|Year : 2022 | Volume
| Issue : 3 | Page : 176-179
Giant cell tumor of distal end radius managed by en bloc resection with wrist arthrodesis using fibula bone: A novel technique
Ashutosh Kumar1, Saurabh Mittal1, Narendra Harji Bamania1, Bhawna Singh2, T Somashekarappa1
1 Department of Orthopaedics, Rohilkhand Medical College and Hospital, Bareilly, Uttar Pradesh, India
2 Department of Anaesthesia, Rohilkhand Medical College and Hospital, Bareilly, Uttar Pradesh, India
|Date of Submission||23-Sep-2022|
|Date of Acceptance||21-Nov-2022|
|Date of Web Publication||15-Dec-2022|
Department of Orthopaedics, Rohilkhand Medical College and Hospital, Bareilly 243006, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Introduction: Giant cell tumor is a benign but locally aggressive tumor typically found in the epiphysis of long bones. Patients are usually females typically presenting between ages 30 and 50. Confirm diagnosis is based on biopsy. Treatment includes radiation therapy, bisphosphonates, denosumab, extensive curettage with adjuvant treatment, and reconstruction. We managed our case by en bloc resection of the tumor with wrist arthrodesis with fibula bone. Result: The patient had a good functional grip with 80° of pronation and 60° of supination. Conclusion: Resection of the tumor along with ipsilateral nonvascularized fibular strut graft with wrist arthrodesis is a good option for wrist reconstruction and provides a good forearm function and strength.
Keywords: Distal end radius, fibula graft, giant cell tumor, wrist arthrodesis
|How to cite this article:|
Kumar A, Mittal S, Bamania NH, Singh B, Somashekarappa T. Giant cell tumor of distal end radius managed by en bloc resection with wrist arthrodesis using fibula bone: A novel technique. J Bone Joint Dis 2022;37:176-9
|How to cite this URL:|
Kumar A, Mittal S, Bamania NH, Singh B, Somashekarappa T. Giant cell tumor of distal end radius managed by en bloc resection with wrist arthrodesis using fibula bone: A novel technique. J Bone Joint Dis [serial online] 2022 [cited 2023 Feb 6];37:176-9. Available from: http://www.jbjd.in/text.asp?2022/37/3/176/363850
| Introduction|| |
Giant cell tumor is a benign but locally aggressive tumor typically found in epiphysis of long bones commonly seen in distal femur followed by proximal tibia, distal radius, and sacral ala. Patients are usually females typically presenting between ages 30 and 50 with insidious onset of pain of the involved extremity with activity, at night, or at rest. Confirm diagnosis is based on biopsy. Treatment includes radiation therapy, bisphosphonates, denosumab, extensive curettage with adjuvant treatment and reconstruction; complete resection and reconstruction, and in some cases amputation may be required. Complications include malignant transformation, secondary aneurysmal bone cyst, recurrence, and pathological fracture.
| Case Report|| |
A 32-year-old woman presented to our outpatient department with chief complaints of pain and swelling in her right wrist since the last 5 months. There was no history of trauma. On examination, a solitary, tender, non-mobile, non-transilluminating, hard swelling was present at the distal end of right radius with the full range of motion at the wrist joint with intact distal neurovascular structures. The patient was investigated with blood investigation, X-ray, and magnetic resonance imaging (MRI) right wrist. X-ray [Figure 1] and MRI [Figure 2] right wrist showed a lytic expansile lesion with thinned out cortex not involving the articular margin which was suggestive of a giant cell tumor. The patient was then planned for biopsy. Core needle biopsy was done and the patient was discharged till the biopsy report was awaited. The biopsy report [Figure 3] showed a giant cell tumor with secondary aneurysmal changes. The patient was then re-admitted for definitive management. There were three options for management: (1) resection and reconstruction using fibular head strut graft, (2) wrist arthrodesis, and (3) below elbow amputation. The patient was a young working female and refused for amputation. The tumor was locally aggressive with secondary changes due to which there were higher chances of recurrence so resection and reconstruction using fibular head could not be done. Therefore, the last option was wrist arthrodesis which was planned in this patient.
|Figure 1: X-ray wrist AP and lateral view showing lytic expansile lesion with thinned out cortex|
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|Figure 3: Histopathological examination and report showing GCT with secondary aneurysmal changes|
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| Procedure|| |
A skin incision of approximately 15 cm was given over dorsal aspect of the right forearm using the Thompson approach extending from mid-shaft of third metacarpal proximally toward the junction of the middle and distal one-third of forearm. Blunt dissection was done. Extensor retinaculum was cut. Extensor tendons were retracted. Distal radius was excised along with 2 cm proximal to tumor margin [Figure 4]. The tumor bed was treated with a 2% phenol solution to sanitize the wound. Ipsilateral fibular strut graft was used to fill the gap between lunate and radius’s cut end. Two K-wires were put in cross fashion to hold the graft in position. Arthrodesis was done using 12 hole 3.5 mm locking recon plate from radius to the third metacarpal through the wrist [Figure 5]. A negative suction drain was placed to prevent hematoma formation. The wound was closed in layers. Above elbow plaster of paris (POP) slab was given. Postop X-ray [Figure 6] was done after 2 days and the drain was removed.
|Figure 5: Intraop pictures showing wrist arthrodesis using locking recon plate|
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|Figure 6: Postop X-ray showing wrist arthrodesis done using recon plate and two K-wires|
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| Result|| |
Postoperatively on follow-up at 2 months movements were elicited [Figure 7]. The patient had a good functional grip with 80° of pronation and 60° of supination [Figure 8].
|Figure 8: Showing clinical pictures of scar mark, wrist arthrodesis position, and finger grip|
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| Discussion|| |
Giant cell tumor (GCT) of the distal radius is difficult to treat owing to the surrounding complex structures. In the advanced stage (grade III), the tumor breaks through the cortex and invades the wrist joint; en bloc resection is recommended to minimize recurrence., The large defects pose problems for restoration of wrist function. The proximal fibular strut graft is a good substitute for distal end radius as its proximal shape and curve match the convexity of the proximal carpal row. The recurrence rates have been reported to be 5%–25%.,
Treatment options we had were wide resection of tumor with ipsilateral proximal fibular graft, wrist arthrodesis, and below-elbow amputation. The tumor was locally aggressive with secondary aneurysmal changes with high chances of recurrence due to which resection and reconstruction with ipsilateral proximal fibular graft could not be done. As our patient was a young female working in her household she refused for amputation. The treatment option we were left with was wrist arthrodesis. We resected the tumor and placed ipsilateral fibular strut graft to fill the gap and then arthrodesis was done using locking recon plate. Using this technique we could salvage the limb, movements in hand were achieved except movements at wrist joint which is a limitation.
Various treatment options available include En-Block resection of the lesion and reconstruction with ipsilateral proximal fibula autograft (vascularized/nonvascularized), tri-cortical iliac graft, structural allografts, distal ulnar centralization, etc. In these cases, problems such as nonunion (12%–38%), fracture of graft (13%–29%), and risk of infection are not uncommon. The increased operative time and additional comorbidity to the donor area are other limitations. The need for advanced microsurgical techniques often limits the use of vascularized grafts in such scenarios. Allografts are readily available only in advanced orthopedic setups. Reconstruction with nonvascularized fibular autograft has been used by various authors with successful results.
In 1945, for the first time, nonvascularized fibular autograft was used for congenital absence of the radius. Later, this technique was used for the treatment of distal radial GCT and resulted in promising outcomes. Advantages of nonvascularized fibular grafting include rapid incorporation, easy accessibility, low risk of significant donor site morbidity, and absence of immunogenic reactions. Flouzat-Lachaniette et al. treated 13 patients with distal radial GCT with limited arthrodesis after en bloc resection and reconstruction with nonvascularized fibular autograft. The functional score was satisfactory; however, ranges of wrist motion were limited. The most important problem was that five patients (38.5%) required a second operation within 6 years yet no revision surgery. Jafari et al. in 2017 operated GCT of distal end of radius by en bloc resection and partial wrist arthrodesis using nonvascularized fibular autograft using rush pin fixation and concluded that there was a good functional outcome, whereas two patients still had a recurrence.
| Conclusion|| |
Resection of tumor along with ipsilateral nonvascularized fibular strut graft with wrist arthrodesis is a good option for wrist reconstruction and provides a good forearm function and strength.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]