The Efficacy of Bisphosphonate in the Treatment of Giant Cell Tumour of the Bone: A Systematic Review and MetaAnalysis

@#Introduction: Anti-osteoclastic mechanism of Bisphosphonate (BP) is crucial to treat Giant Cell Tumour of the Bone (GCTB), however no established guidelines of its use have been published. This systematic review and metaanalysis is the first to summarise recent clinical studies on the subject. Materials and methods: A systematic search was performed based on PRISMA guidelines for clinical trials of BP administration in GCTB. Baseline data including BP regimen, dose and timing was summarised. The primary outcomes assessed were recurrence rate, metastases, survival rate, functional outcome, clinical outcome, radiological outcome, and adverse effect. Results: We identified 8 articles from 2008-2020. Most studies administer 4mg of Zoledronic acid post-operatively, with five studies mentioning pre-operative administration and six studies describing post-operative administration. There was a total of 181 GCTB cases analysed in this study. The BP group presented lower recurrence rate than control group (three studies; Odds Ratio [OR] 0.15; 95% Confidence Interval [CI], 0.05 – 0.43; p<0.05; heterogeneity, I2=0%). As for survival rate, BP group is comparable to control group (two studies; OR 1.67; 95% CI, 0.06 – 48.46; p=0.77; heterogeneity, I2=65%). Conclusion: Bisphosphonate therapy offers satisfactory recurrence rate, functional outcome, clinical outcome, radiological outcome, survival rate and metastases rate in patients with GCTB, with minimal adverse effects. Pre- and post-operative administration of bisphosphonates in combination might be the most beneficial in minimalising the recurrence rate.

Acute Post-Traumatic Locked Knee - An Unmasking of a Rare Knee Disorder

@#Locked knees are commonly caused by meniscal tears, floating osteochondral bodies, ruptured anterior cruciate ligament (ACL) stump, or other mechanical origins in the knee. Some locked knees occur spontaneously, while in most cases, by a preceding knee trauma. Locked knees are rarely caused by a pathological growth in the knee. More unusually is the occurrence of locked knee caused by a pre-existing pathological entity after a traumatic event. We report a rare case of locking in the knee by a pre-existing knee condition presented only after trauma to the knee. This case emphasizes that locking in the knee can be caused by a pathology that may be asymptomatic until it is revealed by a traumatic event.

Grade 3 Giant Cell Tumour of the Distal Humeral Epiphysis Treated with Intralesional Curettage, High Speed Burring and Bone Grafting: A Case Report

@#Giant cell tumours of bone are benign but locally aggressive neoplasms involving the epi- and metaphysis of long bones. Tumours of the distal humeral epiphysis with cortical disruption and invasion into the joint and the soft tissues are rare and generally treated with wide resection and joint reconstruction. We present the case of a 19-year-old woman in whom such a tumour was successfully treated with intralesional curettage, high speed burring and autologous bone grafting. The patient underwent regular clinical and radiological follow-up. Ten years after the procedure she had no signs of tumour recurrence or degenerative changes, and she was pain free and had a normal elbow function.

Functional outcome in patient with giant cell tumour distal radius after reconstruction by en-bloc resection and non-vascularized fibular bone graft: a case report

Giant cell tumor (GCT) is a relatively common benign primary bone tumor, commonly seen in end of long bones. Treatment goals for GCT of the distal radius are complete excision of the tumor and preservation of wrist function. Usually it can be treated by en-bloc resection and reconstruction using autogenous non vascularized ipsilateral proximal fibular graft. Authors present a case of twenty two years old female complaining of pain and lump in left wrist since two years ago. The pain worsened since 1 month before consultation, but did not radiate elsewhere. Pain was aggravated by movement and decreased with rest. Physical examination revealed a 3 cm mass with tenderness over left wrist. With clinical suspicion of benign bone tumor on left wrist, further evaluation was needed. Plain radiograph revealed an expansile, lytic lesion and soap bubble appearance on her left distal radius like a GCT. Open biopsy result revealed similar morphology with GCT. Reconstruction by en-bloc surgical excision, followed with non-vascularized fibular bone graft fixed with dynamic compression plate (DCP) and wrist ligament reconstruction and fixation of the head of the fibula with carpal bones and distal end of the ulna using K-wires along with palmaris longus tendon were performed. En-bloc resection of giant cell tumors of the lower end radius is a widely accepted method. Reconstruction with non-vascularized fibular graft, internal fixation with DCP with trans fixation of the fibular head and wrist ligament reconstruction minimizes the problem and gives satisfactory functional results.

A Rare Case of Giant Cell Tumour of Bilateral Achilles Tendon Sheath - Reconstruction with Dual Tendon Transfer: A Case Report

@#Giant cell tumour of tendon sheath is a benign soft tissue lesion most commonly found in the flexor aspect of hand and wrist. However, it is uncommon in foot and ankle and rare in bilateral achilles tendon. We report a case of 17-year-old female who presented with progressive enlargement of bilateral achilles tendon for six months. MRI findings showed that most of the tumour had intermediate to low signal intensity. Histopathology confirmed the diagnosis of giant cell tumour of tendon sheath. To help the patient regain the strength of the achilles tendon and walking abilities, a large area of tendon tumour was excised, followed by reconstruction with transfer of the peroneus brevis (PB) and posterior tibial (PT) tendon autograft. At two years followup, functional result was satisfactory.

An Analysis of Different Modalities of Surgical Management of Giant Cell Tumor of Distal Radius

The distal end of the radius is one of the common sites of involvement in giant cell tumors (GCTs) with increased chance of recurrence. The objective of the present analysis was to study the modalities of management of the different types of distal end radius GCTs so as to reduce the recurrence rates and retain adequate function. Methods: A prospective study of 24 patients of GCT of distal end of radius treated by various procedures in our institute and followed upto 24 months to analyse complications and functional outcome based on The Musculo Skeletal Tumour Society Score. Results: In our series of 24 patients of GCT distal radius, 7 cases treated with curettage and bone graft 4cases were presented with recurrence, 1 with stiffness, and 2 with superficial infection. Out of14 cases treated with Wide Resection and reconstruction with nonvascularized proximal fibula 4 cases appeared with recurrence,2 showed non-union and 1 delayed union , 3 with wrist deformity,7with stiffness, 4 with carpal subluxation & 2 with donor site morbidity. In 3 patients treated with centralisation of ulna 2 case presented recurrence. Conclusion: A careful clinical and radiological assessment of distal radius GCT and judicious treatment plan is the key for successful outcome.

Treatment of giant cell tumours of bone by radical curettage and bone cement

Background: Giant cell tumour of bone remains a difficult and challenging management problems because there are no absolute clinical radiographic or histologic parameters that accurately predict the tendency of any single lesion to recur or metastasize.Methods: We performed surgery on 12 patients of GCT with radical curettage and bone cement over a period of 5.8 years. Results were evaluated using the musculoskeletal skeletal grading system.Results: The present series consists of 12 case of GCT age ranging from 16-45 years. Painful swelling was the commonest presentation, limitation of motion was seen in 9 cases and pathological fracture was seen in 1 case. 9 of the tumour occurred around knee joint. Rare involvement of talus was seen in 1 case. Overall 9 patients had a perfect functional score of 30 points and 1 patient scored less than 20 points.Conclusions: Acrylic cement reconstruction is safe and effective procedure that provides local adjuvant therapy, the cement field defect is mechanically stable. Patient can bear weight immediately and rehabilitate quickly.

The Sandwich Technique in the Management of a Peri-articular Giant Cell Tumour of the Knee / La técnica del sándwich en el tratamiento de un tumor de células gigantes periarticulares de la rodilla

ABSTRACT Peri-articular giant cell tumours present a unique challenge to the orthopaedic surgeon due to their locally aggressive nature. Native joint-preserving options confer less morbidity in comparison to radical excision and reconstruction; however, recurrence rates tend to be higher. The use of polymethyl methacryllate (PMMA) decreases the recurrence rate, but it has potentially devastating effects on the articular cartilage. To safeguard against this, the use of an insulating layer between the PMMA and the articular cartilage may be utilized with the goal of protecting the latter and is referred to as the Sandwich technique.

RESUMEN Los tumores de células gigantes periarticulares representan un desafío único al cirujano ortopédico debido a su naturaleza localmente agresiva. Las opciones de conservación de las articulaciones nativas confieren menos morbilidad en comparación con la supresión y reconstrucción radicales. Sin embargo, las tasas de recurrencia tienden a ser más altas. El uso de polimetilmetacrilato (PMMA) disminuye la tasa de recurrencia, pero tiene efectos potencialmente devastadores sobre el cartílago articular. Para protegerlo, el uso de una capa aislante entre el PMMA y el cartílago articular puede ser utilizarse con el objetivo de proteger este último, lo que se conoce como la técnica del sándwich.

Three Level Thoracolumbar Spondylectomy for Recurrent Giant Cell Tumour of the Spine: A Case Report

@#Giant cell tumour (GCT) is a benign tumour but can be locally aggressive and with the potential to metastasise especially to the lungs. Successful treatments have been reported for long bone lesions; however, optimal surgical and medical treatment for spinal and sacral lesions are not well established. In treating spinal GCTs, the aim is to achieve complete tumour excision, restore spinal stability and decompress the neural tissues. The ideal surgical procedure is an en bloc spondylectomy or vertebrectomy, where all tumour cells are removed as recurrence is closely related to the extent of initial surgical excision. However, such a surgery has a high complication rate, such as dura tear and massive blood loss. We report a patient with a missed pathological fracture of T12 treated initially with a posterior subtraction osteotomy, who had recurrence three years after the index surgery and subsequently underwent a three level vertebrectomy and posterior spinal fusion.

Endoprosthetic Reconstruction of distal Humerus following Resection of distal Humeral Giant Cell Tumours in Six Patients in Rural India

Giant cell tumour is a commonly occurring benign bone tumour in the Indian population. The common sites of involvement in descending order of frequency are distal femur, proximal tibia, distal radius and proximal humerus. The less commonly occurring sites are distal humerus, pelvis and proximal femur. We present six cases of giant cell tumour involving the distal humerus in rural India. After obtaining a tissue diagnosis by Trucut biopsy and classifying using Enneking's classification, we proceeded to perform wide resection followed by endoprosthetic reconstruction using custom mega prosthesis. We present here six patients (M: F: 2: 4) who were managed by us between 2008-2014. They presented to us with pain around the elbow and restriction in range of movements. They were each noted radiographically to have a lytic lesion involving the distal humerus with the likely diagnosis of giant cell tumour. Closed biopsy was done in all of them to obtain a definitive diagnosis. All patients underwent wide resection and reconstruction using distal humerus custom prosthesis. All patients were followed up at 6, 12, 18 and 24 weeks and thereafter six monthly until the last review. They were assessed using the DASH scoring system. All patients were well with no evidence of recurrence with good to fair functional outcome. We conclude that careful pre-operative planning with meticulous soft tissue dissection and good implant metallurgy and design, these tumours can be treated with good long term functional results.

Giant Cell Tumor of Talus – Role of imaging.

Giant cell tumor (GCT) or Osteoclastoma of the tarsal bone is very rare as compared to that of long bones. The involvement of talus becomes unique in its presentation as it remains undiagnosed for a long time. The tumor usually occurs in younger age especially in small bones of hands and feet. We present a case of 34-years old male who presented with sprain of left foot and was finally diagnosed as giant cell tumor of the talus. This was possible with the help of various radiological modalities like plain X-ray, computerised tomography (CT) and magnetic resonance imaging (MRI). GCT of talus may be found as an incidental finding but the subsequent management depends upon the staging of the tumor as per the radiological evaluation.

Neurological Recovery in Two Patients with Cauda Equina Syndrome Secondary to L5 Lumbar Spine Giant Cell Tumour after Treatment with Denosumab without Surgery

We report two patients with cauda equina syndrome (CES) secondary to L5 giant cell tumour (GCT) who achieved good neurological recovery after treatment with denosumab without surgery. The first patient was a 26-year-old man with L5 GCT causing CES who regained bowel and urinary control, muscle power improvement from grade 2 to grade 4 and Oswestry disability index (ODI) improvement from 48 to 23 after denosumab treatment. The second patient was a 25-year-old woman with L5 GCT causing CES who regained bowel and urinary control, muscle power improvement from grade 0 to grade 4 and ODI improvement from 42 to 20 after denosumab treatment. The usage of denosumab in the treatment of patients with CES due to GCT allows potential neurological recovery without any surgical intervention. If surgery is not contraindicated, more time is obtained to prepare the patient preoperatively to attain safer surgery and to achieve complete tumour clearance.

Giant Cell Tumour of the Tendon Sheath — Arising from Iliotibial Band.

Chassaignac first described about a benign soft-tissue mass in 1852, characterised by a pleomorphic cell population, which includes lipid-laden foam cells, multinucleated giant cells and round or polygonal stromal cells, often with deposits of haemosiderin in a collagenous stroma. and he overstated their biologic potential in referring to them as fibrous xantoma or Giant-cell tumour of the tendon sheath. They are of two types, Localized (common) and Diffuse (rare) .The rare diffuse form is considered the soft tissue counterpart of diffuse pigmented villonodular synovitis (PVNS) and typically affects the lower extremities1 .Its anatomic distribution parallels that of PVNS, with lesions most commonly found around the knee, followed by the ankle and foot; however, it occasionally affects the hand.

Importance of Conventional Radiography in Diagnosis and Management of Giant Cell Tumour at an unusual location.

Giant cell tumour (GCT) or osteoclastoma of the bone is mostly benign but locally aggressive primary tumour of unknown origin occurring at epiphysis. It is a tumour of long bones and rarely seen in bones of hand and foot. The cases are reported in tarsal and carpal bone but involvement of metatarsal bone is very rare. We present a case of twenty years old female patient with GCT of second metatarsal of left foot. The patient underwent aggressive curettage and filling with bone chips and is on regular follow up.

Giant cell tumour with intra-articular extension: a case report.

Giant cell tumour is usually a benign but locally aggressive tumour. Intra-articular extension of giant cell tumour is rare. Treatment options are limited in such cases. I present here a 33 year old male with a history of swelling around his right knee for 6 months. Patient was diagnosed clinically, radiologically and histologically as giant cell tumour. Patient was treated by surgical excision of the tumour and reconstruction with custom mega prosthesis.

Diagnostic Efficacy of Radiology in the Diagnosis of Giant Cell Tumour of Bone.

Background: Giant cell tumour (GCT) is an aggressive and potentially malignant lesion. Microscopic feature reveals osteoclast like giant cells in a mononuclear stromal cells background. The mononuclear stromal cell is interpreted as neoplastic. Objective: As radiological diagnosis is non invasive and cost effective in comparison to histopathological diagnosis, considering the patients’ compliance, the aim of the study was to observe the diagnostic efficacy of radiology in diagnosis of GCT. Materials and method: This cross sectional study was carried out in the department of Pathology, Delta Hopital Ltd., Dhaka, Bangladesh from July 2011 to December 2012. A total of 30 study subjects were enrolled in the study irrespective of age and sex. Biopsy material and relevant data of clinically suspected cases of GCT along with radiology report were sent from National Institute of Traumatology and Orthopaedic Rehabilitation (NITOR), Dhaka, Bangladesh. Histopathological diagnosis was made by expert pathologists. Results: Mean (±SD) age of the study subjects was 29.20 (±7.34) years with highest number of patients were observed in 3rd decade and female was predominant (60%) with a male female ratio of 1:1.5. Common site of GCT was around knee (50%). Among 30 clinically diagnosed GCT, 25 (83.3%) cases were radiologically diagnosed as GCT, 2 (6.7%) diagnosed as fibrous dysplasia, 1 (3.3%) as chondroblastoma, 1 (3.3%) as simple bone cyst and 1 (3.3%) as aneurysmal bone cyst. However among 30 clinically diagnosed GCT, 28 (93.3%) patients were histopathologically diagnosed as Giant cell lesion and rest 2 (6.7%) patients diagnosed as fibrous dysplasia. The sensitivity, specificity, positive predictive value, negative predictive value and accuracy of radiological diagnosis of GCT were found to be 92.6%, 100.0%, 100.0%, 40.0% and 90.0%, respectively. Conclusion: Radiology can be effectively used as a screening tool in diagnosing GCT.

Sarcomatous transformation in a conventional Giant cell tumour of femur.

Although giant cell tumour (GCT) is seen quite frequently, malignant giant cell tumour (MGCT) is a rare entity occurring in less than 1% of patients with GCT. It can develop as a primary (de novo) or a secondary form. Secondary malignant giant cell tumour occurs as a result of previous attempts at local control of a benign GCT i.e. post-surgical or post-irradiation. Malignant transformation has been very rarely reported in patients with GCT who have not received radiation treatment. We report a rare case of sarcomatous transformation in a benign giant cell tumour occurring six years after the primary surgery for GCT and without radiotherapy. This report of malignant spindle cell transformation of a conventional GCT of bone strengths the theory that there is a mesenchymal cell line in GCT which can spontaneously transform into sarcoma. The prognosis of such patients is poor because the malignancies are usually high grade sarcomas. Key Messages: Although giant cell tumour (GCT) is seen quite frequently, malignant giant cell tumour (MGCT) is a rare entity occurring in less than 1% of patients with GCT. It can develop as a primary (de novo) or a secondary form. The prognosis of such patients is poor because the malignancies are usually high grade sarcomas.

Giant Cell Tumour of the Distal Ulna: A Rare Presentation

Giant-cell tumour (GCT) of bone, a primary yet locally aggressive benign tumour, commonly affects patients between the ages of 20 and 40 years, with the peak incidence occurring in the third decade. Women are affected slightly more than men. The distal end of the ulna is an extremely uncommon site for primary bone tumours in general and giant cell tumours in particular. Wide resection of the distal ulna is the recommended treatment for GCT in such locations. Radio-ulna convergence and dorsal displacement of the ulna stump are known complications following ulna resection proximal to the insertion of the pronator quadratus. This leads to reduction in grip power and forearm rotatory motion. Stabilization of the ulna stump with extensor carpi ulnaris (ECU) tendon after wide resection of the tumour has been described in the literature. We report a case of GCT of distal end of ulna treated with wide resection and stabilization with ECU tendon.

Giant Cell Tumour of the Tendon Sheath Masquerading as Trigger Finger

We report a case of a 59-year-old female who presented in the general orthopaedic clinic with triggering of her right middle finger. She did not respond to conventional treatment methods; subsequently she underwent surgical open release under local anaesthesia. Five months postoperatively, the patient presented with signs and symptoms of acute flexor tenosynovitis, and was thought to have a postoperative infection. Re-examination by a hand surgeon raised the possibility of a different aetiology. Based on clinical findings and response to initial treatment, giant cell tumour of the flexor tendon sheath was suspected and later confirmed following surgical biopsy. A high index of suspicion and knowledge of the variegated presentations of giant cell tumour in the hand are beneficial in these types of cases.

Giant Cell Tumours of Proximal Radius and PatellaAn Unusual Sites of Presentation

We report 2 unusual cases of Giant cell tumour involving proximal portion of radius in one and patella in other patient.