Recurrent & Infected Giant Cell Tumour of Lower Tibia
Hi, I am Dr Srimanth B S
Welcome to Sutures & Stories,
Bone tumors are rare! But a few are aggressive and often lead to disability or even slow death, mirroring a cancerous path. Such tumors in rare locations in the extremity often pose a challenge in limb salvage surgery, or worse may even end up in an amputation. Team effort, involving a multidisciplinary team aided with enhanced imaging techniques to identify the tumor and an evolving surgical skill set with approach are crucial for the best of outcomes.
In this context, let me share a “Doctor we trust you- I don’t want to Lose My Leg” story from 2017. Mr. Ganesh, a 2nd year student in civil engineering in Goa (name changed), walked into the clinic with a visibly uncomfortable limp. His lower leg and ankle were swollen, with angry blue-green veins screaming and coursing all along. I asked him if he could walk about and wince he did, with each step. And there was an ulcer along the old scar which was discharging pus. He had undergone two surgeries for bone tumor (Index surgery in 2012 & later for recurrence in 2014 at different hospitals).
Multiple scans were done to precisely ascertain if it was the infection which was troubling him or was it a recurrence of tumor. A biopsy confirmed relapse of tumor. So our team concluded that his relapse situation was complicated by a superadded infection of some rare superbug called “Acinetobacter” . His family shared that they were suggested to go for amputation the day pus started pouring, but they waited and hoped antibiotics would cure it. Summarizing what he had gone through and the road ahead, our team concurred that he would be better off rehabilitated early with an amputation below the knee.
Such situations in the lower leg (distal tibia) pose multiple challenges to surgeons. An inherent anatomical disparity in vascularity of distal tibia, a large relapsed tumor which has destroyed both the tibia & fibula bones around the ankle, a chronic superadded infection and a deficient soft tissue cover were just a few of the obstacles. This case needed an approach which would provide an adequate oncological disease clearance, maintain viable bone-implant-soft tissue for reconstruction to be able to cure him and help him walk. Often, this approach requires two or three stages of surgery. And this could possibly save his limb!
One would be fair to presume that I had gone to Goa to party ! But was instead wheeling in Mr. Ganesh at 7 am on 9th of September 2017 for the limb saving surgery. The procedure entailed stepwise removal of the tumor followed by reconstruction of the leg-ankle using a “Desi Jugaad-Nail Plate Cement Spacer Construct” as we call it and finally microvascular flap surgery (harvesting skin and muscle from thigh with intact blood supply). Our team involved myself (Orthopaedic Oncologist), Senior Orthopaedic surgeon and a microvascular-reconstructive surgeon. Mr. Ganesh’s Surgical Ordeal did end at about 10 pm, about 15 hours from the start line. And that beaming smile seeing his toes wiggle under the plaster said a lot more.
Post operative period was when the calm after the storm was evident. He had an uneventful recovery, ably motivated by his family and rehab specialists. We did go aggressive on him, to instill that confidence to be able to walk well again. Tests done of the tumor specimen confirmed that we had removed it as a whole without any spillage!
6 ½ years later, Mr. Ganesh is smiling, walking around inspecting one of his civil projects with both his feet firmly on the ground.
For more information,
https://bonecancer.in/2020/05/01/giant-cell-tumor/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8531854/
https://doi.org/10.1016/j.knee.2011.06.012