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Gct of distal radius
Gct of distal radius
Gct of distal radius
Gct of distal radius
Gct of distal radius
Gct of distal radius
Gct of distal radius
Gct of distal radius
Gct of distal radius
Gct of distal radius
Gct of distal radius
Gct of distal radius
Gct of distal radius
Gct of distal radius
Gct of distal radius
Gct of distal radius
Gct of distal radius
Gct of distal radius
Gct of distal radius
Gct of distal radius
Gct of distal radius
Gct of distal radius
Gct of distal radius
Gct of distal radius
Gct of distal radius
Gct of distal radius
Gct of distal radius
Gct of distal radius
Gct of distal radius
Gct of distal radius
Gct of distal radius
Gct of distal radius
Gct of distal radius
Gct of distal radius
Gct of distal radius
Gct of distal radius
Gct of distal radius
Gct of distal radius
Gct of distal radius
Gct of distal radius
Gct of distal radius
Gct of distal radius
Gct of distal radius
Gct of distal radius
Gct of distal radius
Gct of distal radius
Gct of distal radius
Gct of distal radius
Gct of distal radius
Gct of distal radius
Gct of distal radius
Gct of distal radius
Gct of distal radius
Gct of distal radius
Gct of distal radius
Gct of distal radius
Gct of distal radius
Gct of distal radius
Gct of distal radius
Gct of distal radius
Gct of distal radius
Gct of distal radius
Gct of distal radius
Gct of distal radius
Gct of distal radius
Gct of distal radius
Gct of distal radius
Gct of distal radius
Gct of distal radius
Gct of distal radius
Gct of distal radius
Gct of distal radius
Gct of distal radius
Gct of distal radius
Gct of distal radius
Gct of distal radius
Gct of distal radius
Gct of distal radius
Gct of distal radius
Gct of distal radius
Gct of distal radius
Gct of distal radius
Gct of distal radius
Gct of distal radius
Gct of distal radius
Gct of distal radius
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Gct of distal radius

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  • 1. Giant cell tumor of Distal Radius Sumroeng Neti, M.D. (1st class honors) Orthopedic Center Bumrungrad International Hospital
  • 2. Epidemiology
    • 5% of bone tumors
    • Age: 20-40 years
    • Slightly female predominant
  • 3. LocaIization
    • Epiphysis/metaphysis lesion
    • eccentrically located
    • Distal femur : most common site
    • Proximal tibia
    • Distal radius
    • Sacrum
  • 4. Clinical presentation
    • Progressive pain with mass
    • : most common 80%
    • Pathologic fracture : 10-30%
    • Joint effusion
  • 5. Plain radiograph Tumor effect to bone - Purely lytic : geographic pattern - Eccentrically located in the epiphyses and abut the subchondral bone Bone response to tumor - Expansile - Margin : Distinct or poorly outlined : Classically nonsclerotic : Erosion through the cortex
  • 6. Classification
    • 15 % latent
    • bone maintain normal contour
    • Sharply defined margin
    • 70 % active lesion
    • deformity and expansion of bone
    • cortical erosion
    • Limited endosteal response
    • 15 % aggressive lesion
    • poorly outlined margin
    • cortical breakthrough and soft tissue mass
    • pathologic fracture
  • 7. MRI
    • To determine the extent of lesion both within the bone and the soft tissue
    • Usually dark on T1-weight images and bright on T2 - weight images
  • 8. Pathology
    • Multinucleated giant cells ( 40-60 nuclei per cell) in a sea of mononuclear stromal cell
    • Area of storiform spindle cell formation
    • Small amount of bone or osteoid
  • 9. Goal of Treatment
    • 1.Tumor removal
    • - Extended curettage : latent, active
    • - En Bloc resection : aggressive
    • “ Prevent local recurrence”
    • 2.Restore function : Reconstruction
    • - Allograft – Osteochondral allograft
    • - Arthrodesis
    • - Arthroplasty
  • 10. Conventional Surgical Treatment GCT of bone Grade En Bloc excision & R econstruction Grade 3 Extended curettage C ement or Bone graft Grade 1 & 2
  • 11. Treatment
    • Local recurrence
      • - Almost happen within first 2 years
      • - Simple c urettage and bone grafting 30-40%
      • - Extended curettage < 10%
      • - Lung metastasis is 6-time higher in recurrence case
    Extended curettage = curettage + high-speed burr + adjuvant agents (phenol, liquid nitrogen , etc.)
  • 12. Treatment
    • Curettage
    • : realize the importance of creating a cortical window at least as large as the lesion to prevent leaving residual tumor cells “ around the corner ”
  • 13. Filling materials
    • Bone cement Advantage
    • - early limb using
    • - early recurrence detection
    • - kill residual tumor cell by heat of polymerization
    • Disadvantage
    • - heat-induced degenerative joint disease
    Bone graft Advantage - biologic healing - preserve bone stock Disadvantage - delayed rehabilitation - difficult tumor recurrence detection
  • 14. Treatment
    • Adjuvant Rx
    • 1. Phenol
    • : concentration should be limited in 5%
    • 2. Electrocautery or argon beam coagulator
    • 3. Liquid nitrogen
    • : Disadvantage
    • - Post – treatment fracture
    • - Wound healing problem
    • - Nerve injury
    • - Difficult to control depth of necrosis
  • 15. Treatment
    • In the expendable bones
    • - distal ulna
    • - proximal radius, fibula
    En Bloc resection  reduce the risk of recurrence
  • 16. Treatment
    • Inoperable lesion
    • - Spine
    • - pelvis
    Radiation A. Chakravarti MD et al JBJS 1999 : 20 patients underwent a single course of megavoltage radiation (40- 70 gray )  tumor had not progress 17/20   : no radiation-induced malignancy (Mean F/U 9.3 yrs)
  • 17. Lung metastasis
    • - 3 % of patients
    • - Slowly grow, stationary or resolve in some lesions
    • - May be surgically resected
    • - Mortality rate from pulmonary metastasis : 10-15%
  • 18. F/U plan
    • - Clinical and x-rays of local recurrence (3-20 yrs) :
    • - mass, painful area
    • - CXR PA and lateral view
    • - CT chest : +
    • Duration
    • - 1 st year q 3 months
    • - 2 nd year q 6 months
    • - then q 6-12 months
  • 19. Case # 1
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  • 27. Dx : GCT of Distal Radius stage III : Aggressive Rx : En Bloc resection + osteochondral allograft with good result
  • 28. Reconstruction of the distal radius with use of an osteoarticular allograft Mankin HJ et al – JBJS(A) 1998
    • 24 patients between 1974-1992
    • F/U 10.9 years (2.1-22.3)
    • 8/24 need revision
      • 7/8 arthrodesis : 4 #’s, 1 recurrence
      • 1/8 amputation
    • Average ROM
      • Dorsi/volar flexion : 36/21
      • Radial/ulnar deviation : 16/15
      • Supination/pronation : 58/72
  • 29. Reconstruction of the distal radius with use of an osteoarticular allograft Mankin HJ et al – JBJS(A) 1998
    • associated with
      • a low rate of recurrence of the tumor
      • moderately high rate of revision
      • little pain in association with common activities
      • good function, and a moderate range of motion
    • Osteoarticular allografts are an option for reconstruction of the distal radius
  • 30. Case # 2 35 year – old Thai male
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  • 43. 4 months postop.
  • 44. 8 months postop.
  • 45. 1 year & 1 month postop.
  • 46. 1 year & 6 month postop.
  • 47. 1 year & 8 month postop.
  • 48. Dx : GCT of Distal Radius stage III : Aggressive Rx : En Bloc resection + osteochondral allograft with allograft collapse
  • 49. Case # 3 21 year – old female S/P wide resection + allograft arthrodesis
  • 50. 1 year postop.
  • 51. 3 year postop.
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  • 60. Dx : GCT of Distal Radius stage III : Aggressive 1 st Rx : En Bloc resection + osteochondral allograft with allograft fracture, nonunion 2 nd Rx : Free vascularized fibular bone graft
  • 61. Vascularized fibular graft for reconstruction of the wrist after excision of GCT Ono H et al – Plast Reconstr Surg. 1997
    • 7 patients of GCT of distal radius
    • radiographic evidence of bone union at the host-graft junctions in all cases
    • No local recurrence
    • There were six good and one excellent functional results
  • 62. Case # 4 52 year – old female
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  • 70. After curettage
  • 71. After burring
  • 72. After phenol & alcohol
  • 73. After cementing
  • 74.  
  • 75.  
  • 76. 1 year 2 months postop.
  • 77. 1 year 9 months postop.
  • 78. 1 year 9 months postop.
  • 79. Dx : GCT of Distal Radius stage III : Aggressive Rx : Extended curettage (+ phenol) & bone cement [ No recurrence within 2 years]
  • 80. Treatment of GCT of bone : a comparison of curettage and wide resection Liu HS et al – Changgeng Yi Xue Za Zhi. 1998
    • 27 patients
    • 11 patients : extended curettage + cement
    • 16 patients : wide resection+ reconstruction
    • F/U 50 months
    • Excellent functional results
      • extended curettage + cement = 80 %
      • wide resection+ reconstruction = 13 %
    • Local control rate
      • extended curettage + cement = 90.9 %
      • wide resection+ reconstruction = 93.75 %
  • 81. Treatment of GCT of bone : a comparison of curettage and wide resection Liu HS et al – Changgeng Yi Xue Za Zhi. 1998
    • Infection rate
      • extended curettage + cement = 0/11
      • wide resection+ reconstruction = 3/16
    • CONCLUSION:
      • better functional result after curettage and packing with cement than following wide resection
      • recommend curettage and cement packing for giant cell tumor of bone whenever it is technically feasible
  • 82.  
  • 83. Currently recommended Surgical Treatment GCT of bone Grade En Bloc excision & R econstruction Grade 3 c marked destruction Extended curettage C ement or Bone graft - Grade 1, 2, 3 s marked destruction -
  • 84. Reconstruction for Distal Radius
  • 85. Reconstruction for Distal Radius
    • Preserve RC & DRUJ
    • Preserve DRUJ
    • No motion preserved
    • Osteochondral allograft or autograft
    • Fusion wrist +
      • Allograft
      • Autograft
        • Vascularized
        • Non – vascularized
    • One bone forearm
  • 86. Thank you for your attention

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