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 Table of Contents  
CASE REPORT
Year : 2014  |  Volume : 19  |  Issue : 2  |  Page : 155-158

Custom prosthetic reconstruction of proximal tibial giant cell tumor


Department of Orthopedics, MGIMS, Sewagram, Maharashtra, India

Date of Web Publication11-Aug-2014

Correspondence Address:
Shailendrasingh Thakur
Department of Orthopedics, MGIMS, Sewagram, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9903.138444

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  Abstract 

Giant cell tumor (GCT) also called osteoclastoma of bone is the most common bone tumor encountered by an orthopedic surgeon. GCT generally occurs in skeletally mature individuals with peak incidence in the third decade of life. Less than 5% are found in patients with open physis and only about 10% of cases occur in patients older than 65 years. We present a case of proximal tibia GCT managed with custom mega prosthetic arthroplasty.

Keywords: Custom mega prosthesis, giant cell tumor, bone tumor


How to cite this article:
Thakur S, Badole C M, Wandile K. Custom prosthetic reconstruction of proximal tibial giant cell tumor. J Mahatma Gandhi Inst Med Sci 2014;19:155-8

How to cite this URL:
Thakur S, Badole C M, Wandile K. Custom prosthetic reconstruction of proximal tibial giant cell tumor. J Mahatma Gandhi Inst Med Sci [serial online] 2014 [cited 2020 Jul 5];19:155-8. Available from: http://www.jmgims.co.in/text.asp?2014/19/2/155/138444


  Introduction Top


Giant cell tumors (GCTs) represent 3-4% of all primary tumors of bone. [1] Distal femur and proximal tibia are the most common sites followed by the distal radius. The ideal aim in the management of GCT is to eradicate the tumor without sacrificing the joint. [1] Current treatment modalities including a meticulous curettage with extension of tumor removal using high speed burrs and adjuvant local therapy. [2] However with these modalities there is a recurrence rate of 60%. Wide resection should be the treatment of choice, especially for situations such as recurrences, pathological fractures and tumors which are frankly malignant tumors. [3],[7] En bloc resection of major joints creates a problem for the reconstruction of large defects. Recent advances in tumor resection defects involve the use of custom-built joints for the replacement of defects near knee.


  Case Report Top


A 47-year-old female from Adilabad district in Andhra Pradesh came to our out-patient department with the chief complaint of swelling around left knee since 4 months. The swelling was insidious in onset and gradually progressive in nature. Patient was experiencing pain in the swelling since 1 month. The pain was insidious in onset and progressive in nature, throbbing in character, radiating to left leg and moderate in intensity, aggravating on bearing weight on the affected limb. There was no history of trauma to the affected knee or leg.

X-rays of left knee with leg in anteroposterior and lateral projections were done, which showed an osteolytic lesion in the epiphysis involving the metaphysis and extending in the subchondral bone of proximal tibia [Figure 1] and [Figure 2]. Fine-needle aspiration cytology of the swelling was done by the Pathologist which revealed GCT. An open biopsy was taken from the swelling which confirmed the diagnosis of GCT [Figure 3]. Magnetic resonance imaging (MRI) of left knee with leg was done to get accurate tumor delineation, which showed subtle cortical destruction and extraosseous extend of the tumor with involvement of joint space without involvement of neurovascular structures around the knee [Figure 4]. The tumor was in Stage 3 according to Enneking system for benign tumors. The patient was screened for metastasis with computed tomography of brain and chest, ultrasonography of abdomen and pelvis and there was no obvious evidence of any secondaries.
Figure 1: X-ray of knee with leg (anteroposterior view) showing osteolytic lesion in proximal tibia

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Figure 2: X-ray of knee with leg (lateral view) showing osteolytic lesion in proximal tibia

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Figure 3: Histopathology slide showing features suggestive of giant cell tumour

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Figure 4: Magnetic resonance imaging showing intra articular extension of tumor

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After getting fitness by the Anesthetist, the patient was posted for wide excision of the tumor and custom mega prosthetic arthroplasty. Extended medial parapatellar approach encircling the biopsy site was used. The hinged custom mega prosthesis, manufactured in Delhi, India was used. The custom mega prosthesis contains a femoral condylar component, a pivot pin, a thrust-bearing pad made of high molecular weight polyethylene and tibial component. Proximally, the prosthesis is angulated laterally by 6° to resemble the valgus angle of the lower limb. Measurement radiography and MRI were used to estimate the size of the prosthesis to be used. Resection of the tumor bearing part and a medial gastrocnemius rotation flap was done. The extensor mechanism was repaired by direct suturing of the patellar tendon to the hook given to the prosthesis. Post-operative X-rays were taken [Figure 5].
Figure 5: Post-operative X-ray with implant in situ

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Quadriceps strengthening exercises were started from the second post-operative day. Patient was allowed to walk with the help of walker on the third post-operative day. On the fifteenth post-operative day sutures were removed and patient was discharged. Knee bending was started after 3 weeks. She had an uneventful recovery. On follow-up after 2 months, patient was walking with good range of flexion, without any support. There was no evidence of flap necrosis, prosthetic failure or peri prosthetic fractures.


  Discussion Top


The treatment of GCTs is directed towards local control without sacrificing joint function. This has traditionally been achieved by intralesional curettage with autograft reconstruction by packing the cavity of excised tumor with morselized iliac cortico-cancellous bone. Regardless of how thoroughly performed, intralesional excision leaves microscopic disease in the bone and hence a reported recurrence rate as high as 60%. Use of modern instruments such as high power burr, pulsatile jet lavage system, head lamp and dental mirror combined with multiple angled curettes to identify and access small pockets of residual disease failed to provide 100% results. Recurrence has been reported instead of the use of adjuvants such as phenol and hydrogen peroxide. Cryosurgery using liquid nitrogen is associated with high incidence of local wound and bone complications. [4],[5]

Adequate removal of tumor seems to be a more important predictive factor for the outcome of surgery. However it leaves large bone defects. Methylmethacrylate cement, used to fill the defect is though strong in compression is relatively weak when subjected to shear and torsional forces. Moreover, it can lead to degeneration of articular cartilage in subchondral lesions. Autografts can be used to fill the defect but its quantity is limited and harvesting autograft causes donor site morbidity. Allograft is expensive and requires a bone bank. Allograft itself can lead to infection, fracture, non-union and joint instability. Bone lengthening is a time consuming procedure. Arthrodesis has complications including a high risk of delayed or non-union and fractures. An arthrodesed knee is awkward and causes problems when sitting, particularly in public transport such as buses, trains etc. The cosmetic outcome of rotation plasty is a serious disadvantage. [8]

Hence, custom mega prosthetic arthroplasty has become the method of choice after bone tumor resection at the knee. It is the primary modality in the treatment of aggressive bone tumors of lower limb. The use of custom mega prosthesis is a simple and technically superior method of filling the bone defects in benign aggressive lesions with pathological fractures and where skeletal reconstruction is difficult after intralesional curettage. The advantages of custom mega prosthetic arthroplasty are least rates of recurrence, immediate resumption of knee function with early ambulation. The possible complications include flap necrosis, secondary infection, aseptic loosening and breakage.[9]


  Conclusion Top


In cases of GCT, the management depends upon the various factors such as site, age, involvement of the bone, extent of bone involvement and whether there is articular involvement or not. If tumor is involving more soft-tissue with involvement of neurovascular structure then limb salvage surgery will not be possible. If there is intra articular extension, then the main aim of management should be eradication of tumor without sacrificing joint function. By using the technique of custom prosthetic reconstruction in proximal tibial GCT with intra articular extension, we have achieved satisfactory oncological and functional outcomes in our patient.

 
  References Top

1.Natarajan MV, Prabhakar R, Mohamed SM, Shashidhar R. Management of juxta articular giant cell tumors around the knee by custom mega prosthetic arthroplasty. Indian J Orthop 2007;41:134-8.  Back to cited text no. 1
[PUBMED]  Medknow Journal  
2.Eckerd JJ, Grogan TJ. Giant cell tumor of bone. Clin Orthop Relat Res 1986 Mar;(204):45-58.  Back to cited text no. 2
    
3.Ghert MA, Rizzo M, Harrelson JM, Scully SP. Giant-cell tumor of the appendicular skeleton. Clin Orthop Relat Res 2002 Jul;(400):201-10.  Back to cited text no. 3
    
4.Szendröi M. Giant-cell tumour of bone. J Bone Joint Surg Br 2004;86:5-12.  Back to cited text no. 4
    
5.McGrath PJ. Giant-cell tumour of bone: An analysis of fifty-two cases. J Bone Joint Surg Br 1972;54:216-29.  Back to cited text no. 5
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6.Kawai A, Lin PP, Boland PJ, Athanasian EA, Healey JH. Relationship between magnitude of resection, complication, and prosthetic survival after prosthetic knee reconstructions for distal femoral tumors. J Surg Oncol 1999;70:109-15.  Back to cited text no. 6
    
7.Hillmann A, Hoffmann C, Gosheger G, Krakau H, Winkelmann W. Malignant tumor of the distal part of the femur or the proximal part of the tibia: Endoprosthetic replacement or rotationplasty. Functional outcome and quality-of-life measurements. J Bone Joint Surg Am 1999;81:462-8.  Back to cited text no. 7
    
8.Natarajan MV, Annamalai K, Williams S, Selvaraj R, Rajagopal TS. Limb salvage in distal tibial osteosarcoma using a custom mega prosthesis. Int Orthop 2000;24:282-4.  Back to cited text no. 8
    
9.Enneking WF. A system of staging musculoskeletal neoplasms. Clin Orthop Relat Res 1986 Mar;(204) :9-24.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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Case Report
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