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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 6  |  Issue : 1  |  Page : 54-56

Giant cell tumor of distal end ulna treated by en BLOC resection: A case series


1 Senior Resident, IGIMS, India
2 Assistant Professor, IGIMS, India
3 Associate Professor, Dept. of Orthopaedics, IGIMS, India
4 Junior Resident Dept. of Pathology, IGIMS, India
5 Professor & Head, Dept. of Orthopaedics, IGIMS, India

Date of Submission08-Jan-2020
Date of Acceptance16-Feb-2020
Date of Web Publication16-Nov-2020

Correspondence Address:
Manish kumar
Associate Professor Dept. of Orthopaedics, IGIMS, Patna
India
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Source of Support: None, Conflict of Interest: None


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  Abstract 



How to cite this article:
kumar R, Chandan K, Sharma G D, kumar M, Shiksha, kumar S. Giant cell tumor of distal end ulna treated by en BLOC resection: A case series. J Indira Gandhi Inst Med Sci 2020;6:54-6

How to cite this URL:
kumar R, Chandan K, Sharma G D, kumar M, Shiksha, kumar S. Giant cell tumor of distal end ulna treated by en BLOC resection: A case series. J Indira Gandhi Inst Med Sci [serial online] 2020 [cited 2020 Nov 26];6:54-6. Available from: http://www.jigims.co.in/text.asp?2020/6/1/54/300741




  Introduction Top


Giant cell tumors represent 5% of the neoplasm of bone. They typically occur in patients 20 to 40 years old, and there is a slight female preponderance. The most common location for this tumor is the distal femur, followed closely by the proximal tibia. In the distal radius (the third most common location), these tumors frequently are more aggressive1.Giant cell tumors are mostly solitary and rarely become malignant. The overall incidence of metastasis is estimated to be <2%.[2]

Giant Cell Tumor occurring at the distal end of ulna are extremely rare, accounting for 0.45% to 3.2% of all the cases of Giant cell tumors.[3]

This site represents a challenge for the treating orthopaedic surgeon. Several treatment options are available for distal end of the ulna like Intralesional curettage with or without adjuvant therapy (e.g. Cytotoxic chemicals,cryotherapy, polymethylmethacrylate), En bloc resection with or without reconstruction or stabilisation of the ulnar stumps. Treatment of Enneking stage 1 and stage 2 Giant cell tumor consists of complete tumor removal with preservation of adjacent structures which is achieved by extended curettage. Due to high rates of recurrence wide resection is reserved for stage 3 tumors.[4],[5]

In this study three cases of distal end of ulna Giant cell tumor were treated with En bloc resection of the tumor. Various literature is reviewed and previous reported methods discussed.


  Case Series Top


We studied three patients (two male and one female), which came to our tertiary care centre hospital with chief complain of painful progressive swelling of the wrist joint. Duration of the swelling varied from 3-4 months. Overlying skin was of normal color with no evidence of dilated or engorged veins in all patients. There was no history of trauma and fever in these patients.

On palpation, tenderness was present but temperature was comparable to normal side. Shape of the swelling was oval and size varied from 4x3 cm to 6x5 cm in dimension at the distal end of ulna. It was firm to hard in consistency. Swelling was not adhered to the overlying skin. Restricted movement of wrist joint was present as compared to normal side. Distal neurovascular status was intact in all three patients.

Routine blood examinations and chest x ray were within normal limits. X ray of the wrist anteroposterior and lateral views showed expansile, lytic and multilocular lesion at distal end of ulna without any rim of reactive bone formation. Clinico-radiological diagnosis of Giant cell tumor was made.

All patients was managed with en bloc resection of distal end ulna using Darrach’s procedure under general anaesthesia. Post-operatively above elbow plaster slab was applied for three weeks. Resected lesion was sent for histopathological examination which showed many osteoclastic multinucleated giant cells in a sea of mononuclear stromal cells. This confirmed the diagnosis of Giant Cell Tumor. After three weeks, plaster slab was removed and physiotherapy started.
Figure 1: Clinical picture

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Figure 2: Pre-operative radiograph

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Figure 3: Intra-operati’ve picture

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Figure 4: Intra-operati’ve picture

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Figure 5: Resected distal ulna

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Figure 6: Post-operative radiograph

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  Discussion Top


Purpose of our study was to evaluate the functional outcome and to minimize the recurrence of the tumor. So in our study en bloc resection was chosen as treatment option. Simple curettage has high recurrence rate as compared to curettage with adjuvant therapy as per campanacci et al.[4] cooney et al. reported good functional outcomes after distal ulna resection without any stabilization and concluded that reconstruction is not routinely indicated.[6] Resection of the distal end of the ulna, so-called Darrach’s operation, is simple and easy solution but long term results are still unpredictable, especially with high stress manual labor.[7],[8],[9] Resection at a lower level could potentially cause impingement symptoms due to the pull of the pronator quadratus muscle, while resection at a higher level causes instability and undue prominence of the distal ulnar stump.[10]

Ferracini et al.[11] reported on eight patients with tumors of the distal ulna, including five patients with Giant cell tumor. They stabilised the ulnar stump with the flexor carpi ulnaris, fascia lata, with an autograft, or with plate arthrodesis. One case was treated without reconstruction and had a fair post-operative result. Therefore, there are no clear-cut guidelines about the preferred modality of treatment.


  Conclusion Top


My study is on a small series of patients but en bloc resection of Giant Cell Tumor distal end ulna can be a simple and good option as treatment modality. A long term follow-up with a large series of patients can give further information regarding the modality of treatment.

Financial Support and Sponcership

None.

Conflicts of Interest

None.



 
  References Top

1.
Azhar FM, Beaty JH, Canale ST, Campbell’s operative orthopaedics. 13th edition, vol. 1, chapter 26, Elsevier; 2017 p.923  Back to cited text no. 1
    
2.
Pirela-Cruz MA, Higgs M, Reddy K, Abdelfattah H, Cameron C, Hakim NM. Treatment of a giant cell tumor of the distal ulna with a fully constrained prosthesis. El Paso Physician. Case Rep (EPCMS), 2014;31:9-13.  Back to cited text no. 2
    
3.
R. R. Goldenberg, C. J. Campbell, and M. Bonfiglio, “Giantcell tumor of bone. An analysis of two hundred and eighteen cases,” Journal of Bone and Joint Surgery. Series A, vol. 52, no.4, pp. 619-664, 1970.  Back to cited text no. 3
    
4.
Campanacci M, Baldini N, Boriani S, Sudanese A. Giant-cell tumor of bone. J Bone Joint Surg Am [Internet]. 1987 Jan [cited 2015 Aug 7]; 6 9 ( 1 ) : 1 0 6 - 1 4. Available from: http://www.ncbi.nlm.nih.gov/pubmed/3805057  Back to cited text no. 4
    
5.
Enneking WF. A system of staging musculoskeletal neoplasms. Clin Orthop Relat Res [Internet]. 1986 Mar [cited 2015 Jul 24];(204):9-24. Available from: http://www.ncbi.nlm.nih.gov/pubmed/3456859.  Back to cited text no. 5
    
6.
Cooney WP, Damron TA, Sim FH, Linscheid RL. En bloc resection of tumors of the distal end of the ulna. J Bone Joint Surg Am 1997;79:406?12.  Back to cited text no. 6
    
7.
C. R. Hartz and R. D. Beckenbaugh, “Long-term results of resection of the distal ulna for post-traumatic conditions,” Journal of Trauma, vol. 19, no. 4, pp. 219-226, 1979.  Back to cited text no. 7
    
8.
P. C. Dell, “Distal radioulnar joint dysfunction,” Hand Clinics, vol. 3, no. 4, pp. 563-582, 1988.  Back to cited text no. 8
    
9.
G. M. White and A. J. Weiland, “Madelung’s deformity: treatment by osteotomy of the radius and Lauenstein procedure,” Journal of Hand Surgery, vol. 12, no. 2, pp. 202-204, 1987.  Back to cited text no. 9
    
10.
Dhillon MS, Saini R, Gill SS. Is there a need for reconstruction after excision of the distal ulna for giant-cell tumour? Acta Orthop Belg 2010;76:30-7.  Back to cited text no. 10
    
11.
Ferracini R, Masterson EL, Bell RS,Wunder JS. Distal ulnar tumours.Results of management by en bloc resection in nine patients and review of the literature. J Hand Surg 1988 ; 23-B : 517521.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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Abstract
Introduction
Case Series
Discussion
Conclusion
References
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