Nyffeler, RW

Ziebarth, K

English

Bern Open Repository and Information System (BORIS)

source: https://doi.org/10.48350/175045 | downloaded: 1.12.20221Malaysian Orthopaedic Journal 2022 Vol 16 No 3 (Published ahead of print) Nyffeler RW, et alABSTRACTGiant cell tumours of bone are benign but locally aggressiveneoplasms involving the epi- and metaphysis of long bones.Tumours of the distal humeral epiphysis with corticaldisruption and invasion into the joint and the soft tissues arerare and generally treated with wide resection and jointreconstruction. We present the case of a 19-year-old womanin whom such a tumour was successfully treated withintralesional curettage, high speed burring and autologousbone grafting. The patient underwent regular clinical andradiological follow-up. Ten years after the procedure she hadno signs of tumour recurrence or degenerative changes, andshe was pain free and had a normal elbow function. Keywords:giant cell tumour, elbow, high speed burring, curettage,bone graftingINTRODUCTIONGiant cell tumours of bone are benign but locally aggressivetumours that nearly always arise within the epiphysis. Theymay rapidly increase in size and spread into the metaphysisor erode the cortex and expand into the joint. They aretreated surgically, most often with curettage, either alone orin combination with additional mechanical proceduresand/or chemical or thermal adjuvants1. Wide resection andreconstruction have been recommended for tumours thathave extended through the cortex (Campanacci Grade 3lesions) and are in close relationship to joint capsules.However, the functional long-term results of thesereconstructions are not well known. We therefore preferred a joint-preserving procedure for thetreatment of a grade 3 lesion in a young and active woman.She consented to the publication of her medical history andpictures in a scientific journal. CASE REPORTA 19-year-old, healthy women without previous medialproblems consulted her general practitioner because of painand decreased range of motion in her left elbow for sixmonths. Standard radiographs showed a lytic lesion in thetrochlea. She was referred to us for further assessment andtreatment. The posteromedial aspect of the elbow wasslightly swollen and sensitive to pressure. Skin temperatureand colour were normal. Flexion was restricted to 100°, theextension deficit was 40°. Pronation and supination andperipheral sensibility and motor function were normal.Additional magnetic resonance images and computedtomography scans of the elbow revealed a locally destructivetumour in the distal humerus, involving almost the wholetrochlea (Fig. 1). The cortical bone adjacent to the olecranonfossa was perforated and the tumour penetrated into theposterior compartment of the joint. It expanded proximallyunder the triceps but did not infiltrate this muscle. An openbiopsy was performed, and the histologic analysis of tissuesamples confirmed the diagnosis of a giant cell tumour. A CTthorax and scintigraphy of the skeleton showed no otherlesions, especially lung metastases.Due to the young age of the patient we decided to perform ajoint preserving procedure. An olecranon osteotomy wasmade to expose the trochlea and the joint. The tumour wasremoved through the cortical defect in the posterior part ofthe trochlea with use of different curettes. A high-speed burrwas then used to eliminate tumour remnants and reduce therisk of local recurrence. During the whole procedure thebone cavity was illuminated and examined with anGrade 3 Giant Cell Tumour of the Distal HumeralEpiphysis Treated with Intralesional Curettage, HighSpeed Burring and Bone Grafting: A Case ReportNyffeler RW1, MD, Ziebarth K2, MD1Department of Shoulder and Elbow Surgery, Orthopädie Sonnenhof, Bern, Switzeland2Division of Pediatric Trauma and Orthopedics, University Hospital of Bern, Bern, SwitzelandThis is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly citedDate of submission: 13th February 2022Date of acceptance: 13th May 2022Corresponding Author: Richard Walter Nyffeler, Department of Shoulder and Elbow Surgery, Orthopädie Sonnenhof, Salvisbergstrasse 4,3006 Bern, SwitzerlandEmail: richard.nyffeler@bluewin.chdoi: https://doi.org/10.5704/MOJ.2211.0009-CR2-024_OA1  01/09/2022  2:05 PM  Page 1Malaysian Orthopaedic Journal 2022 Vol 16 No 3 (Published ahead of print) Nyffeler RW, et al2Fig. 1: Pre- and intra-operative images revealing the big lytic lesion in the epiphysis of the left elbow: (a) anteroposterior radiograph,(b) coronal, (c) axial and (d) sagittal CT-images, (e) sagittal MRI, and (f) posterior view after intralesional curettage and high-speed burring. The subchondral bone of the trochlea and the medial epicondyle was severely thinned out and posteriorlydisrupted. The ulnar nerve was marked with a vessel loop.Fig. 2: Intra- and post-operative images of the same elbow: (a) posterior view after autologous bone grafting. (b) Coronal, (c) axial and(d) sagittal CT-images made three years after tumour removal. The trochlea is anatomically shaped and filled with cancellousbone.9-CR2-024_OA1  01/09/2022  2:05 PM  Page 2GCT of Distal Humeral Epiphysis3arthroscope. Care was taken to not destroy the articularcartilage. The wound was regularly irrigated with salinesolution and the instruments, as well as the drapes and gloveswere changed. Thereafter the trochlear cavity was filled withautologous cancellous bone from the iliac crest. The bonewas carefully compacted and the remaining cortical defect inthe olecranon fossa was closed with two cortico-cancellousbone chips. The press fit was so good that no additionalscrews were necessary. Finally, the olecranon was reducedand stabilised with a tension band wiring. Post-operativelythe elbow was protected in a removable splint for six weeks.During this time unloaded assisted motion exercises wereallowed. Active motion and strengthening exercises werestarted after six weeks and the patient returned to work threemonths after the operation. The tension band wiring slightly incommoded the slenderpatient and was therefore removed after eight months. At thesame time, scar tissue in the olecranon fossa was debridedand the fossa was somewhat deepened with use of a sphericalburr. This procedure allowed restoring full elbow extension.The histologic analysis of the scar tissue showed no tumourcells. Further follow-up examinations with clinical andradiographic investigations were performed after 6 months,1, 2, 3, 5 and 10 years. An additional CT-scan was made afterthree years (Fig. 2). During the whole time and at the latestfollow-up 10 years post-operatively the patient was doingwell. She was pain free, had a normal range of motion,strength and worked full-time as an electrical installationtechnician. The Mayo Elbow Performance Score was 100points. Standard anteroposterior and lateral radiographs ofthe elbow showed an anatomic joint with good incorporationof the bone graft, normal joint spaces and no signs of tumourrecurrence or osteoarthritis (Fig. 3). DISCUSSIONSeveral surgeons treated Grade 3 lesions in the distalhumerus with en bloc resection alone2. Other surgeonsresected the tumour and reconstructed the defect with bonecement, a structured autograft3, an allograft4 or an elbowprosthesis5. En bloc resection alone may compromise jointfunction. Bone cement has high mechanical strength and istherefore often used for large defects close to weight-bearingjoints. In our case the subchondral bone was severely thinnedout and the cartilage risked being damaged by the heatgeneration during curing of the bone cement. We thereforepreferred meticulous mechanical cleaning of the wholecavity and filling the defect with autologous bone. Cui et al3described six cases in which they used autogenous bone. Incontrast to us, they did not use a high-speed burr to eliminateresidual tumour cells adhering to the wall of the cavity butFig. 3: Radiographic and clinical result 10 years after tumour resection and autologous bone grafting. (a) Anteroposterior and (b) lateralradiographs of the elbow show a normal joint without tumour recurrence and without joint space narrowing. Photographs shownormal (c) flexion, (d) extension, (e) pronation and (f) supination.9-CR2-024_OA1  01/09/2022  2:05 PM  Page 3Malaysian Orthopaedic Journal 2022 Vol 16 No 3 (Published ahead of print) Nyffeler RW, et al4REFERENCES1. Algawahmed H, Turcotte R, Farrokhyar F, Ghert M. High-Speed Burring with and without the Use of Surgical Adjuvants in theIntralesional Management of Giant Cell Tumor of Bone: A Systematic Review and Meta-Analysis. Sarcoma. 2010; 2010:586090. doi: 10.1155/2010/5860902. Prakash J, Mehtani A, Baruah T. Giant cell tumour--a very rare differential for a lytic lesion of the medial condyle of thehumerous. BMJ Case Rep. 2015; 2015: bcr2014209261. doi: 10.1136/bcr-2014-2092613. Cui HM, Yu YL, He Y, Kong LZ, Fan CY. Management of elbow dysfunction associated with giant cell tumor of the distalhumerus: achieving oncologic safety and good function by a combined reconstruction. J Shoulder Elbow Surg. 2019; 28(1): 120-5. doi: 10.1016/j.jse.2018.08.0134. Gasbarrini A, Donthineni R, Cappuccio M, Boriani S. Distal humeral reconstruction with osteoarticular allograft: a case reportand review of the literature. J Shoulder Elbow Surg. 2008; 17(6): e1-4. doi: 10.1016/j.jse.2008.01.1445. Balasubramanian N, Gnanasundaram R, Prakasam S. Endoprosthetic Reconstruction of distal Humerus following Resection ofdistal Humeral Giant Cell Tumours in Six Patients in Rural India. Malays Orthop J. 2017; 11(2): 25-9. doi:10.5704/MOJ.1707.001Cite this article:Nyffeler RW, Ziebarth K. Grade 3 Giant Cell Tumour of the Distal Humeral Epiphysis Treated with Intralesional Curettage, HighSpeed Burring and Bone Grafting: A Case Report. Malays Orthop J. 2022; 16(3): xx-xx. doi: chemical adjuvants. These toxic substances, however, didnot seem to have an adverse effect on the joint during thefollow-up period, which ranged from 36 to 60 months. We did not consider reconstructive measures with foreignmaterials in this young and active woman. Allografts mayinfect, fail to integrate, or resorb. Elbow prostheses are alsosusceptible to infections, and the polyethylene liner maywear out, resulting in prosthetic loosening. Elbow prosthesesare therefore good for elderly patients with limited functionaldemands, but less suitable for young and active persons. Theload limit recommended by most manufacturers of elbowprostheses is not compatible with physical work or normalsports activities. In young people, a joint-preservingtreatment should therefore be sought. It has lower risks forcomplications, is less expensive and may provide betterfunctional long-term results than wide resection andendoprosthetic reconstruction. CONFLICT OF INTERESTThe authors declare no potential conflict of interest.9-CR2-024_OA1  01/09/2022  2:05 PM  Page 4

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

https://boris.unibe.ch/175045/1/Grade_3_Giant_Cell_Tumour_of_the_Distal_Humeral.pdf

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

Abstract

Similar works

Full text

Available Versions

Bern Open Repository and Information System (BORIS)