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

Increased tumor marker ca-125 in multiple myeloma: a case report

Multiple myeloma (MM) is a malignant B-cell lymphoproliferative disorder of the marrow, with plasma cells predominating. It is unlikely to encounter rising level of any tumor marker in MM patient. We present a case of 46-year-old female came to the orthopaedic clinic with chief complains of pain on her right arm, left shoulder and right hip after 5 months. The results of the bone survey of these patients showed multiple lytic lesions with a punched-out appearance in calvaria. The expansive lytic mass was seen with cortical destruction in one third proximal metaphysis to diaphysis of humerus with periosteal reaction and surrounding soft tissue mass. The basic metabolic panel (BMP) result of these patient is hipocellular with decrease of erythroid, myeloid, and megakaryocytes activity and there are 30% plasma cells with positive myeloma cells. Therefore, the patient was diagnosed with MM. The laboratory result of these patient also showed elevation of carbohydrate antigen 125 (CA-125) marker to 56 and 92 (normal range is <35). The patient reported herein showed clear signs and symptoms of MM accompanied by elevated level of CA-125 and CA-15.3 tumor markers. Elevated CA-125 values most often are associated with epithelial ovarian cancer, although levels also can be increased in other malignancies such as endometrial, fallopian tube, breast, lung, esophageal, gastric, hepatic, and pancreatic. However, there were no clear mechanism of how a malignant B-cell lymphoproliferative disorder of the marrow stimulates the production of tumor marker such as CA-125

Local injection of leukocyte rich platelet rich plasma produced higher radius union scoring system than local injection of pure platelet rich plasma in conservative therapy of intra-articular closed distal radius fractures

Background: Distal radius fracture often occurs both extra-articular and intra-articular, covering all ages. The use of autologous platelet rich plasma (PRP) consisting of leucocytes rich-PRP (L-PRP) and pure-PRP (P-PRP) thought can help in bone healing process. This study aimed to determine that the administration of L-PRP provides a better healing rate than P-PRP in intra-articular closed distal radius fractures after conservative treatment.Methods: This was a single-blinded experimental study with stratified randomized post-test only group design involving 51 patients with closed distal fractures undergoing closed reduction, consisting of 17 patients per study group. Group 1 received placebo, group 2 received P-PRP, and group 3 with L-PRP. Each group was then re-evaluated using x-ray at week 2, 3, and 6. RUSS score was then measured. Data was analysed using descriptive statistics and normality test, homogeneity test and inferential test were performed to determine the effect of L-PRP, P-PRP on the union rate of fracture distal radius. All obtained data was analysed using SPSS statistics 22 software.Results: Between control and P-PRP group, there was significant difference in mean RUSS with p value of 0.012. Between control and L-PRP injection group, there was a significant difference in mean RUSS with p value of 0.000. Between P-PRP and L-PRP group, there was also significant mean RUSS difference with p value of 0.003.Conclusions: There was a significant difference between the control group given placebo and the group P-PRP and L-PRP in closed fractures of the intraarticular radius after conservative therapy

Operative management of chondrosarcoma in pelvic region: case series

Chondrosarcoma is the second most frequent malignant bone tumour after osteosarcoma. It most often occurs in the pelvis. Treatment of pelvic chondrosarcoma is a difficult problem for the musculoskeletal oncologist. We report 3 patient with chondrosarcoma in pelvic region that undergoing internal hemipelvectomy. First patient, male 28 y.o. with chondrosarcoma in left iliac wing 11.2cm x 10.8cm x 9.2cm. Second, woman, 47 y.o with chondrosarcoma in right superior and inferior pubic rami 13.7cm x 11.5cm x 14.2cm with soft tissue mass around extended to medial part of proximal thigh. Already done A wide excision of the tumor was performed and we use non-vascularized fibular graft (NVFG) to fill the defect. Last patient, pregnant woman 22 y.o. (16weeks gestational age) with chondrosarcoma in right pubic rami 9.8cm x 11.4cm x 13cm. We already done internal hemipelvectomy without terminating the fetus. The second and third patient confirmed with the histopathology result with chondrosarcoma grade II, and the first patient with chondrosarcoma grade I. After 3month post operatively, all of the patients have no pain, no urinary tract complain. The first patient can ambulatory full weight bearing with no crutches or walker. Second patient ambulatory partial weight bearing with crutches. The last patient ambulatory with wheel chair during the pregnancy. Since chondrosarcomas are unresponsive to chemotherapy or radiotherapy, surgical resection was the only therapeutic solution for these patients. It also reinforce the need of a correct diagnose and collaboration between specialities in the treatment of oncological patients

Unplanned surgery increases the morbidity of patients with solitary plasmacytoma of femoral bone: a case report

Solitary skeletal plasmacytoma is a malignant plasma cell tumour that accounts for 3-5% of all monoclonal gammopathies. Lytic bone disease is a hallmark, and a substantial percentage of patients develop pathologic fractures. For lesions involving the femur, internal fixation frequently fails; therefore, prosthetic reconstruction may be the optimal choice for treatment. A 52-year-old male patient with pathological fracture of right femoral bone. Patient was undergone surgery with internal fixation. The pain had been continuing for several months and giant masses has developed on affected side. Further test was done and showed solitary plasmacytoma of proximal femur. The patient was treated with cemented modular prosthesis following tumor excision. Treatment of pathological fracture often challenging. Unplanned surgery could be devastating for the patient. Compare to internal fixation, cemented modular prosthesis is designed as a modular system that can be used to replace diseased or deficient bone in the femur following wide excision. Treatment of pathological fractures in solitary plasmacytoma with modular prosthesis appears to be a feasible option. They were able to mobilize early with good pain relief and had a useful functional limb. Further diagnostic test should be done for fracture of proximal femoral bone that considered pathologic. Limb salvage surgery with modular prosthesis can be considered as a viable option for treating painful pathological fractures in solitary plasmacytoma. It provides pain relief, early mobilization, and good functional outcome with improved quality of life

Characteristic of risk factor of thyroid cancer related metastatic bone disease at Sanglah General Hospital Denpasar between January 2013 to March 2019

Background: Metastatic bone disease (MBD) causes a massive morbidity, pain, and disability for the sufferers. Thyroid carcinoma, which is the most common endocrine cancer worldwide, also contributes to the increased rate of MBD, as 60% of patients with thyroid carcinoma experience bone metastasis. An urgency to further analyze the risk factors of bone metastasis in thyroid cancer is necessary in order to prevent and treat this unwanted occurrence earlier and better.Methods: A descriptive retrospective study was conducted using patients’s medical record data obtained from Sanglah General Hospital between January 2013 until March 2019. The variables obtained were sex, age, diagnosis, management, and fracture site.Results: There were 15 patients involved in this study, presenting with pathological fracture due to MBD from thyroid cancer. Ten patients were female (66.7%)  and 5 were male (33.3%). According to the age group, 2 patients (13.3%) were 60 years old, while the majority of 8 patients (53.4%) were 40-60 years old. From the pathological result, 9 patients had follicular neoplasm (60%) and 5 patients had papillary neoplasm (33%). The most common site of metastasis was humerus in 7 patients (47%), while the other sites were femur, pelvic, and tibia.Conclusions: According to this series, there are several risk factors related to MBD from thyroid carcinoma, including female gender, the age of 40-60 years old, and follicular type neoplasm. A further study with bigger amount of sample is needed to improve the result

Hemodialysis duration and underweight as a risk factors of renal osteodystrophy (chronic kidney disease - mineral bone disorder) on regular hemodialysis patient

Background: Chronic kidney disease (CKD) is related to systemic disorders affecting multiple organs, including the bone, known as osteoporosis or renal osteodystrophy. Long duration of hemodialysis and underweight based on the Body Mass Index (BMI) is thought to be risk factors for renal osteodystrophy. This study aims to determine the risk factors in the form of hemodialysis duration and underweight in the incidence of renal osteodystrophy in patients with CKD stage 5.Methods: This research is an analytic observational study with case and control group involving 26 patients. In each group, anamnesis, anthropometric examination and bone mass density (BMD) examination with DEXA were performed. Analysis using Chi-squared test, and an odds ratio (OR) calculation were performed to determine the effect of hemodialysis duration and underweight as risk factors for renal osteodystrophy in CKD patientsResults: There is a significant difference in the duration of hemodialysis (p=0.047, 95% CI=0.97-29.39) and underweight (p=0.011, 95% CI=1.39-141.49) between the CKD patient group. In addition, it was also found that the duration of HD (OR=5.33) and underweight (OR=14) were significant risk factors for renal osteodystrophy in CKD patients.Conclusions: There is significant differences in the duration of hemodialysis and underweight between CKD patients with renal osteodystrophy and without renal osteodystrophy. Hemodialysis duration and underweight are also a significant risk factors for renal osteodystrophy in patients with CKD

Efficacy of Minimally Invasive Surgery on Giant Cell Tumour of the Bone: A Systematic Review

BACKGROUND: Although major reconstructive surgeries in the form of excision and reconstruction have been the mainstay treatment for Giant Cell Tumour (GCT) of the bone, its recurrence rate remains high and poses various morbidities such as implant failure or skin breakdown. Minimal invasive surgery (MIS) techniques, which has gained popularity mostly in other fields in orthopaedic surgery, are being introduced as an alternative to limit the surgical complications while achieving the best possible outcome. Until now, there has been no literature summarising the evidence of MIS outcome in treating GCT of the bone. AIM: The purpose of this systematic review was to investigate the efficacy of this relatively new treatment. METHODS: We comprehensively searched PubMed, EMBASE, and Cochrane Library to search for studies about MIS for GCT of the bone treatment up to March 1, 2019. The selection of appropriate studies was performed by two independent investigators based on PRISMA guideline. Given the limited number of studies, there was no restriction in terms of patient’s demographics, the specific minimally invasive surgical method, and publication status. RESULTS: We found 120 articles from the database. After evaluating full text, 5 articles (16 patients) were found to be eligible. The minimally invasive methods were curettage, cryosurgery, and argon beam coagulator. The visualisation methods include a computer-assisted navigation system, endoscope, otoscope, CT, and MRI. Location of tumours includes axial and long bones. The follow-up period ranges from 7 to 126 months. The functional and oncological outcome was found to be satisfying with no recurrence or complications. CONCLUSION: In conclusion, MIS is a familiar method in orthopaedic surgery with potential expansion in tumour field. The current evidence shows that this approach for GCT results in good functional outcome, with low risk of recurrence

Increased thyroglobulin and receptor activator of nuclear factor kappa B ligand expression is a risk factor of bone metastasis on patients with thyroid cancer

Background: Metastatic bone disease (MBD) of thyroid cancer poses increased risk of morbidity and mortality and significant decrease of quality of life of the patient, with 10 years survival rate of 40-70%. This study aims to find correlation between increased expression of thyroglobulin and receptor activator of nuclear factor kappa B ligand (RANKL) on thyroid cancer biopsy and increased risk of bony metastasis.Methods: This study use case control design to analyze the histopathologic preparation taken from biopsy of the patients with thyroid cancer from 2015 until 2020. The histopathology preparation was cut with 4 µm thickness, then analyzed through immunohistochemistry assay using thyroglobulin antibody cocktail and anti-RANKL polyclonal antibody by a pathologic anatomy consultant. Analysis and correlation between the high thyroglobulin and RANKL expression with the incidence of bony metastasis using chi-squared test and odd ratio calculation.Results: There is a significant difference of thyroglobulin and RANKL expression between the group with metastasis and without metastasis (p=0.05 and p=0.02, respectively). ROC curve analysis of thyroglobulin and RANKL expression resulted in the optimal cutoff value of both parameters. Thyroglobulin cutoff value was 1.70 and RANKL cutoff value was 1.95. The analysis showed significant correlation between high expression of thyroglobulin with the incidence of bony metastasis (p=0.044). Similar result was also found in the high expression of RANKL (p=0.02).Conclusions: Increased thyroglobulin and RANKL expression are a risk factor of bone metastasis on patients with thyroid cancer

Pathological fracture of subtrochanter femur, soft tissue infection along the fracture site, shaft femur bone cortex thickening and blastic lession on contralateral shaft femur due to renal osteodystrophy on the end stage renal disease patient: a case report

Renal osteodystrophy (ROD) is a skeletal complication resulting from pathologic alterations in calcium, phosphate, and bone metabolism. The potential link between bone turnover and bone quality is an important question meriting study because of the relatively high incidence of fractures reported. In this case presents a pathological fracture on a routinely hemodialyzed woman. She complained pain on her left subtrochanteric area after low energy trauma accident. A thickening of the shaft femoral bone cortex was also found, reflecting the osteosclerosis event due to imbalance of proliferation and differentiation of osteoblast with increase bone formation. She also had a blastic lesion on her contralateral shaft femoral during the bone survey, but this finding remains asymptomatic. Decreased osteoclastic activity may contribute to cortical thickening, resulting in overall bone mass increase, which may lead to decreased elasticity of the bone or impaired repair capabilities, therefore increasing the risk of fracture. The blastic lesion that occurred on contralateral side may indicated effect of ROD or primary bone lesion. Careful assessment and holistic management of patients with kidney disease is necessary to achieve optimal outcome. The prevention of falls is also an important strategy to prevent pathological fractures. End stage renal disease (ESRD) have reduced bone mineral density, a risk factor for fracture incidence. Careful anamnesis and clinical examination are needed for diagnosis and management