Management of the giant-cell tumours of the distal radius

A Rare Case of Giant Cell Tumour of the Medial Epicondyle of the Humerus Managed With Curettage and Bone Grafting

Giant cell tumours (GCTs) of the medial epicondyle of the humerus are rare. These are generally benign tumours but have the potential to be locally aggressive. They can invade the adjacent joint or the surrounding soft tissues or, in rare cases, cause distant metastasis. Locally aggressive GCTs are generally treated with wide resection, curettage, and bone grafting, followed by joint reconstructions. Here we present a case of a 49-year-old female with a history of swelling over the medial epicondyle of the humerus for six months. The patient was diagnosed with a locally aggressive GCT and was managed with wide excision of the tumour followed by sandwich bone grafting. A two-year follow-up of the patient shows no signs of recurrence. The patient is pain-free and has decent elbow function.

Management of giant cell tumors of the distal radius

Background

The distal radius is the most common location for giant cell tumors (GCT) in the upper extremity. Treatment should balance the goals of maximizing function and minimizing recurrence and other complications. Given the complexity in surgical treatment, various techniques have been described without clear standards of treatment.

Objectives

The purpose of this review is to provide an overview of evaluation of patients presenting with GCT of the distal radius, discuss management, and provide an updated summary on outcomes of treatment options.

Conclusion

Surgical treatment should consider tumor Grade, involvement of the articular surface, and patient-specific factors. Options include intralesional curettage and en bloc resection with reconstruction. Within reconstruction techniques, radiocarpal joint preserving and sparing procedures can be considered. Campanacci Grade 1 tumors can be successfully treated with joint preserving procedures, whereas for Campanacci Grade 3 tumors consideration should be given to joint resection to prevent recurrence. Treatment of Campanacci Grade 2 tumors is debated in the literature. Intralesional curettage and adjuvants can successfully treat cases where the articular surface can be preserved, while en-bloc resection should be used in cases where the articular surface cannot undergo aggressive curettage. A variety of reconstructive techniques are used for cases needing resection, with no clear gold standard. Joint sparing procedures preserve motion at the wrist joint, whereas joint sacrificing procedures preserve grip strength. Choice of reconstructive procedure should be made based on patient-specific factors, considering relative functional outcomes, complications, and recurrence rates.

Adjuvant Denosumab therapy following curettage and external fixator for a giant cell tumor of the distal radius presenting with a pathological fracture: A case report

INTRODUCTION AND IMPORTANCE

Denosumab is used as a neoadjuvant therapy for giant cell tumours (GCT) prior to surgery to improve surgical clearance and reduce the rate of recurrence. However, the use of denosumab as adjuvant therapy following an external fixator for GCT of the distal radius has not been commonly described. We describe the use of adjuvant denosumab following curettage and external fixation in a patient with GCT of the distal radius presenting with a pathological fracture.

CASE PRESENTATION

A 23-year-old male presented with a right distal radius fracture. Imaging was suggestive of a Campanacci grade 3 GCT at the distal radius with a pathological fracture. His chest X-ray was normal. He was managed with a dorsal open distal radius curettage and stabilization of the fracture with an external minifixator. Histology confirmed a GCT and adjuvant denosumab therapy was given. The response was satisfactory and the external fixator was removed at 5 months. At 42 months post-treatment, he had satisfactory function with no evidence of recurrence.

CLINICAL DISCUSSION

The extensive involvement of the distal radius and local invasion precluded the use of internal fixation after thorough curettage. Therefore, an external minifixator was applied to stabilize the fracture and started on denosumab following oncology opinion.

CONCLUSION

External fixation and adjuvant denosumab may be considered as an option in patients who are not suitable for internal fixation. However, cohort studies with long term follow up is necessary before it can be recommended in routine practice.

Vascularized Ulnar Transposition and Ulno-scapholunate Fusion for Reconstructing Campanacci Grade 3 Giant Cell Tumor of Distal Radius: Technique and a Series of 5 Cases

Campanacci grade 3 distal radius giant cell tumors are difficult to treat and just doing a curettage and bone grafting is insufficient. These lesions are associated with a high chance of recurrence. We are presenting our technique and series of 5 patients who underwent enbloc excision and ulna transposition with ulno-scapholunate fusion. Between 2014 and 2017 5 patients underwent en bloc excision of Campanacci grade 3 giant cell tumor of the distal radius, ulna transposition and ulno carpal fusion. These patients were regularly followed for evidence of union, range of motion, grip strength, and to look for recurrence of tumor. All 5 patients were Campanacci grade 3 tumors. The average duration of symptoms was 5 months (1 to 9 mo). The average duration of follow-up was 33 months (24 to 48 mo). The average time for ulno-scapholuante fusion was 8 weeks (6 to 10 wk) and the average time to radio ulnar fusion was 14.5 weeks (12 to 16 wk). The average arc of wrist flexion and extension was 34 degrees. The average grip strength was 58.2% of the contralateral side (48% to 69%). In conclusion vascularized ulnar transposition with partial wrist fusion for a Camapanacci grade 3 giant cell tumor is an alternate procedure in the management of these difficult tumors.

Wrist Reconstruction after En bloc Resection of Bone Tumors of the Distal Radius

Wrist reconstruction after en bloc resection of bone tumors of the distal radius has been a great challenge. Although many techniques have been used for the reconstruction of long bone defects following en bloc resection of the distal radius, the optimal reconstruction method remains controversial. This is the first review to systematically describe various reconstruction techniques. We not only discuss the indications, functional outcomes, and complications of these reconstruction techniques but also review the technical refinement strategies for improving the stability of the wrist joint.

En bloc resection should be performed for Campanacci grade III giant cell tumors (GCT) as well as malignant tumors of the distal radius. However, wrist reconstruction after en bloc resection of the distal radius represents a great challenge. Although several surgical techniques, either achieving a stable wrist by arthrodesis or reconstructing a flexible wrist by arthroplasty, have been reported, the optimal reconstruction procedure remains controversial. The purpose of this review was to investigate which reconstruction methods might be the best option by analyzing the indications, techniques, limitations, and problems of different reconstruction methods. With the advancement of imaging, surgical techniques and materials, some reconstruction techniques have been further refined. Each of the techniques discussed in this review has its advantages and disadvantages. Wrist arthrodesis seems to be preferred over wrist arthroplasty in terms of grip strength and long‐term complications, while wrist arthroplasty seems to be superior to wrist arthrodesis in terms of wrist motion. All things considered, wrist arthroplasty with a vascularized fibular head autograft might be a good option because of better wrist function, acceptable grip strength, and a relatively lower complication rate. Moreover, wrist arthrodesis is still an option if the fibular head autograft reconstruction fails. Orthopaedic oncologists should familiarize themselves with the characteristics of each technique to select the most appropriate reconstruction method depending on each patient's situation.

Giant Cell Tumors of the Upper Extremity: Predictors of Recurrence

PURPOSE

Giant cell tumors (GCT) of the distal radius are thought to be more aggressive than in other locations. Therefore, the aim of this study was to investigate factors associated with recurrence of GCTs in the upper extremity.

METHODS

We retrospectively identified 82 patients who underwent primary surgical treatment for an upper extremity GCT. Tumors were located in the radius (n = 47), humerus (n = 17), ulna (n = 9), and hand (n = 9). Treatment consisted of either wide resection or amputation or intralesional resection with or without adjuvants. A multivariable logistic regression was performed including tumor grade, type of surgery, and tumor location, from which the percentage of contribution to the model of each variable was calculated.

RESULTS

The recurrence rate after intralesional resection was 48%; after wide resection or amputation, it was 12%. Two patients developed a pulmonary metastasis (2.4%). In multivariable analysis, intralesional resection was independently associated with recurrence. Intralesional resection had a 77% contribution to predict recurrence and the distal radius location had a 16% contribution in the predictive model.

CONCLUSIONS

As expected, intralesional resection was the strongest independent predictor of recurrence after surgical treatment for GCT. The distal radius location contributed to the prediction of giant cell tumor recurrence to a lesser extent.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

Comorbidities and Pregnancy Do Not Affect Local Recurrence in Patients With Giant Cell Tumour of Bone

This study evaluates the relationship between pregnancy, comorbid conditions and giant cell tumour of bone. Furthermore, it examines if pregnancy and comorbid conditions affect the outcome following treatment for this tumour. A multi-centre retrospective review was conducted of consecutive patients with a confirmed histological diagnosis of giant cell tumour of bone between June 2012 and May 2017. A total of 195 patients were identified from two centres. Of these, 168 patients were treated with curative intent and had more than six months follow-up. Data were collected on pregnancy status, comorbid conditions, site of disease, surgical management and local recurrence rates. Statistical analysis included the Fisher exact test and Kaplan-Meier survival analysis. There were 72 females of childbearing age, of which 15 (21%) were currently pregnant or had been pregnant within the last six months. The pregnancy rate is higher than the highest reported pregnancy rate over the last 10 years (8.4%; Fisher test, p = 0.033). Women were more likely to have a comorbid condition than men (Fisher test, p < 0.002) and had a higher rate of autoimmune disease than the normal population (p = 0.015). Men were older than women (Wilcoxon test, p = 0.046) and had less risk of local recurrence (logrank test, p = 0.014). Pregnancy or comorbid conditions did not increase the local recurrence rate. Predictors for local recurrence included location in the distal radius (logrank test, p < 0.001), intralesional treatment (logrank test, p = 0.008) and age less than 40 (logrank test, p = 0.043). In conclusion, giant cell tumour of bone is more common in pregnant females and patients with immune disease. Comorbidities and pregnancy do not affect the local recurrence rate. Male patients over 40 years of age have a lower risk of local recurrence, and patients with disease in the distal radius have a high risk of recurrence.

Bone tumours around the elbow: a rare entity

Bone tumours around the elbow are rare. Even nowadays diagnostic dilemmas and delays are common. During recent decades the management and prognosis of patients with elbow bone tumours has improved significantly.Benign tumours can be treated using minimally invasive procedures, whereas malignant ones require a multidisciplinary team approach based on an adjuvant therapeutic regimen of chemotherapy, radiotherapy and limb salvage procedures.This article reviews the most commonly encountered elbow bone tumours and their management. Cite this article: EFORT Open Rev 2019;4:133-142. DOI: 10.1302/2058-5241.4.180086.

Reconstruction giant cell tumor of the right proximal humerus Campanacci 3 with pedicle and rod system: A case report

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Giant Cell tumors (GCT) are benign tumors with potential for aggressive behavior and capacity to metastasize.

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GCT were classified by Enneking and later by Campanacci based on radiographic appearance.

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Wide resection is associated with decreased risk of local recurrence compared to intralesional curettage and may increase the recurrence free survival rate.

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A 24-years-old male presented with Giant cell tumor (GCT) of the right proximal humerus Campanacci 3 and underwent wide resection and reconstruction type 1B with pedicle screw and rod system.

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The procedure provided excellent local control as the outcome was good both aesthetically and functionally.

Introduction

Giant Cell tumors (GCT) are benign tumors with potential for aggressive behavior and capacity to metastasize. Although considered to be benign tumors of bone, GCT has a relatively high recurrence rate. Tumor often extends to the articular subchondral bone or even abuts the cartilage. The joint and/or its capsule are rarely invaded. Surgical resection is the universal standard of care for the treatment of bone GCT. The key ensuring an adequate surgical treatment with complete removal of tumor is by obtaining adequate exposure of the lesion.

Presentation of case

We reported a case of 24-years-old male with Giant cell tumor (GCT) of the right proximal humerus. Patient presented with chief complaint of pain on the right shoulder and had a history of fell on the right elbow. Radiographic examination showed a primary bone tumor of the proximal humerus. MRI provided excellent depiction in suggesting the diagnosis of cutaneous GCT Campanacci 3, which was later, affirmed by biopsy. Patient underwent successful wide excision and reconstruction. The limb salvage procedure consisted of shoulder resection type 1B and reconstruction with pedicle screw and rod system. During 5 days post-operative period, there was no major event observed. Patient could do shoulder flexion forward 0–30, shoulder extension 0–20, elbow extension – Flexion, wrist flexion extension, and fingers flexion.

Discussion

GCT of bone typically shown as an epiphyseal, eccentric, expansive lytic lesion with a ‘soap-bubble appearance’. MRI is useful to assess extracortical spread and intramedullary extension. Surgery is the treatment of choice. Curettage is usually combined with cementing or bone grafting. Hemi-articular and total elbow allografts have been used for reconstruction of the defects following tumor excision, but the complication rates are high, and these techniques are reserved as salvage procedures following failed total elbow arthroplasty.

Conclusion

Wide resection and total elbow arthroplasty enables good functional outcome and lower risk for recurrence. Pedicle and rod system for shoulder reconstruction is a viable option, as it provides good pain relief and functional improvement with lower complication rates.

Treatment of giant cell tumor of distal radius with limited soft tissue invasion: Curettage and cementing versus wide excision

BACKGROUND

Intralesional curettage and adjuvant versus wide en bloc excision (WEE) as the best treatment method of giant cell tumor (GCT) of distal radius with limited soft tissue extension is a controversial topic.

METHODS

Prospectively, 13 patients who had GCT of distal radius with perforation of either volar or dorsal cortex of the bone and soft tissue extension which was confined to one plane were enrolled in the study. Six patients treated with ICC and seven cases cured by WEE technique and proximal fibular arthroplasty. The results were evaluated based on recurrence, range of motion of the wrist joint, rotation of the forearm, grip and pinch power.

RESULTS

The mean age of the patients treated with ICC and WEE techniques were 32.7 (range: 23-43) and 34.5 (range: 28-44), respectively. Mean follow-up period was 72 months (range: 28-148). Local recurrence was seen in 4 of 6 patients (66.7%) underwent ICC technique but in none of the 7 subjects treated with WEE technique (P value = 0.021). The overall range of flexion/extension and supination/pronation in the WEE group were 83% and 92% of the ICC group, respectively. Both of pinch and grip power were 14% less in the WEE group compared to the ICC group.

CONCLUSIONS

In GCT lesion of distal radius even with limited soft tissue extension, WEE and proximal fibular arthroplasty may be a more reasonable suggestion when the patient seeks a one-shot surgery.

Epidemiological and Clinical Features of Primary Giant Cell Tumors of the Distal Radium: A Multicenter Retrospective Study in China

Giant cell tumors of the distal radius are challenging for surgeons because they are associated with high recurrence rates and poor functional outcomes. Between June 2005 and October 2015, patients with primary giant cell tumors of the distal radius were recruited from seven orthopedic centers in China. The patients’ clinical features and demographic characteristics were obtained from medical records and reviewed retrospectively. Overall, 48 cases of giant cell tumors of the distal radius were assessed in this study. These patients were more likely to be between 20 and 40 years of age, to have a Campanacci grade of III, and to undergo a surgical style of resection. The prevalence of pathological fractures was 12.5% overall (20.0% in men and 4.3% in women). The prevalence of local recurrence was 30.0% overall (38.1% in men and 21.1% in women) during the average follow-up period of 62.5 months, with a pulmonary metastasis rate of 5.0%. Giant cell tumors of the distal radius were predominant in men and were more likely to recur locally than around the knee. These findings suggest that it is crucial to evaluate the optimal surgical approach for balancing local recurrence control and functional outcomes to reduce the disease burden.

Functional outcome of en bloc resection of a giant cell tumour of the distal radius and arthrodesis of the wrist and distal ulna using an ipsilateral double barrel segmental ulna bone graft combined with a modified Sauve-Kapandji procedure

Giant cell tumour of the distal radius is a locally aggressive lesion. In this study, we performed a wrist arthrodesis reconstruction with an ipsilateral double barrel segmental ulnar bone graft combined with a modified Sauve-Kapandji procedure for a giant cell tumour of the distal radius. From January 2007 to September 2013, we followed eight patients for a mean duration of 36 months. One patient developed a recurrence and was treated by amputation; the other seven patients achieved radiological union in about 8 months. There was no wrist instability, deformation or dislocation; the mean range of motion of the forearm achieved 75° of supination and 70° of pronation. The patients could recover reasonable grip strength. This new operative procedure can excise the tumour with a low rate of recurrence, fewer functional deficits and fewer complications than reported for other procedures.

LEVEL OF EVIDENCE

IV, therapeutic.

Giant cell tumor of distal radius treated with ulnar translocation and wrist arthrodesis

INTRODUCTION

The aim is to analyze the functional outcomes of patients of giant cell tumor (GCT) of distal radius treated with ulnar translocation and wrist arthrodesis.

METHODS

Study included 25 patients of aggressive GCT of distal radius, resected and reconstructed using ulnar translocation and wrist arthrodesis. The ulna-carpal radius fixation was performed with plate and screws. The patients were followed to bony union and minimum follow-up was 1 year.

RESULT

Twenty-two patients were of Campanacci grade 3 and three patients were of Campanacci grade2. The mean follow-up was of 23 months (12-36). All patients had an excellent range of pronation and supination. The mean Musculoskeletal Tumor Society score was 24 (range 22-28). Grip strength of affected hand compared to the contra lateral hand was found good in 17 cases and average in 7 cases. The mean bone union time at ulna to radius junction was at 6.5 (5-8) months and ulna to carpal junction at 4.5 (4-6) months. The complications were surgical site infection (one case), recurrence (one case) and failure of union (one case), and ulna graft fracture with implant failure in (two cases).

CONCLUSION

Reconstruction of distal end of radius using ulnar translocation and wrist arthrodesis provides excellent functional outcomes with preservation of rotational movement of forearm and hand function. Reconstruction of the distal radius by ulnar translocation without complete detachment from surrounding soft tissues functions like vascularized graft without use of microvascular techniques.

Giant Cell Tumor of Bone - An Overview

Giant Cell tumors (GCT) are benign tumors with potential for aggressive behavior and capacity to metastasize. Although rarely lethal, benign bone tumors may be associated with a substantial disturbance of the local bony architecture that can be particularly troublesome in peri-articular locations. Its histogenesis remains unclear. It is characterized by a proliferation of mononuclear stromal cells and the presence of many multi- nucleated giant cells with homogenous distribution. There is no widely held consensus regarding the ideal treatment method selection. There are advocates of varying surgical techniques ranging from intra-lesional curettage to wide resection. As most giant cell tumors are benign and are located near a joint in young adults, several authors favor an intralesional approach that preserves anatomy of bone in lieu of resection. Although GCT is classified as a benign lesion, few patients develop progressive lung metastases with poor outcomes. Treatment is mainly surgical. Options of chemotherapy and radiotherapy are reserved for selected cases. Recent advances in the understanding of pathogenesis are essential to develop new treatments for this locally destructive primary bone tumor.

Carpus translocation into the ipsilateral ulna for distal radius recurrence giant cell tumour: A case report and literature review

Giant cell tumour is a frequent benign neoplasm. It is characterized by local aggressive behaviour and frequent recurrence. The most common localization is the distal femur followed by proximal tibia (40%). The distal radius is the next place (10%). The recurrence in the distal radius in primary cases is reported 10%, in recurrent cases is almost 30% and depends to the kind and the stage of the tumour at the time of treatment. Multiple options have been reported for treatment of Campanacci III giant-cell tumour (GCT) of the distal radius after resection. Actually the treatment of recurrence remains a real dilemma. Several reconstructive options (e.g. resection arthroplasty, prosthetic replacement, arthrodesis, ulnar translocation, centralization of the carpus over the remaining ulna, use of vascularized or nonvascularized fibular graft, with or without, arthrodesis, have been described up to date. We present a case of recurrence of GCT of distal radius after curettage, where we selected the centralization of the ulna into the carpus as a salvage procedure with satisfactory results. The procedure provides a valid option for the management of recurrent GCTs of distal radius offering excellent cosmetic and acceptable functional result.

Which treatment is the best for giant cell tumors of the distal radius? A meta-analysis

BACKGROUND

Intralesional excision and en bloc resection are used to treat giant cell tumors (GCTs) of the distal radius. However, it is unclear whether one provides lower rates of recurrences and fewer complications, and whether the use of polymethylmethacrylate (PMMA) after curettage reduces the risk of recurrence.

QUESTIONS/PURPOSES

We examined whether curettage was associated with lower rates of recurrence and fewer major complications compared with en bloc excision, and whether PMMA resulted in lower rates of recurrence compared with a bone graft.

METHODS

We systematically searched the literature using the criteria, "giant cell tumor" AND "curettage" OR "intralesional excision" OR "resection". Six relevant articles were identified that reported data for 80 curettage cases (PMMA, n = 49; bone graft, n = 26; no PMMA or bone grafts, n = 5) and 59 involving en bloc excision. A meta-analysis was performed using these data.

RESULTS

Overall, patients in the intralesional excision group had a higher recurrence rate (relative risk [RR], 2.80; 95% CI, 1.17-6.71), especially for Campanacci grade 3 GCTs (RR, 4.90; 95% CI, 1.36-17.66), yet fewer major complications (RR, 0.21; 95% CI, 0.09-0.54) than the en bloc resection group. The use of PMMA versus bone graft did not affect the recurrence rate (RR, 0.98; 95% CI, 0.44-2.17).

CONCLUSIONS

Based on data obtained from the limited number of studies available, intralesional excision appears to be more appropriate for the treatment of local lesions (e.g., grades 1 and 2) than grade 3 GCTs of the distal radius. Moreover, PMMA was not additionally effective as an adjuvant.

LEVEL OF EVIDENCE

Level III, therapeutic study (systematic review). See Guidelines for Authors for a complete description of levels of evidence.

Giant cell tumor of bone: are we stratifying results appropriately?

BACKGROUND

There is no consensus as to which surgical approach to the treatment of giant cell tumor of bone is most appropriate or which patients are at a higher risk for recurrence or metastasis.

QUESTIONS/PURPOSES

Therefore, we asked: (1) Are there subsets of patients who are associated with a more recalcitrant disease course? And (2) are surgeons appropriately stratifying patients by identifying risk factors for increased local recurrence and pulmonary metastases?

METHODS

We retrospectively reviewed the records of 230 patients with giant cell tumor of bone treated from 1980 to 2010, stratifying them by primary versus recurrent disease and by surgical treatment. From the records, we determined local recurrence, metastatic disease, and complications of treatment. The median follow up was 47 months (range, 0.1-312 months).

RESULTS

Overall incidence of local recurrence was 10% and pulmonary metastasis was 2%. When stratified by surgical treatment, the incidence of local recurrence among patients undergoing intralesional curettage (12%) was greater than in those undergoing resection (2%). The incidence of local recurrence among primary tumors, independent of treatment, was 9%, whereas the incidence of local recurrence after treatment of recurrent lesions was 16%. The incidence of pulmonary metastases was similar, regardless of treatment or whether primary or recurrent.

CONCLUSIONS

Our observations suggest there are subsets of patients with giant cell tumor of bone who are at higher risk of recurrence and should be clinically followed more closely. This should allow surgeons to provide patients with more informed expectations.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Features of grade 3 giant cell tumors of the distal radius associated with successful intralesional treatment

PURPOSE

The goal of this study was to identify radiographic and anatomic features of Campanacci grade 3 distal radius giant cell tumors that are associated with an acceptable rate of local recurrence after intralesional treatment.

METHODS

We retrospectively reviewed 15 grade 3 distal radius giant cell tumors treated with intralesional curettage, cryosurgery, and cementation (CCC) (n = 9) or with wide en bloc excision and reconstruction (WEE) (n = 6). Success was defined as local control after CCC without conversion to wide excision, and as a recurrence rate comparable with rates in the scientific literature. Preoperative radiographic evaluation and intraoperative determination of tumor extension guided the choice of treatment. Tumor width on x-rays and tumor volume on magnetic resonance imaging were measured. Outcome was assessed with postoperative motion and grip strength, and the Disabilities of the Shoulder, Arm and Hand, the visual analog pain score, and a satisfaction questionnaire.

RESULTS

Local recurrence occurred in 2 of 9 patients after primary CCC, in none with repeat CCC, and in none of the 6 with WEE. No patient treated with secondary CCC had unresectable recurrence requiring conversion to WEE. Patients with a single site of cortical perforation who received CCC treatment achieved local control with intralesional treatment alone. Average tumor volume was 12 cm(3) (range, 9-17 cm(3)) with CCC and 43 cm(3) (range, 29-57 cm(3)) with WEE. Postoperative motion and strength, Disabilities of the Shoulder, Arm and Hand score, and visual analog pain scale score were acceptable in all and superior with CCC. All patients were highly satisfied.

CONCLUSIONS

Tumor volume measured with magnetic resonance imaging and anatomically defined limits of soft tissue extension may help identify grade 3 lesions that can be treated with with CCC with an acceptable rate of local recurrence. We propose subclassification of Campanacci grade 3 lesions. Under this classification, tumors with extension assessed by preoperative imaging and confirmed by intraoperatively to be limited to a single site of palmar cortical perforation are classified as grade 3(p), where (p) denotes a single site bound by the pronator quadratus.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Ulnar translocation after excision of a Campanacci grade-3 giant-cell tumour of the distal radius: an effective method of reconstruction

Between June 2005 and March 2008, 14 patients with a Campanacci grade-3 giant-cell tumour of the distal radius were treated by en bloc resection and reconstruction by ulnar translocation with arthrodesis of the wrist. The mean length of radius resected was 7.9 cm (5.5 to 15). All the patients were followed to bony union and 12 were available at a mean follow-up of 26 months (10 to 49). The mean time to union was four months (3 to 7) at the ulnocarpal junction and five months (3 to 8) at the ulnoradial junction. All except one patient had an excellent range of pronation and supination. The remaining patient developed a radio-ulnar synostosis. The mean Musculoskeletal Tumor Society score was 26 (87%, range 20 to 28). Three patients had a soft-tissue recurrence, but with no bony involvement. They underwent a further excision and are currently well and free from disease. Ulnar translocation provides a local vascularised bone graft to reconstruct the defect left after excision of the distal radius for giant cell tumour. It avoids the need for a microvascular procedure while retaining rotation of the forearm and good function of the hand.

Ressecção ampla e transposição fibular no tratamento do TCG da extremidade distal do rádio

OBJETIVO: Avaliação funcional e oncológica do tratamento do TCG do segmento distal do rádio (estadio B3) mediante ressecção ampla e reconstrução com enxerto autólogo avascular da extremidade proximal da fíbula. MÉTODOS: A função residual foi avaliada mediante escore ISOLS, medida do arco residual global do punho operado, do percentual residual da força de preensão da mão e da preensão entre o polegar e o indicador. O controle oncológico foi avaliado mediante exame clínico do membro operado e avaliação por imagens do punho e do tórax. RESULTADOS: 17 pacientes avaliados, dez do sexo feminino (58,8%) e sete do sexo masculino (41,2%) com idades entre 16 e 61 anos (média de 32,3 anos), todos destros. Na avaliação funcional (ISOLS) observamos 11 resultados excelentes, dois bons e um ruim; os três casos que demandaram artrodese evoluíram com escore excelente. O arco residual global foi de 196,2 ± 116,6º. O arco residual do punho operada correspondeu a 58,9% do controle. A força de preensão da mão correspondeu a 55,4 ± 17,4% do controle. O percentual de "pinça" foi de 80,6 ± 14,8% do controle. Não constatamos recidiva ou metástases nesta casuística. CONCLUSÃO: A técnica propiciou resultados funcionais alentadores, assegurando o retorno dos pacientes às suas atividades. A ausência de recidiva local e/ou metástases, observada inclusive nos pacientes com seguimento mais longo, permite sugerir que a técnica parece ser segura no controle oncológico do tumor.

Funktionelle Rekonstruktion der Radiusgelenkfläche nach Riesenzelltumor

Giant cell tumor is a benign locally aggressive tumor with a high tendency to recurrence, with a small rate of pulmonary metastases. In 90% of cases the tumor occurs in the long bones, especially near the epiphysis. A case of a 37-year-old female with a recurrent giant cell tumor of the distal radius including the radioulnar articular surface, successfully treated with a wide resection and reconstruction of the articular surface between the radius, scaphoid, lunatum, and ulna by an iliac crest graft, is reported.

Primary giant cell tumours of the digital bones of the hand

Primary giant cell tumours involving digital bones of the hand are rare lesions which are generally diagnosed at an advanced stage. Accurate diagnosis requires clinical evaluation, imaging studies and histopathological assessment. Conservative treatment by digit-sparing surgery is associated with high recurrence rates. In a ten year retrospective review, this study identified only four cases. Three cases involved a phalanx and were treated by distal amputation of the involved digit. None recurred. One involved the metacarpal and recurred twice following repeated curettage and bone grafting. No further recurrence has been detected after resection and replacement with a non-vascularised fibular graft and Silastic implant replacement of the metacarpophalangeal joint. Our small series of cases supports a policy of aggressive primary surgery, including amputation or en bloc resection and reconstruction.

Giant cell tumor - distal end radius: Do we know the answer?

BACKGROUND

The distal end of the radius is one of the common sites of involvement in giant cell tumors (GCTs) with reportedly increased propensity of recurrence. The objective of the present analysis was to study the modalities of management of the different types of distal end radius GCTs so as to minimize the recurrence rates and retain adequate function.

MATERIALS AND METHODS

Twenty-four patients of distal end radius GCTs treated between January 2000 and December 2004 were retrospectively reviewed. Nineteen cases were available for follow-up with an average follow-up of 37.5 months. There was one Campanacci Grade 1 lesion, nine Grade 2 and 14 Grade 3 lesions. Thirteen (54%) of these patients were treated elsewhere earlier and presented with recurrence. The operative procedures that were performed were: curettage and cementing (five), curettage and bone grafting (seven), excision and proximal fibular arthroplasty (two), excision and wrist arthrodesis (nine) and excision of soft tissue recurrence (one).

RESULTS

Functional status was evaluated using Musculo Skeletal Tumor Society scoring system which averaged 78%. The recurrence rate was 32%. Complications included local recurrence (six), nonunion at the graft bone junction (one), infection (one), deformity (two), stiffness (two), subluxation (two) and bony metastasis (one).

CONCLUSIONS

The majority of patients undergoing curettage were either Campanacci Grade 1 or 2. Patients undergoing curettage and reconstruction had a better functional result (82%) as compared to arthrodesis or fibular arthroplasty (69%). Previous intervention did not appear to increase the recurrence rates. Even though complications occur, judicious decision-making and an appropriate treatment plan can ensure a satisfactory outcome in the majority of cases.

Treatment of giant cell tumor of bone: Current concepts

Giant cell tumor (GCT) of bone though one of the commonest bone tumors encountered by an orthopedic surgeon continues to intrigue treating surgeons. Usually benign, they are locally aggressive and may occasionally undergo malignant transformation. The surgeon needs to strike a balance during treatment between reducing the incidence of local recurrence while preserving maximal function.Differing opinions pertaining to the use of adjuvants for extension of curettage, the relative role of bone graft or cement to pack the defect and the management of recurrent lesions are some of the issues that offer topics for eternal debate.Current literature suggests that intralesional curettage strikes the best balance between controlling disease and preserving optimum function in the majority of the cases though there may be occasions where the extent of the disease mandates resection to ensure adequate disease clearance.An accompanying treatment algorithm helps outline the management strategy in GCT.

Ethanol as a local adjuvant for giant cell tumor of bone

Giant cell tumor is an aggressive benign neoplasm of bone. A number of adjuvant agents have been used to supplement intralesional curettage to reduce the otherwise high local recurrence rate. High concentration ethanol is more readily available and less toxic to use than some common alternatives. No report on its use in a group of patients with giant cell tumor is available. Records were retrospectively reviewed for all giant cell tumors treated by intralesional curettage and high concentration ethanol irrigation as the only chemical adjuvant. Twenty-five primary excisional curettages and 12 repeat curettages for giant cell tumors of bone were performed in 31 patients. Patients were followed for a mean of three years and 10 months. There were five recurrences after primary excision procedures, and three after repeat excisions. Only use of a high-speed burr and lower Campanacci staging correlated with reduced recurrence rate, and these were not statistically significant. Most defects were filled with allograft or calcium sulfate. In the 11 patients treated primarily with curettage using a high-speed burr and adjuvant ethanol with minimum two-year follow-up, only one stage 3 lesion in a distal radius recurred. Multiple washes with high concentration ethanol, when used in conjunction with aggressive curettage including high-speed burring, is an effective and safe adjuvant. The necessity of any chemical adjuvant after appropriately aggressive curettage and burring can only be definitively demonstrated with a prospective, randomized, multi-center trial. Until such evidence becomes available, the use of adjuvant ethanol offers a compromise between higher toxicity adjuvants and no chemical adjuvant at all.

Giant cell tumor of bone

Giant cell tumor is a common benign bone tumor that possesses specific features including location at the end of long bone, a strong tendency toward local recurrence, and the rare capacity to metastasize to the lungs. Preferred treatment usually consists of extensive curettage and filling of the cavity with bone graft or cement. Debate still exists about the usefulness of local adjuvant treatment. Functional outcome is usually very good.

Intralesional curettage for grades II and III giant cell tumors of bone

Grade III Campanacci lesions are traditionally treated with wide resections based on their postulated aggressiveness and potential for local recurrence and metastasis. The purpose of this study was to determine if there was a difference in local recurrence rates of Grade II and III lesions treated with intralesional curettage, burring, phenol cauterization, and polymethylmethacrylate application. Sixty-three patients (26 Campanacci Grade II and 37 Grade III lesions) met the inclusion criteria. No pathologic fractures, including intraarticular fractures, were included in this study. Followup averaged 108 months (range, 25-259 months). The overall local recurrence rate was 6% (4 of 63 patients), with no observed difference between Grade II and III lesions. The average Musculoskeletal Tumor Society functional score was 27.9/30 (93%). The mean range of motion of the adjacent joint was 97%. Patients with radiographic signs of osteoarthritis before treatment did not show substantial progression, and only one patient developed radiographic signs of degenerative arthritis postoperatively. Our distal metastatic rate was 3.2%. These data support the use of intralesional curettage and burring with adjuvant phenol and polymethylmethacrylate even in Grade III lesions, in the absence of pathologic fracture, regardless of the presence or extent of extraosseous extension.

LEVEL OF EVIDENCE

Therapeutic study, Level III-1 (retrospective cohort). See the Guidelines for Authors for a complete description of levels of evidence.

Giant-cell tumours of bone of the hand and wrist: a review of imaging findings and differential diagnoses

Giant-cell tumour of bone (GCTOB) is a benign, locally aggressive, primary bone tumour. Involvement of the distal radius accounts for between 10 and 12% of cases of GCTOB, with the bones of the hand and wrist being rarely affected. GCTOB most commonly affects skeletally mature patients between the ages of 20 and 40 years, with the peak incidence being in the third decade. Women are affected slightly more commonly than men. GCTOB involving the bones of the hand most commonly occurs in a central location, which differs from the usual eccentric location seen in GCTOB at other sites. The radiographic features of GCTOB in the hand and wrist are presented. The role of bone scintigraphy, computed tomography and magnetic resonance imaging is discussed. Evaluation of the postoperative patient is also addressed, including the role of dynamic contrast-enhanced magnetic resonance imaging. A comprehensive review of the potential differential diagnoses that should be considered when GCTOB is suspected in the hand and wrist is also presented.