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1.  Multifocal Metachronous Giant Cell Tumor: Case Report and Review of the Literature 
Case Reports in Medicine  2014;2014:678035.
Introduction. Giant cell tumors (GCTs) of bone are known for their local aggressiveness and high recurrence rate. There are rare cases of multicentric GCT and most are synchronous. We herein review metachronous multicentric GCT reported in the literature. Material and Methods. A MEDLINE, Cochrane, and Google Scholar search was done to collect all cases of multicentric metachronous GCT specifying the clinical, radiological, and histological characteristics of each location and its treatment. Results. A total of 37 multifocal giant cell tumors were found in the literature. 68% of cases of multicentric giant cell tumors occur in less than 4 years following treatment of the first lesion. Thirty-seven cases of multifocal metachronous GCT were identified in the literature until 2012. Patients with multicentric GCT tend to be younger averaging 23. There is a slight female predominance in metachronous GCT. The most common site of the primary GCT is around the knee followed by wrist and hand and feet. Recurrence rate of multicentric GCT is 28.5%. Conclusion. Multicentric giant cell tumor is rare. The correct diagnosis relies on correlation of clinical and radiographic findings with confirmation of the diagnosis by histopathologic examination.
doi:10.1155/2014/678035
PMCID: PMC3912820  PMID: 24511316
2.  Completely extruded talus without soft tissue attachments 
Clinics and Practice  2011;1(1):e12.
A completely extruded talus without any remaining soft tissue attachments is extremely rare. The present report describes treatment of a 45-year-old man who sustained a completely extruded talus injury following a rock-climbing fall. Upon admission, the extruded talus was deep-frozen in our bone bank. The open ankle joint underwent massive wound debridement and irrigation for 3 days. Four days later we performed a primary subtalar fusion between the extruded talus and the calcaneus, anticipating revascularization from the calcaneus. However, aseptic loosening and osteolysis developed around the screw and talus. At 12 months post-trauma we performed a tibiocalcaneal ankle fusion with a femoral head allograft to fill the talar defect. Follow-up at 24 months post-trauma showed the patient had midfoot motion, tibio-talar-calcaneal fusion, and was able partake in 4-hour physical activity twice per week.
doi:10.4081/cp.2011.e12
PMCID: PMC3981216  PMID: 24765266
completely extruded talus; primary subtalar fusion; osteolysis.
3.  Tibiotalar arthrodesis for injuries of the talus 
Indian Journal of Orthopaedics  2008;42(1):87-90.
Background:
Fracture-dislocation of the talus is one of the most severe injuries of the ankle. Opinion varies widely as to the proper treatment of this injury. Since Blair's original description of the tibiotalar fusion in 1943, there is little mention in the literature of his method. The present study reports the results of tibiotalar arthrodesis with modification in Blair's technique.
Materials and Methods:
Eleven cases of modified Blair's tibiotalar arthrodesis were retrospectively studied. The average age was 32.4 years (range, 26-51 years). Six patients had posttraumatic avascular necrosis; five had neglected fracture-dislocation of the talus.
Results:
The mean followup is 8 years (range 3-12 years). Tibiotalar fusion was achieved in all the ankles at an average of 20.5 weeks (range 16-28 weeks). Nine cases having 15°-20° tibiopedal motion had excellent results and two ankles having 10°-15° of tibiopedal motion had good result.
Conclusion:
We achieved good long term results with tibiotalar arthrodesis with modification in Blair technique. The principal modification in the present study is retention of the talar body while performing arthrodesis with anterior sliding graft. The retention of the talar body provides intraoperative stability and in the long term, the retained talar body shares the load transmitted to the anterior and middle subtalar joints thus resulting in improved hind foot function and gait.
doi:10.4103/0019-5413.38588
PMCID: PMC2759590  PMID: 19823662
Anterior tibial sliding graft; arthrodesis; avascular necrosis of talus
4.  Therapeutic management of complicated talar extrusion: literature review and case report 
Total extrusion of the talus with interruption of all ligaments (missing talus) is a rare injury. We describe the case of a 27-year-old man who reported total extrusion of the talus after a motorbike accident with interruption of all talar ligaments. In the first repair effort, the articular void left by the talus was filled with antibiotic cement and the wound was closed primarily. Nevertheless, the skin overlying the talar joint displayed necrosis. In order to cover the cutaneous defect, improve local vascularization, and allow reimplantation of the talus, a sural fasciocutaneous island flap was harvested. Subsequently, the original talus was placed and arthrodesis of the subtalar joint was performed. The patient was able to walk bearing full weight without support equipment after 6 months. Several therapeutic options have been suggested in such cases, including replacing the talus, tibiocalcaneal arthrodesis, and pseudoarthrodesis. The rarity and peculiarity of such cases make the establishment of generalized guidelines an arduous task, leaving the choice of treatment to the surgeon, in conformity with each case’s peculiarity. In this case use of the flap may have promoted the vascularization of the reimplanted talus, thus avoiding avascular necrosis and allowing successful reimplantation of the original talus.
doi:10.1007/s10195-011-0129-z
PMCID: PMC3052426  PMID: 21350893
Total talar dislocation; Talar extrusion; Missing talus; Distally-based sural fasciocutaneous flap
5.  Therapeutic management of complicated talar extrusion: literature review and case report 
Total extrusion of the talus with interruption of all ligaments (missing talus) is a rare injury. We describe the case of a 27-year-old man who reported total extrusion of the talus after a motorbike accident with interruption of all talar ligaments. In the first repair effort, the articular void left by the talus was filled with antibiotic cement and the wound was closed primarily. Nevertheless, the skin overlying the talar joint displayed necrosis. In order to cover the cutaneous defect, improve local vascularization, and allow reimplantation of the talus, a sural fasciocutaneous island flap was harvested. Subsequently, the original talus was placed and arthrodesis of the subtalar joint was performed. The patient was able to walk bearing full weight without support equipment after 6 months. Several therapeutic options have been suggested in such cases, including replacing the talus, tibiocalcaneal arthrodesis, and pseudoarthrodesis. The rarity and peculiarity of such cases make the establishment of generalized guidelines an arduous task, leaving the choice of treatment to the surgeon, in conformity with each case’s peculiarity. In this case use of the flap may have promoted the vascularization of the reimplanted talus, thus avoiding avascular necrosis and allowing successful reimplantation of the original talus.
doi:10.1007/s10195-011-0129-z
PMCID: PMC3052426  PMID: 21350893
Total talar dislocation; Talar extrusion; Missing talus; Distally-based sural fasciocutaneous flap
6.  Giant Cell Tumors of the Axial Skeleton 
Sarcoma  2012;2012:410973.
Background. We report on 19 cases of giant cell tumor of bone (GCT) affecting the spine or sacrum and evaluate the outcome of different treatment modalities. Methods. Nineteen patients with GCT of the spine (n = 6) or sacrum (n = 13) have been included in this study. The mean followup was 51.6 months. Ten sacral GCT were treated by intralesional procedures of which 4 also received embolization, and 3 with irradiation only. All spinal GCT were surgically treated. Results. Two (15.4%) patients with sacral and 4 (66.7%) with spinal tumors had a local recurrence, two of the letter developed pulmonary metastases. One local recurrence of the spine was successfully treated by serial arterial embolization, a procedure previously described only for sacral tumors. At last followup, 9 patients had no evidence of disease, 8 had stable disease, 1 had progressive disease, 1 died due to disease. Six patients had neurological deficits. Conclusions. GCT of the axial skeleton have a high local recurrence rate. Neurological deficits are common. En-bloc spondylectomy combined with embolization is the treatment of choice. In case of inoperability, serial arterial embolization seems to be an alternative not only for sacral but also for spinal tumors.
doi:10.1155/2012/410973
PMCID: PMC3289906  PMID: 22448122
7.  The use of a retrograde fixed-angle intramedullary nail for tibiocalcaneal arthrodesis after severe loss of the talus 
Tibiocalcaneal arthrodesis may be the only means of obtaining a painless and stable limb when there is loss of the talus. We present the early results of a prospective study on tibiocalcaneal arthrodesis using a latest-generation retrograde intramedullary nail. In the period 2006–2007, nine patients underwent tibiocalcaneal arthrodesis with retrograde intramedullary nailing. Five of these patients had infection-related loss of the talus. SF-36, AOFAS ankle-hindfoot, and Mazur Ankle Arthrodesis scores were obtained pre-fusion, and at 6 weeks, 6 months and 1 year post-fusion. The patients were also followed up clinically and radiologically. Previous surgical procedures, chronic musculoskeletal problems and other comorbidities, and complications were recorded and analyzed. All patients were available for initial follow-up and were subjectively satisfied with their outcomes. Solid fusion was achieved and fully confirmed in nine cases. One subject died 8 weeks postoperatively of a pulmonary embolism. One patient had recurrent infection. At 1 year, only one patient still needed NSAIDs regularly for pain relief. The AOFAS score improved significantly (P = 0.012) from 32.1 pre-fusion to 71.5 points at 1 year as did the Mazur score, which rose by 31.2 to 72.5 points at 1 year (P = 0.012). The SF-36 score improved significantly in the domains physical functioning, role limitations due to physical problems, bodily pain, vitality, social functioning and mental health, as did the Physical Component Summary Score. Retrograde intramedullary nailing for tibiocalcaneal arthrodesis can produce a good outcome. However, in the presence of infection, patient selection for intramedullary procedures must be carefully considered on a case-by-case basis.
doi:10.1007/s11751-009-0067-y
PMCID: PMC2746277  PMID: 19756949
Talectomy; Tibiocalcaneal arthrodesis; Retrograde; Intramedullary nail; Ankle arthrodisis; Hindfoot
8.  The use of a retrograde fixed-angle intramedullary nail for tibiocalcaneal arthrodesis after severe loss of the talus 
Tibiocalcaneal arthrodesis may be the only means of obtaining a painless and stable limb when there is loss of the talus. We present the early results of a prospective study on tibiocalcaneal arthrodesis using a latest-generation retrograde intramedullary nail. In the period 2006–2007, nine patients underwent tibiocalcaneal arthrodesis with retrograde intramedullary nailing. Five of these patients had infection-related loss of the talus. SF-36, AOFAS ankle-hindfoot, and Mazur Ankle Arthrodesis scores were obtained pre-fusion, and at 6 weeks, 6 months and 1 year post-fusion. The patients were also followed up clinically and radiologically. Previous surgical procedures, chronic musculoskeletal problems and other comorbidities, and complications were recorded and analyzed. All patients were available for initial follow-up and were subjectively satisfied with their outcomes. Solid fusion was achieved and fully confirmed in nine cases. One subject died 8 weeks postoperatively of a pulmonary embolism. One patient had recurrent infection. At 1 year, only one patient still needed NSAIDs regularly for pain relief. The AOFAS score improved significantly (P = 0.012) from 32.1 pre-fusion to 71.5 points at 1 year as did the Mazur score, which rose by 31.2 to 72.5 points at 1 year (P = 0.012). The SF-36 score improved significantly in the domains physical functioning, role limitations due to physical problems, bodily pain, vitality, social functioning and mental health, as did the Physical Component Summary Score. Retrograde intramedullary nailing for tibiocalcaneal arthrodesis can produce a good outcome. However, in the presence of infection, patient selection for intramedullary procedures must be carefully considered on a case-by-case basis.
doi:10.1007/s11751-009-0067-y
PMCID: PMC2746277  PMID: 19756949
Talectomy; Tibiocalcaneal arthrodesis; Retrograde; Intramedullary nail; Ankle arthrodisis; Hindfoot
9.  Weaver syndrome associated with bilateral congenital hip and unilateral subtalar dislocation 
Hippokratia  2010;14(3):212-214.
Background: Weaver syndrome is a congenital paediatric syndrome characterized by mental, respiratory and musculoskeletal manifestations. The coexisting deformities of the skull, the face, fingers and toes are typical. We report a case of a girl with Weaver syndrome associated with rare bilateral congenital dislocation of the hips associated with congenital hypoplastic talus and subtalar dislocation of her ankle joint.
Case Report: A 3-year old girl was admitted in our department with typical manifestations of Weaver syndrome, associated with congenital dislocation of bilateral hips, hypoplastic talus and subtalar dislocation of her right ankle. She was in pain while standing upright and incapable of independent walking. Both hips were treated operatively with open reduction and bilateral iliac osteotomy. Two years afterwards she had an open reduction of her talus and extraarticular arthrodesis of her subtalar joint in her right ankle. Six years postoperatively after the hip operations and four years after the ankle operation the girl is ambulant with a painless independent and unaided walking with a mild limp and full range of movements in all the operated joints.
Conclusions: We suggest that children with Weaver syndrome and disabling musculosceletal deformities, particularly affecting their ability to stand up and walk should be treated early, before bone maturity, in order to achieve the best potential musculoskeletal as well as developmental outcome.
PMCID: PMC2943362  PMID: 20981173
Weaver Syndrome; congenital dislocation; hip; ankle
10.  Wrist Joint Reconstruction With a Vascularized Fibula Free Flap Following Giant Cell Tumor Excision in the Distal Radius 
Eplasty  2010;10:e38.
Objective: Multiple therapeutic modalities exist for giant cell tumors (GCT) in the distal radius. The majority of GCTs are amenable to curettage, with the expanded lesions requiring a more radical approach. This case report examines the technique of managing a GCT that has extended beyond the boundaries of the cortex and into local tissues. The decision to use arthroplasty versus arthrodesis and the proximal fibular head as a vascularized free flap is discussed in reference to a patient requiring a proximal row carpectomy (PRC) secondary to tumor invasion. Methods: A 47-year-old woman with GCT in the right distal radius presented with decreased range of motion secondary to pain. Confirmation of the GCT was made with radiographic imaging and biopsy. The extensive invasion of the lesion required en bloc tumor resection with PRC and subsequent arthroplasty. Results: Treatment involved resection of tumor and PRC with arthroplasty using the proximal head of the fibula and reattachment of the radioscaphocapitate and ulnar carpal ligaments. Success was measured on functionality of the joint, viability of the flap, and the absence of tumor recurrence and pain. Conclusion: This case presents an example of successful excision of a GCT in the distal radius with a PRC and arthroplasty using a vascularized fibula free flap autograft. The patient remained pain-free, had no evidence of tumor recurrence, demonstrated 50% range of motion in the wrist, and 80% preoperative strength as expected following PRC.
PMCID: PMC2875920  PMID: 20505792
11.  Synchronous Multicentric Giant Cell Tumour (GCT)-A Rare Case Report 
Giant Cell Tumours (GCT) of bone account for 5% of all primary bone tumours. Multicentric variety is a rare variant of this condition, accounting for less than 1% of all cases and can occur as synchronous or metachronous lesions. We report a 22-year-old male patient with 18 months history of painful progressive swellings around the right knee. Radiographs revealed expansile lytic lesions in the distal femur, proximal tibia and fibula and core needle biopsy was typical of GCT. Biochemical parameters were normal and radiological investigations did not reveal any metastasis. The patient was treated by above knee amputation due to the extensive nature of the tumours. The excised tissue from all sites had features of giant cell tumor with no atypia or malignant cells seen. The patient is free from recurrence or metastasis at three years follow up.
doi:10.7860/JCDR/2014/8153.4055
PMCID: PMC3972558  PMID: 24701530
Neoplasms; Synchronous multiple primary; Amputation
12.  Ankle Arthritis in a 6-Year-Old Boy After a Tick Bite – A Case Report 
Background:
Monoarthritis of the ankle is a rare condition in children, and is most often caused by a bacterial infection. Lyme disease is endemic in southern Scandinavia, and diagnosis remains a challenge. The clinical presentation of Lyme disease varies greatly, and often with considerable delay between exposure and presentation.
Case Presentation:
We report a case of ankle arthritis in a boy who presented one year earlier with a tick bite on the dorsum of the foot. He was suboptimally treated with oral antibiotics for one week, and developed in the following months a painless limp. Radiographs revealed a severe arthritis of the right ankle joint with necrosis of the talus and deformation of the talocrural and subtalar joints. There was no history of malaise, fever or other systemic symptoms. He remains seronegative for antibodies against B. burgdorferi.
Conclusions:
The suboptimal oral antibiotic treatment may have hindered the antibody production against B burgdorferi, while not being therapeutic, resulting in severe ankle arthritis due to seronegative Lyme disease.
doi:10.2174/1874325001105010165
PMCID: PMC3096051  PMID: 21594002
Arthritis; children; seronegative Lyme disease; borreliosis.
13.  The epidemiology of malignant giant cell tumors of bone: an analysis of data from the Surveillance, Epidemiology and End Results Program (1975–2004) 
Rare Tumors  2009;1(2):e52.
Malignant giant cell tumor (GCT) of bone is a rare tumor with debilitating consequences. Patients with GCT of bone typically present with mechanical difficulty and pain as a result of bone destruction and are at an increased risk for fracture. Because of its unusual occurrence, little is known about the epidemiology of malignant GCT of bone. This report offers the first reliable population-based estimates of incidence, patient demographics, treatment course and survival for malignancy in GCT of bone in the United States. Using data from the National Cancer Institute's Surveillance, Epidemiology and End Results (SEER) program, we estimated the overall incidence and determinants of survival among patients diagnosed with malignant GCT of bone from 1975–2004. Cox proportional hazards regression was used to evaluate demographic and clinical determinants of survival among malignant GCT cases. Based on analyses of 117 malignant GCT cases, the estimated annual incidence in the United States was 1.6 per 10,000,000 persons per year. Incidence was highest among adults aged 20 to 44 years (2.4 per 10,000,000 per year) and most patients were diagnosed with localized (31.6%) or regional (29.9%) disease compared to distant disease (16.2%). Approximately 85% of patients survived at least 5 years, with survival poorest among older patients and those with evidence of distant metastases at time of diagnosis. The current study represents the largest systematic investigation examining the occurrence and distribution of malignancy in GCT of bone in the general U.S. population. We confirm its rare occurrence and suggest that age and stage at diagnosis are strongly associated with long-term survival.
doi:10.4081/rt.2009.e52
PMCID: PMC2994468  PMID: 21139931
giant cell tumor of bone; surveillance; epidemiology and end results; descriptive epidemiology; incidence; survival; osteosarcoma.
14.  A clinicopathological study of giant cell tumor of small bones 
Upsala Journal of Medical Sciences  2011;116(4):265-268.
Background and purpose
Giant cell tumor (GCT) of the small bones (small-bone GCT) is usually rare and considered somewhat different from conventional GCT. The purpose of this study was to investigate and report the clinicopathological features of 11 cases with small-bone GCT.
Materials and methods
Patient information was obtained with the help of questionnaires. X-rays and paraffin blocks obtained from several institutions were clinically, radiographically, and histologically evaluated.
Results
Small-bone GCT was observed in younger patients compared to conventional GCT; 5 of the 11 (45%) patients were below 20 years of age, whereas the corresponding figure for all GCT patients is 16% in Japan. Excessive cortical bone expansion is a special feature. There were two cases of recurrence and one case of lung metastasis; the primary lesion was in the hand for all three cases. In contrast, no primary lesion of the foot recurred or metastasized. Varying degrees of positive p63 immunostaining were observed in all examined cases (n = 9) of small-bone GCT but were negative in case of giant cell reparative granuloma (GCRG) and solid variant of aneurysmal bone cyst (ABC). One case that demonstrated high-intensity positive staining had two episodes of recurrence.
Conclusion
Small-bone GCT tends to develop in younger patients than does conventional GCT. Primary GCTs of the hand may be biologically more aggressive than those of the feet. The p63 immunostaining may be useful not only for differential diagnosis but also for prognostication of small-bone GCT.
doi:10.3109/03009734.2011.596290
PMCID: PMC3207302  PMID: 21919814
clinicopathological study; giant cell tumor; p63 immunostaining; small bone
15.  Total Dislocation of the Talus without a Fracture. Open or Closed Treatment? Report of Two Cases and Review of the Literature 
Complete dislocation of the talus not accompanied by a fracture is a very rare injury. The injury is encountered as a closed one even more rarely. Reviewing the literature we found that proposed treatments for total talus dislocation varied from primary talectomy or arthodesis (to avoid complications) to closed reduction and an under knee cast. Most importantly, there was no agreement among authors about the method of reduction (open/closed). We report our experience with two cases of closed total talus dislocation not accompanied by a fracture, and review the literature to retrieve evidence on whether a closed or open treatment should be preferred for this type of injury.
doi:10.2174/1874325000903010052
PMCID: PMC2707762  PMID: 19590615
Talus; total dislocation; treatment.
16.  Extensive Implant Reaction in Failed Subtalar Joint Arthroereisis: Report of Two Cases 
HSS Journal  2007;3(2):177-181.
Foreign body synovitis with extensive granulomatous giant cell reaction to refractile polyethelene debris is a complication of subtalar arthroereisis not previously reported. We present two cases whereby STA-peg implants were used to treat bilateral painful flexible flatfoot deformities in children. Two boys, presented at 7 and 10 years of age, 2 years after STA-peg procedures and tendo-Achilles lengthening for painful flatfeet. They each had minimal subtalar motion and pain at the sinus tarsi. Radiographs demonstrated surgical defects in the calcaneus with surrounding high signal on the magnetic resonance imaging (MRI) in the subchondral bone of the calcaneus and talus. Both patients failed conservative management and had their implants removed with good relief of their pain. Histology was submitted at the time of implant removal. We present the radiographic and pathologic findings seen in these two patients with failed subtalar arthroereisis due to extensive implant reaction. The pathologic process seen in these patients is a previously unreported complication of this procedure. We do not recommend arthroereisis in the treatment of painful flexible flatfoot in children.
doi:10.1007/s11420-007-9057-0
PMCID: PMC2504261  PMID: 18751791
arthroereisis; pes planus; children; subtalar synovitis
17.  Contribution of magnetic resonance imaging in the diagnosis of talus skip metastases of Ewing's sarcoma of the calcaneus in a child: a case report 
Introduction
Ewing's sarcoma of the calcaneus is rare. About thirty cases with calcaneus involvement have been reported in the literature. Talus skip metastases have rarely been described in the available literature
Case presentation
We report a case of a 14-year-old Moroccan boy, who presented with Ewing's sarcoma of his right calcaneus, diagnosed by swelling of the calcaneus evolving over a year. Radiography, computed tomography and magnetic resonance imaging showed an important tumoral process of the calcaneus and talus skip metastases. The diagnosis was confirmed with histology after a biopsy. In spite of amputation and postoperative chemotherapy, our patient died six months later due to secondary respiratory distress after lung metastasis.
Conclusion
Imaging, especially magnetic resonance, is important in the diagnosis of Ewing sarcoma and skeletal skip metastases. Treatment of Ewing's sarcoma consists of chemotherapy, radiation therapy and surgical resection depending on the stage and extent of the disease. With the exception of lesions in the calcaneus, the prognosis for disease-free survival of Ewing's sarcoma of the foot is excellent.
doi:10.1186/1752-1947-5-451
PMCID: PMC3183038  PMID: 21910875
18.  Resection arthrodesis for the management of aggressive giant cell tumor of the distal femur 
Indian Journal of Orthopaedics  2009;43(1):67-71.
Background:
Giant cell tumors (GCTs) of bone are aggressive benign tumors. Wide resection is reserved for a small subset of patients with biologically more aggressive, recurrent, and extensive tumors. Wide resection and mobile joint reconstruction are preferable for treating tumors around the knee. In certain situations, resection arthrodesis or an amputation is suggested. In this prospective study we report the outcome of 8 patients of aggressive GCT of lower end of femur treated with resection arthrodesis.
Materials and Methods:
Eight patients with mean age of 37.25 years (range 30–45 years) with Campanacci Grade III (Enneking stage III) giant cell tumors at the distal femur were treated with wide resection and arthrodesis using dual free fibular graft and locked intramedullary nail from January 2003 to January 2008. There were four males and four females patients. The mean follow-up was 48.75 months (range 30–60 months). The functional evaluation was done using the standard system of musculoskeletal tumor society with its modification developed by Enneking et al.
Results:
At the final follow up the functional score ranged from 20 to 27 out of total score of 30. Graft union was achieved in all cases in a duration mean of 14.5 months (range 12-20 months).One case required secondary bone graft due to delayed union, and one case had superficial wound infection which healed on systemic antibiotics. At final followup, all the patients were disease free.
Conclusion:
Wide resection and arthrodesis in aggressive GCTs of the distal femur with involvement of all muscle compartments is a good treatment option. Resection arthrodesis offers a biological reconstruction alternative to amputation in a special group of patients when extensive resection precludes mobile joint reconstruction.
doi:10.4103/0019-5413.44432
PMCID: PMC2739496  PMID: 19753183
Giant cell tumor; intra medullary nail; resection arthrodesis
19.  GIANT CELL TUMOR OF THE SACRUM AND SPINE: SERIES OF 23 CASES AND A REVIEW OF THE LITERATURE 
Although there have been a few large case series of giant cell tumor (GCT) in the spine and sacrum, the treatment of these lesions remains controversial. We are reporting 23 additional cases of giant cell tumor in the spine and sacrum gathered from our institution and the personal consultation files of the senior author. Ten lesions occurred in the sacrum with an average age of 31 years (range of 13-49) and 13 occurred in the mobile spine with an average age of 39.1 years (range of 13-64). Most patients presented with pain or neurologic deficit at the site of tumor involvement, and symptoms were usually present for many months prior to diagnosis. Six of the sacral GCT patients were treated with pre-operative arterial embolization and intralesional surgical resection, and two developed a recurrence. Two of the sacral GCT patients had an en bloc resection and neither developed a recurrence. One sacral GCT patient was treated only with serial arterial embolization with good disease control. One sacral GCT patient did not receive any treatment. Eleven spinal GCT patients were treated with en bloc surgical resection and two developed a recurrence, the other two spinal GCT patients were treated with intralesional surgical resection and both developed a recurrence. Giant cell tumors of the spine and sacrum should be managed with en bloc resections whenever possible as this provides the greatest chance for cure. When the risk of post-operative neurologic deficit after en bloc excision is high, as in most of our sacral lesions, conservative therapy involving arterial embolization and intralesional resection offers the best results.
PMCID: PMC2958273  PMID: 21045974
20.  Giant Cell Tumor of Bone: Risk Factors for Recurrence 
Background
Many surgeons treat giant cell tumor of bone (GCT) with intralesional curettage. Wide resection is reserved for extensive bone destruction where joint preservation is impossible or when expendable sites (eg, fibular head) are affected. Adjuvants such as polymethylmethacrylate and phenol have been recommended to reduce the risk of local recurrence after intralesional surgery. However, the best treatment of these tumors and risk factors for recurrence remain controversial.
Questions/purposes
We evaluated the recurrence-free survival after surgical treatment of GCT to determine the influence of the surgical approach, adjuvant treatment, local tumor presentation, and demographic factors on the risk of recurrence.
Methods
We retrospectively reviewed 118 patients treated for benign GCT of bone between 1985 and 2005. Recurrence rates, risk factors for recurrence and the development of pulmonary metastases were determined. The minimum followup was 36 months (mean, 108.4 ± 43.7; range, 36–233 months).
Results
Wide resection had a lower recurrence rate than intralesional surgery (5% versus 25%). Application of polymethylmethacrylate decreased the risk of local recurrence after intralesional surgery compared with bone grafting; phenol application alone had no effect on the risk of recurrence. Pulmonary metastases occurred in 4%; multidisciplinary treatment including wedge resection, chemotherapy, and radiotherapy achieved disease-free survival or stable disease in all of these patients.
Conclusion
We recommend intralesional surgery with polymethylmethacrylate for the majority of primary GCTs. Because pulmonary metastases are rare and aggressive treatment of pulmonary metastases is usually successful, we believe the potential for metastases should not by itself create an indication for wide resection of primary tumors.
Level of Evidence
Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
doi:10.1007/s11999-010-1501-7
PMCID: PMC3018195  PMID: 20706812
21.  Comparative analysis of uniplanar external fixator and retrograde intramedullary nailing for ankle arthrodesis in diabetic Charcot's neuroarthropathy 
Indian Journal of Orthopaedics  2011;45(4):359-364.
Background:
Charcot's neuroarthropathy of ankle leads to instability, destruction of the joint with significant morbidity that may require an amputation. Aim of surgical treatment is to achieve painless stable plantigrade foot through arthrodesis. Achieving surgical arthrodesis in Charcot's neuroarthropathy has a high failure rate. This is a retrospective nonrandomized comparative study assessing the outcomes of tibio-talar arthrodesis for Charcot's neuroarthropathy treated by uniplanar external fixation assisted by external immobilization or retrograde intramedullary interlocked nailing.
Materials and Methods:
Records of the authors′ institution were reviewed to identify those patients who had undergone ankle fusion for diabetic neuroarthropathy from January 1998 to December 2008. A total of11 patients (six males and five females) with a mean age of 56 year and diabetes of a mean duration of 15.4 years with ankle tibio-talar arthrodesis using retrograde nailing or external fixator for Charcot's neuroarthropathy were enrolled for the analysis. Neuropathy was clinically diagnosed, documented and substantiated using the monofilament test. All procedures were performed in Eichenholz stage II/III.Six patients were treated with uniplanar external fixator, while the remaining five underwent retrograde intramedullary interlocking nail. The outcomes were measured for union radiologically, development of complications and clinical follow-up, according to digital archiving systems and old case notes.
Results:
All five (100%) patients treated by intramedullary nailing achieved radiological union on an average follow-up of 16 weeks. The external fixation group had significantly higher rate of complications with one amputation, four non unions (66.7%) and a delayed union which went on to full osseous union.
Conclusion:
The retrograde intramedullary nailing for tibio-talar arthrodesis in Charcot's neuroarthropathy yielded significantly better outcomes as compared to the use of uniplanar external fixator.
doi:10.4103/0019-5413.82343
PMCID: PMC3134023  PMID: 21772631
Charcot's diabetic neuropathy; retrograde intramedullary nailing; tibio-talar arthrodesis; uniplanar external fixator
22.  Delayed surgical treatment for neglected or mal-reduced talar fractures 
International Orthopaedics  2005;29(5):326-329.
From 1993 to 2002, we treated nine patients for neglected or mal-reduced talar fractures. Average patient age was 39 (20–64) years and average follow-up 53 months. The time interval between injury and index operation ranged from 4 weeks to 4 years. Surgical procedures included open reduction with or without bone grafting in six cases, open reduction combined with ankle fusion in one case, talar neck osteotomy in one case, and talar neck osteotomy combined with subtalar fusion in one case. All cases had solid bone union. One patient developed avascular necrosis of the talus needing subsequent ankle arthrodesis. In six patients, adjacent hindfoot arthrosis occurred. The overall AOFAS ankle–hindfoot score was in average 77.4. We conclude that in neglected and mal-reduced talar fractures, surgical treatment can lead to a favourable outcome if the hindfoot joints are not arthritic.
doi:10.1007/s00264-005-0675-1
PMCID: PMC3456640  PMID: 16094539
23.  Giant cell tumor of the uterus: case report and response to chemotherapy 
BMC Cancer  2007;7:46.
Background
Giant cell tumor (GCT) is usually a benign but locally aggressive primary bone neoplasm in which monocytic macrophage/osteoclast precursor cells and multinucleated osteoclast-like giant cells infiltrate the tumor. The etiology of GCT is unknown, however the tumor cells of GCT have been reported to produce chemoattractants that can attract osteoclasts and osteoclast precursors. Rarely, GCT can originate at extraosseous sites. More rarely, GCT may exhibit a much more aggressive phenotype. The role of chemotherapy in metastatic GCT is not well defined.
Case presentation
We report a case of an aggressive GCT of the uterus with rapidly growing lung metastases, and its response to chemotherapy with pegylated-liposomal doxorubicin, ifosfamide, and bevacizumab, along with a review of the literature.
Conclusion
Aggressive metastasizing GCT may arise in the uterus, and may respond to combination chemotherapy.
doi:10.1186/1471-2407-7-46
PMCID: PMC1832205  PMID: 17359524
24.  Recurrent Giant Cell Tumor of Long Bones: Analysis of Surgical Management 
Background
Treatment of giant cell tumor of bone (GCT) often is complicated by local recurrence. Intralesional curettage is the standard of care for primary GCTs. However, there is controversy whether intralesional curettage should be preferred over wide resection in recurrent GCTs.
Questions/purposes
We investigated the rerecurrence-free survival after surgical treatment of recurrent GCTs to determine the influence of the surgical approach, adjuvant treatment, local tumor presentation, and demographic factors on the risk of further recurrence.
Patients and Methods
We retrospectively reviewed the medical records of 46 patients with recurrent GCTs of long bones treated with wide resection or intralesional curettage and compared these cohorts. Recurrence rates, risk factors for recurrence, and the development of pulmonary metastases were determined. The minimum followup was 37 months (mean, 134 months; range, 37–337 months).
Results
The rate of rerecurrence after wide resection was 6%. Intralesional curettage showed an overall rerecurrence rate of 32%. Implantation of polymethylmethacrylate (PMMA) instead of bone grafting was associated with a lower risk of subsequent recurrence in intralesional procedures (14% versus 50%). Extracompartmental disease did not increase the risk of rerecurrence. Pulmonary metastases occurred in seven patients and appeared independent of the surgical treatment modality chosen.
Conclusions
Intralesional curettage with methylmethacrylate for recurrent GCT provided equivalent tumor control compared with resection in this retrospective study. If joint salvage is possible, we advocate this treatment over resection in recurrent GCTs to preserve the native joint articulation.
Level of Evidence
Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
doi:10.1007/s11999-010-1560-9
PMCID: PMC3048273  PMID: 20857250
25.  Osteochondral lesion of the talus in a recreational athlete: a case report 
A 23-year-old recreational male athlete presented with intermittent pain of three weeks duration, localized to the left ankle. Pain was aggravated by walking, although his symptoms had not affected the patient’s jogging activity which was performed three times per week. Past history revealed an inversion sprain of the left ankle, sustained fifteen months previously. Examination showed mild swelling anterior to the ankle mortise joint while other tests including range of motion, strength and motion palpation of specific joints of the ankle were noted to be unremarkable. Radiographic findings revealed a defect in the medial aspect of the talus. An orthopaedic referral was made for further evaluation. Tomography revealed a Grade III osteochondral lesion of the talus.
It was determined that follow-up views be taken in three months to demonstrate if the lesion was progressing or healing. Within the three month period, activity modifications and modalities for pain control were indicated. Surgery was considered a reasonable option should conservative measures fail.
The present case illustrates an osteochondral lesion of the talus, a condition which has not previously been reported in the chiropractic literature. A review of the pertinent orthopaedic literature has indicated an average delay of three years in diagnosing the existence of this lesion.
Although considered rare, the diagnostic frequency of the condition appears to be on the rise due to increased awareness and the use of bone and CT scans. The osteochondral lesion of the talus deserves particular consideration by practitioners working with athletes due to its higher incidence within this group. This diagnosis should be considered in patients presenting with chronic ankle pain particularly when a history of an inversion sprain exists.
The purpose of this report is to increase awareness of this condition, and review diagnosis and management strategies.
Images
PMCID: PMC2485432
osteochondral lesion; talus; osteochondritis dissecans; diagnosis; chiropractic; athletic injuries; ankle

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