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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 1  |  Issue : 1  |  Page : 33-37

Do we need internal fixation devices for giant cell tumors around knee joint? An outcome study


Department of Orthopaedics, Indira Gandhi Institute of Medical Sciences, Patna, Bihar, India

Date of Web Publication28-Dec-2018

Correspondence Address:
Dr. Ritesh Runu
Department of Orthopaedics, Indira Gandhi Institute of Medical Sciences, Patna 800014, Bihar
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jodp.JODP_4_18

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  Abstract 

Introduction: Giant cell tumors around the knee joint are the most common aggressive benign tumors. Several limb sparing and limb ablation surgeries are practiced with varying level of success. Here we present an original outcome study conducted on 14 patients with giant cell tumor around the knee joint, treated with intralesional curettage, bone grafting and bone cementing with or without internal fixation. Material and Methods: This is a retrospective study carried out in an institutional set up. Fourteen patients were operated and Internal fixation was used in five cases. the patients were followed up for 2 years minimum. Results: Total fourteen patients were treated with giant cell tumors around knee joint. Phenol cauterization showed reduced recurrence compared to no phenol cauterization. Collapse was noted in cases done with curettage and only cementing or only bone grafting. plating group showed no collapse. No collapse was noted in cases with subchondral bone more than 5 mm. Conclusion: For giant cell tumor, campannaci grade III, internal fixation is suggested if subchondral bone is less than 5 mm and articular involvement is more than 50%.

Keywords: Bone cementing, bone grafting, giant cell tumor, internal fixation, intralesional curettage


How to cite this article:
Runu R, Sagar V, Kumar A, Sinha A, Kumar S. Do we need internal fixation devices for giant cell tumors around knee joint? An outcome study. J Orthop Dis Traumatol 2018;1:33-7

How to cite this URL:
Runu R, Sagar V, Kumar A, Sinha A, Kumar S. Do we need internal fixation devices for giant cell tumors around knee joint? An outcome study. J Orthop Dis Traumatol [serial online] 2018 [cited 2019 Jan 23];1:33-7. Available from: http://www.jodt.org/text.asp?2018/1/1/33/248903


  Introduction Top


Giant cell tumor (GCT) around the knee joint is very common.[1] With an increase in limb preservation and joint preservation surgery, the morbidity associated with this condition has increased.[2] To completely eradicate the disease, the lesion is thoroughly curetted, cauterized, and then cementing is done.[2] On review of English literature, we could not find any literature regarding indications for use of internal fixation (IF) in GCT around the knee joint. Hence we conducted a retrospective analysis to find the role of IF in terms of articular collapse and its relation to tumor volume, subchondral thickness, and metaphyseal break.


  Materials and Methods Top


A total of 30 patients with GCT at various sites were enrolled in this study. Twenty-two patients with GCT around knee were included. Eleven patients had upper tibial lesion, eight had lower femoral lesion, and three had proximal fibular lesion. Four patients with amputation, one with excision and megaprosthesis, and three with fibular lesion were excluded. Finally, fourteen patients were followed up for 2 years. In all cases, radiological survey, magnetic resonance imaging of the affected site, and bone biopsy with immunohistochemistry was carried out. After confirmation of GCT, operation was planned. For Campanacci grade I and II, limb salvage was carried out, whereas for grade III, choice of amputation and megaprosthesis was given to the patients.


  Surgical Technique Top


Informed consent was obtained from the patients after explaining the pros and cons of limb salvage and risk of recurrence. Anterior midline incision or lateral hockey stick incision was used. The tumor area was widely exposed and large bony window was created for thorough curettage and chemical cauterization. Phenol (80%) and hydrogen peroxide were used for chemical cauterization. After extended curettage, the subarticular areas and the broken cortices were covered with autologous iliac crest bone graft. Remaining cavity was filled with G bone (Surgiwear, Uttar Pradesh, India) in one case without any complications. The remaining cavity was filled with bone cement, and the plate was fixed immediately in setting phase. After curing, extra cement in the soft tissue was removed and wound was thoroughly lavaged and closed in layers [Figure 1].
Figure 1: Case 1: Right upper tibia giant cell tumor, internal fixation done

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Postoperatively, the patients were given brace or plaster of Paris slab for rest and pain relief. On 12th day, stitch removal was carried out and non-weight-bearing mobilization was started. Follow-up was carried out in outpatient department every 6 weeks till 3 months, then every 3 months in first year, and every 6 months thereafter. On every visit, pain, swelling, tenderness, range of motion, and neurovascular status was checked. X-ray of the affected part was taken. Articular collapse was measured on digital X-ray. Every 6 months, chest X-ray was also taken for any pulmonary metastasis. Complaints of pain over the lesion and radiological lucency on X-ray were regarded as recurrence.


  Results Top


A total of 14 patients were followed up for 2 years. The average age of patients was 30 years (18–59 years). Upper tibia was affected in nine and lower femur in five. Campanacci grade III was observed in six, grade II in six, and grade I in two cases. The average follow-up was of 34 months (3–108 months) and median follow-up was of 24 months.

[Table 1] Phenol cauterization was used in eight cases, only with one (12.5%) recurrence. No phenol group showed recurrence in two of six cases (33%).
Table 1: Master chart

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Post-curettage gap was filled by autologous bone graft, allograft, and cement. Only autologous grafting was carried out in two, only cementing in two, and autologous grafting along with allograft and cementing in eight cases. Cryotherapy with fibular grafting and autologous bone grafting with allograft and IF was carried out in one case each. Collapse was noted in cases with only bone grafting and only cementing [Figure 2].
Figure 2: Case 17: Left upper tibia giant cell tumor, without internal fixation

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Plating was performed in five cases along with curettage, cauterization, bone grafting, and cementing. In nine cases, IF was not carried out because of small cavity, the patient did not consent for it and abnormal bony surface was precluding plate positioning. All the cases with implant were mobilized partial weight-bearing. Case 4 with plate in distal femur had prominent implant causing iliotibial band irritation and reduced range of knee motion. Case 13 with distal femur GCT developed postoperative infection at 1 month. The wound was thoroughly debrided; implant, bone graft, and cement were removed; and repeat antibiotic cementing was done. She was counted in non-plating group. Finally, IF was carried out in four cases and no IF in 10 cases.

Postoperatively articular collapse was noted in seven cases at complete 2 years of follow-up. Three were in distal femur and four were in proximal tibia. IF group showed one collapse (25%) in Case 4, whereas non-IF group showed collapse in six of ten cases (60%). Early collapse noted in one case (Case 13) was due to postoperative infection at 1 month. Early weight-bearing was noted for articular depression in two cases. Late collapse occurred in four cases at 1 year.

Subchondral thickness was less than 5mm in eight cases. Collapse was noted in five cases without IF, whereas those with IF did not show any collapse.

Arthritic changes were seen in one case with distal femur lesion.

Recurrence was seen in three cases, which reported with pain at the end of 1 year. Phenol was used in one, whereas it was not used in two cases. Small bony window and no chemical cauterization were consistent with recurrence rate.


  Discussion Top


GCT around the knee joint has different characteristics than other sites. Being epiphyseo-metaphyseal lesion, the chances of articular collapse are high after curettage.[3] To fill the gap, autologous bone graft, allograft, and bone cement are used frequently.[4] Use of screws improves the bone cement fixation in cavity.[1] In this study, we found that more than 50% of articular area affected had high chance of collapse. Ward and Li[5] suggested wide local resection and reconstruction in more than 50% joint involvement.

Subchondral bone thickness was studied by Chen et al.[6] They found poor functional outcome in larger subchondral bone loss of more than 3mm. In our study, we found that less than 5mm subchondral bone had high chances of articular collapse without IF. This complication can be avoided by subchondral bone grafting and IF.

Metaphyseal breach had not been studied specially in any study. Its relationship with articular collapse was not studied earlier. In our study, we found that it had no relationship with collapse. Neither was it related to IF.

Weakness of this study is the small number of cases. This study is continued to find long-term (5 years) follow-up. Maximum recurrence is noticeable by 1 year; hence, 2-year follow up is sufficient. For subchondral thickness digital X-ray was used. For more accuracy computed tomography scan could be used.


  Conclusion Top


For GCT Campanacci grade III, IF around knee joint is recommended if subchondral bone thickness is less than 5mm and articular surface involvement is more than 50%.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Niu X, Zhang Q, Hao L, Ding Y, Li Y, Xu H, et al. Giant cell tumor of the extremity: Retrospective analysis of 621 Chinese patients from one institution. J Bone Joint Surg Am 2012;1:461-7.  Back to cited text no. 1
    
2.
Fraquet N, Faizon G, Rosset P, Phillipeau J-, Waast D, Gouin F. Long bones giant cells tumors: Treatment by curretage and cavity filling cementation. Orthop Traumatol Surg Res 2009;1:402-6.  Back to cited text no. 2
    
3.
Prosser GH, Baloch KG, Tillman RM, Carter SR, Grimer RJ. Does curettage without adjuvant therapy provide low recurrence rate in giant cell tumors of bone? Clin Orthop Relat Res 2005;1:211-8.  Back to cited text no. 3
    
4.
Xiuchun Y, Ming Xu, Songfeng X, Qing Su. Clinical out of giant cell tumour of bone treated with bone cement filling and internal fixation, and oral bisphosphonates. Oncology Letters 2013;1:447-51.  Back to cited text no. 4
    
5.
Ward WG Sr., Li G 3rd. Customised treatment algorithm for giant cell tumour of bone: Report of a series. Clin Orthop Rel Res 2002;1:259-70.  Back to cited text no. 5
    
6.
Chen TH, Su YP, Chen WM. Giant cell tumors of the knee: Subchondral bone integrity affects the outcome. Int Orthop 2005;1:30-4.  Back to cited text no. 6
    


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Abstract
Introduction
Materials and Me...
Surgical Technique
Results
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