"giant cell tumor" AND "Ilizarov" AND "arthrodesis" AND "knee"

PMID: 16822642

PMID: 21139765

PMID: 16724184

"giant cell tumor" AND knee AND resection AND reconstruction

resection arthrodesis Ilizarov fixator giant cell tumor GCT knee outcomes complications

https://www.cureus.com/articles/437639-complications-and-sal…

https://pmc.ncbi.nlm.nih.gov/articles/PMC2989135

"giant cell tumor" AND bone AND Ilizarov AND reconstruction

PMID: 39667742

cd /home/daytona/workspace/attachments/9e023bfe-5030-4b2b-b16b-f674ea0ff8c0 && p…

cd /home/daytona/workspace/attachments/9e023bfe-5030-4b2b-b16b-f674ea0ff8c0 && p…

cd /home/daytona/workspace/attachments/9e023bfe-5030-4b2b-b16b-f674ea0ff8c0 && p…

mkdir -p /home/daytona/workspace/gct-ppt/images && python3 -c " import fitz # P…

mkdir -p /home/daytona/workspace/gct-ppt/images && python3 -c " import pdfplumbe…

python3 -c " from PIL import Image import os # Check image sizes for f in sorte…

python3 -c " from PIL import Image # Crop the figure areas from each page # Pag…

~/gct-ppt/build_ppt.js

const pptxgen = require("pptxgenjs");
const fs = require("fs");
const path = require("path");

// ─── Colour palette ───────────────────────────────────────────────────────────
const DARK_BG   = "0D1B2A";  // deep navy
const MID_BG    = "1B2A3B";  // medium navy
const ACCENT    = "E8A020";  // amber/gold
const ACCENT2   = "3AA8D8";  // teal blue
const WHITE     = "FFFFFF";
const LIGHT_GR  = "E8EEF4";  // light grey-blue
const TEXT_DARK = "1A2540";
const BULLET_BG = "162030";  // slightly lighter navy for bullet boxes

// ─── Helpers ─────────────────────────────────────────────────────────────────
function imgData(relPath) {
  const full = path.join("/home/daytona/workspace/gct-ppt/images", relPath);
  const buf  = fs.readFileSync(full);
  return "image/png;base64," + buf.toString("base64");
}

function darkSlide(pres) {
  const s = pres.addSlide();
  s.background = { color: DARK_BG };
  return s;
}

function midSlide(pres) {
  const s = pres.addSlide();
  s.background = { color: MID_BG };
  return s;
}

function whiteSlide(pres) {
  const s = pres.addSlide();
  s.background = { color: LIGHT_GR };
  return s;
}

function addSlideHeader(slide, title, isDark = true) {
  const txtColor = isDark ? ACCENT : TEXT_DARK;
  // Accent bar
  slide.addShape("rect", { x: 0, y: 0, w: 10, h: 0.08, fill: { color: ACCENT } });
  slide.addText(title.toUpperCase(), {
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    fontSize: 18, bold: true, color: txtColor,
    fontFace: "Calibri", charSpacing: 2,
  });
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    line: { color: isDark ? ACCENT2 : "9AAFC2", width: 1.2 }
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}

function addBullets(slide, items, opts = {}) {
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    fontSize = 14, color = WHITE, bold = false,
    indent = 0
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    text: item,
    options: {
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      indentLevel: indent,
      paraSpaceBefore: 4,
    }
  }));
  slide.addText(rows, { x, y, w, h, fontFace: "Calibri", valign: "top" });
}

// ─── Initialise presentation ─────────────────────────────────────────────────
const pres = new pptxgen();
pres.layout  = "LAYOUT_16x9";
pres.author  = "Jishnu Prakash Baruah, Shyam Sunder";
pres.title   = "Ilizarov Reconstruction after GCT Distal Femur";
pres.subject = "MS Orthopaedics Conference Presentation";

// ═══════════════════════════════════════════════════════════════════════════════
// SLIDE 1 – TITLE
// ═══════════════════════════════════════════════════════════════════════════════
{
  const s = darkSlide(pres);
  s.addShape("rect", { x: 0, y: 0, w: 10, h: 0.12, fill: { color: ACCENT } });

  // Institution tag line top-right
  s.addText("MS Orthopaedics Conference — 2026", {
    x: 0, y: 0.18, w: 9.7, h: 0.35,
    fontSize: 10, color: ACCENT2, fontFace: "Calibri", align: "right", italic: true
  });

  // Main title
  s.addText("Complications and Salvage Management in", {
    x: 0.4, y: 1.0, w: 9.2, h: 0.65,
    fontSize: 24, color: ACCENT, bold: true, fontFace: "Calibri", align: "left"
  });
  s.addText("Ilizarov Reconstruction", {
    x: 0.4, y: 1.65, w: 9.2, h: 0.9,
    fontSize: 40, color: WHITE, bold: true, fontFace: "Calibri", align: "left"
  });
  s.addText("After Wide Excision for Distal Femoral Giant Cell Tumour", {
    x: 0.4, y: 2.5, w: 9.2, h: 0.65,
    fontSize: 20, color: LIGHT_GR, fontFace: "Calibri", align: "left"
  });
  s.addText("A Retrospective Series of 10 Cases", {
    x: 0.4, y: 3.15, w: 6, h: 0.45,
    fontSize: 16, color: ACCENT2, italic: true, fontFace: "Calibri"
  });

  // Bottom bar
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  s.addText([
    { text: "Jishnu Prakash Baruah", options: { bold: true, color: WHITE, fontSize: 13 } },
    { text: "  |  Dept. of Orthopaedics, Assam Medical College & Hospital, Dibrugarh", options: { color: LIGHT_GR, fontSize: 12 } },
  ], { x: 0.4, y: 4.95, w: 7.5, h: 0.5, fontFace: "Calibri" });
  s.addText([
    { text: "Shyam Sunder", options: { bold: true, color: WHITE, fontSize: 13 } },
    { text: "  |  Pondicherry Institute of Medical Sciences, Puducherry", options: { color: LIGHT_GR, fontSize: 12 } },
  ], { x: 0.4, y: 5.28, w: 8, h: 0.35, fontFace: "Calibri" });

  s.addText("Cureus 18(4): e107972  •  DOI: 10.7759/cureus.107972  •  Published April 2026", {
    x: 0.4, y: 5.35, w: 9.2, h: 0.28,
    fontSize: 9, color: "778899", fontFace: "Calibri", align: "right", italic: true
  });
}

// ═══════════════════════════════════════════════════════════════════════════════
// SLIDE 2 – BACKGROUND & PROBLEM STATEMENT
// ═══════════════════════════════════════════════════════════════════════════════
{
  const s = darkSlide(pres);
  addSlideHeader(s, "Background");

  // Two columns
  // Left col - context
  s.addText("The Problem", {
    x: 0.35, y: 0.85, w: 4.5, h: 0.38,
    fontSize: 14, bold: true, color: ACCENT, fontFace: "Calibri"
  });
  const leftBullets = [
    "GCT accounts for ~5% of all primary bone tumours; knee region is the commonest site (~50% of all cases)",
    "Campanacci Grade III lesions: extensive cortical destruction with large soft-tissue mass",
    "Wide en-bloc resection mandatory for Grade III or recurrent disease — but creates major segmental defects (≥8 cm)",
    "Reconstruction options: endoprosthesis, allograft, vascularised fibular graft, resection arthrodesis",
  ];
  addBullets(s, leftBullets, { x: 0.35, y: 1.25, w: 4.55, h: 3.8, fontSize: 13 });

  // Right col - why Ilizarov
  s.addText("Why Ilizarov?", {
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    fontSize: 14, bold: true, color: ACCENT2, fontFace: "Calibri"
  });
  const rightBullets = [
    "Endoprosthesis: 5-yr survival ~73-83%; 10-yr ~59-67%; high cost; limited availability in resource-constrained settings",
    "Allograft: risk of infection, sequestration, non-union",
    "Vascularised fibula: technically demanding, donor morbidity",
    "Ilizarov distraction osteogenesis: biologic, cost-effective, restores limb length — but complications are common",
    "Very few series specifically for GCT near the knee exist (only handful of reports)",
  ];
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  // Divider between columns
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}

// ═══════════════════════════════════════════════════════════════════════════════
// SLIDE 3 – OBJECTIVES & STUDY DESIGN
// ═══════════════════════════════════════════════════════════════════════════════
{
  const s = midSlide(pres);
  addSlideHeader(s, "Objectives & Methodology");

  // Objective box
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    fill: { color: ACCENT }, line: { color: ACCENT, width: 0 } });
  s.addText("OBJECTIVE: To describe clinical outcomes, complication profiles, management strategies, and salvage interventions in consecutive cases of wide resection followed by Ilizarov reconstruction for distal femoral GCT.", {
    x: 0.5, y: 0.86, w: 9.0, h: 0.75,
    fontSize: 13, bold: false, color: TEXT_DARK, fontFace: "Calibri", valign: "middle"
  });

  // Method boxes
  const boxes = [
    { label: "Study Design", val: "Retrospective cohort study\nSingle tertiary centre (AMCH, Dibrugarh)\nJanuary 2013 – December 2020" },
    { label: "Population", val: "10 consecutive patients\nAge 20-38 yrs (mean 29.7)\nHistologically confirmed Campanacci III GCT distal femur" },
    { label: "Inclusion Criteria", val: "Wide resection → segmental defect ≥8 cm\nPrimary Ilizarov ring fixator + bone transport\nMinimum 24-month follow-up from frame removal" },
    { label: "Outcomes Measured", val: "Union rate, defect length, regenerate length\nExternal fixation index (months/cm)\nComplications (defined a priori)\nMSTS functional score at final follow-up" },
  ];

  boxes.forEach((b, i) => {
    const col = i % 2;
    const row = Math.floor(i / 2);
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    const y = 1.82 + row * 1.85;
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  s.addText("Ethics approval: IEC (H) AMCH — IEC/No 2026/AMC/EC/259", {
    x: 0.35, y: 5.35, w: 9.3, h: 0.25,
    fontSize: 9.5, color: "778899", italic: true, fontFace: "Calibri"
  });
}

// ═══════════════════════════════════════════════════════════════════════════════
// SLIDE 4 – SURGICAL TECHNIQUE (with Fig 1 image)
// ═══════════════════════════════════════════════════════════════════════════════
{
  const s = darkSlide(pres);
  addSlideHeader(s, "Surgical Technique");

  // Steps on left
  const steps = [
    ["1.", "Wide en-bloc resection of GCT segment"],
    ["2.", "Frame: 3-4 rings proximally & distally, 1.8 mm tensioned olive wires + 6 mm half-pins"],
    ["3.", "Proximal metaphyseal-diaphyseal low-energy corticotomy (drill holes + osteotome)"],
    ["4.", "Latent period 7-10 days, then distraction at 1 mm/day (4 × 0.25 mm increments)"],
    ["5.", "Controlled transport with serial biplanar radiographic correction"],
    ["6.", "At docking: axial compression 0.25 mm/day; autogenous iliac crest graft for sclerotic ends (n=2)"],
    ["7.", "Weight-bearing: toe-touch → partial → full WB on radiographic criteria"],
  ];

  steps.forEach(([num, txt], i) => {
    const y = 0.88 + i * 0.61;
    s.addShape("rect", { x: 0.3, y, w: 0.38, h: 0.42,
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    s.addText(num, {
      x: 0.3, y, w: 0.38, h: 0.42,
      fontSize: 12, bold: true, color: TEXT_DARK, fontFace: "Calibri", align: "center", valign: "middle"
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    s.addText(txt, {
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      fontSize: 12, color: WHITE, fontFace: "Calibri", valign: "middle"
    });
  });

  // Figure on right
  s.addImage({ data: imgData("fig1_crop.png"), x: 5.5, y: 0.8, w: 4.15, h: 3.4 });
  s.addShape("rect", { x: 5.5, y: 4.22, w: 4.15, h: 0.65,
    fill: { color: BULLET_BG }, line: { color: ACCENT2, width: 1 } });
  s.addText("Fig 1. A: Preop X-rays  B: Resection specimen  C: Post-resection X-ray  D: Serial bone transport X-rays  E: Varus angulation  F: Final docking", {
    x: 5.55, y: 4.24, w: 4.05, h: 0.62,
    fontSize: 9.5, color: LIGHT_GR, fontFace: "Calibri", italic: true, valign: "middle"
  });
}

// ═══════════════════════════════════════════════════════════════════════════════
// SLIDE 5 – PATIENT DEMOGRAPHICS & OUTCOMES TABLE
// ═══════════════════════════════════════════════════════════════════════════════
{
  const s = whiteSlide(pres);
  addSlideHeader(s, "Patient Demographics & Surgical Outcomes", false);

  // Summary stats row
  const stats = [
    ["10", "Patients\n(7F / 3M)"],
    ["29.7 yrs", "Mean age\n(range 20-38)"],
    ["13.5 cm", "Mean defect\n(range 12-16)"],
    ["16.2 mo", "Mean fixation\nduration"],
    ["10.9 cm", "Mean regenerate\nlength"],
    ["23.1/30", "Mean MSTS\nscore (77%)"],
  ];
  stats.forEach((st, i) => {
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      x, y: 1.28, w: 1.45, h: 0.45,
      fontSize: 9, color: WHITE, fontFace: "Calibri", align: "center"
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    ["2","23/F","12","14","9.5","No","No","No","Yes","No","22"],
    ["3","28/M","14","18","12","Yes","Yes","No","No","Yes","21"],
    ["4","31/F","13.5","17","11","No","No","Rail*","No","No","26"],
    ["5","38/F","16","19","12.5","Yes","Yes","No","Yes","Yes","24"],
    ["6","33/F","13","14","10","No","No","No","No","No","25"],
    ["7","27/M","12.5","16","10.5","No","No","Cons†","No","No","23"],
    ["8","25/M","13","15","10.5","No","No","No","No","No","23"],
    ["9","35/F","14.5","17","11.5","No","No","No","Yes","No","25"],
    ["10","29/F","15","19","11.5","Yes","No","No","No","No","24"],
    ["Mean/Total","29.7±5.8","13.5±1.4","16.2±1.8","10.9±1.0","40%","20%","20%","30%","30%","23.1±1.4"],
  ];

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      fill: { color: bgColor }, line: { color: "C0C8D0", width: 0.5 } });
    s.addText(tHdr[ci], {
      x: curX, y: headerY, w: cw, h: 0.34,
      fontSize: 8, bold: true, color: WHITE, fontFace: "Calibri", align: "center", valign: "middle"
    });
    curX += cw;
  });

  // Draw data rows
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    const isLast = ri === tRows.length - 1;
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    colW.forEach((cw, ci) => {
      const cellVal = row[ci];
      const isRed = ["Yes", "Rail*", "Cons†"].includes(cellVal) && ci >= 5;
      const isGreen = cellVal === "No" && ci >= 5;
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        fill: { color: cellBg }, line: { color: "C0C8D0", width: 0.5 } });
      s.addText(cellVal, {
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        fontFace: "Calibri", align: "center", valign: "middle"
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  s.addText("* Rail Fixator conversion + bone grafting (partial Ilizarov failure, successful salvage)   † Conservative management (prolonged compression, union at 9 months)", {
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    fontSize: 8.5, color: "556677", italic: true, fontFace: "Calibri"
  });
}

// ═══════════════════════════════════════════════════════════════════════════════
// SLIDE 6 – COMPLICATION 1: VARUS DEFORMITY (with figure)
// ═══════════════════════════════════════════════════════════════════════════════
{
  const s = darkSlide(pres);
  addSlideHeader(s, "Complication 1 — Varus Deformity of Regenerate");

  // Left text
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    x: 0.35, y: 0.85, w: 5.1, h: 0.45,
    fontSize: 22, bold: true, color: ACCENT, fontFace: "Calibri"
  });

  const varItems = [
    "Most frequent mechanical complication in this series",
    "Defined as >5° mechanical axis deviation on monthly biplanar X-rays",
    "Medial drift during femoral transport — related to adductor forces & biomechanical demands of the femur",
    "Detected early with monthly radiographic surveillance",
    "Management: timely frame adjustment + counter-distraction",
    "Mild residual axis deviation acceptable if union is achieved without pain or instability",
    "No patient required additional corrective osteotomy",
  ];
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  // Image + caption
  s.addImage({ data: imgData("fig2_varus_crop.png"), x: 5.65, y: 0.82, w: 4.0, h: 2.6 });
  s.addShape("rect", { x: 5.65, y: 3.44, w: 4.0, h: 0.46,
    fill: { color: BULLET_BG }, line: { color: ACCENT, width: 1 } });
  s.addText("Fig 2. Progressive varus angulation of the transported segment", {
    x: 5.7, y: 3.46, w: 3.9, h: 0.42,
    fontSize: 9.5, color: LIGHT_GR, italic: true, fontFace: "Calibri", valign: "middle"
  });

  // Prevention box
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    fill: { color: BULLET_BG }, line: { color: ACCENT2, width: 1 } });
  s.addText("Prevention Strategies", {
    x: 5.78, y: 4.05, w: 3.75, h: 0.33,
    fontSize: 12, bold: true, color: ACCENT2, fontFace: "Calibri"
  });
  addBullets(s, [
    "Monthly biplanar radiographic monitoring",
    "Add IM nail as internal guide (combined technique)",
    "Timely frame adjustment with counter-distraction half-rings",
  ], { x: 5.78, y: 4.38, w: 3.75, h: 1.1, fontSize: 11 });
}

// ═══════════════════════════════════════════════════════════════════════════════
// SLIDE 7 – COMPLICATION 2 & 3: LLD + NON-UNION
// ═══════════════════════════════════════════════════════════════════════════════
{
  const s = midSlide(pres);
  addSlideHeader(s, "Complications 2 & 3 — LLD and Docking-Site Non-Union");

  // LLD left column
  s.addShape("rect", { x: 0.3, y: 0.82, w: 4.55, h: 0.42,
    fill: { color: ACCENT }, line: { color: ACCENT, width: 0 } });
  s.addText("Limb Length Discrepancy  —  2 / 10 (20%)", {
    x: 0.3, y: 0.82, w: 4.55, h: 0.42,
    fontSize: 13, bold: true, color: TEXT_DARK, fontFace: "Calibri", align: "center", valign: "middle"
  });

  addBullets(s, [
    "Defined as >3 cm discrepancy at final follow-up",
    "Cause: regenerate formation lagging behind planned distraction; patient intolerance for prolonged transport; premature docking",
    "Management: permanent shoe lifts (3-4 cm) — both patients achieved comfortable adaptation",
    "Secondary lengthening not required in either case",
    "Mild gait abnormality persisted — functional limitation minimal",
  ], { x: 0.35, y: 1.3, w: 4.45, h: 2.95, fontSize: 12.5 });

  s.addShape("rect", { x: 0.35, y: 4.32, w: 4.4, h: 0.55,
    fill: { color: BULLET_BG }, line: { color: ACCENT2, width: 1 } });
  s.addText("Tip: Ilizarov technique is the ONLY method that reliably corrects limb length in this setting — patients treated with nail/plating alone often walk with persistent shortening", {
    x: 0.45, y: 4.34, w: 4.2, h: 0.5,
    fontSize: 10, color: ACCENT2, italic: true, fontFace: "Calibri", valign: "middle"
  });

  // Divider
  s.addShape("line", { x: 5.05, y: 0.82, w: 0, h: 4.3, line: { color: ACCENT2, width: 0.8 } });

  // Non-union right column
  s.addShape("rect", { x: 5.15, y: 0.82, w: 4.5, h: 0.42,
    fill: { color: ACCENT2 }, line: { color: ACCENT2, width: 0 } });
  s.addText("Docking-Site Non-Union  —  2 / 10 (20%)", {
    x: 5.15, y: 0.82, w: 4.5, h: 0.42,
    fontSize: 13, bold: true, color: TEXT_DARK, fontFace: "Calibri", align: "center", valign: "middle"
  });

  addBullets(s, [
    "Defined as >3 mm radiolucency at 6 months post-docking",
    "Case 7: Resolved with prolonged compression (union at 9 months total) — conservative management",
    "Case 4: Required iliac crest bone grafting + conversion to monolateral Rail Fixator (non-compliance with circular frame at 6 months) → union at 10 months — classified as partial Ilizarov failure requiring hybrid salvage",
    "Risk factors: sclerotic bone ends, biological compromise, patient non-compliance",
    "Prevention: prophylactic iliac crest graft at docking in high-risk defects (sclerotic metaphyseal ends)",
  ], { x: 5.2, y: 1.32, w: 4.45, h: 4.0, fontSize: 12.5, color: LIGHT_GR });
}

// ═══════════════════════════════════════════════════════════════════════════════
// SLIDE 8 – COMPLICATIONS 4 & 5: PIN TRACTS + FLUID COLLECTION (with Fig 5)
// ═══════════════════════════════════════════════════════════════════════════════
{
  const s = darkSlide(pres);
  addSlideHeader(s, "Complications 4 & 5 — Infection & Fluid Collection");

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    fontSize: 13, bold: true, color: WHITE, fontFace: "Calibri", align: "center", valign: "middle"
  });
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    "All 3 cases: superficial soft tissue involvement only",
    "No deep infections or osteomyelitis in any patient",
    "Management: enhanced local care (chlorhexidine irrigation), temporary wire removal, oral antibiotics (7-10 days)",
    "All resolved completely; no surgical debridement required",
  ], { x: 0.35, y: 1.28, w: 4.95, h: 2.0, fontSize: 12.5 });

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    x: 0.3, y: 3.35, w: 5.1, h: 0.4,
    fontSize: 13, bold: true, color: WHITE, fontFace: "Calibri", align: "center", valign: "middle"
  });
  addBullets(s, [
    "Subacute seromas / haematomas (3-8 weeks post-docking, >10 mm on ultrasound)",
    "Management: single aspiration + compression bandaging",
    "All 3 cases resolved completely — no recurrence",
    "No unplanned readmissions or neurovascular injuries",
  ], { x: 0.35, y: 3.82, w: 4.95, h: 1.7, fontSize: 12.5 });

  // Other complications note
  s.addText("Other: mild hardware loosening (n=2) → frame realignment;  superficial skin irritation (n=2) → topical care", {
    x: 0.35, y: 5.35, w: 5.1, h: 0.28,
    fontSize: 9.5, color: "8899AA", italic: true, fontFace: "Calibri"
  });

  // Image
  s.addImage({ data: imgData("fig5_nonunion_crop.png"), x: 5.65, y: 0.82, w: 4.0, h: 4.2 });
  s.addShape("rect", { x: 5.65, y: 5.04, w: 4.0, h: 0.52,
    fill: { color: BULLET_BG }, line: { color: ACCENT, width: 1 } });
  s.addText("Fig 5. Docking-site non-union managed with bone grafting and Rail Fixator application (salvage)", {
    x: 5.7, y: 5.06, w: 3.9, h: 0.48,
    fontSize: 9.5, color: LIGHT_GR, italic: true, fontFace: "Calibri", valign: "middle"
  });
}

// ═══════════════════════════════════════════════════════════════════════════════
// SLIDE 9 – FUNCTIONAL OUTCOMES
// ═══════════════════════════════════════════════════════════════════════════════
{
  const s = whiteSlide(pres);
  addSlideHeader(s, "Functional Outcomes", false);

  // Big MSTS box
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    fill: { color: DARK_BG }, line: { color: ACCENT, width: 2 } });
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    fontSize: 54, bold: true, color: ACCENT, fontFace: "Calibri", align: "center"
  });
  s.addText("Mean MSTS Score / 30  (77%)", {
    x: 0.3, y: 1.75, w: 2.8, h: 0.58,
    fontSize: 11, color: WHITE, fontFace: "Calibri", align: "center"
  });

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    fill: { color: DARK_BG }, line: { color: ACCENT2, width: 2 } });
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    x: 3.3, y: 0.88, w: 2.8, h: 0.9,
    fontSize: 54, bold: true, color: ACCENT2, fontFace: "Calibri", align: "center"
  });
  s.addText("Union rate (incl. 10% hybrid salvage)", {
    x: 3.3, y: 1.75, w: 2.8, h: 0.58,
    fontSize: 11, color: WHITE, fontFace: "Calibri", align: "center"
  });

  s.addShape("rect", { x: 6.3, y: 0.82, w: 3.4, h: 1.6,
    fill: { color: DARK_BG }, line: { color: "2ECC71", width: 2 } });
  s.addText("0%", {
    x: 6.3, y: 0.88, w: 3.4, h: 0.9,
    fontSize: 54, bold: true, color: "2ECC71", fontFace: "Calibri", align: "center"
  });
  s.addText("Tumour recurrence / Deep infection / Neurovascular injury", {
    x: 6.3, y: 1.75, w: 3.4, h: 0.58,
    fontSize: 11, color: WHITE, fontFace: "Calibri", align: "center"
  });

  // Follow-up details
  s.addShape("rect", { x: 0.3, y: 2.55, w: 9.4, h: 0.38,
    fill: { color: "C8D4DF" }, line: { color: "C8D4DF", width: 0 } });
  s.addText("Mean follow-up: 34 months  (range 25–48)   •   Assessed by independent physiotherapist", {
    x: 0.3, y: 2.55, w: 9.4, h: 0.38,
    fontSize: 12, color: TEXT_DARK, fontFace: "Calibri", align: "center", bold: true
  });

  // Outcome bullets
  const outItems = [
    "All 10 patients achieved independent ambulation without walking aids at final follow-up",
    "MSTS score range: 21–26/30; standard deviation 1.4 — indicating consistent good functional outcomes",
    "2 patients (20%) required permanent shoe lifts for residual LLD; mild gait abnormality persisted but was well-tolerated",
    "No tumour recurrences detected during the observation period",
    "No late complications, unplanned readmissions, or hardware failures in the followed cohort",
    "External fixation index: mean 1.49 months/cm regenerate (range 1.36–1.52) — consistent across patients",
  ];
  addBullets(s, outItems, {
    x: 0.35, y: 3.05, w: 9.3, h: 2.55, fontSize: 13, color: TEXT_DARK
  });
}

// ═══════════════════════════════════════════════════════════════════════════════
// SLIDE 10 – COMPARISON WITH OTHER TECHNIQUES
// ═══════════════════════════════════════════════════════════════════════════════
{
  const s = darkSlide(pres);
  addSlideHeader(s, "Reconstruction Options — Comparative Overview");

  const headers = ["Technique", "Fusion / Union", "LLD", "Infection Risk", "Graft Fracture", "Cost", "LOS Durability"];
  const rows2 = [
    ["Plating + fibular graft", "~78%", "3 cm avg", "Moderate-high\n(wound dehiscence 22%)", "22% (4/18)", "Low", "Lower"],
    ["IM nail alone", "~75%", "4.5 cm avg", "Low", "0%", "Low", "Moderate"],
    ["Ring fixator + IM nail", "~90% ✓", "2.5 cm avg ✓", "Moderate\n(pin tracts)", "0% ✓", "Moderate", "High ✓"],
    ["Endoprosthesis", "N/A", "0 ✓", "Moderate", "N/A", "Very high", "73-83%\n5-yr; ~60% 10-yr"],
    ["Allograft + nail", "~67%", "3 cm", "Very high ✗", "Sequestration risk", "Moderate", "Low"],
    ["Vascularised fibula", "Good", "Variable", "Donor morbidity", "Hypertrophy risk", "High", "Good"],
  ];

  const colWs2 = [2.0, 1.2, 0.95, 1.5, 1.15, 0.9, 1.5];
  const rowH2 = 0.5;
  const startY = 0.88;
  let cx = 0.2;

  // Header row
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      fill: { color: ACCENT }, line: { color: DARK_BG, width: 0.5 } });
    s.addText(h, {
      x: cx, y: startY, w: colWs2[ci], h: 0.4,
      fontSize: 10.5, bold: true, color: TEXT_DARK, fontFace: "Calibri", align: "center", valign: "middle"
    });
    cx += colWs2[ci];
  });

  rows2.forEach((row, ri) => {
    cx = 0.2;
    const rowY = startY + 0.4 + ri * rowH2;
    const isIlizarov = ri === 2;
    row.forEach((cell, ci) => {
      const bg = isIlizarov ? "162A3A" : (ri % 2 === 0 ? BULLET_BG : "182535");
      const borderColor = isIlizarov ? ACCENT : "2A3F55";
      s.addShape("rect", { x: cx, y: rowY, w: colWs2[ci], h: rowH2,
        fill: { color: bg }, line: { color: borderColor, width: isIlizarov ? 1.5 : 0.5 } });
      const hasCheck = cell.includes("✓");
      const hasCross = cell.includes("✗");
      s.addText(cell, {
        x: cx + 0.04, y: rowY, w: colWs2[ci] - 0.08, h: rowH2,
        fontSize: 10, bold: isIlizarov,
        color: isIlizarov ? ACCENT : (hasCheck ? "2ECC71" : hasCross ? "E74C3C" : LIGHT_GR),
        fontFace: "Calibri", align: ci === 0 ? "left" : "center", valign: "middle"
      });
      cx += colWs2[ci];
    });
  });

  s.addText("Data synthesised from: Vidyadhara & Rao (EJSO 2007), Aggarwal et al. (Indian J Orthop 2007), Kapoor & Tiwari (Indian J Orthop 2007), Baruah & Sunder (Cureus 2026)", {
    x: 0.2, y: 5.38, w: 9.6, h: 0.22,
    fontSize: 8, color: "778899", italic: true, fontFace: "Calibri"
  });
}

// ═══════════════════════════════════════════════════════════════════════════════
// SLIDE 11 – TECHNICAL PEARLS & PROBLEM MITIGATION
// ═══════════════════════════════════════════════════════════════════════════════
{
  const s = midSlide(pres);
  addSlideHeader(s, "Technical Pearls & Complication Mitigation");

  const pearls = [
    {
      icon: "1",
      title: "Two-ring construct",
      text: "Minimise total pin/wire number → reduces pin-tract sepsis load and patient discomfort",
      color: ACCENT
    },
    {
      icon: "2",
      title: "Thin-diameter long IM nail (combined technique)",
      text: "Internal guide prevents varus/valgus deformity of regenerate; preserves endosteal blood supply; reduces frame time",
      color: ACCENT2
    },
    {
      icon: "3",
      title: "Early plate + bone graft at docking site",
      text: "Perform even before full regenerate consolidation — accelerates docking union; allows earlier frame removal",
      color: "2ECC71"
    },
    {
      icon: "4",
      title: "Bifocal bone transport",
      text: "Simultaneous transport from both ends shortens total frame time; reduces patient burden",
      color: ACCENT
    },
    {
      icon: "5",
      title: "Monthly biplanar radiographic surveillance",
      text: "Early detection of varus drift → timely frame adjustment with counter-distraction rings",
      color: ACCENT2
    },
    {
      icon: "6",
      title: "Patient education & compliance protocol",
      text: "4× daily distraction turns; chlorhexidine pin-site care; fortnightly clinic; monthly psychological counselling",
      color: "2ECC71"
    },
    {
      icon: "7",
      title: "Prophylactic ankle-foot orthosis",
      text: "Prevents equinovarus deformity during prolonged bone transport across a long segment",
      color: ACCENT
    },
  ];

  const colCount = 2;
  const boxW = 4.55;
  const boxH = 0.78;
  pearls.forEach((p, i) => {
    const col = i % colCount;
    const row = Math.floor(i / colCount);
    const x = 0.3 + col * 4.85;
    const y = 0.85 + row * (boxH + 0.12);
    // last item centers if odd
    const xAdjust = (i === pearls.length - 1 && pearls.length % 2 === 1) ? 2.45 : x;
    s.addShape("rect", { x: xAdjust, y, w: boxW, h: boxH,
      fill: { color: BULLET_BG }, line: { color: p.color, width: 1.5 } });
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      fill: { color: p.color }, line: { color: p.color, width: 0 } });
    s.addText(p.icon, {
      x: xAdjust, y, w: 0.35, h: boxH,
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    s.addText(p.title, {
      x: xAdjust + 0.42, y: y + 0.06, w: boxW - 0.5, h: 0.3,
      fontSize: 12, bold: true, color: p.color, fontFace: "Calibri"
    });
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      x: xAdjust + 0.42, y: y + 0.35, w: boxW - 0.5, h: 0.38,
      fontSize: 10.5, color: LIGHT_GR, fontFace: "Calibri"
    });
  });
}

// ═══════════════════════════════════════════════════════════════════════════════
// SLIDE 12 – DISCUSSION
// ═══════════════════════════════════════════════════════════════════════════════
{
  const s = darkSlide(pres);
  addSlideHeader(s, "Discussion");

  // Two column layout
  const leftItems = [
    "Mechanical complications prominent — varus deformity is most frequent, related to adductor forces in the femur",
    "Ilizarov-mediated bone transport is one of very few published series specifically for GCT of the distal femur",
    "100% union achieved (with 10% hybrid salvage) — compares favourably with reported rates for plating (~78%) and IM nailing (~75%)",
    "Docking-site non-union is a challenging complication especially in sclerotic bone — judicious autografting at docking reduces risk",
    "Prolonged frame time (mean 16.2 months) is a major obstacle — combined IM nail technique helps shorten this",
  ];
  const rightItems = [
    "No local recurrence: wide en-bloc resection essentially eliminates intralesional contamination risk",
    "MSTS 23.1/30 (77%) achieved at mean 34 months — comparable to results reported with endoprosthesis in similar populations",
    "Psychosocial burden should not be underestimated: monthly counselling is recommended in prolonged frame protocols",
    "Resource-constrained settings: Ilizarov provides a viable alternative where megaprosthesis is unavailable",
    "Study limitations: retrospective design, small n=10, no control group, single centre — generalisation restricted to selected young adults",
  ];

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  addBullets(s, rightItems, { x: 5.2, y: 0.85, w: 4.45, h: 4.4, fontSize: 12.5, color: LIGHT_GR });
}

// ═══════════════════════════════════════════════════════════════════════════════
// SLIDE 13 – CONCLUSIONS
// ═══════════════════════════════════════════════════════════════════════════════
{
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  s.addShape("rect", { x: 0, y: 0, w: 10, h: 0.08, fill: { color: ACCENT } });

  s.addText("CONCLUSIONS", {
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    fontSize: 22, bold: true, color: ACCENT, fontFace: "Calibri", charSpacing: 3
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    x: 0.4, y: 0.74, w: 9.2, h: 0,
    line: { color: ACCENT2, width: 1.2 }
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  const conclusions = [
    { num: "1", text: "Ilizarov reconstruction achieves 100% union after wide distal femoral GCT excision (including 10% hybrid Rail Fixator salvage) — the highest fusion rate among arthrodesis techniques in comparative series" },
    { num: "2", text: "Mean MSTS score of 23.1/30 (77%) represents good functional outcome; all patients achieved independent ambulation without aids at mean 34-month follow-up" },
    { num: "3", text: "Complications are common (varus 40%, pin infection 30%, fluid collection 30%, LLD 20%, non-union 20%) but HIGH and manageable with vigilant multidisciplinary care and defined salvage strategies" },
    { num: "4", text: "Zero tumour recurrences, deep infections, or neurovascular injuries confirm the oncologic safety and biological soundness of the technique" },
    { num: "5", text: "Technique is particularly valuable in resource-constrained settings where endoprosthetic options are limited — superior limb length restoration compared to plating or nailing alone" },
    { num: "6", text: "Larger prospective controlled series are needed to refine patient selection criteria and optimise outcomes" },
  ];

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      fontSize: 12.5, color: LIGHT_GR, fontFace: "Calibri", valign: "middle"
    });
  });
}

// ═══════════════════════════════════════════════════════════════════════════════
// SLIDE 14 – REFERENCES
// ═══════════════════════════════════════════════════════════════════════════════
{
  const s = midSlide(pres);
  addSlideHeader(s, "References");

  const refs = [
    "1. Baruah JP, Sunder S. Complications and Salvage Management in Ilizarov Reconstruction After Wide Excision for Distal Femoral GCT. Cureus 2026;18(4):e107972. DOI:10.7759/cureus.107972",
    "2. Vidyadhara S, Rao SK. Techniques in the management of juxta-articular aggressive and recurrent GCTs around the knee. Eur J Surg Oncol 2007;33:75-83.",
    "3. Kapoor SK, Tiwari A. Resection arthrodesis for giant cell tumors around the knee. Indian J Orthop 2007;41:124-8.",
    "4. Aggarwal AN, Jain AK, Kumar S, et al. Reconstructive procedures for segmental resection in GCT around the knee. Indian J Orthop 2007;41:129-33.",
    "5. Vidyadhara S, Rao SK. A novel approach to juxta-articular aggressive GCTs: resection arthrodesis using bone transport over an IM nail. Int Orthop 2007;31:243-7.",
    "6. Myers GJ, Abudu AT, Carter SR, Tillman RM, Grimer RJ. Endoprosthetic replacement of the distal femur for bone tumours: long-term results. J Bone Joint Surg Br 2007;89:521-6.",
    "7. Zheng K, Yu XC, Cai J, et al. Management of bone defects and complications after bone tumour resection using the Ilizarov method. Orthop Surg 2025. DOI:10.1111/os.14318.",
    "8. Enneking WF, Dunham W, Gebhardt MC, et al. A system for functional evaluation of reconstructive procedures after surgical treatment of musculoskeletal tumours. Clin Orthop 1993;286:241-6.",
    "9. Wada T, Usui M, Nagoya S, et al. Resection arthrodesis of the knee with a vascularised fibular graft. J Bone Joint Surg Br 2000;82:489-93.",
    "10. Yu XC, Xu M, Song RX, et al. Long-term outcome of GCT around the knee treated by en-bloc resection and prosthesis reconstruction. Orthop Surg 2010;2:211-7.",
  ];

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    s.addText(ref, {
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      bold: i === 0, fontFace: "Calibri", valign: "top"
    });
  });
}

// ═══════════════════════════════════════════════════════════════════════════════
// SLIDE 15 – THANK YOU
// ═══════════════════════════════════════════════════════════════════════════════
{
  const s = darkSlide(pres);
  s.addShape("rect", { x: 0, y: 0, w: 10, h: 0.08, fill: { color: ACCENT } });
  s.addShape("rect", { x: 0, y: 5.545, w: 10, h: 0.08, fill: { color: ACCENT } });

  s.addText("THANK YOU", {
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    fontSize: 60, bold: true, color: WHITE, fontFace: "Calibri", align: "center", charSpacing: 8
  });
  s.addText("Questions & Discussion Welcome", {
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    fontSize: 22, color: ACCENT, fontFace: "Calibri", align: "center", italic: true
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  s.addText("Corresponding Author:", {
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  s.addText("Dr. Shyam Sunder  |  shyam.arun90@gmail.com", {
    x: 1, y: 3.82, w: 8, h: 0.42,
    fontSize: 14, color: LIGHT_GR, fontFace: "Calibri", align: "center"
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  s.addText("Dept. of Orthopaedics, Pondicherry Institute of Medical Sciences, Puducherry, India", {
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    fontSize: 12, color: "778899", fontFace: "Calibri", align: "center", italic: true
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  s.addText("Cureus 2026; 18(4): e107972  •  DOI: 10.7759/cureus.107972  •  Open Access CC-BY 4.0", {
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    fontSize: 10, color: "556677", fontFace: "Calibri", align: "center"
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}

// ─── Write file ───────────────────────────────────────────────────────────────
const outPath = "/home/daytona/workspace/gct-ppt/GCT_Ilizarov_Reconstruction_MS_Ortho_Conference.pptx";
pres.writeFile({ fileName: outPath }).then(() => {
  console.log("SUCCESS:", outPath);
}).catch(err => {
  console.error("ERROR:", err);
  process.exit(1);
});

cd /home/daytona/workspace/gct-ppt && node build_ppt.js 2>&1

ls -lh /home/daytona/workspace/gct-ppt/GCT_Ilizarov_Reconstruction_MS_Ortho_Conf…

"giant cell tumor" AND bone AND reconstruction

meta-analysis giant cell tumor bone reconstruction outcomes 2020 2025

"giant cell tumor" AND knee AND surgery

"giant cell tumor" AND recurrence AND curettage

denosumab "giant cell tumor" bone outcomes

PMID: 39236154

PMID: 38654497

PMID: 41662446

PMID: 37006039

PMID: 39939368

PMID: 35377078

PMID: 37726111

"giant cell tumor" AND endoprosthesis AND limb salvage

PMID: 32312263

"giant cell tumor" AND recurrence AND prognostic factors