Endoprosthetic reconstruction for giant cell tumors of the distal tibia: A short term review

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1 s_s_nner Asi-Pcific Journl of Clinicl Oncology 2012 doi: /j x CASE REPORT Endoprosthetic reconstruction for gint cell tumors of the distl tii: A short term review Vivek AJIT SINGH, 1 Norztulsyim NASIRUDIN 2 nd Michel BERNATT 2 1 Deprtment of Orthopedics, University of Mly nd 2 Deprtment of Orthopedics, Ministry of Helth, Kul Lumpur, Mlysi Astrct Custom-mde endoprosthetic reconstruction for distl tii tumors is vile option of tretment in crefully selected ptients. It mintins stisfctory function nd provides good pin relief. We report four cses of gint cell tumors of the distl tii successfully treted y endoprosthetic reconstruction. This is fesile option in cses of this nture nd offers etter function thn the other ville options. Key words: pthology, srcom, surgicl oncology. INTRODUCTION A gint cell tumor (GCT) of one is enign nd loclly ggressive lesion. It usully involves the metphyselepiphysel region of long ones. It is reltively rre t the nkle ut is known to ehve unpredictly when situted t tht loction. It comprises less thn 4% of GCT cses. The usul mode of tretment for these tumors is extended curettge ut for recurrence of the tumor, elow-knee mputtion hs een the tretment of choice ecuse complete excision of tumors in this region is difficult to chieve nd reconstruction options usully give poor functionl results. This is due to the tumor s sucutneous loction nd the proximity of the distl tii to the neurovsculr undle nd tendons. However, lim slvge hs replced mputtion s the minsty of surgicl tretment in tumors in the other regions such s the proximl femur, the distl femur nd the proximl tii, principlly ecuse of improvements in surgicl technique nd in the design nd production of the implnt. An endoprosthetic replcement enles the erly restortion of function s the ptients cn er weight Correspondence: Dr Vivek Ajit Singh FRCS MS(Ortho), Deprtment of Orthopedics, University of Mly, Kul Lumpur 50603, Mlysi. Emil: drvivek69@gmil.com Accepted for puliction 28 Mrch erly. The prosthesis tht we use is custom-mde from Egle Osteon Technologies, Chenni, Indi. Figure 1 shows the stretch y the engineers, which is mde sed on mesured roentgenogrms nd the length of resection, which is determined y the surgeons. The prosthesis is mde from titnium lloy nd consists of two components tht re locked together y the three screws nd centrl peg (Fig. 2). The distl component hs sddle joint tht sits on the dome of the tlus nd is stilized y four screws into the tlus (Fig. 2). The sddle joint consists of r lined with polyethylene liner tht rticultes with n olong hole t the superior spect of the tlus end of the prosthesis. The proximl component hs cylindricl stem tht is cemented intrmedullry to the proximl end of the tii. The rticulr surfces re lined y ultr-high moleculr-weight polyethylene. The movement t the nkle is not hinge movement, rther sddle joint movement to etter mimic the mechnics of norml nkle joint. Opertive technique The nterior lterl pproch ws used for ll ptients. The iopsy trct is excised in ll ptients. The tumor is dissected with wide mrgins. The proximl one cuts were mde 3 cm from the distl mrgin of the tumor. The crtilge over the tlr dome is shved off nd the hed of tlus is fshioned to fit the cup end of the 2012 Blckwell Pulishing Asi Pty Ltd

2 120 2 V Ajit Singh et l Figure 1 The plnned stretch y the engineers sed on mesured roentgenogrms shown on the left. Figure 2 () The two components of the prosthesis connected together y locking mechnism nd three screws, () the distl portion of the prosthesis tht sits on the dome of the tlus; stilized y four screws. prosthesis. This component is cemented onto the tlus nd secured with four fully treded 4-mm cncellous screws (Fig. 3). The proximl end of the one is remed to 2 mm igger thn the stem dimeter nd the stem is cemented in without cement spcer. The two components re reduced nd locked together y the peg nd secured y three screws (Fig. 3). The finl implnt in situ is shown in Figure 4. To dte there re only three pulictions on the endoprosthetic replcement of the distl tii. 1 5 We report our series of four cses of recurrent GCT of the distl tii tht were successfully treted with wide resection nd endoprosthetic reconstruction. We elieve tht distl tiil endoprosthetic replcement is vile option tht enles ptients to mintin their lims nd function Blckwell Pulishing Asi Pty Ltd Asi-Pc J Clin Oncol 2012

3 Endoprosthesis of distl tii 3 Figure 3 () The distl component cemented onto the tlr dome nd secured in with four screws, () the proximl nd distl components re reduced nd locked together with the peg nd three screws. Figure 4 Intropertive imge of the implnt in situ. Proximlly the implnt is cemented into the proximl tii nd distlly it is cemented into the dome of tlus, ugmented with screw fixtion (two screws nteriorly nd two screws posteriorly). CASE REPORTS Ptient 1 This is 25-yer old mn who presented with right nkle swelling 8 yers prior to presenttion. A dignosis of GCT of the distl tii ws mde y rdiogrphy (Fig. 5) nd confirmed y needle iopsy. He underwent n extended curettge nd one grfting. No djuvnt tretment ws given. In August 2007 he presented gin with recurrence of pin over the nkle for over 6 months. The pin hd een getting progressively worse nd roentgenogrm showed recurrent expnsile lesion over the distl tii, suggestive of recurrence, Cmpncci grde 2 (Fig. 5). The dignosis ws reconfirmed with needle iopsy. A wide resection of the distl tii with endoprosthesis replcement ws done on Septemer The ptient ws llowed full weight ering 3 dys fter the surgery nd strted wlking unided 2 weeks fterwrds. The ltest rdiogrph tken 30 months fter the surgery is shown in Figure 6. There is no evidence of loosening. His ltest Musculoskeletl Tumor Society (MSTS) score is 86.7%. Cse 2 The second ptient is 16-yer-old girl who presented with 6-month history of ching pin nd swelling of the right nkle when she ws first seen, y our oncology unit in The ptient hd no systemic symptoms or prolems relted to the joint. On exmintion, the ptient wlked normlly nd hd slight tenderness to plption of the distl prt of the tii. Rdiogrphs reveled lytic expnsile lesion in the distl metphysis of the right tii. The dignosis of GCT of the one ws estlished with iopsy. The lesion ws curetted, the distl end of fiulr ws excised together with the lesion nd the cvity ws filled with corticocncellous one grft from the ilic crest nd the middle portion of fiul ws used to reconstruct the nkle joint. The Asi-Pc J Clin Oncol Blckwell Pulishing Asi Pty Ltd

4 4 V Ajit Singh et l. Figure 5 () Roentgenogrms of the right distl tii showing n expnsile lesion in the right distl tii locted t the metphysis extending into the epiphysis, () the repet roentgenogrms fter 8 yers, showing recurrence of the expnsile lesion of the distl tii with multiple res of cvittion. Figure 6 The ltest rdiogrph for ptient 1. There is no evidence of loosening nd there is one growth over the proximl ttchment of prosthesis Blckwell Pulishing Asi Pty Ltd Asi-Pc J Clin Oncol 2012

5 Endoprosthesis of distl tii 5 Figure 7 () The nterior posterior views of the right distl tii. There is lytic lesion on the medil spect of the right distl tii extending into the distl fiulr. There is erosion of the lterl fiulr cortex, () loosening over the proximl end of the implnt. postopertive ptient resumed full weight-ering within 3 months. She remined symptomtic for 3 yers. In Decemer 2007 she noted progressively worsening pin with ctivity nd the recurrent swelling of the right nkle. Rdiogrphs reveled recurrence of the lytic lesion in the distl prt of the right tii, s shown in Figure 7. A study of specimen otined y mens of needle iopsy reveled the dignosis of recurrent GCT of the one. A wide resection of distl tii with endoprosthesis reconstruction ws done in Ferury Postopertively, she recovered well nd went ck to college. Aout 2 yers fter the surgery, she developed over the shin sinus dischrging pus nd complined of occsionl mechnicl pin over the region. The rdiogrphs tken show septic loosening over the proximl end of the implnt (Fig. 7). The wound cultures grew methicillin-resistnt stphylococcus infection. She refused two-stge revision nd is currently on chronic ntiiotic suppression. Her ltest MSTS score is 73.3%. Cse 3 The third ptient is 27-yer-old mn who presented with 9-month history of incresing pin nd decresing motion in the right nkle when our unit first sw him in Mrch Rdiogrphs reveled lytic expnsile lesion in the distl prt of the right tii. After iopsy confirmtion, n extended curettge nd utologous one grfting ws crried out from the ilic crest. In Septemer 2007 the ptient hd recurrence of disese. He went to nother institution nd n mputtion ws plnned ut he defulted. In Ferury 2008, when he cme to see us, he ws wlking with non-weight ering crutches. Rdiogrphs show the expnsion nd thinning of the distl tii cortex, suggestive of recurrence of the tumor, Cmpncci grde 3 (Fig. 8). After iopsy confirmtion, wide resection nd endoprosthesis replcement ws done. He ws ck to function within 2 weeks. On follow up, it ws noted tht his nkle ws in 15 degrees vlgus nd the follow-up rdiogrph showed tlr collpse (Fig. 8) ut the implnt ws still stle nd he is le to er his full weight without ny pin. His ltest MSTS score is 80%. Cse 4 This is 26-yer-old mn who presented with 6-month history of right distl tii swelling nd 2-month history of pin. The rdiogrphs nd mgnetic Asi-Pc J Clin Oncol Blckwell Pulishing Asi Pty Ltd

6 6 V Ajit Singh et l. Figure 8 () Expnsile lesion over the right distl tii (Cmpncci grde 3), () tlr collpse with cking out of screws ut the implnt ppers stle. Figure 9 () MRI of the right nkle with expnsion of the distl tii with tumor, () resected specimen with the custom mde endoprosthesis. resonnce imging t presenttion re shown in Figure 9. We opted for n endoprosthesis replcement s the lesion ws extensive nd involved lmost the entire distl tii. He underwent the surgery in July The resected specimen nd the endoprosthesis re shown in Figure 9. He ws ering weight on dy 2 postopertively nd ws le to wlk without ssistnce fter 2 weeks. His ltest MSTS score is 90%. A summry of ll the four ptients is given in Tle 1. The detils of the MSTS score re shown in Tle 2. The verge MSTS score 82.5%. DISCUSSION GCT generlly occurs in those with mture skeletons with pek incidence in the third decde of life. GCT of 2012 Blckwell Pulishing Asi Pty Ltd Asi-Pc J Clin Oncol 2012

7 Endoprosthesis of distl tii 7 Tle 1 Summry of the four ptients with gint cell tumor (GCT) Ptient no Age Sex Side of lesion Dignosis () Durtion of follow up (months) MSTS score Compliction Mle Right Recurrent GCT None Femle Right Recurrent GCT Deep infection Mle Right Recurrent GCT 30 80% Tlr collpse Mle Right GCT 12 90% None MSTS, Musculoskeletl Tumor Society score. Tle 2 Ptient no Detils of the functionl results (MSTS Scores) Pin Functionl ctivities Emotionl cceptnce Externl support Wlking ility Git Totl functionl score (%) the foot nd nkle re very rre nd occur commonly in young dults with n verge ge of 28.8 yers. 6 Vrious forms of tretment for GCT of the distl tii hve een proposed, including extended intr-lesionl curettge, with the use of phenol, cryotherpy nd urr nd one grfting, cryotherpy, cementtion, lim slvge nd even mputtion. Trditionlly, trnstiil mputtion hs een the tretment of choice for treting locl one tumors involving the distl tii nd fiul. 7 A wide mrgin of resection nd stisfctory functionl result with n pproprite elow-knee prosthesis cn e chieved with mputtion. However, mputtion is ssocited with significnt psychologicl, physicl, socil nd finncil cost to ptients. As the surgery of lim slvge hs developed, reconstruction of nkle joint hs een ttempted using utogrfts, llogrfts nd endoprosthesis. Among the mny options of reconstruction, rthrodesis ws regrded s the est option. It provided excellent stility of the nkle joint nd voided prolems relting to prosthetic implnttion. A study y Csdei et l. 8 reported good functionl outcome in ptients with distl tii tumor treted y resection nd utogenous one grft rthrodesis. However, rthrodesis of the nkle hs severl limittions, including the loss of joint movement, long period of recovery, the need for multiple opertions to chieve rthrodesis nd the possiility of non-union. This ws overcome y the use of vsculrized free fiulr grft, which gve etter union rtes ut still stiff nkle. 9 Shly et l. 10 reported series of six cses of osteosrcom of the distl tii treted with fiulr grfts (vsculrized nd nonvsculrized) stilized with n Ilizrov externl fixtor. It took n verge of 13.2 months to chieve union nd he reported tht the vsculrized grfts gve etter union thn non-vsculrized grfts. Their verge MSTS score ws 70%. Jeon et l. 11 reported series of nine ptients where the reconstruction ws done with psteurized utogrft. In his series, six ptients hd postopertive complictions such s superficil wound infection, non-union nd frcture. In our series of four cses, ptients were llowed to er weight 2 to 3 dys fter surgery nd fter 2 weeks were ck to full function. The verge MSTS score in this series is 82.5%. We did not encounter soft tissue prolems, s ll four cses were GCT nd the resections were done close to the one, preserving the soft tissue envelope. Thus, lim slvge opertions using distl end endoprosthesis hve potentil dvntges compred to iologicl lterntives. These include erly stility, erly moiliztion nd weight ering, nd etter ppernce nd psychologicl cceptnce. All the ptients in our series showed excellent stility of their nkles t the ltest follow up. All the ptients hd n excellent oncology outcome. One hd tlr collpse without loosening of the implnt or compromising his function. Another ptient developed deep infection with methicillin-resistnt stphylococcus ut still mintined the endoprosthesis with chronic ntiiotic suppression. The remining two ptients re functioning well. Audu Asi-Pc J Clin Oncol Blckwell Pulishing Asi Pty Ltd

8 8 V Ajit Singh et l. et l. 12 concluded in their series of five ptients tht endoprosthesis replcement of the distl tii hs significnt medium-term moridity nd functionl deteriortion. Shekkeris et l. 13 in his series of six ptients, reported deep infection in two cses tht eventully led to mputtion. The verge MSTS score for the remining four ptients in his series ws 70%. He concluded tht endoprosthetic replcement is vile option providing tht ptients understnd the risk of uncontrolled infection, which my led to mputtion. The prosthesis tht we use is custom mde y Egle Osteon Technologies, Chenni, Indi. It hs semiconstrined joint t the nkle portion. Our design does not hve n osseous integrtion collr proximlly for long-term one in growth nd stility. We foresee loosening s one of the prolems tht we might fce in the long term due to the high torsionl forces tht re trnsmitted through the one implnt junction. We hve highlighted this potentil prolem to the mnufcturers nd hve dvised them to incorporte it in their future designs. So fr, in our follow up, there hve een no cses of loosening. We elieve tht distl endoprosthestic replcement is fesile option in cses of extensive distl tii tumors (especilly loclly ggressive tumors) tht would otherwise require mputtion. It enles us to mintin functionl nkle joint nd n lmost full function of the lim. However, it is still erly to predict the long-term survivl of this implnt in our series of ptients. REFERENCES 1 Unwin P, Cnnon S, Kemp H et l. The Stnmore distl tii replcement. In: lim slvge current trends. Proceedings of the 7 th ISOLS Meeting, 1993; Audu A, Tillmn RM, Crter SR, Grimer RJ. Endoprosthesic reconstruction of the distl tii nd nkle joint following tumour excision. J Bone Joint Surg Br 1995; 77-B (Suppl 3): Lee SH, Kim H-S, Prk Y-B, Rhie T-Y, Lee HK.Prosthetic reconstruction for tumours of the distl tii nd fiul. J Bone Joint Surg Br 1999; 81-B: Ntrjn MV, Annmli K, Willims S, Selvrj R, Rjgopl TS. Lim slvge in distl tiil osteosrcom using custom meg prosthesis. Int Orthop 2000; 24: Hmd K, Nk N, Murt Y, Ysui Y, Joym S, Arki N. Prosthetic reconstruction for tumors of the distl tii. Report of two cses. Foot (Edin) 2011; 21: Kmth S. Gint cell tumour round the foot nd nkle. Foot Ankle Surg 2006; 12: Ozki T, Hillmn A, Lindner N, Winkelmnn W. Surgicl tretment of one srcoms of the fiul: nlysis of 19 cses. Arch Orthop Trum Surg 1997; 116: Csdei R, Ruggieri P, Giuseppe T, Bigini R, Mercuri M. Ankle resection rthrodesis in ptients with one tumours. Foot Ankle Int 1994; 15: Bishop AT, Wood MB, Sheetz KK. Arthrodesis of the nkle with free vsculrised utogenous one grft: reconstruction of segmentl loss of one secondry to osteomyelitis, tumor or trum. J Bone Joint Surg Am 1995; 77-A: Shly S, Sly H, Bssiony A. Lim slvge for osteosrcom of the distl tii with resection rthrodesis, utogenous fiulr grft nd ilizrov externl fixtor. J Bone Joint Surg Br 2006; 88-B: Jeon D-G, Kim MS, Cho WH, Song WS, Lee S-Y. Reconstruction with psteurized utogrft for distl tiil tumor. Arch Orthop Trum Surg 2008; 128: Audu A, Grimer RJ, Tilmn RM, Crter SR. Endoprosthetic replcement of the distl tii nd nkle joint for ggressive one tumours. Int Orthop 1999; 23: Shekkeris AS, Hnn SA, Sewell MD et l. Endoprosthetic reconstruction of the distl tii nd nkle joint fter resection of primry one tumours. J Bone Joint Surg Br 2009; 91-B: Blckwell Pulishing Asi Pty Ltd Asi-Pc J Clin Oncol 2012