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|Year : 1995 | Volume
| Issue : 3 | Page : 83-4
Distal fibular giant cell tumour.
AS Dogra, SS Kulkarni, PB Bhosale
Department of Orthopaedics, Seth G S Medical College, Parel, Mumbai.
A S Dogra
Department of Orthopaedics, Seth G S Medical College, Parel, Mumbai.
Source of Support: None, Conflict of Interest: None
A patient who reported with a slowly growing swelling ovr thee lateral aspect of the left ankle, was investigated and diagnosed to have a giant cell tumour which was confirmed on FNAC. The tumour was managed with excision biopsy and reconstruction. The case is being reported for its rare site of occurrence.
Keywords: Adult, Ankle Joint, pathology,radiography,surgery,Biopsy, Needle, Bone Neoplasms, diagnosis,surgery,Case Report, Female, Fibula, Follow-Up Studies, Giant Cell Tumor of Bone, diagnosis,surgery,Human, Orthopedic Procedures, methods,Treatment Outcome,
|How to cite this article:|
Dogra A S, Kulkarni S S, Bhosale P B. Distal fibular giant cell tumour. J Postgrad Med 1995;41:83
Giant Cell Tumour (GCT) is one of the commonly encountered bone tumours in clinical practice with an incidence of upto 30.3% in parts of South India. More than 50% of these occur around the knee joint. In India, distal radius is also a very common site. We present here a rare site for occurrence of the GCT i.e. the distal fibula, and its subsequent management.
The rarity of this location for the occurrence of GCT can be well appreciated as reported by Mirra with an incidence of less than 1% of 1182 cases. Schajowicz, in his series of 362 cases has reported only a single case affecting the lower end of the fibula (0.28%).
A 28-year-old housewife presented to our hospital with a slowly growing swelling of 8 months duration over the lateral aspect of her left ankle. Her daily activities were restricted because of pain on weight bearing. There was no other significant contributory history.
On examination there was a well demarcated bony swelling arising from the lateral malleolus measuring 6 cm x 4 cm x 2 cm, firm to hard in consistency. The skin over the swelling was normal. The ankle range of motion was from 30 degrees of plantar flexion to 10 degrees of dorsiflexion, which was terminally painful. There was no significant lymphadenopathy or distal neurovascular deficit. The general examination was unremarkable.
Plain roentgenograms revealed an expansile lytic lesion restricted to the lateral malleolus. It was well demarcated with a narrow zone of transition and showing a "soap-bubble" appearance. There was evidence of breach of the cortex. [Figure:1]. All routine haematological investigations and chest X-ray were normal. A fine needle aspiration cytology (FNAC) confirmed the clinical diagnosis of giant cell tumour of bone
An excisional biopsy was planned with reconstruction using the proximal end of the ipsilateral fibula. Under pneumatic tourniquet without exsanguination an en bloc excision of the lateral malleolus with lower third of the fibula was carried out through a lateral incision. An adequate length of proximal fibula was resected extra periosteally after isolation of the lateral popliteal nerve. The proximal fibula was reversed and fixed to the remaining lower fibula using a one third tubular plate and screws. A laterally based open wedge osteotomy of the (now) distal end of fibula enabled proper articular orientation and congruity to be restored. The transposed fibula was fixed to the distal tibia with a syndesmotic screw. Meticulous haemostasis was achieved after release of the tourniquet, and the wounds were closed in layers. Postoperatively the patient was maintained in an above knee cast. Subsequently the patient was ambulatory, non-weight bearing on axillary crutches for a period of 3 months. At 3 months the patient was advised removal of the synclesmotic screw. However, the patient refused the same and proceeded to graduated weight bearing.
The surgical specimen of the lateral malleolus with lower fibula, showed an expansile tumour affecting the lateral malleolus with evidence of breach of cortex posteriorly covered with a thin shell of fibrous tissue. Articular cartilage appeared to be intact. Specimen was cut open and showed cystic areas of haemorrhage and necrosis. Microscopic evaluation confirmed the diagnosis of GCT showing stromal cells with slight atypism and occasional irregular whorled arrangement. A few pleomorphic cells were also seen with abundant giant cells (Grade II) X-ray of the specimen is shown in [Figure:2]. The postoperative, X-ray is shown in [Figure:3].
At 24 months follow-up, the wounds had healed by primary intention and there was no evidence of local recurrence. The patient was pain-free and satisfied with a left ankle range of motion of 40 degrees of plantar flexion to 20 degrees of dorsiflexion. The patient was walking, full weight - bearing and performing all her daily activities unhindered.
The reconstruction of the lower fourth of the fibula following excision for tumours is essential for maintenance of stability at the ankle mortise. It has been shown that 20% of weight transmission occurs through the fibula against belief to the contrary earlier. The proximal fibula can be sacrificed for purposes of reconstruction as is recommended for lower end fibula and distal radius. The articular surface of the fibular head can be used to substitute for the articular surface of the lateral malleolus, as has been done in this case. An open wedge osteotomy of the reconstructed lateral malleolus was necessary to achieve near normal congruity of the ankle mortise. Though Histo-pathological and radiological staging exist they do not correlate clinically with the incidence of recurrence. Our case which was Grade II on histopathology, at a 24 month follow-up, has had no recurrence.
| :: References|| |
Reddy CR, Rao PS, Rajakumari K. Giant Cell tumours of bone in South India. J Bone Joint Surg 1974; 56-A, 617. |
|2.||Mirra JM. Giant Cell Tumours. Mirra JM (Ed), Bone Tumours. Clinical Radiologic and Pathologic correlations, Vol 2. Philadelphia: Lea and Febiger; 1989, pp 942. |
|3.||Schajowicz F. Giant Cell Tumour (Osteoclastoma). Schajowicz F, editor. Tumours and Tumour like Lesions of Bone and Joints. New York: Springer-Verlag; 1981, pp 205. |
|4.||Jafte HL, Lichtenstein L, Portis RB. GCT of bone. Its Pathological Appearance, Grading, Supposed Variants and Treatment. Arch Pathology 1940; 30:993. |
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