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Evaluation of results of wide resection and reconstruction using non-vascularised ipsilateral proximal fibula for giant cell tumor of lower end of radius.

INTRODUCTION: Giant cell tumour of bone was first described by Cooper in 1818. It is an aggressive benign tumour with potential to become malignant. (1) Lower end of Radius is the third commonest site of occurrence. (1,2) If it is diagnosed very early extended curettage and bone grafting gives god result but recurrence can occur. (2,3,4,5,6,7)

If there is extension of tumour and there is break in the cortex resection of tumour and reconstruction is the treatment of choice to prevent recurrence. Reconstruction can be done vascularised or non-vascularised ipsilateral proximal fibula, custom made prosthesis, bone graft with arthrodesis of wrist. (8,6,9,10,11,12,7,13,14,15) Vascularised fibular graft needs expertise and fail sometimes but non-vascularised fibular graft is simple, less expensive and has good results.

MATERIALS AND METHODS: Ten patients underwent resection and reconstruction of distal end of Radius for Giant cell tumour of bone from 2003 to 2014. There were six males and four females. The age of the patients varied from 25 to 41 years with an average of 33 years. The tumour was assessed radiologically by X- rays and MRI. According to companacci grading(4) four were of grade two and six were grade three. MRI was done to know the extent of tumour and soft tissue involvement. The tumour was confirmed by FNAC in six cases and by biopsy in four cases.

PROCEDURE: The tumour was approached by volar incision along the radial side. The incision was extended dorsally depending on the size of the tumour. After exposing the tumour taking care of vessels and tendons the tumour was resected enblock with a cuff of soft tissue saving the carpal ligaments. The Radius was resected 5cm above the tumour margin. Biopsy was taken from the distal cut end of Radius to make sure that there is no tumour tissue. The proximal end of fibula was exposed taking care of lateral popliteal nerve. The length of the excised Radius was measured and the length of the fibula taken out is equal to length of radius plus 2 cm. A step cut of 2 cm is cut in the Radius and the fibular graft.

The fibula was fixed to the radius with a narrow DCP. The carpal ligaments were attached to head of radius as much as possible. To stabilize the graft a K wire was passed from 3rd metacarpal to the head of fibula. The inferior fibular joint created is fixed with K wire passed from head of ulna to the head of fibula transversly. The anastomotic site of radius and fibula was grafted with the leftover bone graft.

Postoperatively above elbow slab was given for two weeks and after suture removal above elbow cast was applied. After three months X-ray was taken to see the union of the fibula with radius. If there is delay in union the cast was continued for another six weeks.

Once the fibula unites with radius, active and passive exercises of the wrist were started. The hand and wrist was assessed for pain, stability, functional status every three months for one year later half yearly. Grip strength, pinch strength and range of motion were measured. The results were assessed musculoskeletal tumour score.

RESULTS: The follow up period varied from 36 to 60 months with an average of 43 months. The union of bone occurred by 16 weeks in eight patients, one was delayed union which united by six months. There was one nonunion which united after autogenous iliac graft. The results were assessed by musculoskeletal tumor score. (16) The grip strength was 65% of normal side and overall functional range of combined movements was 155 degrees which is comparable to published results. The result was good in eight patients. In two there was mild pain at fibula carpal junction and disabling to carryout manual work. There was no recurrence in our series.

COMPLICATIONS: There was one delayed union and one nonunion which united after grafting. There was mild subluxation at wrist in two cases and did not need any further surgery like arthrodesis. The patients could manage their routine day to day activities.

DISCUSSION: Lower end of Radius is the third common site for giant cell tumour of bone. (1,2) Many a times the patient seeks medical advice after a prolonged time. By the time patient seeks advice the tumour has expanded and cortex broken extending in to the soft tissues. In these cases enblock resection is done including a cuff of soft tissue to prevent recurrence of the tumour. (9,11,13,15) The large defect in the Radius has to be filed and normal wrist joint has to be restored. Ipsilateral proximal end of fibula is an ideal graft for reconstruction as it resembles lower end of Radius. One can use vascularised fibula, non vascularised fibula, custom made prosthesis or osteoarticular allograft (8,6,9,10,11,12,7,13,14,17,15,18)

The recurrence rate has been reported to be 0% or 5 to 25%. (5,13,19) In our study there was no recurrence. In some series subluxation of wrist has been reported. (9,13,20)

In our study there was mild subluxation in two cases. There was one nonunion at the site of fibula and radius which united after grafting. (20)

CONCLUSION: Non-vascularised fibular grafting after adequate resection of giant cell tumour of distal end radius achieved good cosmetic and functional outcome even though there is substantial loss of movement of the wrist. The results are acceptable to the patient. Therefore non-vascularised fibular graft for giant cell tumour of distal end of radius after resection of tumour may be considered as an effective and appropriate procedure.

ILLUSTRATIONS:

DOI: 10.14260/jemds/2015/1335

REFERENCES:

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(2.) Goldenberg RR, Cambell CJ, Bonfiglio M, Giant cell tumors of bone. An analysis of two hundreden eighteen cases. J Bone Joint Surg Am 1970, 52 (4) 619-64.

(3.) Szendrol M; Giant cell tumor of bone; J Bone Joint Surg Br 2004, 86(1) 5-12.

(4.) Companacci M, Baldini N, Boriani S, Sudanese A: Giant- cell tumor of bone. J Bone Joint Surg Am 1987, 69(1): 106-14.

(5.) O'Donnel RJ, Sprigfield DS, Motwani HK, Ready JE, Gebhardt MC, Mankin HK: Recurrence of giant cell tumors after curettage and packing with cement. J Bone Joint Surg Am 199476(12): 1827-33.

(6.) Lackman RD, MaDonald DJ, Beckenbaugh RD, Sim FH: Fibular reconstruction for giant cell tumor of distal end of radius. Clin Orthop Relat Res 1987, 218: 232-8.

(7.) Chadha M, Arora ss, Singh AP, Gulati G, Singh AP: Autogenous non vascularised fibulafor treatment of giat cell tumour of distal end radius. Arch Orthop Trauma Surg 2010, 130(12): 1467-73.

(8.) Gold AM: Use of prosthesis for the distal portion of the radius fallowing resection of a recurrent giat cell tumor. J Bone Joint Surg Am 1975, 57(7) 982-86.

(9.) Murray JA, Schlafly B: Giant cell tumors in the distal end of radius. Treatment by resection and fibular auto graft interpositional arthrodesis. J Bone Joint Surg Am 1986, 68(5) 687-94.

(10.) Pho RW; Free vascularised fibular transplant for replacement of the lower radius. J Bone Joint Surg Br 1979, 61(3) 362-5.

(11.) Selenius P, Santavita S, Kivluoto O, Kosknen EV: Application of the autogenous fibular graft in the treatment of aggresiive bone tumorsof the distal end of the radius. Arch Trauma Sug 1981: 98(4)285-7.

(12.) Smith RJ, Mankin HJ: Allograft replacement of distal radius for giant cell tumor. J Hand Surg Am 1977, 2(4) 299-308.

(13.) Maruthainar N, Zambakidis C, Harper C, Calder D, Cannon SR, Briggs TW. Functional outcome fallowing excision of tumors of the distal radius and reconstruction by autologous non vascularised ostearticular fibula grafting. J Hand Surg Br 2002, 27(2): 171-4.

(14.) Aithal VK, Bhaskaranand k: Reconstruction of the distal radius by fibula fallowing excision of giant cell tumor. Int Orthop 2003, 27(2)110-3.

(15.) Bassiony AA: Giant cell tumor of the distal radius: wide resection and reconstruction by nonvascularised proximal fibular graft. Ann Acad Med Singapore 2009, 38(10) 900-4.

(16.) Enneking WF, Dunham W, Gebardt MC, Malawar M, Pichard DJ: Asystem for functional evaluation of reconstructive procedure after surgical treatment of tumors of the muscloskeletal system. Clin Orthop Relat Res 1993, 286: 241-6.

(17.) Asavamongkolkul A, Waikakul S, Phimolsarnti, R, Kiatisevi P: Functional outcome following excision of a tumor and reconstruction of distal radius. Int Orthop 2009 33(1): 203-9.

(18.) Harris WR, Lehman EC: Recurrent giat cell tumor after enblock excision of the distal radius and fibular autograft replacement. J Bone Joint Surg Br 1983, 65(5): 618-20.

(19.) Saikia KC, Borgohain M, Bhuyan SK, Goswami S Bora A: Resection and reconstruction arthroplasty for giant cell tumor of distal radius. Indian J Orthop 2010, 44(3): 327-32.

(20.) Saraf SK, Goel SC. Complications of resection and reconstruction in giat cell tumour of distal end of radius. An analysis. Indian J Orthopp 2005: 39: 206-11.

Sujai S [1], Jayakrishnan S [2], Abhijeet Jayaswal [3], M. K. Siddalingaswamy [4], Venugopal N [5]

AUTHORS:

[1.] Sujai S.

[2.] Jayakrishnan S.

[3.] Abhij eet J ayaswal

[4.] M. K. Siddalingaswamy

[5.] Venugopal N.

PARTICULARS OF CONTRIBUTORS:

[1.] Assistant Professor, Department of Orthopaedics, MVJ Medical College & Research Hospital, Bangalore.

[2.] Assistant Professor, Department of Orthopaedics, MVJ Medical College & Research Hospital, Bangalore.

[3.] Post Graduate, Department of Orthopaedics, MVJ Medical College & Research Hospital, Bangalore.

[4.] Professor& HOD, Department of Orthopaedics, MVJ Medical College & Research Hospital, Bangalore.

[5.] Professor, Department of Orthopaedics, MVJ Medical College & Research Hospital, Bangalore.

FINANCIAL OR OTHER COMPETING INTERESTS: None

NAME ADDRESS EMAIL ID OF THE CORRESPONDING AUTHOR:

Dr. Sujai S, Flat No. 204, JRS complex, Above New Life Hospital, Opp. Whitefield Railway Station Entrance, Kadugodi Main Road, Kadugodi, Bangalore- 560067.

E-mail: drsujaisukumaran@gmail.com

Date of Submission: 12/06/2015. Date of Peer Review: 13/06/2015. Date of Acceptance: 26/06/2015. Date of Publishing: 30/06/2015.
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Article Details
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Title Annotation:ORIGINAL ARTICLE
Author:Sujai, S.; Jayakrishnan, S.; Jayaswal, Abhijeet; Siddalingaswamy, M.K.; Venugopal, N.
Publication:Journal of Evolution of Medical and Dental Sciences
Article Type:Clinical report
Date:Jul 2, 2015
Words:1686
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