Publications by authors named "Anshu Shekhar"

16 Publications

  • Page 1 of 1

Anterior Cruciate Ligament Rupture with Medial Collateral Ligament Tear with Lateral Meniscus Posterior Root Tear with Posterolateral Tibia Osteochondral Fracture: A New Injury Tetrad of the Knee.

J Orthop Case Rep 2020 May-Jun;10(3):36-42

The Orthopaedic Speciality Clinic, Pune, Maharashtra, India.

Introduction: Injuries to the knee ligaments, menisci, and cartilage are possible in high-velocity trauma as in road traffic accidents. Similarly, these structures can be disrupted in proximal tibia fractures. We present a series of three cases which had a previously undescribed injury combination.

Case Presentation: The first and second patients presented primarily to us following fall from motorbikes. Both these patients had injuries of the anterior cruciate ligament (ACL), medial collateral ligament (MCL), lateral meniscus body and posterior root tear, and osteochondral fracture of posterolateral tibia. The osteochondral fracture was managed by internal fixation with headless compression screws. The ligaments were either repaired or reconstructed and meniscus root tear was treated by transtibial pull through repair. The third patient also had the same injury but was treated at another center. He presented with early arthritis of the lateral tibiofemoral joint and valgus malalignment. Treatment for him was in the form of lateral distal femur open-wedge osteotomy and MCL reconstruction. All three patients had good outcome at the end of 1year.

Conclusion: We report a new injury tetrad of ACL tear, MCL tear, lateral meniscus posterior root tear, and posterolateral tibia osteochondral fracture. The mechanism of injury is most likely a violent external rotation and anterior translation of the tibia with a valgus directed force during impact. The treatment of this injury can be performed in single or two stages based on the merits of the case. Anatomic reduction and fixation of the fracture takes precedence to avoid later devastating sequel for the knee.
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http://dx.doi.org/10.13107/jocr.2020.v10.i03.1738DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8051566PMC
May 2021

Indirect Magnetic Resonance Arthrography May Help Avoid Second Look Arthroscopy for Assessment of Healing After Bucket Handle Medial Meniscus Repairs: A Prospective Clinico-Radiological Observational Study.

Indian J Orthop 2021 Apr 12;55(2):416-424. Epub 2021 Mar 12.

SRM University, Kattankulathur, Tamilnadu India.

Objectives: The objectives were: (1) to analyze the MRI healing rates of bucket-handle meniscus repair; (2) to compare the accuracy of assessment of meniscus healing for conventional MRI and Indirect Magnetic Resonance Arthrography (IMRA); and (3) to identify patients who may require second-look arthroscopy after meniscus repair.

Methods: This is a prospective observational case series of thirty-seven patients with repaired bucket-handle medial meniscus tear with a minimum one year follow-up. Meniscus healing rates were assessed on direct MRI and IMRA using Henning's criteria. At the same time, patients' symptoms were evaluated according to Barrett's criteria and functional outcomes were recorded using International Knee Documentation Committee (IKDC) score, Knee Osteoarthritis and Outcomes Score (KOOS) and Tegner-Lysholm scores. A further clinical review was performed 18 months after the imaging to assess the evolution of symptoms.

Results: At a mean of 22.3 ± 7.8 months after the meniscus repair, 56.7% patients showed complete healing and 40.5% patients demonstrated incomplete repair healing on IMRA. 52% patients with complete healing and 40% patients with incomplete healing demonstrated meniscus symptoms. At the second clinical review, 19% patients with complete healing and 20% patients with incomplete healing had meniscus symptoms. There was no co-relation between symptoms, PROMs and healing on MRI.

Conclusion: Indirect MR arthrography offers distinct advantages over direct MRI for assessment of meniscus healing, especially in symptomatic patients. Patient-reported outcome measures and symptomatology are not co-related with the healing status of the meniscus and they resolve in the majority on longer follow-up. A more conservative approach guided by IMRA to assess meniscus healing will avoid early re-operations.
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http://dx.doi.org/10.1007/s43465-020-00334-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8046888PMC
April 2021

Revision ACL Reconstruction: Principles and Practice.

Indian J Orthop 2021 Apr 19;55(2):263-275. Epub 2021 Jan 19.

The Orthopaedic Speciality Clinic, 16 Status Chambers, 1221/A Wrangler Paranjpe Road, Pune, 411004 India.

Introduction: The incidence of anterior cruciate ligament reconstruction (ACLR) surgeries is increasing and so is the number of revision surgeries for a failed ACLR. The spectrum of ACL failure includes symptoms of recurrent instability, pain, and/or stiffness.

Discussion: Factors contributing to ACL failure may be classified as patient-related, surgeon-related, and biological factors. Of these, tunnel malposition and recurrent trauma are the most common causes. Detailed patient assessment, imaging, and studying details of the index surgery are critical prior to planning revision surgery. Infection has to be ruled out prior to planning any reconstructive surgical procedure. Osseous malalignment in the coronal or sagittal planes would also need correction along with or prior to revision ACL surgery. Revision ACL reconstruction maybe performed as a one-stage or two-stage procedure. Severe tunnel dilatation, infection, or arthrofibrosis necessitates a two-stage approach. Autografts are preferred for revision ACL due their lesser re-tear rates and better outcomes. Associated meniscus tears and cartilage injuries are more common in revision than in primary surgery and need to be managed appropriately. Extra-articular reconstruction for controlling anterolateral instability is frequently required as well.

Conclusion: Revision ACL reconstruction is a complex undertaking due to limited graft options, compromised anatomy and high frequency of associated injuries. Patient expectations must be tempered because functional outcomes and return to pre-injury sports are inferior to a primary surgery.
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http://dx.doi.org/10.1007/s43465-020-00328-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8046893PMC
April 2021

Discoid lateral meniscus: current concepts.

J ISAKOS 2021 01 16;6(1):14-21. Epub 2020 Sep 16.

Orthopedic Surgery, Stockholm South Hospital, Karolinska Institutet, Stockholm, Sweden.

The discoid meniscus is a congenital morphological abnormality encountered far more commonly on the lateral than the medial side. The discoid lateral meniscus (DLM) is more prevalent in Asia with an incidence of 10%-13%, than in the Western world with an incidence of 3%-5%. DLM can be bilateral in more than 80% cases. Due to its abnormal shape and size, the discoid meniscus is prone to tearing and has an impact on gait mechanics. The discoid meniscus has deranged collagen arrangement and vascularity which can have implications for healing after a repair. Patients with a DLM may or may not be symptomatic with mechanical complaints of locking, clicking, snapping or pain. Symptoms often arise due to a tear in the body of the meniscus or a peripheral detachment. Asymptomatic patients usually do not require any treatment, while symptomatic patients who do not have locking are managed conservatively. When a peripheral detachment is present, it must be stabilised while preserving the meniscus rim to allow transmission of hoop stresses. Rehabilitation after surgery is highly individualised and return to sports is possible after more than 4 months in those undergoing a repair. The functional outcomes and onset of radiographic arthritis after saucerisation and repairing a discoid meniscus are better in the long term, compared with a subtotal meniscectomy. However, there is no compelling evidence currently favouring a repair as results deteriorate with increasing follow-up. Poor prognosis is reported in patients undergoing a total meniscectomy, a higher age at presentation and valgus malalignment.
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http://dx.doi.org/10.1136/jisakos-2017-000162DOI Listing
January 2021

Anatomic medial knee reconstruction restores stability and function at minimum 2 years follow-up.

Knee Surg Sports Traumatol Arthrosc 2021 Feb 22. Epub 2021 Feb 22.

Consultant Orthopaedic Surgeon, Fowler Kennedy Sport Medicine Clinic, London, Ontario, Canada.

Purpose: Chronic grade 3 tears of the medial collateral ligament and posterior oblique ligament may result in valgus laxity and anteromedial rotational instability after an isolated or multiligament injury. The purpose of this study was to prospectively analyze the restoration of physiologic medial laxity as assessed on stress radiography and patient reported subjective functional outcomes in patients who undergo an anatomic medial knee reconstruction.

Methods: This was a prospective study which included patients with chronic (> 6 weeks old) posteromedial corner injury with or without other ligament and meniscus lesions. Pre- and post-operative valgus stress radiographs were performed in 20° knee flexion and functional outcome was recorded as per the International Knee Documentation Committee (IKDC) and Lysholm scores. All patients underwent anatomic medial reconstruction with two femoral and two tibial sockets using ipsilateral hamstring tendon autograft. Simultaneous ligament and meniscus surgery was performed as per the associated injury pattern. All patients were followed up for a minimum of 24 months post-surgery.

Results: Thirty-four patients (23 males, 11 females) were enrolled in the study and all were available till final follow-up of mean 49.7 ± 14.9 months. The mean age was 30.6 ± 7.9 (18-52 years). Two patients had isolated medial sided lesions and 23 had associated ligament injuries. The mean follow up was 49.7 (24-72) months. The mean IKDC score improved from 58 ± 8.3 to 78.2 ± 9.5 (p < 0.001). Post-operatively there were 15 excellent, 11 good and 8 fair outcomes on Lysholm score. The mean pre-operative valgus side-to-side opening improved from 7.5 ± 2.5 mm to 1.2 ± 0.7 mm on stress radiography (p < 0.001).

Conclusion: Anatomic reconstruction of the superficial medial collateral and posterior oblique ligaments restore stability in a consistent manner cases of chronic grade 3 instability. The objective functional results, subjective outcomes and measures of static medial stability are satisfactory in the short term.

Level Of Evidence: IV.
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http://dx.doi.org/10.1007/s00167-021-06502-1DOI Listing
February 2021

Limb position influences component orientation in Oxford mobile bearing unicompartmental knee arthroplasty: an experimental cadaveric study.

Bone Joint Res 2020 Jun 23;9(6):272-278. Epub 2020 Jul 23.

University of Leeds, Leeds, UK.

Aims: The mobile bearing Oxford unicompartmental knee arthroplasty (OUKA) is recommended to be performed with the leg in the hanging leg (HL) position, and the thigh placed in a stirrup. This comparative cadaveric study assesses implant positioning and intraoperative kinematics of OUKA implanted either in the HL position or in the supine leg (SL) position.

Methods: A total of 16 fresh-frozen knees in eight human cadavers, without macroscopic anatomical defects, were selected. The knees from each cadaver were randomized to have the OUKA implanted in the HL or SL position.

Results: Tibial base plate rotation was significantly more variable in the SL group with 75% of tibiae mal-rotated. Multivariate analysis of navigation data found no difference based on all kinematic parameters across the range of motion (ROM). However, area under the curve analysis showed that knees placed in the HL position had much smaller differences between the pre- and post-surgery conditions for kinematics mean values across the entire ROM.

Conclusion: The sagittal tibia cut, not dependent on standard instrumentation, determines the tibial component rotation. The HL position improves accuracy of this step compared to the SL position, probably due to better visuospatial orientation of the hip and knee to the surgeon. The HL position is better for replicating native kinematics of the knee as shown by the area under the curve analysis. In the supine knee position, care must be taken during the sagittal tibia cut, while checking flexion balance and when sizing the tibial component.
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http://dx.doi.org/10.1302/2046-3758.96.BJR-2019-0258.R1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7376280PMC
June 2020

Does increased femoral component size options reduce anterior femoral notching in total knee replacement?

J Clin Orthop Trauma 2020 Mar 16;11(Suppl 2):S223-S227. Epub 2019 Mar 16.

The Orthopaedic Speciality Clinic, 16 Status Chambers, 1221/A Wrangler Paranjpe Road, Off F.C. Road, Pune, 411004, India.

Objective: Total knee arthroplasty (TKA) is currently the best option for management of advanced knee arthritis for patients who have exhausted conservative management. There have been significant implant design improvements and this is a continuing process to help the surgeon replicate patient anatomy and kinematics. Amongst the many variables in implantation to achieve a well-functioning TKA, getting optimal femoral component sizing is one. Every implant system has certain discreet implant sizes and the surgeon has to strive to obtain the best fit possible for the patient and attain a well aligned and stable TKA. The aim of this study was to assess the frequency of various femoral component sizes being implanted with a system which has 2.5 mm antero-posterior increment between sizes, and to assess the incidence of anterior femoral notching when using a posterior referencing system.

Materials And Methods: A retrospective analysis of 739 TKAs implanted in 532 patients between January 2013 and January 2016 at a single center using a single posterior stabilized implant system was done. Patient demographics and femur component size used was obtained from hospital patient records. Immediate post-operative radiographs were analyzed to look for anterior femoral notching and presence of this was classified according to Tayside classification. A telephonic follow up at minimum 2 tears post-surgery was done to interview for occurrence of supracondylar femur fracture or revision for any other causes.

Results: There were 207 bilateral and 325 unilateral TKAs performed in 532 patients during the study period. There were 245 males and 287 females with an average age of 61.3 years (43-81 years, SD = 7.2). The most commonly used femoral component was 60 mm and an intermediate size prosthesis was used in 43.11% patients. The incidence of femoral notching ranged from 0 to 6.3%. No patient had sustained a supracondylar condylar fracture at minimum 2 years follow up.

Conclusion: The availability of a larger number of femoral components in a TKA system allows the surgeon the modularity to choose and obtain the best fit possible. Restoration of posterior condylar offset, preventing anterior notching, medio-lateral overhang and patellofemoral joint stuffing are greatly dependent on correct femoral component sizing. The findings from our study underscore the need to use an implant system with as many femoral size options as possible with lesser increments in between sizes to minimize anterior femoral notching when using a posterior referencing technique.
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http://dx.doi.org/10.1016/j.jcot.2019.03.006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7068002PMC
March 2020

Anatomic Posterolateral Corner Reconstruction With Autogenous Peroneus Longus Y Graft Construct.

Arthrosc Tech 2019 Dec 11;8(12):e1501-e1509. Epub 2019 Nov 11.

SRM Medical College, SRM Institute of Science and Technology, Kattankulathur, India.

The posterolateral corner of the knee is composed of the fibular collateral ligament, popliteus tendon, and popliteofibular ligament, which provide varus and rotational stability to the knee. An anatomic technique reconstructs these structures through 2 femoral sockets and 1 tibial and 1 fibular tunnel. This reconstruction can be performed using a peroneus longus autograft that is prepared as a Y construct. The peroneus longus autograft is preferred because it provides adequate length and diameter for the entire reconstruction. Initially, the doubled loop of the Y is passed into the tibial tunnel and fixed with an adjustable cortical button. The shorter limb of the Y is used for reconstruction of the popliteus tendon. The longer limb of the Y is passed from posterior to anterior through the fibular tunnel and is fixed in the tunnel with an interference screw to re-create the popliteofibular ligament. The remaining graft is then shuttled deep to the iliotibial band and superficial to the popliteus tendon, into the femoral socket, to re-create the fibular collateral ligament.
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http://dx.doi.org/10.1016/j.eats.2019.07.024DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6928377PMC
December 2019

Comparison of Gap Balancing vs Measured Resection Technique in Patients Undergoing Simultaneous Bilateral Total Knee Arthroplasty: One Technique per Knee.

J Arthroplasty 2020 03 10;35(3):732-740. Epub 2019 Oct 10.

Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Santa Monica, CA.

Background: Total knee arthroplasty requires careful surgical technique to attain the goal of a well-aligned and symmetrically balanced knee. Soft tissue balance and correct femoral component rotation are paramount in achieving these goals. The two competing techniques to select femoral component rotation and soft tissue balance are the gap balance technique and the measured resection technique.

Methods: We performed a randomized, prospective study to compare the two techniques in patients undergoing simultaneous bilateral total knee arthroplasty, whereby one technique was performed in each knee. Fifty (50) subjects were enrolled into the study. The inclusion criteria were osteoarthritic varus knee deformities with similar deformities in both knees. Subjects were followed up for a minimum of two years.

Results: The knees balanced via the gap balance technique had significantly more posterior medial bone removed from the femur than those knees balanced via the measured resection technique (P < .001). Knees in the gap balance group tended to require more medial knee releases in extension and tended to have smaller sized femoral components as a result of cutting more bone from the femur in flexion. The modular tibial polyethylene bearing tended to be thicker in the gap balance group. Despite these differences, average knee flexion and functional revised Oxford Knee Scores at 2-year follow-up were not statistically different.

Conclusion: At 2-year follow-up, there were no differences between the function and scores using the two techniques. Long-term follow-up will be necessary to evaluate any differences in long-term durability.
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http://dx.doi.org/10.1016/j.arth.2019.10.002DOI Listing
March 2020

Osteochondral Lesion in Diffuse Pigmented Villonodular Synovitis of the Knee.

Knee Surg Relat Res 2019 Mar;31(1):67-71

Department of Orthopaedic Surgery, The Orthopaedic Speciality Clinic, Pune.

Pigmented villonodular synovitis (PVNS) is a rare benign condition that is locally aggressive and may destructively invade the surrounding soft tissues and bone causing functional loss of the joint and the limb. The knee is the most affected joint (range, 28% to 70%) but involvement of the bone is not a common feature seen at this site. We present a rare case of diffuse PVNS of the knee associated with subchondral cyst of the lateral femoral condyle. This posed a diagnostic dilemma because of bone invasion. The radiological image of synovitis was pathognomonic of PVNS but etiology of the osteolytic lesion was confirmed only on histopathology. The large osteochondral defect was eventually managed in a staged manner with bone grafting and osteochondral autograft transfer.
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http://dx.doi.org/10.5792/ksrr.18.015DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6425890PMC
March 2019

Knotless Medial Meniscus Posterior Root Repair.

Arthrosc Tech 2018 May 2;7(5):e429-e435. Epub 2018 Apr 2.

Orthopaedic Specialty Clinic, Pune, India.

Medial meniscus posterior root tears are common injuries, especially in the Asian world. This injury must be repaired where indicated to restore knee biomechanics and prevent arthritis. Suturing the meniscus using suture tapes provides good hold of the tissue. The use of a 70° arthroscope and creation of a transseptal portal improve visualization of the posterior compartment. Creation of a high posteromedial portal achieves the correct trajectory for the suture anchor insertion. A knotless suture anchor can be used to fix the posterior root at its anatomic attachment site. This obliterates the need for transtibial drilling for a suture pull-out repair or for knot tying and suture shuttling as for a conventional suture anchor.
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http://dx.doi.org/10.1016/j.eats.2017.11.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5984279PMC
May 2018

Primary Anterior Cruciate Ligament Repair With Augmentation.

Arthrosc Tech 2018 Feb 22;7(2):e139-e145. Epub 2018 Jan 22.

SRM Medical College, SRM University, Kattankulathur, Tamil Nadu, India.

Anterior cruciate ligament (ACL) tears are usually managed by reconstruction with autograft or allograft, but primary repair in carefully selected patients is a reasonable option. Proximal avulsions presenting early with excellent tissue quality are amenable to repair and healing. Restoration of native ACL preserves its proprioceptive and kinematic functions. A repair is less invasive and avoids graft-related problems, and faster rehabilitation is possible. Protection for the repair in the early stages will allow better healing. We present our technique of ACL repair using knotless suture anchors with high-strength sutures and protection using high-strength sutures tapes inserted through the same anchors.
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http://dx.doi.org/10.1016/j.eats.2017.08.063DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5851946PMC
February 2018

Meniscal Preservation is Important for the Knee Joint.

Indian J Orthop 2017 Sep-Oct;51(5):576-587

The Orthopaedic Speciality Clinic, Pune, Maharashtra, India.

Native joint preservation has gained importance in recent years. This is mostly to find solutions for limitations of arthroplasty. In the knee joint, the menisci perform critical functions, adding stability during range of motion and efficiently transferring load across the tibiofemoral articulation while protecting the cartilage. The menisci are the most common injury seen by orthopedicians, especially in the younger active patients. Advances in technology and our knowledge on functioning of the knee joint have made meniscus repair an important mode of treatment. This review summarizes the various techniques of meniscus tear repair and also describes biological enhancements of healing.
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http://dx.doi.org/10.4103/ortho.IJOrtho_247_17DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5609379PMC
October 2017

Localized pigmented villonodular synovitis of posterior compartment of the knee.

J Orthop Surg (Hong Kong) 2017 Sep-Dec;25(3):2309499017727923

1 The Orthopaedic Speciality Clinic, Pune, Maharashtra, India.

Pigmented villonodular synovitis (PVNS) is an uncommon entity involving articular or extra-articular tissues and maybe localized or diffuse in extent. The knee is by far the commonest joint to get involved. Localized PVNS of the knee can occur in any location but its confinement to the posterior compartment is infrequent. We present our experience of managing localized posterior compartment PVNS of the knee. There were 10 patients (7 males and 3 females) with average age of 33 years. These patients had symptoms of pain, locking, or swelling for a mean of 13.9 years before diagnosis. All the patients underwent arthroscopic synovectomy without adjuvant therapy, and PVNS was proven on histopathology. At an average follow-up of 23 months, no patient had recurrence of symptoms. The average International Knee Documentation Committee (IKDC) score at last follow-up was 85.21. Magnetic resonance imaging evaluation at final follow-up did not reveal any residual disease or recurrence in any patient.
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http://dx.doi.org/10.1177/2309499017727923DOI Listing
July 2018

Ewing's sarcoma of proximal phalanx of the hand with skip metastases to metacarpals.

Indian J Orthop 2015 May-Jun;49(3):365-8

Department of Orthopaedics, Karnataka Institute of Medical Sciences and Hospital, Hubli, Karnataka, India.

Ewing's sarcoma is the second most common malignant primary bone tumor of childhood and adolescence affecting mainly the diaphysis of long bones and flat bones. This tumor is extraordinarily rare in small bones of the hand and presents as a swelling with atypical radiological features of cystic and lytic lesion with scant periosteal reaction. The common differential diagnosis include osteomyelitis, tuberculosis, enchondroma and benign tumors. Moreover, skip metastasis to adjacent bones is even rarer. The prognosis of this condition is greatly influenced by the presence of metastasis at presentation, further emphasizing the importance of early diagnosis. Multimodality treatment using surgery, radiotherapy and chemotherapy is currently recommended though no consensus exists. We report a case of Ewing's sarcoma of the little finger proximal phalanx which was initially missed and developed skip metastasis to several metacarpals within 4 months.
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http://dx.doi.org/10.4103/0019-5413.156229DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4443423PMC
May 2015

Synchronous Multicentric Giant Cell Tumour (GCT)-A Rare Case Report.

J Clin Diagn Res 2014 Feb 3;8(2):185-6. Epub 2014 Feb 3.

Professor and HOD, Department of Orthopaedics, K.I.M.S., Hubli , Karnataka, India .

Giant Cell Tumours (GCT) of bone account for 5% of all primary bone tumours. Multicentric variety is a rare variant of this condition, accounting for less than 1% of all cases and can occur as synchronous or metachronous lesions. We report a 22-year-old male patient with 18 months history of painful progressive swellings around the right knee. Radiographs revealed expansile lytic lesions in the distal femur, proximal tibia and fibula and core needle biopsy was typical of GCT. Biochemical parameters were normal and radiological investigations did not reveal any metastasis. The patient was treated by above knee amputation due to the extensive nature of the tumours. The excised tissue from all sites had features of giant cell tumor with no atypia or malignant cells seen. The patient is free from recurrence or metastasis at three years follow up.
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http://dx.doi.org/10.7860/JCDR/2014/8153.4055DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3972558PMC
February 2014