrum of these features and describes the imaging characteristics of GCT in conventional radiographs, computerized tomography scans, magnetic resonance imaging, bone scans, positron emission tomography scans and angiography.
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Giant cell tumor of bone: Is curettage the answer?
Shishir Rastogi, I Prashanth, Shah Alam Khan, Vivek Trikha, Ravi Mittal
April-June 2007, 41(2):109-114
DOI:10.4103/0019-5413.32040  PMID:21139761
Background: Giant cell tumors (GCT) are neoplasms of mesenchymal stromal cells with varied manifestations. There is no uniform accepted treatment protocol for these tumors, Materials and Methods: 49 cases of proven giant cell tumors of appendicular skeleton, 27 prospective and 22 retrospective constituteed this study. The retrospective cases were collected by using computerized data base collection method. The patients were evaluated clinically, radiologically and by histology. Companacci grading and Enneking staging was used in the study. Two treatment modalities were used a) extended curettage (with/ without bone grafting/ cementation) or b) wide excision and reconstruction with a prosthesis or arthrodesis. Functional evaluation was done by Enneking's system. Chi square tests, mann- whitney test and ANOVA were used for statistical analysis. Results: The average age was 26.82 years (16-50 years). 25 patients (51%) were recurrent GCT at presentation. The commonest site was lower end of femur (16 cases, 32.65%) and upper end of tibia (13 cases, 26.53%). 40 (81.63%) tumors had less than 5 mm of subchondral bone free of tumor. 35 (71.43%) tumors were Enneking's surgical stage III and companacci grade III. Pathological fractures were seen in 12 (24.49%) cases. Intra-lesional currettage was used in 28 and enbloc excision in 19 patients and 2 (4.08%) underwent amputation. The average follow up period was 18.6 months (range 2-84). One recurrence was seen in a grade III recurrent distal radial lesion in the intralesional curettage group (3.57%) Enneking's functional score with intralesional curettage (25.41) was better than enbloc excision (21.37). Enbloc excision had higher rates of infections (36.84 % Vs 25%) and soft tissue coverage problems (21.05% Vs 0). Conclusion: Intralesional therapy has a better functional outcome and less complications than enbloc excision, albeit with a high recurrence rate which can however be effectively treated with repeat extended curettage.
  10 5,749 431
Taylor spatial frame-software-controlled fixator for deformity correction-the early Indian experience
Milind Chaudhary
April-June 2007, 41(2):169-174
DOI:10.4103/0019-5413.32052  PMID:21139773
Background: Complex deformity correction and fracture treatment with the Ilizarov method needs extensive preoperative analysis and laborious postoperative fixator alterations, which are error-prone. We report our initial experience in treating the first 22 patients having fractures and complex deformities and shortening with software-controlled Taylor spatial frame (TSF) external fixator, for its ease of use and accuracy in achieving fracture reduction and complex deformity correction. Settings and Design: The struts of the TSF fixator have multiplane hinges at both ends and the six struts allow correction in all six axes. Hence the same struts act to correct either angulation or translation or rotation. With a single construct assembled during surgery all the desired axis corrections can be performed without a change of the montage as is needed with the Ilizarov fixator. Materials and Methods: Twenty-seven limb segments were operated with the TSF fixator. There were 23 tibiae, two femora, one knee joint and one ankle joint. Seven patients had comminuted fractures. Ten patients who had 13 deformed segments achieved full correction. Eight patients had lengthening in 10 tibiae. (Five of these also had simultaneous correction of deformities). One patient each had correction of knee and ankle deformities. Accurate reduction of fractures and correction of deformities and length could be achieved in all of our patients with minimum postoperative fixator alterations as compared to the Ilizarov system. The X-ray visualization of the osteotomy or lengthening site due to the six crossing struts and added bulk of the fixator rings which made positioning in bed and walking slightly more difficult as compared to the Ilizarov fixator. Conclusions: The TSF external fixator allows accurate fracture reduction and deformity correction without tedious analysis and postoperative frame alterations. The high cost of the fixator is a deterrent. The need for an internet connection and special X-rays to operate the fixator add to its complexity.
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Giant cell tumor - distal end radius: Do we know the answer?
Yogesh Panchwagh, Ajay Puri, Manish Agarwal, Chetan Anchan, Mandip Shah
April-June 2007, 41(2):139-145
DOI:10.4103/0019-5413.32046  PMID:21139767
Background: The distal end of the radius is one of the common sites of involvement in giant cell tumors (GCTs) with reportedly increased propensity of recurrence. The objective of the present analysis was to study the modalities of management of the different types of distal end radius GCTs so as to minimize the recurrence rates and retain adequate function. Materials and methods: Twenty-four patients of distal end radius GCTs treated between January 2000 and December 2004 were retrospectively reviewed. Nineteen cases were available for follow-up with an average follow-up of 37.5 months. There was one Campanacci Grade 1 lesion, nine Grade 2 and 14 Grade 3 lesions. Thirteen (54%) of these patients were treated elsewhere earlier and presented with recurrence. The operative procedures that were performed were: curettage and cementing (five), curettage and bone grafting (seven), excision and proximal fibular arthroplasty (two), excision and wrist arthrodesis (nine) and excision of soft tissue recurrence (one). Results: Functional status was evaluated using Musculo Skeletal Tumor Society scoring system which averaged 78%. The recurrence rate was 32%. Complications included local recurrence (six), nonunion at the graft bone junction (one), infection (one), deformity (two), stiffness (two), subluxation (two) and bony metastasis (one). Conclusions: The majority of patients undergoing curettage were either Campanacci Grade 1 or 2. Patients undergoing curettage and reconstruction had a better functional result (82%) as compared to arthrodesis or fibular arthroplasty (69%). Previous intervention did not appear to increase the recurrence rates. Even though complications occur, judicious decision-making and an appropriate treatment plan can ensure a satisfactory outcome in the majority of cases.
  6 7,600 511
Fingertip injuries
Sanjay Saraf, VK Tiwari
April-June 2007, 41(2):163-168
DOI:10.4103/0019-5413.32051  PMID:21139772
Background: Fingertip injuries are extremely common. Out of the various available reconstructive options, one needs to select an option which achieves a painless fingertip with durable and sensate skin cover. The present analysis was conducted to evaluate the management and outcome of fingertip injuries. Materials and Methods: This is a retrospective study of 150 cases of fingertip Injuries of patients aged six to 65 years managed over a period of two years. Various reconstructive options were considered for the fingertip lesions greater than or equal to 1 cm 2 . The total duration of treatment varied from two to six weeks with follow-up from two months to one year. Results: The results showed preservation of finger length and contour, retention of sensation and healing without significant complication. Conclusion: The treatment needs to be individualized and all possible techniques of reconstruction must be known to achieve optimal recovery.
  4 12,460 954
Giant cell tumor of bone: Multimodal approach
AK Gupta, R Nath, MP Mishra
April-June 2007, 41(2):115-120
DOI:10.4103/0019-5413.32041  PMID:21139762
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.
  4 6,739 590
Resection arthrodesis for giant cell tumors around the knee
Sudhir K Kapoor, Akshay Tiwari
April-June 2007, 41(2):124-128
DOI:10.4103/0019-5413.32043  PMID:21139764
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. As the patients affected with GCT are young or middle-aged adults with a normal life expectancy, arthrodesis is an attractive option for reconstruction in these patients. Materials and Methods: Thirty-six patients of mean age 33.1 years with Campanacci Grade III giant cell tumors around the knee (20 distal femoral and 16 proximal tibial) were treated with wide resection and arthrodesis from January 1996 through January 2006. Arthrodesis was performed using plating with free fibular graft (n = 18), IM nail with free fibular graft (n = 8) and IM nail combined with ring fixator using bone transport (n = 10). Results: Fusion after the first surgery was achieved in 77.7%, 75% and 90% of the patients in the three groups respectively. Local recurrence was seen in two patients and repeat surgery for nonunion/ graft fracture had to be done in four patients and two patients in the plating and nailing groups respectively. Conclusion: Wide resection and arthrodesis in aggressive GCTs around the knee is a good treatment option. IM nail combined with a ring fixator seems to be a good method of arthrodesis with high fusion rates, least shortening and early rehabilitation.
  3 4,855 391
Trapezoid fracture caused by assault
VA Malshikare, AV Oswal
April-June 2007, 41(2):175-176
DOI:10.4103/0019-5413.32053  PMID:21139774
In this report we describe an open fracture of trapezoid and break in anterior cortex of capitate due to assault in a young adult male. Direct impact force of a sharp object to the first web space caused the above fractures. Open reduction and internal fixation of the trapezoid was carried out using Kirschner wires. Cut extensor tendons, extensor retaniculum, capsule, adductor pollicis muscle, first dorsal interosseous muscle, soft tissue and overlying skin were sutured primarily. Three months after the operation the patient has made a complete recovery. There is no similar case reported in the literature.
  2 3,941 219
Assessment of changes in gait parameters and vertical ground reaction forces after total hip arthroplasty
P Bhargava, P Shrivastava, SP Nagariya
April-June 2007, 41(2):158-162
DOI:10.4103/0019-5413.32050  PMID:21139771
The principal objectives of arthroplasty are relief of pain and enhancement of range of motion. Currently, postoperative pain and functional capacity are assessed largely on the basis of subjective evaluation scores. Because of the lack of control inherent in this method it is often difficult to interpret data presented by different observers in the critical evaluation of surgical method, new components and modes of rehabilitation. Gait analysis is a rapid, simple and reliable method to assess functional outcome. This study was undertaken in an effort to evaluate the gait characteristics of patients who underwent arthroplasty, using an Ultraflex gait analyzer. Materials and Methods: The study was based on the assessment of gait and weight-bearing pattern of both hips in patients who underwent total hip replacement and its comparison with an age and sex-matched control group. Twenty subjects of total arthroplasty group having unilateral involvement, operated by posterior approach at our institution with a minimum six-month postoperative period were selected. Control group was age and sex-matched, randomly selected from the general population. Gait analysis was done using Ultraflex gait analyzer. Gait parameters and vertical ground reaction forces assessment was done by measuring the gait cycle properties, step time parameters and VGRF variables. Data of affected limb was compared with unaffected limb as well as control group to assess the weight-bearing pattern. Statistical analysis was done by't' test. Results: Frequency is reduced and gait cycle duration increased in total arthroplasty group as compared with control. Step time parameters including Step time, Stance time and Single support time are significantly reduced ( P value <.05) while Double support time and Single swing time are significantly increased ( P value <.05) in the THR group. Forces over each sensor are increased more on the unaffected limb of the THR group as compared to the control group. Vertical ground reaction force variables are also altered. Conclusion: Significant changes ( P value <.05) in gait parameters and vertical ground reaction forces show that gait pattern is not normalized after THR and weight-bearing is not equally shared by both hips. Patient walks with residual antalgic gait even after surgery, which results in abnormal loading around hip joints and the integrity of the prosthesis fixation could be compromised.
  2 6,770 356
Management of juxta articular giant cell tumors around the knee by custom mega prosthetic arthroplasty
Mayil Vahanan Natarajan, R Prabhakar, M Mohamed Sameer, RA Shashidhar
April-June 2007, 41(2):134-138
DOI:10.4103/0019-5413.32045  PMID:21139766
Background: Juxtaarticular giant cell tumors around the knee are common and pose a special problem of reconstruction after tumor excision. This article analyzes the functional outcome after resection of juxtaarticular giant cell tumors around the knee and replacement by custom mega prosthetic arthroplasty. Materials and Methods: One hundred and forty-three patients with juxtaarticular giant cell tumors around the knee with mean age of 30.8 years (range 15 to 64 years) underwent resection and replacement by custom mega prosthetic arthroplasty during the period 1994 to 2005. Eighty-one patients were males and 62 were females. Fourteen patients were in Enneking Stage 2 while 129 patients were in Stage 3. Distal femur was involved in 87 patients and proximal tibia in 56 patients. Forty patients presented with pathological fracture at the time of diagnosis. The technique of sleeve resection of the quadriceps musculature was followed to achieve local clearance in distal femoral tumors, and for proximal tibial lesions resection of the tumor-bearing part and a medial gastronemius rotation flap was used routinely. The prosthesis used was a rotating hinge custom mega prosthesis manufactured locally. Results: The mean follow-up was 5.4 years (1.5 years to 11 years). Functional results were analyzed using Enneking criteria. Excellent results were obtained in 90 patients (62%) and 39 patients had good (27%) results. Periprosthetic fracture (8.3%) and infection (6.9%) were the most common complications followed by aseptic loosening (4.2%). Recurrence of lesion was found in only one patient (0.69%) who was managed with wide local excision. Conclusion: Custom mega prosthetic arthroplasty is effective in achieving the desired goals of reconstruction with good functional results and least complications in selected patients.
  2 6,051 392
Multicentric giant cell tumor around the knee
Anil Salgia, SK Biswas, Rahul Agrawal, Vishavdeep Goyal
April-June 2007, 41(2):151-153
DOI:10.4103/0019-5413.32048  PMID:21139769
A case of multicentric giant cell tumor with synchronous occurrence in all three bones around the knee is reported here in view of its rarity. A 33-year-old average built male reported with complaints of severe pain, gradually increasing swelling around the right knee. A 3 x 2 cm swelling was present on the lateral aspect of the distal end of the right femur and a 3 x 3 cm swelling on the proximal part of the right tibia. Plain X-ray of right knee showed subarticular eccentrically located expansile lytic lesion in the lateral tibia condyle, lateral condyle of femur and patella. Fine needle aspiration cytology and subsequent histology ascertained the diagnosis of giant cell tumor of the bone. The patient was treated successfully with curettage, bone grafting and methyl methacrylate cementing (Sandwich technique).
  2 8,372 421
Multicentric giant cell tumor involving the same foot: A case report and review of literature
Mandeep S Dhillon, AP Prabhudev Prasad, Mandeep S Virk, Sameer Aggarwal
April-June 2007, 41(2):154-157
DOI:10.4103/0019-5413.32049  PMID:21139770
Multicentric giant cell tumour (GCT) is extremely rare; no case has been previously reported where two lesions occurred in the same foot at different sites. We report a case involving the calcaneus and subsequently the 3 rd toe of the same foot and review the reported literature. In established cases of multicentricity, the histopathology has to be properly reviewed and the patient has to be followed up for a longer time with serial whole body assessment to pick up any subsquent lesions. The treatment of the local disease does not differ from a standard GCT.
  2 5,213 361
Reconstructive procedures for segmental resection of bone in giant cell tumors around the knee
Aditya N Aggarwal, Anil K Jain, Sudhir Kumar, Ish K Dhammi, Bhagwat Prashad
April-June 2007, 41(2):129-133
DOI:10.4103/0019-5413.32044  PMID:21139765
Background: Segmental resection of bone in Giant Cell Tumor (GCT) around the knee, in indicated cases, leaves a gap which requires a complex reconstructive procedure. The present study analyzes various reconstructive procedures in terms of morbidity and various complications encountered. Materials and Methods: Thirteen cases (M-six and F-seven; lower end femur-six and upper end tibia -seven) of GCT around the knee, radiologically either Campanacci Grade II, Grade II with pathological fracture or Grade III were included. Mean age was 25.6 years (range 19-30 years). Resection arthrodesis with telescoping (shortening) over intramedullary nail ( n=5), resection arthrodesis with an intercalary allograft threaded over a long intramedullary nail ( n=3) and resection arthrodesis with intercalary fibular autograft and simultaneous limb lengthening ( n=5) were the procedure performed. Results: Shortening was the major problem following resection arthrodesis with telescoping (shortening) over intramedullary nail. Only two patients agreed for subsequent limb lengthening. The rest continued to walk with shortening. Infection was the major problem in all cases of resection arthrodesis with an intercalary allograft threaded over a long intramedullary nail and required multiple drainage procedures. Fusion was achieved after two years in two patients. In the third patient the allograft sequestrated. The patient underwent sequestrectomy, telescoping of fragments and ilizarov fixator application with subsequent limb lengthening. The patient was finally given an ischial weight relieving orthosis, 54 months after the index procedure. After resection arthrodesis with intercalary autograft and simultaneous lengthening the resultant gap (~15cm) was partially bridged by intercalary nonvascularized dual fibular strut graft (6-7cm) and additional corticocancellous bone graft from ipsilateral patella. Simultaneous limb lengthening with a distal tibial corticotomy was performed on an ilizarov fixator. The complications were superficial infection ( n=5), stress fracture of fibula ( n=2). The stress fracture fibula required DCP fixation and bone grafting. The usual time taken for union and limb length equalization was approximately one year. Conclusion: Resection arthrodesis with intercalary dual fibular autograft and cortico-cancellous bone grafting with simultaneous limb lengthening achieved limb length equalization with relatively short morbidity.
  1 5,187 440
Giant cell tumor of the spine: A review of 9 surgical interventions in 6 cases
Shekhar Y Bhojraj, Abhay Nene, Sheetal Mohite, Raghuprasad Varma
April-June 2007, 41(2):146-150
DOI:10.4103/0019-5413.32047  PMID:21139768
Background: Giant cell tumor (GCT) of the spine is uncommon but most aggressive benign tumor of the spine with unpredictable outcome. We present our observation on six cases of GCT of the spine. We treated six patients with giant cell tumors (GCT) of the spine between 1993 and 2006. A total of nine surgical interventions were carried out. Four interventions were carried out in patients presented as 'new' cases, while five on recurrences from past GCT resections. All presented with cord compression and neurological deficits of varying grades. All patients also presented with clinical as well as radiological instability. Preoperative tissue diagnosis was available only in the five recurrences (tissue from the old resection). Posterior only (n=2), anterior only (n=4) and single-stage back and front (n=3) surgeries were carried out depending on the nature of the tumor. Results: Overall results were satisfactory, as all patients were symptom-free postoperatively. Two out of our four new patients had tumor recurrence and both needed repeat resection. Both have been disease-free at last follow-up. Conclusion: Surgical intervention is mandatory. Close follow up is needed for early diagnosis of recurrences.
  1 10,012 456
Giant cell tumor: Curettage and bone grafting
Dominic Puthoor, Wilson Iype
April-June 2007, 41(2):121-123
DOI:10.4103/0019-5413.32042  PMID:21139763
Background: Curettage and wide resection are accepted methods of treatment of giant cell tumor (GCT) of bone. The success rate with curettage in different reports varies widely. There is a paucity in the literature regarding selection of cases for curettage. Present study is an analysis of outcome of 34 cases treated by curettage and bone grafting. Materials and Methods: Thirty-four cases of GCT of bone, 28 fresh and six with recurrence were treated by curettage and bone grafting. All cases of Campanancci grade 1, 2 and grade 3 which on computerized tomography scan showed break in the cortex confined to one surface and cortical break less than one third of circumference were treated by curettage and bone grafting. Results: 4 (14%) of these lesions treated primarily by us showed recurrence after one and half year. Conclusion: Curettage and bone grafting is a reliable method in the treatment of GCT, provided guidelines regarding selection of cases and principles of tumor surgery are strictly adhered to.
  1 5,898 468
Treating giant cell tumors: The eternal conundrum
Ajay Puri
April-June 2007, 41(2):89-90
DOI:10.4103/0019-5413.32036  PMID:21139757
  - 3,274 396
The value of recognizing suspect diagnoses in the triple diagnosis of giant cell tumor of bone
Mrinalini Kotru, Navjeevan Singh
April-June 2007, 41(2):97-100
DOI:10.4103/0019-5413.32038  PMID:21139759
Giant cell tumor (GCT) of bone is the most frequently over-diagnosed neoplasm in orthopedic pathology because giant cells are a common component of many neoplastic and nonneoplastic conditions of bone. Triple diagnosis, requiring substantial individual and collective inputs by orthopedic surgeons, radiologists and pathologists, is the preferred method for the workup of patients with suspected bone neoplasms. At each stage in triple diagnosis, deviations from the typical must be regarded as clues to alternate diagnoses: the greater the deviation, the more a diagnosis of GCT must be considered suspect. A suspect diagnosis must trigger renewed analysis of the available data and a diligent search to exclude alternate diagnoses.
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