A Rare Giant Cell Tumour in the Distal Radius of a Seven-Year-Old Girl: A Case Report

A giant cell tumour (GCT) is a benign and locally aggressive tumour that is usually observable in a skeletally mature patient involving the end of long bones. The reported incidence of this tumour in a skeletally immature patient is extremely rare. However, we report one such case in the distal radius of a seven-year-old female patient. Having presented with painful swelling of the right distal forearm, she underwent clinical and radiological examination, and a diagnosis of distal radius GCT was made. The tumour was treated with curettage, fibular graft, and synthetic bone graft. This case report shows the importance of including GCT in children as a differential diagnosis. This tumour may have a good prognosis if diagnosed and treated early.

Does the Number of Screws Influence the Union Rate in Ankle Arthrodesis? A Meta-analysis and Systematic Review

OBJECTIVE

The purpose of this study was to determine whether the number of cannulated screws used during ankle arthrodesis (AA) might influence the union and complication rate.

METHODS

In this Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)-compliant PROSPERO-registered systematic review, multiple databases were searched including studies in which patients undergone AA using cannulated screws as exclusive fixation method were followed. Data were harvested regarding the cohort, the study design, the surgical technique, the nonunion, and complication rate at the longest follow-up. Risk of bias was assessed using the modified Coleman Methodology Score (mCMS). Two groups were built (arthrodeses fixed with 2 screws [group 1, G1] vs arthrodeses fixed with 3 screws [group 2 G2]) and compared.

RESULTS

Fifteen series of patients from 15 studies (667 ankles) were selected (G1 = 458 ankles and G2 = 209). The pooled proportion estimate revealed a similar nonunion rate in the 2-screw group as compared with the 3-screw group (4% vs 3%; P = .68). The pooled proportion of complications was higher in G1 (19%) than in G2 (8%), but it was not significantly different either (P = .45). After exclusion of "symptomatic hardware and screw removal," the difference was still not significant (P = .28) although it resulted lower in G1 than in G2 (4% vs 8%, respectively).

CONCLUSIONS

Using 3 cannulated screws during AA as compared with a 2-screw construct does not significantly reduce the risk of nonunion nor the risk of complications.

LEVEL OF EVIDENCE

Level IV, Systematic review of level IV.

Bony Hypertrophy in Vascularized Fibular Grafts

Background: Vascularized fibula graft (VFG) transfer is an established method of repairing large skeletal defects resulting from trauma, tumor resection, or infection. It obviates the process of creeping substitution that conventional bone grafts undergo and therefore exhibits better healing and improved strength. The aim of this study is to evaluate hypertrophy in VFG. Methods: We retrospectively reviewed patients undergoing VFG and studied immediate and late postoperative radiographs. Orthogonal views were measured for width of graft cortex and intramedullary canal, as well as adjacent recipient bone. Changes were measured for total cross sectional area, cortical area, intramedullary area, and graft width. Results: Thirty patients were included in the analysis, with recipient sites including 3 forearm, 4 humerus, 12 tibia, and 11 femur. Mean follow-up was 7.6 years (0.5-24.9 years). Patients' mean age was 31 (16-59 years). Average hypertrophy was 254% in early postoperative period and 340% in the late postoperative period. There was rapid graft hypertrophy in early postoperative period that plateaued with time. The width of the graft increased over time but didn't exceed the width of the adjacent recipient bone. In the later postoperative period, the size of graft intramedullary canal increased. Upper and lower extremity grafts showed similar hypertrophy. Conclusions: Using VFG to treat large skeletal defects is an attractive option in part due to the graft's ability to hypertrophy. We describe an early period of periosteal hypertrophy, followed by endosteal hypertrophy. These processes have relevance to function, mechanical strength, and surgical decision-making.

A Rare Case of Posterior Tibial Artery Hypoplasia and Fibular Artery Enlargement and their Impact on the Arterial Supply of Posterior Crural Region

BACKGROUND

Detailed knowledge of the popliteal artery division and possible anatomical variants is of paramount importance for vascular surgery.

AIM

The aim of the current study was to highlight a rare unilateral case of posterior tibial artery hypoplasia.

MATERIALS AND METHODS

A dissection was performed at the posterior surface of the tibia in a 78-year-old Caucasian male cadaver of Greek origin.

RESULTS

The findings were consistent with unilateral posterior tibial artery hypoplasia and fibular artery enlargement. The variant fibular artery supplied the posterior surface of the distal leg and foot. Clinical implications of the fibular artery dominance are discussed.

CONCLUSIONS

Rare anatomical variants of the tibial artery are of clinical significance to maximize safety and minimize intraoperative complications.

[Long-term effectiveness of vascularized fibula flap in radiocarpal joint reconstruction following excision of Campanacci grade giant cell tumor]

OBJECTIVE

To evaluate the long-term effectiveness of vascularized fibula flap in radiocarpal joint reconstruction following excision of Campanacci grade Ⅲ giant cell tumor (GCT) of distal radius.

METHODS

Between December 2010 and December 2014, 10 patients with Campanacci grade Ⅲ GCT of distal radius were treated with en bloc excision and inradiocarpal joint reconstruction using vascularized fibula flap. They were 6 males and 4 females, with an average age of 39.9 years (range, 22-65 years). The disease duration was 1.5-6.0 months (mean, 2.6 months). The length of distal radius defect was 6.0-12.5 cm (mean, 8.4 cm) after en bloc excision of GCT. Vascularized fibula flap with inferior lateral genicular vessels were performed in 6 patients and with inferior lateral genicular vessels and peroneal vessels in 4 cases.

RESULTS

All incisions healed by first intention. All patients were followed up 4.4-8.3 years (mean, 6.0 years). There was no tumor recurrence during follow-up. At last follow-up, the mean ranges of motion of wrist joint were 55.0° (range, 25-85°) in extension, 26.5° (range, 15-40°) in flexion, 12.0° (range, 5-25°) in radial deviation, 19.6° (range, 10-30°) in ulnar deviation, 50.5° (range, 5-90°) in pronation, and 66.5° (range, 20-90°) in supination. The mean grip strength of effected wrist was 75% (range, 60%-85%) of the healthy wrist. The mean Musculoskeletal Tumor Society (MSTS) score was 82.7% (range, 75%-90%). X-ray films showed that the fibula flap healed at 12-16 weeks after operation (mean, 14.1 weeks) and there were 9 cases of radiological complications.

CONCLUSION

For Campanacci grade Ⅲ GCT of distal radius, application of the vascularized fibula flap in radiocarpal joint reconstruction after en bloc excision of GCT can obtain good wrist function.

Free non-vascularized fibular graft reconstruction after resection of metacarpal unicameral bone cyst: A case report

Unicameral bone cyst (UBC) or simple bone cyst (SBC) is a benign cystic lesion commonly found in the humerus and femur that is mainly encountered during childhood. The currently available treatments for UBC of the hand commonly involve curettage, bone grafting, partial resection with or without grafting, multiple drilling, fracture immobilization and observation alone, and steroid injection. We herein report a case treated with total resection of the cyst and non-vascularized fibular graft in a 9-year-old right-handed female patient. The patient presented with a chief complaint of a large, fast growing lump over the first metacarpal of the left hand. Flexion of the first metacarpophalangeal joint was limited. After the diagnosis was established with plain radiographs followed by biopsy, the cyst was completely removed by resecting the shaft of the metacarpal bone with preservation of the epiphyseal plate. A bone graft was obtained from the fibula and inserted in the gap, distally attached to the epiphyseal plate of the metacarpal and fixed with a Kirshner wire proximally. Radiographs revealed solid union of the bone graft to the epiphyseal plate at the head after 7 weeks, with improving function of the thumb. SBC or UBC of the metacarpal bone is very rare. A more aggressive method, such as in the case presented herein, may be necessary to treat this condition.

Long-term follow-up of fibular graft for the reconstruction of bone defects

The use of fibular graft for the reconstruction of bone defects has been demonstrated to be a reliable method. The aim of this study was to assess the clinical outcome of graft union, functional outcome (hypertrophy of the graft bones) and complications of both non-vascularized and vascularized grafts.From 1981 to 2015, 10 patients were treated using non-vascularized fibular graft or free vascularized fibular graft. The outcomes were bony union time, graft hypertrophy and complications based on radiograph and functional outcomes according to the Musculoskeletal Tumor Society (MSTS) score. Mobility of the ankle at the donor site was evaluated using the Kofoed ankle score system.This study included 10 patients with an average follow-up of 6.8 years. The union rate for all patients was 100%. The mean union time was 21.3 weeks for vascularized fibular grafts and 30.5 weeks for non-vascularized fibular grafts (P = .310). There was a significant difference between the upper limbs and the lower limbs regarding hypertrophy of the grafts in 5 patients (P = .003). The mean MSTS score in 10 patients was 84% (range 53%-97%). Stress fracture of the graft occurred in 1 patient. Donor site complications, including valgus deformity and length discrepancy, between 2 legs occurred in 2 patients who were under 18 years of age at the time of operation (P = .114). The mean Kofoed score was 96.8 (range 88-100).A greater increase in hypertrophy of grafts was observed with reconstruction in the lower limbs. There was no difference in MSTS score between these 2 types of grafts. Children were more likely to experience the valgus deformity at the donor site after harvesting the fibula. Keeping at least the distal 1/4 of the fibula intact during the surgery is a valid means of ensuring ankle stability at the donor site, and children should be considered for prophylactic distal tibiofibular synostosis creation to prevent the valgus deformity of the ankle at the donor site.

Introduction of an algorithm for planning of autologous fibular transfer in mandibular reconstruction based on individual bone curvatures

BACKGROUND

Reconstruction of the mandible with autologous transplants is a challenging task and current computer-aided surgical planning remains cumbersome. Thus, the aim of the present study was to create an automated computational approach for this procedure.

METHODS

The developed algorithm is based on curves following characteristic anatomical features. Geometrical data from a physiological mandible and a fibula were used to generate six different defects, and geometrical accordance was investigated to demonstrate the applicability of the method with different reconstruction parameters (n = 309).

RESULTS

The method proved to be applicable, it recognized given clinical constraints and the values of accordance could be used to quantify the success of reconstructions.

CONCLUSIONS

With the present approach, the complex three-dimensional task of mandibular reconstruction was simplified, and thus it allows implementation in clinical routine. The computational planning that is proposed may be used to design cutting guides or as geometrical input data for real-time navigated surgery.

Single-cortex is better than double-cortex in fibula grafts for large tibia bone defect in a 2-year-old child: A case report of a successful surgery and discussion of bone graft choices

BACKGROUND

Large bone defect in infant or small patients has been little reported and the management of such a patient is difficult. Considering the little knowledge of this area, we present this special case of a successful single-cortex fibula graft for the treatment of a large tibia bone defect in a 2-year-old patient to share our experience.

CASE SUMMARY

A 2-year-old male patient presented to our hospital with history of leg pain for 4 months. According to his medical records, he was involved in a traffic accident and diagnosed with open tibia fracture. A previous surgery of emergent debridement and external fixation was performed in our institution, leaving a 6-cm tibia bone defect. After that this patient received several times of vacuum sealing drainage (VSD), skin grafting, and changed external fixation to cast because of pin tract infection.The physical examination of the patient showed a healed skin wound and a good dorsal arterial pulse. X-ray indicated a large bone defect at the tibia fracture site with osteosclerosis at the fracture sections. This patient received ipsilateral single-cortex vascularized single-cortex fibula graft, other than double-cortex fibula graft. X-ray and CT scan 4 months after the operation confined bone healing. The patient returned to normal activities with an inconspicuous limb.

CONCLUSION

Ipsilateral single-cortex fibula graft is effective for the treatment of large tibia bone defect in infant or small aged patients. It exhibited better potential benefits than double-cortex graft in such cases.

Use of fibular bone graft and cancellous screw fixation in the management of neglected femur neck fractures in young patients

OBJECTIVE

To present the clinical outcome of patients with neglected femur neck fracture treated with fibular bone graft.

METHODS

During May 2010-February 2013, 15 patients younger than 35 years of age with neglected fracture neck of femur were managed with non-vascularized fibular graft and cannulated screws. Fractures were classified according to Sandhu Classification. Hip function was assessed using Harris hip score.

RESULTS

Fifteen patients with mean age of 28.67 years were managed. Mean period of delay from injury to presentation was 3.07 months. Mean follow-up was 18.5 months. Union was achieved in 13 cases. 2 patients developed nonunion with progression of avascular necrosis (AVN). Patients with healed fracture did not show radiological signs of AVN till the past follow-up. Functional status was evaluated at 6 months according to Harris hip score and was poor in 2 patients, fair in 2 patients, good in 6 patients, and excellent in 5 patients.

CONCLUSION

Fibular graft along with two cancellous screws proved to be an effective technique in our cases with neglected femur neck fractures.

Nonvascularized fibular grafting in nonunion of femoral neck fracture: A systematic review

Nonunion of femoral neck fractures following primary fixation and neglected femoral neck fracture in young adults is a challenging task. Every effort should be directed toward hip joint salvage in these patients. Among different available options of hip salvage, nonvascularized fibular graft (NVFG) osteosynthesis is simple, easy to perform, and a successful technique. In this review, the available literature on NVFG in neglected and nonunion femoral neck fractures has been analyzed. After review of 15 articles on NVFG, the average nonunion rate was estimated to be 7.86% (range 0-31%). Six articles that evaluated the preoperative and postoperative osteonecrosis reported improvement in 50% patients. The clinical and/or functional outcome was good to excellent in 56-96% patients following fibular osteosynthesis. Few complications such as coxa vara deformity, limb shortening, and intraarticular penetration of the graft or hardware have been reported. However, there are minimal donor site morbidities such as mild ankle pain, transient loss of toe flexors and extensors and transient lateral popliteal nerve palsy.

Global Reconstruction for Extensive Destruction in Tuberculosis of the Lumbar Spine and Lumbosacral Junction: A Case Report

Study Design Case report. Objective To analyze the surgical difficulties in restoring global spinal stability and to describe an effective surgical option for tuberculosis with extensive destruction of the lumbosacral spine. Advanced tuberculosis with destruction of the lumbosacral spine can result in a kyphosis or hypolordosis, leading to back pain, spinal instability, and neurological deficits. The conventional treatment goals of lumbosacral tuberculosis are to correct and prevent a lumbar kyphosis, treat or prevent a neurological deficit, and restore global spinal stability. Instrumentation at the lumbosacral junction is technically demanding due to the complex local anatomy, the unique biomechanics, and the difficult fixation in the surrounding diseased bone. Methods We report a 21-year-old woman with tuberculosis from L1 to S2 with back pain and spinal instability. The radiographs showed a kyphosis of the lumbar spine. The magnetic resonance imaging and computed tomography scans revealed extensive destruction of the lumbar and lumbosacral spine. Spinopelvic stabilization combined with anterior debridement and reconstruction with free fibular strut graft was performed. Results The radiographs at follow-up showed a good correction of the kyphosis and excellent graft incorporation and fusion. Conclusions Anterior column reconstruction with a fibular strut graft helps restore and maintain the vertebral height. Posterior stabilization with spinopelvic fixation can be an effective surgical option for reconstructing the spine in extensive lumbosacral tuberculosis with sacral body destruction, requiring long fusions to the sacrum. It augments spinal stability, prevents graft-related complications, and accelerates the graft incorporation and fusion, thereby permitting early mobilization and rehabilitation. In spinal tuberculosis, antitubercular therapy may have to be prolonged in cases with large disease load, based on the clinicoradiographic and laboratory parameters.

Role of (99m)Tc-methylene diphosphonate bone scan in the evaluation of the viability of the bone flap in mandibular reconstruction in patients with oromaxillofacial malignancies

Osteo-cutaneous flap are commonly used for reconstruction of bone defect after oncology surgery. The success of surgery depends on the viability of the bone flap. Bone scan is a known, but less performed method, to look for viability of bone flaps. We describe a case of 50-year-old lady, presenting with squamous cell carcinoma of left buccal mucosa (cT4N1M0) involving the skin and mandible. She underwent left segmental mandibulectomy and upper alveolectomy with neck dissection, followed by reconstruction using a fibular osteo-cutaneous flap and anterolateral thigh free flap. On postoperative day 10, the intraoral flap showed signs of nonviability. The patient was sent to nuclear medicine for assessment of viability of the free fibula flap. The patient underwent three phase ^99mTc-methylene diphosphonate (MDP) bone scan and single-photon emission computerized tomography. Computerized tomography showing good tracer uptake in fibula confirming viability. The case reflects the use of ^99mTc-MDP in viability assessment of the bone flap.

Clinical outcome of en-block resection and reconstruction with nonvascularized fibular autograft for the treatment of giant cell tumor of distal radius

BACKGROUND

Although giant cell tumor (GCT) is considered to be a primary benign bone tumor, its aggressive behavior makes its diagnosis and treatment, difficult and challenging. This is especially true in distal radius where GCT appears to be more aggressive and difficult to control locally. We report our clinical outcome of en-block resection and reconstruction with non-vascularized fibular autograft in 15 patients with distal radius GCT.

MATERIALS AND METHODS

We retrospectively reviewed 15 patients with GCT (Grade 2 and 3) of distal radius who were treated with en-block resection and non-vascularized fibular autograft. Five of 15 were recurrent GCT treated initially with extended curettage; local adjuvant therapy and filling the cavity with cement or bone graft. We followed the patients for mean 7.2 years post operation (range: 4-11 years). Patients were evaluated post operation with clinical examination, plain radiography of distal radius and chest X-ray and/or computed tomography scan. Furthermore pain, function, range of motion and grip strength of the affected limb were evaluated and mMayo wrist score was assessed.

RESULTS

A total of 11 patients were women and 4 were men. Mean age of patients was 29 years (range: 19-48). We had no lung metastasis and bony recurrence occurred in one patient (6.6%). Nearly 53.3% of patients had excellent or good functional wrist score, 80% of the patients were free of pain or had only occasional pain and 80% of patients returned to work. Mean range of motion of the wrist was 77° of flexion-extension and mean grip strength was 70% of the normal hand.

CONCLUSION

En-block resection of distal radius GCT and reconstruction with non-vascularized fibular autograft is an effective technique for treatment in local control of the tumor and preserving function of the limb.

Stability of tibial defect reconstruction with fibular graft and unilateral external fixation: a finite element study

Tibial defect is generally caused by high-energy injury, tumor, osteomyelitis, development deformity and bone non-union after internal fixation. This study was to determine stability of tibial defect reconstruction with fibular graft (FG) of different lengths by single free vascularized fibular graft (SFVFG) and double-barrel free vascularized fibular graft (DBFVFG). The left lower extremity of a male volunteer was scanned with computer tomography scanner. The contours of the tibia and fibula were extracted and the geometry of both bones rebuilt. From this intact model, the models of tibial defect reconstruction with fibular graft and external fixation were developed. Inter-fragmentary motion (IFM) and Von Mises stress on the fibular bone flap, and the locations of maximum Von Mises stress were introduced to quantify the biomechanical environment. Under the condition of the same graft length, the Von Mises stress value in DBFVFG group was 1.37 to 1.77 times higher than that in SFVFG group. When the length of graft was greater than 15 cm in the SFVFG group, the IFM exceeded 1 mm, but the IFM of the graft in the DBFVFG group was always less than 1 mm. The maximum Von Mises stress of models was frequently located at the second or third pin-bone interface. Thus, external fixation can provide a stable biomechanical environment for the reconstruction of tibial defect by both SFVFG and DBFVFG. The second or third pin-bone interface requires intensive care and that in the reconstruction of tibial defect by SFVFG, the graft length should not exceed 15 cm.

Aneurysmal Bone Cyst In Metacarpal of a Child

INTRODUCTION

Aneurysmal bone cyst is a rare, rapidly growing, and destructive benign bone tumor that rarely involves the bones of the hand. Various treatment options for aneurysmal bone cyst have been reported in the literature, but controversy exists regarding optimal treatment.

CASE REPORT

A six year old boy presented with a history of pain and local swelling over his third metacarpal of five months' duration. Physical and radiographic examination of the hand was consistent with aneurysmal bone cyst. After biopsy, pathologic examination confirmed the diagnosis of aneurysmal bone cyst. En- block resection of the tumor and autologous fibular strut graft fixation with Kirschner wires was performed. The hand was immobilized in a short arm cast for three weeks; after the patient received three weeks of physiotherapy, the kirschner wires were removed six weeks postoperatively. Excellent clinical and functional results were obtained with no recurrence after two years of follow-up with en-block resection and reconstruction by autologous graft.

CONCLUSION

Aneurysmal bone cyst in third metacarpal of child of age six is rare entity and decision making for management poses difficulties. Our experience with En-block resection of tumor and autologus fibular sturt grafting was quite satisfactory with excellent clinical result, and we recommend this is as one modality of treatment of ABC in metacarpal of child.