An aggressive chondroblastoma of the knee treated with resection arthrodesis and limb lengthening using the Ilizarov technique
© Tomić et al; licensee BioMed Central Ltd. 2010
Received: 31 January 2010
Accepted: 28 July 2010
Published: 28 July 2010
This case report describes the management of a 15 year old male with a biologically aggressive chondroblastoma of the knee. Following CT, bone scan, angiography and an open biopsy, the diagnosis was confirmed histologically and immunohistochemically. The patient underwent a 13 cm en-bloc excision of the knee, and knee arthrodesis with simultaneous bone transport using an Ilizarov ring fixator. Following 136 days of bone transport, the patient achieved radiological and clinical bony union after a total frame time of 372 days. He then commenced 50% partial weight-bear in a protective knee brace and gradually worked up to full weight-bearing by 4 months. The patient developed superficial pin tract infections around the k-wires on 2 occasions; these settled with a cephalosporin antibiotic spray and local dressings. At 13 years follow-up there are no signs of disease recurrence or failure at the fusion site. The patient is able to fully weight bear and stand independently on the operated leg. Knee arthrodesis with simultaneous limb-lengthening is an effective treatment modality following en-bloc resection of an aggressive chondroblastoma. The case is discussed with reference to the literature.
First described by Ewing in 1928, chondroblastomas were originally named "epiphyseal chondroblastomatous giant cell tumors of the proximal humerus" by Codman in 1931, and are often still termed Codman tumors [1–4]. They occur mostly in the second decade of life, and are more common in males [5–8]. Usually arising from the epiphyseal plate [9–11] and measuring between 1 and 7 cm , chondroblastomas are most frequently found in the proximal humerus, distal femur, proximal tibia, and the iliac bones [2–4, 7, 9, 13–16]; they can also appear in the talus, ribs and digits [17–20].
Though normally benign, and accounting for 1-2% of all benign bone tumors [2–4], histologically aggressive forms of the disease can also occur [5, 13, 21, 22], with associated high recurrence rates (5-38%) and occasional lung metastases [14, 16, 23].
We report the case of a biologically aggressive chondroblastoma of the knee treated with a 13 cm en-bloc excision, knee arthrodesis, and bone transport using an Ilizarov ring fixator.
Benign chondroblastomas can often be treated with simple curettage with or without bone grafting [4, 14], or with other adjuvant therapies including alcohol, cryotherapy and methylmethacrylate bone cementing [4, 15], however these treatments are associated with recurrence rates of up to 30% , and are thus unacceptable in the more aggressive forms of this disease.
Aggressive disease requires an aggressive management strategy, and in cases involving the knee joint the treatment involves radical joint resection to prevent local recurrence and metastatic disease . As with other tumors occurring around the knee, the residual defect can be managed with massive bony allograft or tumor prostheses following knee excision [13, 24–26]. However these options are not always available due to financial constraints , and if the extensor mechanism has also been included in the resection then a mobile prosthesis is often not possible . The bony defect can be alternatively managed through arthrodesis utilising a variety of internal fixation devices with bone graft/free fibula graft, or by external fixation in conjunction with bone transport in order to preserve limb length [15, 21, 29–33].
In a series of 8 patients undergoing resection arthrodesis for distal femoral giant cell tumors (GCT), successful union and good functional results were achieved in 7 patients for defects measuring 14-17 cm, using dual free fibular grafts and locked intramedullary nails, over a mean 14.5 months . Another series achieved good functional outcomes and 100% union rates using dual fibular grafts alone following en bloc knee resection for 37 GCTs and 16 osteosarcomas, with defects ranging 9-24 cm . A further report of 26 patients with primary bone tumors (including GCT, osteosarcoma and chondrosarcoma) underwent tumor resection and successful knee arthrodesis using autogenous bone graft .
Patients undergoing knee arthrodesis are often left with limb shortening particularly following large resections, and prior to skeletal maturity, and there are many advocates for performing simultaneous limb lengthening surgery [29, 35–38]. The Ilizarov technique has been successfully utilised with bone transport in a series of 5 proximal tibial GCTs, with a mean defect of 5.7 cm , and in 7 distal femoral tumors with defects ranging from 8 to 20 cm ; others have also successfully used this technique in non-tumor cases, such as knee arthrodesis following infected total knee arthroplasty [39–42].
We favoured using the Ilizarov method with bone transport because of its versatility, its ability to provide excellent stability even with poor bone quality, the ability for our patient to fully weight-bear in his frame, and the predicted high rate of bony union [35, 36, 40–42]. In addition the technique creates "live" regenerate bone which we felt was preferable to "dead" allograft or non-vascularised fibular graft. However, aside from being technically challenging, this technique had the disadavantages of requiring a large proximal ring around the distal femur, which made walking awkward, and there was a prolonged fixation time of 372 days. Our patient also suffered pin tract infections on 2 occasions, which is common with all external fixation methods [37, 40–44].
Though one might assume that a knee arthrodesis is an inferior treatment following knee joint excision, a comparison of patients undergoing knee arthrodesis, constrained total knee arthroplasty and below knee amputation, found that patients' function, walking velocity, efficiency and the rate of oxygen consumption were similar . Arthrodesis patients had better limb stability and were able to perform more physically demanding activities, but had difficulty sitting. Arthroplasty patients had to be more sedentary due to weakness/instability, but were generally more positive . Another study found that arthroplasty patients had better physical function scores, though arthrodesis patients had better mean pain scores and scored higher globally .
Our patient continues to do well 13 years following surgery, without any signs of disease recurrence or failure at the fusion site. He has no leg-length discrepancy, is able to fully weight-bear and stand independently on the operated leg, has no pain symptoms, and works full-time as a school teacher.
In conclusion, knee arthrodesis with simultaneous limb-lengthening with an Ilizarov ring fixator is an effective treatment modality following en-bloc resection of an aggressive knee chondroblastoma. The technique is versatile, providing excellent stability, an ability to weight bear in the frame and has a predicatble high rate of bony union.
Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal
Hematoxylin and Eosin stain
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