CASE PRESENTATION. Dr. Faseeh Shahab PGY3 Orthopaedic Resident, Khyber Teaching Hospital, Peshawar, PAKISTAN

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1 CASE PRESENTATION Dr. Faseeh Shahab PGY3 Orthopaedic Resident, Khyber Teaching Hospital, Peshawar, PAKISTAN

2 CASE PRESENTATION - History Ms. SB, 30yo Afghan National Presented with 3 months history of Swelling and pain of Left Knee area

3 CASE PRESENTATION - History Past Medical History: Not significant Denied Hypertension, DM, Bleeding events, blood transfusion Past Surgical History No Previous Surgery Drug History Recent use of analgesics, antibiotics Family History Denies any family history of HTN/DM/TB/Bleeding Disorder/Cancer

4 CASE PRESENTATION - Examination VITALS: Vitally Stable, BP- 110/70, Pulse 74bpm, R/R 14bpm GPE: Young woman, alert, oriented, no significant finding Local Examination: LOOK : Swelling in left knee area (proximal tibia region) FEEL: Temperature normal, non tender MOVE: ROM 0 to 100 degrees, unable to extend knee

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11 BIOPSY REPORT

12 GIANT CELL TUMOR

13 GIANT CELL TUMOR A benign aggressive tumor typically found in the epiphysis of long bones Females > Males years Distal femur > proximal tibia > distal radius > sacral ala 50% occur around knee (distal femur or proximal tibia)

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15 GIANT CELL TUMOR Malignant Potential: Primary malignant giant cell tumor Metastatic to lung in 2-5% Hand lesions have greater chance of metastasis Secondary malignant giant cell tumor Occurs following radiation or multiple resections of giant cell tumor

16 CLINICAL PRESENTATION Symptoms Pain referable to involved joint Physical exam Palpable mass Decreased range of motion around affected joint

17 IMAGING Radiographs Eccentric lytic epiphyseal/metaphyseal lesion that often extends into the distal epiphysis and borders subchondral bone "neo-cortex" is characteristic of benign aggressive lesions, and not unique to GCT Bone scan is very hot MRI shows clear demarcation on T1 image between fatty marrow and tumor

18 HISTOLOGY Characteristic findings Neoplastic cell is the mononucleur stro mal cell Hallmark giant cells are numerous Nuclei of giant cell appears same as stromal cells Secondary aneurysmal bone cyst degeneration is not uncommon

19 TREATMENT Non Operative Radiation alone Only indicated for inoperable or multiply recurrent lesions Leads to 15% malignant transformation Medical management Medical therapy can be used to augment or replace surgical management depending on the specific clinical scenario medications bisphosphonates denosumab monoclonal antibody against RANK-ligand recent clinical trials suggest it can decrease the size of the bone defect in giant cell tumor

20 TREATMENT Operative Extensive curettage and reconstruction: lesions amenable to currettage Technique Remove lesion while preserving joint and providing support to subchondral joint extensive exterioration (removal of a large cortical window over the lesion) is required can fill lesion with bone cement or autograft/allograft bone

21 TREATMENT Operative Outcomes 10-30% recurrence with curettage alone verses 3% with adjuvant treatment (phenol, hydrogen peroxide, argon beam, etc)

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29 FOLLOW UP Wound intact No infection ROM : degrees flexion No active extension Allowed to PWB

30 RANDOM THOUGHTS

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33 MULTICENTER STUDIES Ex-Fix vs SIGN Nail for Open Fractures of Femur Ex-Fix vs SIGN Nail for Open Fractures of Tibia Outcomes of Standard vs Fin nail in Humeral Fractures Number of screws 2+2 vs 2+1 vs 1+1 Factors for Missed Distal Interlocks

34 THANK YOU