Giant aneurysmal bone cyst - البروفيسور فريح ابوحسان - اكياس العظام...

11/1/2014Professor Freih Abuhassan - University

of Jordan 1

Giant Aneurysmal Bone Cyst

F.R.C.S.(Eng.), F.R.C.S.(Tr.& Orth.)

Professor of Orthopaedics

Giant Aneurysmal Bone Cyst

11/1/2014 2Professor Freih Abuhassan - University

of Jordan

Patient profile:A 9-years old male child, MF, Overweight.

Chief complaint:

Progressive painless swelling of the right distal thigh of 14 m duration

Referred to us on the

17th Nov. 200811/1/2014 3

Professor Freih Abuhassan - University

of Jordan

History of present illness:

4th Sep. 2007, had pain in the distal femur after a fall while playing.

Diagnosed as pathological fracture of the distal femur.

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of Jordan

4th Sep. 2007

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of Jordan

Treated by complete POP for 3 M

4th Dec. 2007

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of Jordan

19th Jan. 2008

Trivial trauma Supracondylar distal

femur fractures treated by POP for

7 weeks

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of Jordan

19th Jan. 200811/1/2014 8

Professor Freih Abuhassan - University

of Jordan

5th Mar. 200811/1/2014 9

Professor Freih Abuhassan - University

of Jordan

Past medical history

=History of two surgical biopsies with

blood transfusion

Diagnosis: Aneurysmal bone cyst

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of Jordan

Patient offered the following

advices outside JUH

1- Above Knee Amputation

2- Resection and Joint replacement

3- To be treated abroad

Patient was wheel chair dependent

since the start of treatment.11/1/2014 11

Professor Freih Abuhassan - University

of Jordan

6th June 2008

Lesion contineued to grow

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Professor Freih Abuhassan - University

of Jordan

26th Sep. 2008

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of Jordan

Physical examination:

General: no abnormality detected

Right lower limb:

= Diffuse swelling of the knee and lower thigh with

10 cm diameter difference form the left thigh

(firm, not tender, not pulsatile)

=Decreased knee ROM due to the bulky swelling

=Normal distal NV examination

17th Nov. 2008

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of Jordan

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of Jordan

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of Jordan

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of Jordan

Laboratory investigation

CBC

KFT

LFT

ESR

CRP

All were Normal11/1/2014 18

Professor Freih Abuhassan - University

of Jordan

17th Nov. 2008

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of Jordan

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of Jordan

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of Jordan

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of Jordan

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of Jordan

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of Jordan

Surgery at JUH

19th Nov. 2008

Local curretage of the cyst +

application of monoplanar external

fixator + Circular Ex.Fix. (across

the knee joint) Ilizarov Frame.

First stage

11/1/2014 25Professor Freih Abuhassan - University

of Jordan

Problems1- Difficult to apply Tourniquet

2- Lateral Scar of previous surgery

3-Soft bone (prolonged disuse)

4-Extensive bleeding

5-Overweight

6-Residual defect after resection.

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of Jordan

Packing the cyst after surgery to stop

bleeding.

Received in the perioperative period

= 5.5 L R/L

= 4 U PRBC’s

= 10 U FFP

Role of anaesthetic team

in the management 11/1/2014 27

Professor Freih Abuhassan - University

of Jordan

=Transferred to the ICU and kept

there till 24/11

=Initially DIC W/up +ve

=21st Nov. 2008 R/O pack

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of Jordan

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University of Jordan

Histopathology

ABC11/1/2014 30

Professor Freih Abuhassan - University

of Jordan

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University of Jordan

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University of Jordan

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University of Jordan

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University of Jordan

= Under tourniquet, Anterior approach,

Complete resection of the cyst.

=Turbid hematoma was found inside

the cavity.

=Delay reconstruction of the bone

defect till results of C&S.

=Bone cement spacer was inserted.

16th Dec. 20082nd stage Surgery

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of Jordan

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University of Jordan

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University of Jordan

Cultures: no bacterial growth

Gram stain:

only WBC’s & RBC’s, no bacteria

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of Jordan

Reconstructive Procedure

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of Jordan

3nd stage Surgery

23rd Dec. 20081. Removal of Cement spacer

2. Strut tibial autograft from the mid

ipsilateral tibia, to femur and

stabilized by long screws to the

ilizarov frame.

3. Application of ilizarov to tibia +

bone marrow inserted.

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of Jordan

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of Jordan

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of Jordan

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of Jordan

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University of Jordan

23rd Dec. 200811/1/2014 45

Professor Freih Abuhassan -

University of Jordan

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of Jordan

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of Jordan

5th Jan. 2009

Admitted as a case popliteal fossa

swelling to R/O organised hematoma

U/S: no definite fluid collection but

significant soft tissue edema.

= Percutaneous evacuation of hematoma,

=R/O Orthofix and application of long

Ilizarov plate externally and fixed to the

graft by Schanz screws11/1/2014 48

Professor Freih Abuhassan - University

of Jordan

Followed regularly in OPD

Partial weight bearing was started

in the on 21st Jan. 2009.

Now FWB on crutches

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of Jordan

25th March 2009

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University of Jordan

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University of Jordan

With Ilizarov family

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University of Jordan

ABCIn 1942, Jaffe and Lichtenstein

first described ABC when they

discovered "a peculiar blood

containing cyst of large size.

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of Jordan

Benign Aggressive Bone

Tumor Locally destructive yet do not

metastasize or show malignant

changes at a cellular levelcellular

level

ABC, GCT, CMF,

Chondroblastoma,

Osteoblastoma.11/1/2014 54

Professor Freih Abuhassan - University

of Jordan

WHO

Blood-filled spaces of variable

size,separated by CT containing

trabeculae of bone or osteoid

tissue and osteoclast giant cells

ABCs represent 1%–2% of all

primary bone lesions

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of Jordan

Giant Cell tumour

Aneurysmal bone cyst

Telangiectatic osteosarcoma

Secondary ABC –upto 35% of all ABCs

Most commonly due to GCT (39%)

D.Dx

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of Jordan

No bone is immune

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Giant Humerus ABC

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University of Jordan

Giant femur ABC

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of Jordan

Giant ABCs

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University of Jordan

Local recurrence rate after

classic surgical procedures

(curettage and grafting) is about

11.8%–30.8%

Treatment depends on

site & size of the lesion.

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of Jordan

11/1/2014 62Professor Freih Abuhassan - University

of Jordan