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Hendrian Chaniago

FUNCTIONAL OUTCOME OF ROTATIONAL PEDICLE FIBULAR GRAFT PROCEDURE AFTER RESECTION GIANT CELL TUMOR CAMPANACCI STAGE 3 AROUND THE KNEE JOINT. Hendrian Chaniago. Background. Reported 50% of GCT occur in the knee joint (1)

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Hendrian Chaniago

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  1. FUNCTIONAL OUTCOME OF ROTATIONAL PEDICLE FIBULAR GRAFT PROCEDURE AFTER RESECTION GIANT CELL TUMOR CAMPANACCI STAGE 3 AROUND THE KNEE JOINT HendrianChaniago

  2. Background • Reported 50% of GCT occur in the knee joint(1) • This GCT was classified by Enneking and Campanacci et al(1). • One of the option for Limb salvage procedure is fibular bone graft as knee arthrodesis • Un-supported of clinical data on functional outcome of this procedure  research (1) M. Szendröi M, Professor. Giant cell tumor of bone. J Bone Joint Surg [Br]. [Review article]. 2004;86-B(1).

  3. Problem • Want to know functional outcome of this procedure has been done in Orthopedics and Traumatology Department of Medical Faculty of Hasanuddin University, Makassar.

  4. Hypothesis • Functional outcome of this procedure is really not satisfactory patients

  5. AIM OF STUDY • General • To analyze functional outcome of rotational pedicle fibular graft procedure after resection GCT Campanacci Stage 3 around the knee joint.

  6. Specific • To analyze functional outcome of the procedure on: • The distal femur • The proximal tibia • To assess the complications

  7. LITERATURE STUDY • Giant Cell Tumor (GCT) • 2nd to 4th decades of life (male : female = 1:1,5)(1). • Histological features are unpredictable(1). • Clinical symptoms  swelling, pain and pathological fracture in 10-30% of cases(2). M. Szendröi M, Professor. Giant cell tumor of bone. J Bone Joint Surg [Br]. [Review article]. 2004;86-B(1). Sudqi A. Hamed MD FZHM. Giant Cell Tumor Of Bones: Management by Different Surgical techniqes. Journal of The Royal Medical Services. [Reseach]. 2008 April 12, 2006;15(1):23-30.

  8. Diagnosis clinical and radiological examination (x-ray, CT scan and MRI)(1). • Preoperative biopsy to confirm the diagnosis  grade of the malignancy(1). • Treatment Curettage or en bloc resection combined with bone cement, bone graft (free / vascularized), limb salvage and amputation(2.3) (1) Sudqi A. Hamed MD FZHM. Giant Cell Tumor Of Bones: Management by Different Surgical techniqes. Journal of The Royal Medical Services. [Reseach]. 2008 April 12, 2006;15(1):23-30. (2) Yoshinao oda HM, et al. Giant Cell Tumor of Bone: Oncological and Functional Results of Long-term Follow-up. Jpn J Clin Oncol. [a retrospective review]. 1998 February 3;5(28):323-8. (3) El Sayed Ashraf Khalil MD, FRCS, Alaa Younis,M.D, Shrif A.Aziz,M.D, Magdy El Shahawy,M.D. Surgical Management for Giant Cell Tumor of Bones. Journal of the Egyptian Nat Cancer Inst. [Original article]. 2004 September, 2004;16(3):154-52.

  9. Enneking and Campanacci et al developed a classification based on clinical, radiographic and histological features consist of stage(1) • 1. Latent A quiescent form, the cortical involvement is minimal. Rare stage, asymptomatic. • 2. Active Show extensive cortical thinning and bulging. • 3. Aggressive Lesions break through the cortical bone and have a soft tissue component covered by a pseudo capsule and periosteum. On rare occasions, the tumour extends its barrier, the articular cartilage, and enters the joint. (1) M. Szendröi M, Professor. Giant cell tumor of bone. J Bone Joint Surg [Br]. [Review article]. 2004;86-B(1).

  10. Limb salvage procedures around the knee includes knee prosthesis, auto / allograft as arthrodesis or conversion to rotationplasty. • Depends on several factors: the spread of tumors, bone and tissue conditions remaining and the needs of patients and their expectancy(1). (1) Huang T-L, Chen T-H, Chen WY-K, Chen W-M, Liu C-L, Lo W-H. Allograft Arthrodesis of the Knee in High-grade Osteosarcoma. J Chin Med Assoc. [Original Article]. 2005 December 6, 2004;68(9):425-6.

  11. Advantages of endoprosthethic(1) • Good stability and durability • Immediately load bearing (1) Peh Khee Tan MD MHTM. Functional Outcome Study of Mega-Endoprosthetic Recontruction in limbs With Bone Tumour Surgery. Annals Academy of Medicine. 2009 March, 2009 38(3):192-6.

  12. Disadvantages of endoprosthethic(1) • Depends on daily activity • long term use cannot be expected • young age  increases the wear • Large resection  to ensure safety of margin • Bone cement application  difficult to control of depth of the necrotic margin and high risk of bone fracture and skin necrosis(1) • Increased rates of complications such as infection, fatigue fracture • Cost ↗↗↗ (1) Peh Khee Tan MD MHTM. Functional Outcome Study of Mega-Endoprosthetic Recontruction in limbs With Bone Tumour Surgery. Annals Academy of Medicine. 2009 March, 2009 38(3):192-6.

  13. Rotational Pedicle Fibular Graft • First introduced by Lexer in 1908 as arthrodesis the knee(1). • Develop procedure with rotate the fibula while keeping his fibular pedicle(2). • Union as normal bone healing process(3). • Negates of creeping substitution system(4).  Feasible and applicable in this country because of costs and ability of patients Huang T-L, Chen T-H, Chen WY-K, Chen W-M, Liu C-L, Lo W-H. Allograft Arthrodesis of the Knee in High-grade Osteosarcoma. J Chin Med Assoc. [Original Article]. 2005 December 6, 2004;68(9):425-6. El Sayed Ashraf Khalil MD, FRCS, Alaa Younis,M.D, Shrif A.Aziz,M.D, Magdy El Shahawy,M.D. Surgical Management for Giant Cell Tumor of Bones. Journal of the Egyptian Nat Cancer Inst. [Original article]. 2004 September, 2004;16(3):154-52. Jeffrey B. Friedrich M, et al. Free Vascularized Fibular Graft Salvage of Complications of Long-Bone Allograft After Tumor Reconstruction. J Bone Joint Surg Am. [Reseach]. 2008;90-A(1):93-100. Donald S. Bae MaPMW, MD. Free Vascularized Fibula Grafting: Principles, Techniques, and Applications in Pediatric Orthopaedics. Journal Orthopedic Surgery Harvard Medical School. [Original article]. 2006:86-9.

  14. a limb-length discrepancy (LLD) occurred  affect the functional outcome(1). • LLD ≥2 cm  correcting by a shoe lift or with limb-lengthening procedures(1). (1) Hiroyuki Futani M, Takeshi Minamizaki, MD, et al. Long-Term Follow-up After Limb Salvage in Skeletally Immature Children with a Primary Malignant Tumor of the Distal End of the Femur. The Journal of Bone and Joint Surgery. [Original Article]. 2006 March, 2006;88-A(3):595-603.

  15. Functional outcome evaluations • Introduced by Enneking et al in 1991 • Has been revised by the Musculoskeletal Tumor Society Score(1). • Consists of six factors; pain, function, emotional acceptance, support / aids, walking ability, and gait(1). • a maximum value of the range 0% to 100%(2). • Emmanuel P. Estrella M, Edward HM Wang M, MSc, Leo Daniel D. Caro M, Vicente G. Castillo M. Functional Outcomes of Reconstruction for Soft Tissue Sarcomas of the Foot and Ankle. The Foot and Ankle Online Journal 2. 2009 February, 2009;(3): 2. • Tunn PU, Pomraenke D, Goerling U, Hohenberger P. Functional outcome after endoprosthetic limb-salvage therapy of primary bone tumours—a comparative analysis using the MSTS score, the TESS and the RNL index. International Orthopaedics (SICOT). [Original Article]. 2007 March 16, 2007;32:619-6.

  16. Working frame

  17. Material and Method • Material • Stationery • Medical record • Measuring Instruments • Digital camera “SONY Cybershot 10.1 MEGAPIXEL” • X-ray machine type (Siemens Model No.03070013 Made in German-Siemens Opitop 150/40/80/HC-1003 PH Model No.03345209 Serial No. 401330944 Made in China). • CT Scan machine type (GE Model No.5124069-112 Serial No. 27695YC6/October 2010 Made in Japan). • MRI machine type (HITACHI AIRIS II Type MR-RGP-I Serial  Number : KR 11674 401 Made in Japan)

  18. Method • Design of study • Retrospective cross sectional case study • Place and time • Orthopedics & Traumatology Department of Medical Faculty of Hasanuddin University, Makassar, Indonesia on June 2013 • Populations • Who had underwent rotational pedicle fibular graft procedure after resection GCT campanacci stage 3 around the knee joint from June 2008 to June 2013

  19. Criteria • Inclusion Criteria • Agreed as the research object • Had underwent rotational pedicle fibular graft procedure • Minimal follow-up 6 months after operation • Exlusion Criteria • Other abnormalities on the same side of the leg; fractures, malunion, non-union

  20. Surgery procedure (1) Resection proximal tibia (2) Resection distal femur (3) Skeletal defect after resection (4)Rotation of fibula and pedicle 180° (5) Inlay fibula with femur (6) complete arthrodesis using plate and screw

  21. Research Flow • Identifying patients who including criteria on the medical record in Dr. WahidinSudirohusodo Hospital, Makassar as secondary data • Goes to interview and physical examination as primary data to obtain functional outcome data • Evaluate the functional outcome by Musculoskeletal Tumor Society Score • Statistical analysis using the non-parametric test • Analyzing disability after procedure by a limb-length discrepancy (LLD) related to daily activities • Assessed the incidence of recurrence and postoperative union • Results are collected, recorded, analyzed, and then will be discussion to decision-making of the procedure

  22. Research Flow

  23. Operational definition • Rotational pedicle fibular graft procedure is a rotating the bone graft with intact fibula following proximal vascular pedicle, was transferred into the distal femur and proximal fibula into the proximal tibia • Functional outcome is clinical assessment and statistical analysis from functional outcome parameters by MSTS Score • Union is radiographic union of fibular graft which is characterized by callus formation and loss of fracture line at least 6 months of follow-up

  24. RESULT • Inclusion criteria patient who underwent rotational pedicle fibular graft procedure

  25. Patient Range, Mean and SD, who underwent rotational pedicle fibular graft procedure

  26. MSTS score related to site of tumor after Rotational Pedicle Fibular Graft Procedure • MSTS score related to site of tumor after Endoprosthetic Procedure By P.U.Tunn et.al, April 2007(1) (1) Tunn PU, Pomraenke D, Goerling U, Hohenberger P. Functional outcome after endoprosthetic limb-salvage therapy of primary bone tumours—a comparative analysis using the MSTS score, the TESS and the RNL index. International Orthopaedics (SICOT). [Original Article]. 2007 March 16, 2007;32:619-6.

  27. Statistics Analysis By Non-parametric Mann-Whitney U Test • Mann-Whitney U Test is significant (P>0,05)

  28. The complication

  29. DISCUSSION • The treatment a primary bone tumor depending on surgical classification and the availability of tools • Stage-3 of campanacci is the final stage, a greater risk of local recurrence should be treated as high-grade bone sarcomas(1). • M. Szendröi M, Professor. Giant cell tumor of bone. J Bone Joint Surg [Br]. [Review article]. 2004;86-B(1).

  30. Due to cost of endoprosthetic  the rotational pedicle fibular graft procedure is one of the options reasonable does not expensive and also does not require expertise microsurgery techniques

  31. Allograft procedure was not chosen because of increasing cases of infection, transverse-borne diseases from the donor graft, absence of bone banks for graft donor and the graft healing only as creeping substitution.

  32. In our patient, skeletal defect and LLD which formed  no significant influence of functional outcome  improved patient satisfaction scores and their expectation after the procedure done.

  33. No significant difference in functional outcomes of clinical studies conducted P.U.Tunn et.al, April 2007 using endoprosthetic around the knee(1) (1) Tunn PU, Pomraenke D, Goerling U, Hohenberger P. Functional outcome after endoprosthetic limb-salvage therapy of primary bone tumours—a comparative analysis using the MSTS score, the TESS and the RNL index. International Orthopaedics (SICOT). [Original Article]. 2007 March 16, 2007;32:619-6.

  34. CONCLUSION • Treatment of primary bone tumors in developing countries with low economic level and lack of facilities  must be considered • This procedure is reasonable and applicable  suggestion to applied

  35. Advice • More sample

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