Total hip arthroplasty for giant cell tumour.

SS Kulkarni, AS Dogra, PB Bhosale 
 Department of Orthopaedics, Seth GS Medical College, Parel, Mumbai.

Correspondence Address:
S S Kulkarni
Department of Orthopaedics, Seth GS Medical College, Parel, Mumbai.

Full Text

::   Introduction

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. We present here an uncommon site for occurrence of the GCT i.e. the proximal femur, and its subsequent management.

The proximal femur is an uncommon location for the occurrence of Giant Cell Tumour. Mirra[2] has reported an incidence of less than 4% of 1182 cases in this location. Schajowicz[3] in his series of 362 cases has reported only 11 cases affecting the upper end of the femur (3%).

::   Case report

A 39-year-old sedentary worker, presented to our hospital with a history of inability to walk following trivial trauma to the left hip region. The patient gave a history of constant dull ache in the left hip region since 4 months. There was no significant proximal lymphadenopathy or distal neurovascular deficit. The general examination was unremarkable. Clinically a diagnosis of pathological transcervical fracture neck femur was made. Plain roentgenograms revealed a transcervical fracture neck femur with a lytic lesion involving the head neck region. It was well demarcated with a narrow zone of transition. There was evidence of breach of the cortex posterosuperiorly [Figure:1], [Figure:2]. All routine hematological investigations and X-ray chest were normal. A Fine Needle Aspiration Cytology (FNAC) failed to give a definite diagnosis, revealing haemorrhagic fluid and no malignant cells.

An excisional biopsy was planned with reconstruction using the Charnley type of low friction total hip arthroplasty. On exploration through the posterolateral approach, the headneck region demonstrated friable bony tissue containing various sized cavitations with old blood and fibrous tissue. An intralesional excision of the tumour was performed with excision of head and neck and sent for frozen section to confirm the clinical suspicion of a Giant Cell Tumour. The acetabulum and proximal femur were prepared for cementing and the margins were sent for frozen section biopsy to confirm adequacy of resection margins. The acetabular and femoral components were cemented in place and the wound was closed over a negative suction drain after meticulous haemostasis. Postoperatively the patient was made to stand with support on the fifth day and started partial weight bearing on the tenth day. The wounds healed without complications.

Microscopic evaluation of the tumour, which confirmed the diagnosis of GCT showing stromal cells with no appreciable atypism. Occasional stromal cells showed large nuclei with abundant giant cells. The stroma showed little evidence of fibrous or collagenous differentiation. (Grade 1)[4].

At a 32 months followup the wounds had healed by primary intention and there was no evidence of recurrence locally. The patient was painfree and satisfied with a left hip range of motion of:

Flexion - 0? - 90? Abduction - 0? - 30?

Int. Rotation  0? - 20? Ext. Rotation - 0? - 20?

There was a limb length discrepancy of 1 cm, which was treated with an appropriate heel raise. The patient returned to his daily activities and was walking full weight bearing, with a mild Trendelenberg lurch.

::   Discussion

The reconstruction of the hip joint following excision for tumours is essential for maintenance of stability and normalisation of gait patterns. The options after excision include a Girdlestone type of excisional arthroplasty, hemiarthroplasty or total hip arthroplasty. The instability and shortening caused by an excisional arthroplasty was not acceptable to our patient. Poor results of hemiarthroplasty in young patients have been well documented in literature[5]. Good long-term followup of cemented arthroplasty in young patients has recently been documented[6]. Also the use of bone cement has been shown to decrease the incidence of local recurrence in GCT[7]. The use of methymethacrylate leads to the formation of a 2 mm osteolytic zone surrounding it which is surrounded by sclerotic rim. Lysis or failed development of the sclerotic zone adjacent to the lytic zone is suspicious of recurrence, which was not seen in our case. Though histo-pathological and radiological staging exist they do not correlate clinically with the incidence of recurrence. Our case was Grade 1 (Jaffe) histo-pathologically and at a 32 month follow-up there has been no recurrence.

References