Does curettage-cement packing for treating giant cell tumors at the knee lead to osteoarthritis?

Total Knee Arthroplasty for Osteoarthritis Is Uncommon after Intralesional Curettage in Giant Cell Tumor of Bone

Giant cell tumor of bone (GCTB) is most often treated with intralesional curettage; however, periarticular lesions have been shown to increase risk for osteoarthritis. Additionally, the location of these lesions may occasionally preclude a joint-sparing procedure in recurrent tumors. This study sought to investigate rates of secondary arthroplasty in long-term follow-up of knee GCTB. Cases of knee GCTB treated at our institution were reviewed. Rates of recurrence and secondary arthroplasty were recorded, and Kaplan-Meier survival analyses were performed. The records of 40 patients were reviewed. Local recurrence occurred in 25% of patients. The 1-, 5-, and 10-year recurrence-free survival (RFS) probability was 87.4% (95% CI, 77.0-97.7), 72.4% (95% CI, 57.6-87.2), and 72.4% (95% CI, 57.6-87.2), respectively. Function improved after surgery with a mean preoperative MSTS score of 14.9 (standard deviation [SD] 8.4) and mean postoperative MSTS score of 25.1 (SD 5.6) (p <0.001). Three patients had evidence of radiographic osteoarthritis at the last follow-up though they did not require arthroplasty. Arthroplasty was performed as a secondary procedure in six patients. Five patients underwent arthroplasty for recurrent tumors after initial treatment with curettage and one patient underwent patellar arthroplasty for osteoarthritis after initial treatment with an allograft composite arthroplasty. Arthroplasty is performed as a secondary procedure in patients with GCTB at a relatively infrequent rate and more often for cases of recurrent disease than for osteoarthritis. Overall, patients treated for GCTB have improved functional outcomes after surgery than before. Large, multi-institutional studies may be required to assess the incidence of secondary osteoarthritis requiring arthroplasty as this was an infrequent finding in our cohort.

Incidence and progression of osteoarthritis following curettage and cementation of giant cell tumor of bone around the knee: long-term follow-up

BACKGROUND

Giant cell tumor of bone (GCTB) is a benign locally aggressive tumor frequently treated with intralesional curettage and cementation. The aim of this study was to investigate the long-term incidence of arthritic changes following curettage and cementation of GCTB around the knee.

MATERIALS AND METHODS

This study was a retrospective review of patients with GCTB around the knee treated with curettage and cementation with a minimum follow-up of 10 years. The functional results were assessed using the Musculoskeletal Tumor Society (MSTS) score. The arthritic changes were classified using the Kellgren-Lawrence (KL) classification system of osteoarthritis.

RESULTS

This study included 119 patients, 54 males and 65 females, with a mean age of 29.4 ± 9.2 years. There were 35 (29.4%) patients with pathological fractures. There were 84 (70.6%) patients with de novo lesions and 35 (29.4%) with recurrent lesions. The mean follow-up period was 13.2 ± 3.16 years. The mean MSTS score was 28.5 ± 1.9. Overall, 25 (21%) patients developed variable degrees of arthritis of KL grade 1 (n = 7), KL grade 2 (n = 11), KL grade 3 (n = 4), and KL grade 4 (n = 3). Ten patients showed progression of arthritis during the follow-up period. Age at presentation, gender, presence of pathological fracture, whether the tumor was de novo or recurrent, and tumor location were not associated with arthritis incidence.

CONCLUSIONS

Curettage and cementation can be used safely to treat GCTB around the knee. Arthritis of the knee is a possible complication, but mild grades are expected in most cases. There was no association between arthritis incidence and age, gender, pathological fractures, tumor location, or recurrent tumors.

LEVEL OF EVIDENCE

Level IV.

The giant cell tumor during pregnancy: A review of literature

BACKGROUND

Giant cell tumors (GTC) of bone are benign, locally aggressive tumors generally occurring in young people with a female predominance during reproductive age. Considering their worsening during pregnancy it has been suggested that pregnancy can accelerate GCT progression or favor recurrence but correlation between tumor growth and pregnancy has not yet been clarified. Aim of this study was to clarify clinical characteristics, timing and type of treatment through a literature review on GTCs occurring during pregnancy.

PATIENTS AND METHODS

An electronic search was performed in December 2020 in PubMed, Scopus, Embase, Medline, Cochrane Register using the keywords "giant cell tumor" AND "pregnancy" looking for papers reporting cases of giant cell tumors of the bone onset or recurred during pregnancy. The electronic search identified 212 papers; sixteen studies were selected, for a total of 32 cases.

RESULTS

The diagnosis was made during pregnancy in 24 cases and after the partum in 8 cases. 27 cases were new diagnoses while 5 cases were recurrences. Pulmonary metastases were reported in 3 patients. The treatment was performed during the pregnancy in 7 out of 32 cases; in the remaining 27 cases treatment was performed after delivery. The hormone receptor status was reported in 14 patients. Data regarding follow-up was reported for 26 out of 32 patients; three patients had local recurrences that were treated with wide resection and amputation in 2 and 1 case, respectively; at the last follow-up all patients were apparently without any evidence of disease except for three patients who had stable lung metastases.

DISCUSSION

In case of GCT during pregnancy, a multidisciplinary approach is necessary to offer the patients the best treatment in terms of mother and child's health. A correct diagnosis is necessary and not confusing tumor symptoms with ones of pregnancy is mandatory in order not to delay the diagnosis and let the tumor progress. Actually, even though pregnancy would seem to promote GCT growth and aggressiveness, the relationship is not clear. More studies are necessary to clarify this interesting aspect.

LEVEL OF EVIDENCE

IV, systematic review.

Primary total knee arthroplasty assisted by computed tomography-free navigation for secondary knee osteoarthritis following massive calcium phosphate cement packing for distal femoral giant-cell bone tumor treatment: a case report

BACKGROUND

Giant cell tumor of bone (GCTB) is an intermediate tumor commonly arising from the epiphysis of the distal femur and proximal tibia. Standard GCTB treatment is joint-preserving surgery performed using thorough curettage and the filling of the cavity with allo-, auto-, polymethyl methacrylate (PMMA), or synthetic bone graft. Calcium phosphate cement (CPC) is an artificial bone substitute, which has the benefit of being able to adjust defects, consequently inducing immediate mechanical strength, and promoting biological healing. Secondary osteoarthritis may occur following GCTB treatment and may need additional surgery if severe. However, details regarding surgery for secondary osteoarthritis have not been fully elucidated. There are no reports on the use of total knee arthroplasty (TKA) for the treatment of secondary osteoarthritis following CPC packing. The insertion of an alignment rod is a standard procedure in TKA; however, it was difficult to perform in this case due to CPC. Therefore, we used a computed tomography (CT)-free navigation system to assist the distal femur cut. This study presents a knee joint secondary osteoarthritis case following CPC packing for GCTB curettage that was treated with standard TKA.

CASE PRESENTATION

A 67-year-old Japanese woman, who was previously diagnosed with left distal femur GCTB and was treated by curettage and CPC packing 7 years ago, complained of severe knee pain. Left knee joint plain radiography revealed Kellgren and Lawrence (K-L) grade 4 osteoarthritis without evidence of tumor recurrence. Therefore, she was scheduled for TKA. There are no reports on the cutting of a femoral condyle surface with massive CPC with accurate alignment. Because it is difficult to insert the alignment rod intramedullary and cut the femoral condyle with CPC, we planned CT-free navigation-guided surgery for accurate bone cutting using an oscillating tip saw system to prevent CPC cracks. We performed standard TKA without complications, as planned. Postoperative X-ray showed normal alignment. Knee Society Knee Score (KSKS) and Knee Society Function Score (KSFS) ameliorated from 27 and 29 to 64 and 68, respectively The patient can walk without a cane postoperatively.

CONCLUSION

There was no report about the surface TKA guided by CT-free navigation after primary GCT surgery with CPC. We believe that this case report will help in planning salvage surgery for secondary osteoarthritis after CPC packing.

Fibular strut allograft or bone cement for reconstruction after curettage of a giant cell tumour of the proximal femur : a retrospective cohort study

AIMS

Giant cell tumours (GCTs) of the proximal femur are rare, and there is no consensus about the best method of filling the defect left by curettage. In this study, we compared the outcome of using a fibular strut allograft and bone cement to reconstruct the bone defect after extended curettage of a GCT of the proximal femur.

METHODS

In a retrospective study, we reviewed 26 patients with a GCT of the proximal femur in whom the bone defect had been filled with either a fibular strut allograft (n = 12) or bone cement (n = 14). Their demographic details and oncological and nononcological complications were retrieved from their medical records. Limb function was assessed using the Musculoskeletal Tumor Society (MSTS) score.

RESULTS

Mean follow-up was 116 months (SD 59.2; 48 to 240) for the fibular strut allograft group and 113 months (SD 43.7; 60 to 192) for the bone cement group (p = 0.391). The rate of recurrence was not significantly different between the two groups (25% vs 21.4%). The rate of nononcological complications was 16.7% in the strut allograft group and 42.8% in the bone cement group. Degenerative joint disease was the most frequent nononcological complication in the cement group. The mean MSTS score of the patients was 92.4% (SD 11.5%; 73.3% to 100.0%) in the fibular strut allograft group and 74.2% (SD 10.5%; 66.7% to 96.7%) in the bone cement group (p < 0.001).

CONCLUSION

Given the similar rate of recurrence and a lower rate of nononcological complications, fibular strut grafting could be recommended as a method of reconstructing the bone defect left by curettage of a GCT of the proximal femur. Cite this article: Bone Joint J 2022;104-B(2):297-301.

Discovery of Lijianmin-Chengkun Complexes and Their Oncological Application in Osseous and Intraarticular Lesions Around the Knee

Objective: This research aims to refresh the limited understanding about the canal and vascular structures within the epiphysis and metaphysis of the tibia and femur and their oncological significance.

Methods: This study was started with characterization of a novel structure using radiographs and anatomic dissections, followed by a descriptive clinical study with 55 participants to investigate the effects of tumors on this novel discovery and a retrospective cohort study with 82 participants to investigate whether the structure would be a risk factor for tumor recurrence after the curettage of giant cell tumor of bone.

Results: A new anatomical knee structure, the Lijianmin-Chengkun (LC) complex, was discovered in healthy adults, and its clinical implications were examined in this study. This new-found anatomical structure is composed of an epiphyseal and metaphyseal canal which surrounds a blood vessel, foramen, and foramen-covered synovium. All LC complexes showed similar radiographical, anatomical, and histological characteristics and were located within specific tibial and femoral intercondylar regions. These LC complexes seem to facilitate tumor residue and extension and may be a risk factor for tumor recurrence after curettage of femoral and tibial giant cell tumors (P = 0.031).

Conclusion: The LC complexes are related to local tumor recurrence and bidirectional tumor dissemination between intraosseous and intraarticular regions. These findings have opened up a new perspective and may provide new targets for intervention in malignant and aggressive tumors around the knee joint.

Secondary Osteoarthritis After Curettage and Calcium Phosphate Cementing for Giant-Cell Tumor of Bone Around the Knee Joint: Long-Term Follow-up

Giant-cell tumor of bone (GCTB) is a locally aggressive intermediate bone tumor with a rarely metastasizing disposition. Standard surgical treatment consists of curettage, adjuvant treatment, and augmentation with allograft, autograft, or synthetics. Polymethylmethacrylate (PMMA) has been widely used for augmentation of the bone defect; however, the hyperthermic polymerization of PMMA may cause damage to articular cartilage, and the stiffness of the material may decrease the ability of the joint to absorb shock. These properties were reported to result in secondary osteoarthritis. Calcium phosphate cement has a low degree of thermal reaction and a strength that is similar to cortical bone. The aim of the present study was to investigate the incidence of secondary osteoarthritis around the knee joint following augmentation with calcium phosphate cement.

[Treatment of giant cell tumor of bone around knee joint with three-dimensional printing personalized prosthesis]

OBJECTIVE

To investigate the short-term effectiveness of three-dimensional (3D) printing personalized prosthesis in the treatment of giant cell tumor of bone around knee joint.

METHODS

A clinical data of 9 patients with giant cell tumor of bone around knee joints and met the inclusive criteria between May 2014 and August 2017 was retrospectively analysed. There were 4 males and 5 females, with an average age of 35.8 years (range, 24-50 years). The lesion located at the distal femur in 4 cases and at the proximal tibia in 5 cases. The disease duration was 5-25 months (mean, 12.9 months). According to Campanacci grading, there were 2 patients of grade Ⅰ and 7 of grade Ⅱ. The 3D printing personalized prosthesis was designed based on the CT scanning and 3D reconstruction prepared before operation. All patients were treated with the tumor resection and 3D printing personalized prosthesis reconstruction. The radiological examination was taken to observe the tumor recurrence and the Musculoskeletal Tumor Society 1993 (MSTS93) score was used to evaluate the knee function.

RESULTS

All operations were successful and all incisions healed by first intention without early complications. All patients were followed up 24-40 months (mean, 31.2 months). At last follow-up, no complication such as pain, pathological fracture, prosthesis loosening, or tumor recurrence occurred. The MSTS93 score was 20-29 (mean, 24.7). The knee function was rated as excellent in 6 cases and good in 3 cases, with the excellent and good rate of 100%.

CONCLUSION

For giant cell tumor of bone around knee joint, 3D printing personalized prosthesis has the advantages of bio-fusion with host bone, mechanical stability, good joint function, and ideal short-term effectiveness. But the middle- and long-term effectiveness still need to be further observed.

Current status of bone cementing and bone grafting for giant cell tumour of bone: a systemic review

INTRODUCTION

Extended intralesional curettage, together with bone grafting/cementing, is considered as a surgical treatment option for giant cell tumour of the bone. This study aimed to discover the efficacy and recurrence rate with the use of bone cement in giant cell tumour and to compare it with that of bone grafting.

MATERIAL AND METHODS

The present systemic review is derived from the publications in the past 10 years (2009-2018). A literature search was performed via PubMed, using suitable keywords and Boolean operators database ('Giant cell tumor,' 'osteoclastoma,' 'bone,' 'bone cement,' 'bone graft' and 'curettage'). A detailed statistical analysis of the data derived from the published literature was done.

RESULTS

The patients who underwent bone graft only exhibited significantly higher recurrence rates than those treated with polymethyl methacrylate only (risk ratio 1.90; 95% confidence interval 1.14, 3.16; overall effect Z = 2.488; P-value 0.012). The observational analysis was done in rest of the seven studies; three studies showed no recurrence rate. Only one study reported the highest recurrence rate of 42% and the remaining six had an overall recurrence rate of 20.4%.

CONCLUSION

The use of bone cement was associated with a statistically significantly lower recurrence rate than bone grafting in giant cell tumour of bones. We therefore recommend the use of bone cement with extensive intralesional curettage. Adjuvant therapy like electrocautery, phenol irrigation and the use of intravenous denosumab or bisphosphonates may help in decreasing the incidence of recurrence in giant cell tumour of bone.