Reconstructive procedures for segmental resection of bone in giant cell tumors around the knee

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.

G iant cell tumor (GCT) most frequently occurs in wide/radical resection requires reconstructive procedures. the distal end of the femur and the proximal end The present study evaluates various reconstructive options of the tibia. The majority of patients are between after en bloc resection for GCT around the knee to evolve a 20 and 45 years of age. 1 biologically sound, reconstructive procedure with reduced morbidity. A variety of treatment modalities are available for GCT.

The complications
They include curettage and bone grafting, cryotherapy, phenol application, insertion of methylmethacrylate, insertion of hydroxyapatite, resection followed by allograft or prosthetic reconstruction.
Intralesional procedures have very high local recurrence while wide or radical procedures few recurrence. 1 However,

MATERIALS AND METHODS
Thirteen cases of GCT around the knee presenting between 1988 and 2003 were included in the study. All the cases included were radiographically either Campanacci Grade II, Grade II with pathological fracture or Grade III.
There were six males and seven females in the study group. The mean age was 25.6 years (range 19-30 years). The distal end of the femur was involved in six cases and the upper end of the tibia was involved in seven cases. Two cases had additional findings of aneurysmal bone cyst. Twelve patients were fresh cases of GCT while one patient presented with recurrence and infection after having an initial curettage and bone grafting procedure done elsewhere for GCT of lower end femur. All the cases were operated by two senior authors (SK, AKJ). The segmental resection of tumor bone was done. The various reconstructive procedures used to bridge the bone gap in our series were shortening over intramedullary nail (telescoping) (n=five), resection arthrodesis with intercalary allograft (n=three), resection arthrodesis with intercalary autograft (n=five) and Resection arthrodesis with shortening (telescoping) was performed in five cases. Four patients underwent segmental resection of the bone and telescoping over an intramedullary nail. Out of these four patients, only one patient [ Figure 1] who had residual shortening of 12 cm agreed for limb lengthening. One year later the nail was removed and the tibia was lengthened 10 cm by a ring external fixator. In the fifth patient (Campanacci Grade III) a segmental resection of limb was preformed. There was soft tissue extension with a fungating mass on the anterior aspect of the knee. The skin, soft tissue, affected lower end of the femur and knee joint were removed en bloc. At this stage the distal limb was attached to the proximal limb by neurovascular bundle only. After achieving safe margins, a gap of 20 cm was created. The distal stump was telescoped on the femur and stabilized with a prefabricated intramedullary nail [ Figure  2]. The patient was immobilized in a toe to groin cast till clinico-radiological arthrodesis was achieved. This patient was taken up for subsequent lengthening with ring external fixator. The lengthening of the limb was performed in two stages, initially by tibial corticolomy (12 cm) and then by femoral corticolomy (6 cm).
Resection arthrodesis with an intercalary allograft (decalcified and ethanol preserved) was preformed in three patients. After achieving wide margins following segmental bone resection, the defect was bridged by tubular allografts threaded over an intramedullary nail [ Figure 3]. All three developed secondary infection. In two superficial infection  IJO -April -June 2007 / Volume 41 / Issue 2 could be controlled. In one case, the allograft sequestered due to prolonged infection.
In our subsequent cases (n=five) we performed resection arthrodesis with intercalary autograft. After en bloc excision of the tumor, the resultant gap (~ 15 cm) was partially bridged by intercalary nonvascularized fibular strut graft (6-7 cm). Additional corticocancellous bone graft from ipsilateral patella was also used. The extremity was stabilized by an Ilizarov ring fixator assembly. A distal tibial corticotomy was performed for simultaneous limb lengthening. In the first two patients only a single fibular graft was used. After limb lengthening and consolidation of the regenerate, the ring fixator assembly was removed at eight and 17 months, respectively. Subsequently both the patients developed pathological fracture of intercalary fibular graft [ Figure 4].
Aggarwal AN, et al.: Segmental resection of bone in giant cell tumor Z-plasty, and pin tract infections. It took three years to complete the treatment. .
Infection was a major problem in all the patients who underwent resection arthrodesis with an intercalary allograft (decalcified and ethanol-preserved). The arthrodesis was achieved after two years in two patients. The third patient underwent nail removal, debridement, sequestrectomy, telescoping of fragments over an AO external fixator stabilization, 27 months after the index surgery. Four months later the AO fixator was converted to ring external fixator with tibial corticotomy for simultaneous limb lengthening. The ring external fixator was removed after subsequent 23 months and the patient was given an ischial weight-relieving caliper for one year. Both patients required plating and bone grafting for the pathological fracture, which subsequently united. So, the procedure was modified and dual fibular grafting with K wire stabilization of the fibula was done in the next three cases [ Figure 5].

m e d k n o w
The patients who underwent segmental resection of bone with shortening were ambulatory with a shoe raise. Shortening was the major problem in three cases. The arthrodesis was achieved in 12-18 months in all cases. Only two underwent lengthening subsequently. The problems encountered during lengthening were long morbidity, multiple surgical procedures, tendo-achilles contracture and toe flexor contractures which required  Three patients who underwent segmental resection of bone with intercalary dual fibular autograft with simultaneous lengthening had no major complications except for superficial pin tract infection. The mean time of fixator application in these cases was 54 weeks. The mean lengthening achieved in the last three cases was 6.3 cm.

DISCUSSION
The World Health Organization has classified GCT as "an Aggarwal AN, et al.: Segmental resection of bone in giant cell tumor reported only one recurrence in the intralesional surgery group. There were no recurrences in the patients who had an en bloc resection. However, the disadvantage of this treatment was the relatively poor functional outcome. The limitation of this study was that only Campanacci Stage II tumors around the knee were subjected to intralesional surgery 7 (curettage + phenol +methylmethacrylate / bone graft) while in the resection group they had Stage III lesion also. 50%). 2 aggressive, potentially malignant lesion". 2 Its histogenesis An arthrodesis is less attractive initially but once it is is uncertain. 2,3 Historically, curettage / intralesional excision achieved it provides a stable leg and the patient is unlikely to has been associated with a high rate of recurrence (30-require revision surgery. A realistic estimate of the expected Intralesional excision / curettage combined with function after a proposed reconstructive procedure must be local adjuvants like methylmethacrylate and liquid nitrogen given preoperatively. Resection arthrodesis with shortening (thermal action) or phenol and hydrogen peroxide (chemical provided a stable extremity, but with unacceptable action), may decrease the rates of local recurrence. 3 shortening. A patient refusing subsequent lengthening However, the adequacy of the removal of tumor rather procedures is probably an indicator of the limited resources than the use of adjuvant modalities is what determines the available to the patient in the developing world. Although risk of recurrence. 4,5 the function of the extremity was compromised, the emotional acceptance of the residual deficit was good due to The risk of local recurrence after an en bloc resection preoperative counseling of the patients in our series. In most involving the joint is lower than that after an intralesional developing countries resection-shortening-distraction offers procedure. 4 Campanacci reported a recurrence rate of zero a very real alternative. In a young active patient with GCT in 58 wide (en bloc resections) or radical procedures. 1 around the knee, with a normal lifespan, endoprosthesis is not a sound biological solution that matches life expectancy. Now increasing emphasis is being laid on preservation of It is likely to require multiple revision surgeries. joint in treating GCT. 2,3 Resection is usually performed in a) Stage 3 lesions, which have already destroyed the cortex The limited availability of autogenous bone has led to the and tend to recur more often; b) when the defect is large; interest in the use of allograft for arthrodesis. The major and c) when the joint surface is destroyed or cannot be concern about allograft is the high complication rate. 8,9 salvaged. However, Szendroi tries to preserve the joint even These include infection, fracture and nonunion. 8 in Stage 3 lesion, taking into account the higher probability patients, infection was the major problem. of recurrence. He believes that extended curettage and application of bone cement are the most accepted methods Another method of reconstruction after en bloc resection of treatment of GCT. 2 When the tumor is less than 1 cm is the use of intercalary autograft. Enneking and Shirly from the articular surface, the incidence of degenerative reported 20 cases of local resection and arthrodesis changes in articular cartilage after the use of cement alone employing an intramedullary nail and autogenous is more than 2.5 times greater than that when the tumor is segmental cortical grafts obtained from the same extremity. more than 1 cm away. 6 Interposing a cm or two of bone graft The indication for selection of the procedure was a lesion between the cartilage and cement may reduce heat damage in the epiphyseal region of the femur or tibia in such a way In our and the resultant early degenerative changes. 6 Studies have shown that cement constructs are less rigid than normal subchondral bone or successful bone graft. 3 Our patients generally presented late in the course of the disease when the lesion had become large in size and abutting the articular cartilage despite being Campanacci Grade 2 lesion. Most of our cases are from the last two decades and hence we have used various methods to reconstruct the gap. IJO -April -June 2007 / Volume 41 / Issue 2 gap ranged from 9-24 cm. In the later part of his series he advocates the use of Kirschner wires inside the long grafts to help in maintaining the continuity of the graft when a stress fracture occurs. 13 In the last 15 years distraction histogenesis is in vogue. Resection-shortening-distraction offers a very good alternative. However, in large defects the lengthening and consolidation time can be substantial. 11 We have used intercalary autogenous nonvascularized fibular graft to partially bridge the defect and achieve simultaneous intramedullary K-wires with cortico-cancellous graft and simultaneous distraction histogenesis may provide a good biological long-term alternative solution for GCT around the knee. It helped us in achieving a functional limb with a Source of Support: Nil, Conflict of Interest: None declared.
sound arthrodesis in a reasonably short duration of time.
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