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

Management of Giant Cell Tumor of Distal Radius-Does Curettage Work?

Giant cell tumor affecting distal radius has been considered more aggressive, as compared to its counterparts in other locations. While resection has been advocated as the treatment of choice with lower rates of recurrence, curettage has reportedly led to superior functional outcomes. This retrospective study aimed to evaluate the functional and oncological outcomes of patients managed for GCT distal radius by either extended intralesional curettage (EIC) or resection and arthrodesis with radialisation of ulna (RRU), with respect to rates of local recurrence and function. Twenty-four patients operated for giant cell tumor of distal radius by a single surgeon from 2011 to 2021, were included in the study. The demographic, clinico-radiological, and surgical details were recorded and analyzed, as were the functional and oncological outcomes. At a median (IQR) follow-up of 6.3 years (range 2 years to 15.9 years), the rate of recurrence in curettage was found to be higher than that in resection but was not statistically significant (35.7% vs 20%, p > 0.05). Patients managed elsewhere and then presented to us for recurrence had a higher rate of local recurrence (66.6%, p = 0.01). Average time to recurrence was 14 months (range 2-24 months). On final follow-up, patients in curettage group had better functional outcomes in terms of grip strength and range of motion. Mean Modified Mayo Wrist score and MSTS score were 78.2 and 25.63, respectively, for EIC group and 69.6 and 25.75, respectively, for RRU group. Extended intralesional curettage resulted in an earlier rehabilitation with a mobile wrist and acceptable disease control when compared with resection and arthrodesis with radialisation of ulna.

Performance parametric formulation of carbon fiber-reinforced composite locking bone implant plates based on finite-element analysis

The treatment of Giant Cell Tumor (GCT) in the distal radius poses challenges due to the intricate anatomical features of the bone. It often necessitates the use of long implant plates or the interconnection of multiple short plates after tumor excision. However, the deployment of metal plates may increase the risk of screw loosening and various complications. To address these challenges, this study proposes the adoption of carbon fiber-reinforced PEEK (CFRP) as the base material. As a unique strategy, performance parameters (PP) were developed to compare CFRP implant plates with a Ti-6Al-4V plate using the Finite-element Method. The focus was on four elements: the screw axial force, bone growth, callus formation, and bone resorption. The investigation into the screw axial force involved analyzing the internal force of the screw. The remaining parameters were evaluated using the stress, strain, or elastic energy induced in the bones. The findings showed that the second screw endured the largest screw axial force, measuring 10.16 N under a 90-degree 10-N loading at the translocated bone. The model without a callus exerted a significantly greater force on the screw than the model with a callus, leading to screw loosening in the early stage of treatment. The maximum PP, reached 1.62, was achieved with an angle-ply [456/-456] laminate, featuring a weighting fraction of 0.7 for bone growth and 0.1 for the other parameters. This study provides a generalized methodology for assessing the performances of CFRP implants and offers guidelines for future development in composite implant plate technology.

Microwave-assisted intralesional curettage combined with other adjuvant methods for treatment of Campanacci III giant cell tumor of bone in distal radius: a multicenter clinical study

Objective

To compare the clinical outcomes of microwave-assisted intralesional curettage(MAIC) with those of en bloc resection and autogenous fibular reconstruction (EBR-AFR) for treating grade III giant cell tumor of the bone (GCTB) of the distal radius and to elucidate the indications for wrist preservation surgery.

Materials and methods

In this retrospective study, 19 patients with grade III GCTB of the distal radius who underwent surgery at three medical institutions were included and categorized based on their surgical pattern. Seven patients underwent MAIC and internal fixation with bone cement (MAIC group) and 12 underwent EBR-AFR (EBR-AFR group). To evaluate the function of the affected limb postoperatively, wrist range of motion, grip strength, Musculoskeletal Tumor Society (MSTS) scores were recorded.

Results

The follow-up time of the MAIC group was 73.57 ± 28.61 (36-116) months, with no recurrence or lung metastasis. In contrast, the follow-up time of the EBR-AFR group was 55.67 ± 28.74 (36-132) months, with 1 case of local recurrence (8.3%, 1/12) and 1 case of lung metastasis (8.3%, 1/12). The wrist flexion, extension, supination, pronation, grip strength were better in the MAIC group than in the EBR-AFR group. Although there was no statistically significant difference in the MSTS score between the two groups, it is noteworthy that the MAIC group exhibited significantly superior emotional acceptance and hand positioning compared to the EBR-AFR group(p < 0.05).

Conclusion

The functional outcomes of the MAIC group are better. The treatment strategy for grade III GCTB of the distal radius should be determined based on the specific preoperative imaging findings. Nevertheless, MAIC can be the preferred surgical approach for most patients with grade III GCTB of the distal radius, particularly for young patients.

Evaluating Extended Curettage and Adjuvant Therapy Against Wide Resection and Reconstruction in the Management of Distal Radius Giant Cell Tumors: A Systematic Review and Meta-analysis

BACKGROUND

The management of distal radius giant cell tumors (GCTs) remains challenging, and the optimal approach is still a matter of debate. This systematic review and meta-analysis aimed to compare the outcomes of extended curettage and wide resection, the mainstays of treatment.

METHODS

Medline (via PubMed), Cochrane Library, Web of Science, Google Scholar, ClinicalTrials.gov, and Embase databases were searched for comparative studies that assessed extended curettage with adjuvant therapy and wide resection with reconstruction in patients with GCTs of the distal radius up to April 2023. Data were collected and analyzed on rates of local recurrence, metastasis, overall complications, and functional outcomes. The Newcastle-Ottawa scale was used to appraise the risk of bias within each study.

RESULTS

Fifteen studies (n = 373 patients) were included and analyzed. Patients who underwent curettage were more likely to develop recurrence (risk ratio [RR] = 3.02 [95% confidence interval; CI, 1.87-4.89], P < .01), showed fewer complications (RR = 0.32 [95% CI, 0.21-0.49], P < .01), and showed greater improvement in Visual Analog Scale and lower Disabilities of the Arm, Shoulder, and Hand scores (P < .00001) than those who underwent wide resection. No significant difference was found regarding metastasis (RR = 1.03 [95% CI, 0.38-2.78], P = .95).

CONCLUSIONS

Regarding the surgical approach to GCT of the distal radius, curettage with adjuvant therapy was associated with a higher likelihood of recurrence compared with wide resection with reconstruction. Nevertheless, the curettage approach resulted in significantly lower rates of operative complications, decreased pain scores, and better functional outcomes in comparison to the resection group.

GIANT CELL TUMOR OF BONE: A MULTICENTER EPIDEMIOLOGICAL STUDY IN BRAZIL

Introduction

Giant cell tumor of bone (GCTB) mainly affects young adults' long bone epiphyses, threatening bone strength and joint function. Surgery is the primary treatment, although post-surgery recurrence is significant. This study analyzes patient profiles, treatments, and outcomes for GCTB in Brazil.

Methods

We retrospectively assessed local recurrence, metastasis, and treatment approaches in 643 GCTB patients across 16 Brazilian centers (1989-2021), considering regional differences.

Results

5.1% (n=33) developed pulmonary metastases, 14.3% (n=92) had pathological fractures, and the local recurrence rate was 18.2% (n=114). Higher rates of pulmonary metastases (12.1%) and advanced tumors (Campanacci III, 88.9%) were noted in lower-income North and Northeast regions. The North also had more pathological fractures (33.3%), extensive resections (61.1%), and amputations (27.8%). These regions faced longer surgical delays (36-39 days) than the South and Southeast (27-33 days).

Conclusions

Our findings corroborate international data, underscoring regional disparities in Brazil that may lead to worse outcomes in disadvantaged areas. This highlights the need for improved orthopedic oncology care in Brazil's economically and structurally challenged regions. Level of Evidence III; Retrospective Cohort.

Comprehensive evaluation and advanced modification of polymethylmethacrylate cement in bone tumor treatment

Bone tumors are invasive diseases with a tendency toward recurrence, disability, and high mortality rates due to their grievous complications. As a commercial polymeric biomaterial, polymethylmethacrylate (PMMA) cement possesses remarkable mechanical properties, injectability, and plasticity and is, therefore, frequently applied in bone tissue engineering. Numerous positive effects in bone tumor treatment have been demonstrated, including biomechanical stabilization, analgesic effects, and tumor recurrence prevention. However, to our knowledge, a comprehensive evaluation of the application of the PMMA cement in bone tumor treatment has not yet been reported. This review comprehensively evaluates the efficiency and complications of the PMMA cement in bone tumor treatment, for the first time, and introduces advanced modification strategies, providing an objective and reliable reference for the application of the PMMA cement in treating bone tumors. We have also summarized the current research on modifications to enhance the anti-tumor efficacy of the PMMA cement, such as drug carriers and magnetic hyperthermia.

Reconstruction After En Bloc Resection of a Distal Radius Tumor. An Updated and Concise Review

The distal radius is rarely affected by either primary or metastatic bone cancers. The most frequent tumors of the distal radius are giant cell tumors, which are benign tumors with the propensity to invade. En bloc excision of giant cell tumors of the distal radius achieves a low recurrence rate but compromises the wrist joint, necessitates a significant reconstruction, and has functional consequences. Reconstruction after en bloc resection of a distal radius bone tumor is challenging. Furthermore, orthopedic oncologists disagree on treating such long bone anomalies most effectively. The present article summarizes the various biological and non-biological reconstruction techniques performed after en bloc resection of a distal radius tumor, discusses the advantages and disadvantages of each reconstruction strategy, and summarizes several case studies and case reports.

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.

Recurrent Giant Cell Tumor of Bone with New Pulmonary Metastases 9 Years After En Bloc Distal Radius Resection: A Case Report

CASE

A 31-year-old man with a history of giant cell tumor of bone (GCTB) in the distal radius presents to clinic 9 years after en bloc distal radius resection. He was found to have a new soft tissue mass consistent with GCTB and new pulmonary metastases. Ultimately, he underwent excision of his soft tissue recurrence and partial lobectomy for his lung metastases.

CONCLUSION

This case highlights the importance of having a high level of suspicion for local recurrence or metastasis, even years after wide resection and negative margins.

Curettage versus wide resection followed by arthrodesis/arthroplasty for distal radius Giant cell tumours: A meta-analysis of treatment and reconstruction methods

Purpose

Primary aim of this review was to compare the two treatment modalities-curettage and wide excision (WE)- of Giant cell tumours of distal radius along with the methods of reconstruction viz. arthrodesis (AD) and arthroplasty (AP), and determine which had a better outcome.

Methods

PubMed and Cochrane library databases were systematically searched using a well-defined search strategy by two independent reviewers. Inclusion/exclusion criteria were predetermined using the PICO format. MINORS tool was used to evaluate study quality. Recurrence rate (RR) was the chief oncological determinant whereas range of motion, grip strength, disability of arm, shoulder and hand (DASH) and musculoskeletal tumour society (MSTS) scores and complication rates were the functional outcome measures used.

Results

For the first part, a total of 11 articles (284 patients) were analysed. The second half- AP versus AD-included four studies (71 patients). Quantitative analysis revealed a significantly higher RR (Odds ratio (OR) 8.6 [95% CI, 3.4, 21.75]) with curettage. WE, on the other hand, was associated with a higher complication rate (OR 0.3[ 95% CI, 0.14, 0.62]) and lower grip strength (Standard Mean Difference (SMD) 18.08[95% CI, 13.78, 22.37]). Complication rates were also significantly higher with wrist AP (OR 6.36[ 95% CI, 1.72, 23.52]). Remaining functional parameters failed to show any significant difference between either group.

Conclusion

WE is the preferred surgical strategy in terms of lower RR and functionally equivalent results. In terms of the choice of reconstruction following WE, there is a trend towards higher patient satisfaction after wrist AD.

Campanacci Grade III Giant Cell Tumors of Distal End Radius Treated With Wide Excision and Reconstruction: A Retrospective Case Series

Introduction

Campanacci Grade III Giant Cell tumors of the distal radius are difficult to manage as they are associated with a high recurrence rate. Wide excision of the distal radius and reconstruction with an ipsilateral proximal fibula or ulnar translocation reduces the recurrence rate significantly and gives acceptable function to the hand and wrist.

Methods and materials

This was a retrospective study of eight patients with Campanacci grade III giant cell tumors of distal radius treated with wide excision of distal radius followed by reconstruction at our institute. Four cases were operated on with ulnar translocation and four cases were operated on with ipsilateral proximal fibula grafting after wide excision of the distal radius. Patients were studied for the Musculoskeletal Tumor Society (MSTS) score and visual analogue scale (VAS) score for pain at one year, recurrence, and complications.

Results

The mean MSTS score of the total series was 24.75 ± 1.6. The mean VAS score for the total series was 1.62 ± 0.4. Of the eight cases, two cases had a recurrence, one patient had persistent wrist paint, and two patients had wrist subluxation.

Conclusion

Wide excision of the distal radius followed by reconstruction with a proximal fibula or ulnar translocation is a good option to avoid repeated surgeries in patients with Campanacci grade III giant cell tumors of the distal radius and achieve acceptable functional results for the wrist and hand.

The effective distance and cooling rate of liquid nitrogen-based adjunctive cryotherapy for bone tumors ex vivo

BACKGROUND

Liquid nitrogen (LN) has been used as an adjuvant cryotherapy for bone tumors including giant-cell tumor of the bone (GCTB) to remove residual tumor cells after curettage. This study evaluated variables related to the efficacy of LN-based cryoablation in the context of adjuvant treatment of GCTB using porcine femur bone model.

METHODS

A porcine femur bone model was adopted to simulate intralesional cryotherapy. A LN-holding cavity (point 1, nadir) in the medial epicondyle, 4 holes (points 2-5) in the shaft situated 5, 10, 15, and 20 mm away from the proximal edge of the cavity, and 2 more holes (points 6 and 7) in the condyle cartilage (10 and 20 mm away from the distal edge of the cavity) were made. The cooling rate was compared between the 5 points. The cellular morphological changes and DNA damage in the GCTB tissue attributable to LN-based cryotherapy were determined by H&E stain and TUNEL assay. Cartilage tissue at points 6 and 7 was examined for the extent of tissue injury after cryotherapy.

RESULTS

The temperature kinetics at points 1, 2 reached the reference target and were found to be significantly better than the reference (both p < 0.05). The target temperature kinetics were not achieved at points 4 and 5, which showed a significantly lower cooling rate than the reference (both p < 0.001) without reaching the -60°C target. Compared with untreated samples, significantly higher proportion of shrunken or apoptotic cells were found at points 1-3; very small proportion were observed at points 4, 5. Significantly increased chondrocyte degeneration was observed at point 6, and was absent at point 7.

CONCLUSION

The cryotherapy effective range was within 5 mm from nadir. Complications were restricted to within this distance. The cooling rate was unchanged after three repeated cycles of cryotherapy.

Management of giant cell tumors of the distal radius: a systematic review and meta-analysis

PURPOSE

The treatment of giant cell tumors (GCT) of the distal radius remains challenging, with no consensus on the optimal surgical management. Surgical management remains the mainstay of treatment with options including intralesional curettage and en-bloc resection with reconstruction. The objective of this systematic review and meta-analysis was to evaluate and compare the outcomes of these two procedures.

METHODS

Using OVID-Medline and Embase databases, a systematic literature search was performed. Comparative studies, assessing intralesional curettage and en-bloc resection in patients with GCTs of the distal radius, were included. Data regarding rates of local recurrence, metastasis, overall complications, and functional outcomes, were collected and analyzed. The ROBINS-I tool was utilized for risk of bias appraisal within each study outcome.

RESULTS

Thirteen studies (n = 373 patients) reporting on 191 intralesional curettage procedures and 182 en-bloc resections were included in the analysis. The average age of participants was 31.9 (SD ± 2.4) years and average follow-up was 7.1 (SD ± 3.6) years. Patients that underwent intralesional curettage were more likely to develop local recurrence (Risk Ratio (RR) 3.3, 95% CI, [2.1, 5.4], p < 0.00001) when compared to patients that underwent en-bloc resection. In Campanacci grade 3 lesions, the risk for local recurrence was 5.9 (95% CI, [2.2, 16.3], p = 0.0006) times higher in patients that received intralesional curettage. Patients that underwent intralesional curettage showed an 84% reduction in the relative risk of developing overall complications compared to en-bloc resection (95% CI, [0.1, 0.4], p < 0.00001), and a larger decrease in Visual Analog Scale and lower Disabilities of the Arm, Shoulder, and Hand (DASH) scores (p < 0.00001). Risk ratio for developing a local recurrence, with PMMA versus bone graft following an intralesional procedure was not significant (RR 1.2, 95% CI, [0.6, 2.6], p = 0.62).

CONCLUSIONS

In the surgical management of GCT of the distal radius, intralesional curettage increased local recurrence compared to en-bloc resection with reconstruction, particularly in grade 3 tumors. However, it led to significantly fewer operative complications, lower pain scores, and improved functional outcomes compared to en-bloc resection. Both treatment options remain relevant in the contemporary management of GCTs of the distal radius. Surgical decision making should include both patient and tumor factors when determining the optimal treatment strategy for these patients. LEVEL 3 EVIDENCE: Meta-analysis of Level 3 studies.

Chondrosarcoma of the proximal radius treated by wide resection and reconstructed by 3D printed implant: A case report and description of surgical technique

Introduction

Chondrosarcoma is the second most common primary malignancy of bone that can occur in multiple locations in the skeleton. It has been rarely reported in the proximal radius. While surgical resection is the primary treatment modality for individuals with localized disease, reconstruction can be challenging in the elbow joint due to its complex anatomy. 3D printing technology can be used in such complex cases to restore the normal anatomy after resection.

Case presentation

We present a case of mesenchymal chondrosarcoma in a 33-year-old male occurring in the proximal radius, restricting his elbow motion. That was resected and reconstructed using 3D modeling. Restoring a functional range of motion without instability.

Discussion

Many surgical options for chondrosarcoma presented over the years including en bloc resection, resection with or without reconstruction, or amputation. Usage of 3D modeling in the orthopedic surgery field is relatively new and it can be used in pre-operative planning and shortens surgical time. 3D printing in our case helped in obtaining a full range of motion (flexion, extension, pronation, and supination) for the patient.

Conclusion

It's important to reconstruct elbow joint support structure and function after resection of such a large malignant tumor in young patients. We used 3D printed implant to maintain a functional limb and it was an excellent alternative treatment.

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Chondrosarcoma occurring in the proximal radius is very rare. Up to our knowledge, this is the second case report.

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We report a case of proximal radius chondrosarcoma managed by reconstruction with Three-Dimension printed implant.

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3D printing in the field of orthopedic surgery is relatively new and has upscaled medical management.

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A description of a surgical technique to reconstruct proximal radius and maintaining full range of motion of the elbow.

Reconstruction of the distal radius using a double-barrel vascularized fibula flap: a case series

Treatment of distal radius tumor sometimes requires sacrificing the epiphysis. We propose adding to currently available reconstruction options a technique using a double-barrel vascularized fibula flap fixed distally to the first carpal row, conserving midcarpal mobility. We monitored 4 cases of Campanacci III giant-cell tumor and 2 cases of osteosarcoma. After en-bloc tumor resection, a double-barrel vascularized fibula flap was lodged distally in the scaphoid and lunate and proximally in the radius. Follow-up was clinical and radiological, using DASH, PRWE and MSTS functional scores. At a median 3 years' follow-up, there were no cases of recurrence or non-union. Median ranges of motion were 23° flexion, 28° extension, 90° pronation and 62° supination. Median grip strength proportional to the contralateral side was 67%. Median DASH and PRWE functional scores were respectively 13.7 and 17 points. Median MSTS was 83%. Although this technique is challenging, with difficulties in double-barrel flap placement and in pedicle plication, the double-barrel vascularized fibula flap provided a stable and mobile wrist.

Giant Cell Tumor of the Distal Radius: Wide Resection, Ulna Translocation With Wrist Arthrodesis

Giant cell tumor (GCT) of the bone is a locally aggressive neoplasm and usually managed with extended curettage and adjuvant therapy, which is associated with reduced risk of recurrence. The juxta-articular distal radius giant cell tumor is challenging due to the destruction of subchondral bone and articular cartilage, making it difficult to salvage the wrist joint anatomy and function. Various methods described include wide resection and reconstruction of allograft or centralization of the ulna with wrist arthrodesis. We present the functional outcome of distal end radius GCT, which was successfully managed with wide local excision, ulna translocation, and wrist arthrodesis. At the two years follow-up, the patient shows excellent functional outcome with supination and pronation movements and no local recurrence.

Surgical treatment of distal radius giant cell tumors

We aimed to evaluate the effectiveness of surgical methods commonly used for the clinical treatment of giant cell tumors (GCT) of the distal radius. From 2010 to 2018, 32 patients with GCT of the distal radius who underwent surgical treatment were eligible for the study. Among them, 21 patients with available pathological results, complete imaging data and at least 18 months of follow-up were enrolled in the study. Eleven of the patients underwent en bloc resection and non-vascularized autologous fibula reconstruction (Group A), while 10 patients underwent microwave ablation, lesion curettage, and internal fixation with bone cement (Group B). Imaging was carried out to understand the effect of the surgical treatment and postoperative complications. Variables of interested included operation time and blood loss, preoperative and postoperative wrist joint mobility, and postoperative complications during follow-up. The operation time and intraoperative blood loss in group A were higher than in group B, and the difference between groups was statistically significant. The wrist range of motion before and after surgery was statistically significant both in Group A and Group B (p < 0.05). The scale deviation and MSTS scores of group A were better than group B (p > 0.05), flexion, extension, radial deviation index in group B was better than group A (p < 0.05). By evaluating the postoperative functional outcomes of the operated wrist in the two groups, we found that both surgical methods are reliable for treating GCT of the distal radius, with satisfactory postoperative functional recovery and a low incidence of postoperative recurrence (only 1 of 10 patients in group B). The two surgical methods have their own advantages and disadvantages and provide surgeons with one more choice in the clinical context.

Osteoarticular allograft reconstruction after distal radius tumor resection: Reoperation and patient reported outcomes

BACKGROUND

The aims of this study are to evaluate the rate of wrist joint preservation, allograft retention, factors associated with reoperation and to report the patient reported outcomes after osteoarticular allograft reconstruction of the distal radius.

METHODS

Retrospective chart review identified 33 patients who underwent distal radius resection followed by osteoarticular allograft reconstruction, including 27 giant cell tumors and 6 primary malignancies. Ten patients with a preserved wrist joint completed the QuickDASH, PROMIS-CA physical function, and Toronto extremity salvage score (TESS) at a median of 13 years postoperatively.

RESULTS

The allograft retention rate was 89%, and an allograft fracture predisposed to conversion to wrist arthrodesis. The reoperation rate was 55% and 36% underwent wrist arthrodesis at a median of 4.2 years following index surgery. The use of locking plate fixation was associated with lower reoperation and allograft fracture rates. Patients reported a median QuickDASH of 10.2 (range: 0-52.3), a mean PROMIS physical function of 57.8 (range: 38.9-64.5) and the median TESS was 95.5 (range: 67.0-98.4).

CONCLUSION

Osteoarticular allograft reconstruction results in acceptable long-term patient reported outcomes, despite a high revision rate. Allograft fixation with locking plates seems to reduce the number of reoperations and allograft fractures, along with reduction in wrist arthrodesis rates.

A comparison of depth of necrosis among adjuvant therapies used for the treatment of benign bone tumors

BACKGROUND AND OBJECTIVES

Benign bone tumors are often treated with extended curettage utilizing an adjuvant therapy to eliminate any remaining tumor cells. The purpose of this study was to explore and compare the histologic depth of necrosis created by various adjuvant therapies used in the treatment of benign bone tumors.

METHODS

A high-speed burr was utilized to create cortical defects within porcine humeri and femora. Phenol, polymethyl methacrylate (PMMA), argon beam coagulation (ABC), liquid nitrogen, and the Bipolar Hemostatic Sealer (BHS) were each applied to five defects, with an additional five defects left untreated as a control. The maximal depth of necrosis was determined under microscopic examination.

RESULTS

The phenol, PMMA, ABC, liquid nitrogen, and BHS demonstrated an average histologic depth of necrosis of 0.30, 0.78, 2.54, 2.54, and 0.92 mm, respectively, each of which was significantly increased compared to the control group (p = .001, .003, .003, .01, and  <.001). Their respective variances, a measure of reproducibility, were 0.01, 0.09, 0.96, 1.93, and 0.03 mm² .

CONCLUSION

This study confirms, through histologic analysis, adjuvant therapies create a rim of cellular necrosis beyond that of burring during extended curettage, supporting their use in the treatment of benign bone tumors. Furthermore, it provides a head-to-head comparison.

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.

Novel Strategy of Curettage and Adjuvant Microwave Therapy for the Treatment of Giant Cell Tumor of Bone in Extremities: A Preliminary Study

Objectives

To evaluate whether curettage with adjuvant microwave therapy was successful in the treatment of giant cell tumor of the bone (GCTB) in extremities, especially for GCTB with pathological fractures and GCTB of the distal radius.

Methods

This was a retrospective study of 54 cases of GCTB of the extremities treated by curettage with adjuvant microwave therapy between 2007 and 2019. Five patients were lost to follow up and excluded from the study. A total of 33 male and 21 female patients were included in this study. Patients were aged 15–57 years (mean 29.72 ± 10.48 years). Among these patients, there were 10 cases of GCTB with pathological fractures and eight cases of GCTB of the distal radius; one of these cases was combined with a pathological fracture. Comprehensive imaging examinations (X‐rays [including lesion site and chest], CT, MRI, emission computed tomography, and pathology examination) of all patients were reviewed. The clinical staging of these patients were evaluated radiologically using the Campanacci classification system based on the extent of spread of the tumor. All patients underwent curettage with adjuvant microwave therapy. Clinical and imaging evaluations were performed in all cases to check for recurrence or metastasis. Lower limb and upper limber function were assessed using the Musculoskeletal Tumor Society score (MSTS), and wrist function was assessed according to the disabilities of the arm, shoulder and hand (DASH) score. Data on surgical‐related complications were recorded.

Results

All cases were followed up for 24–126 months (mean 60.69 ± 29.61 months). There were 24 patients with a Campanacci grade of 3 and 30 with a Campanacci grade of 2. The 52 patients were continuously disease‐free. The local recurrence rate was 3.70% (2 patients). One patient had recurrence in the proximal femur, and the other developed in soft tissue of the calf muscle. No recurrence occurred for GCTB of the distal radius. One recurrence occurred in a GCTB with pathological fractures. The intervals were 9 and 28 months, respectively. The cases of recurrence all had a Campanacci grade of 3 (8.33%). The median MSTS among the 54 patients was 27.67 ± 3.81. The mean wrist function DASH score was 8.30 ± 2.53. The mean MSTS was 28.67 ± 1.63 and 26.71 ± 5.49 for patients with GCTB of the distal radius and for those with pathological fractures, respectively. In comparing patients with and without pathological fractures, there was no significant difference in the MSTS functional score. Five patients had complications after the surgery.

Conclusion

Curettage with adjuvant microwave ablation therapy provided favorable local control and satisfactory functional outcomes in the treatment of GCTB, especially for cases with pathological fractures and those with GCTB of the distal radius.

Custom-made wrist prothesis (UNI-2™) in a patient with giant cell tumor of the distal radius: 10-year follow-up

Wrist endoprosthesis is still an exceptional indication compared to the prosthesis of large joints, especially when a rescue surgery procedure of the wrist is no longer possible and the complete wrist arthrodesis is to be considered the ultima ratio. However, a suspended function in the wrist is accompanied by a significant restriction in the patient`s daily life. Using the fourth-generation endoprosthesis, the situation regarding long-term results for the hand has already improved. This means that a durability of more than 6 years is no longer a rarity. Defect situations in joints, in particular those which occur after tumor, still pose a greater challenge. If autologous reconstructions cannot be performed, custom-made prostheses can be considered as very rare indications for joint reconstruction. While these have been used for years on large joints such as shoulder, elbow, knee and hip, they have only been described on the hand in particular cases. We report the 10-year follow-up of implantation of a custom-made wrist prothesis (UNI-2™, KMI, Germany) in a 36-year-old patient with tumorous destruction of the distal radius by a giant cell tumor.

Denosumab for Bone Giant Cell Tumor of the Distal Radius

There are conflicting reports regarding the outcome and effect of denosumab for distal radius giant cell tumor of bone (GCTB). The authors performed this study to evaluate the behavior of distal radius GCTB in relation to the type of treatment and the administration of denosumab. The files of 72 patients with distal radius GCTB treated from 1984 to 2018 were reviewed. Fourteen patients were administered denosumab. Surgical treatment consisted of curettage (25 patients) or resection (47 patients) and allograft or vascularized fibular head graft reconstruction. Median follow-up was 63.1 months (interquartile range [IQR], 35.5-107.1 months). The authors evaluated local recurrences, metastasis, function, and complications. The local recurrence rate was 30.6% at a median of 14.0 months (IQR, 10-19 months), with no difference between curettage and resection. The local recurrence rate was significantly higher in the patients who received denosumab. The metastasis rate was 9.7% at a median of 41.0 months (IQR, 15-114 months), with no difference regarding denosumab administration. Function was significantly better in patients after curettage. The complication rate was 25%; vascularized fibular graft reconstruction was associated with fewer complications. This study found that denosumab increases the risk of local recurrence after curettage, function is better after curettage, and vascularized fibular graft is the optimal reconstruction after resection of distal radius GCTB. [Orthopedics. 2020;43(5):284-291.].

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.

Oncology and functional prognosis are both vital in the surgical treatment of RGCTs around the knee joint

AIMS

To explore and provide reasonable surgical options for recurrent giant cell tumors of bone (RGCTs) around the knee joint and compare the pros and cons of extended curettage (EC) and segmental resection (SR).

MATERIALS AND METHODS

A retrospective analysis was performed of 22 patients (11 male, 11 female; mean age, 34.1 years) with RGCT around the knee joint treated in our hospital between June 2007 and June 2017. Average recurrence time was 14.2 ± 4.7 months. Basic clinical data, including Campanacci grade, lesion location, filler materials, pathological fracture, were recorded. Based on different reoperation methods, patients were divided into the EC and SR groups. Patients were regularly followed up; and recurrence, metastasis, local complications such as osteoarthritis, infection, prosthesis loosening, were recorded. Patient function and surgical efficacy were evaluated using the musculoskeletal tumor society (MSTS) score and Mankin score, respectively.

RESULTS

Postoperative recurrence occurred in one patient in both groups, and no difference in the prognosis of oncology was observed between the groups. In the EC group, seven patients developed postoperative complications, but required no surgical treatment, whereas in the SR group, five patients developed postoperative complications and surgical treatment was performed on two patients. There were significant differences in the functional prognosis and surgical efficacy between the two groups; however, the EC group showed more satisfactory results.

CONCLUSION

The oncological and functional prognosis of patients with RGCT around the knee joint is vital. EC should be considered as the first-line treatment, unless the tumors severely invade the surrounding soft tissues or are accompanied by complex fractures with significant displacement leading to no surgical curettage boundary.

Bisphosphonate-loaded Bone Cement as a Local Adjuvant Therapy for Giant Cell Tumor of Bone: A 1 to 12-Year Follow-up Study

BACKGROUND

Historically, nontargeted adjuvant therapies such as liquid nitrogen, phenol, argon beam, and alcohol have been applied locally after curettage of giant cell tumors (GCT) in the extremities. Systemic bisphosphonates (BP) and denosumab have emerged as osteoclast-targeting therapies because osteoclast-like giant cells, responsible for aggressive bone resorption, are susceptible to BP or denosumab. However, such drugs may cause systemic side effects. We examined the effects of an alternative intraoperative local delivery of BP on GCTs.

MATERIALS AND METHODS

In total, 17 patients with GCTs underwent extended surgical curettage procedures consisting of high-speed burring, traditional adjuvant therapy, and application of BP-loaded polymethylmethacrylate bone cement. Clinical data and follow-up radiographs were reviewed to investigate local recurrence (LR) rate and complications in a retrospective manner.

RESULTS

There were 6 males and 11 females (mean age, 33.7 y). There were no cases of pulmonary metastases. Patient follow-up ranged from 1 to 12 years. There was 1 LR during the follow-up period for an LR rate of 5.9%. The mean final Musculoskeletal Tumor Society (MSTS) score was 29. There were no systemic or localized avascular necrosis or atypical fractures related to BPs noted.

CONCLUSIONS

BP-loaded polymethylmethacrylate is a targeted local adjuvant therapy that is feasible, safe, and may reduce LRs while alleviating the risk of systemic side effects of BPs such as avascular necrosis of jaw and atypical femur fractures. Future prospective randomized clinical trials will strengthen the level of evidence of this proposed targeted therapy.

LEVEL OF EVIDENCE

Therapeutic level IV-see instructions for authors for a complete description of evidence.

Have the difficulties and complications of surgical treatment for chondroblastoma of the adjoining knee joint been overestimated?

BACKGROUND AND OBJECTIVE

Chondroblastoma is difficult to treat as the tumor is surrounded by both articular cartilage and the epiphyseal plate. The differences in joint shape further complicate the problem. This retrospective study evaluates the efficacy of intraregional aggressive curettage and allogeneic bone grafting for treating chondroblastoma of the adjoining knee joint.

METHODS

From February 2010 to February 2017, 36 patients with chondroblastoma of the adjoining knee joint were identified. All patients were treated with intraregional aggressive curettage, phenolization, and allogeneic bone grafting. Follow-up for lesion healing, local recurrence, functional outcomes and secondary osteoarthritis were assessed both clinically and radiologically.

RESULTS

Thirty-six patients (mean age 17 years) were enrolled with a mean follow-up of 51.8 months (18-98 months). The tumor locations were as follows: distal femur (14), proximal tibia (20), and patella (2). Only 1 patient relapsed, 10 months post-operation. All patients had good bone healing. No knee varus or valgus deformity developed. The mean Musculoskeletal Tumor Society functional score was 28.6 ± 1.1 post-operation. At the last follow-up, secondary osteoarthritis was found in 1 patient, the patient was asymptomatic.

CONCLUSIONS

Intraregional aggressive curettage, phenolization, and allogeneic bone grafting are effective for treatment of chondroblastoma of the adjoining knee joint.

Extended intralesional curettage preferred over resection-arthrodesis for giant cell tumour of the distal radius

BACKGROUND

Distal radius giant cell tumour (GCT) is known to be associated with distinct management difficulties, including high rates of local recurrence and lung metastases compared to other anatomic locations. Multiple treatment options exist, each with different outcomes and complications.

QUESTIONS/PURPOSES

To compare oncological and functional outcomes and complications following treatment of patients with distal radius GCT by extended intralesional curettage (EIC) or resection-arthrodesis.

METHODS

Patients operated on for distal radius GCT were identified from prospectively collected databases at four Canadian musculoskeletal oncology specialty centres. There were 57 patients with a mean age of 35.4 years (range 17-57). Thirteen tumours were Campanacci grade 2, and 40 were Grade 3 (4 unknown). Twenty patients presented with an associated pathologic fracture. There were 34 patients treated by EIC and 23 by en bloc resection and wrist arthrodesis. All resections were performed for grade 3 tumours. The mean follow-up was 86 months (range 1-280).

RESULTS

There were a total of 11 (19%) local recurrences: 10 of 34 (29%) in the EIC group compared to only 1 of 23 (4%) in the resection-arthrodesis group (p = 0.028). For the 10 patients with local recurrence following initial treatment by EIC, 7 underwent repeat EIC, while 3 required resection-arthrodesis. The one local recurrence following initial resection was managed with repeat resection-arthrodesis. Six of the 11 local recurrences followed treatment of Campanacci grade 3 tumours, while 4 were in grade 2 lesions and in one case of recurrence the grade was unknown. There were no post-operative complications after EIC, whereas 7 patients (30%) had post-operative complications following resection-arthrodesis including 4 infections, one malunion, one non-union and one fracture (p = 0.001). The mean post-operative Musculoskeletal Tumor Society score was 33.5 in the curettage group compared to 27 in the resection group (p = 0.001). The mean Toronto Extremity Salvage Score was 98.3% following curettage compared to 91.5% after resection (p = 0.006). No patients experienced lung metastasis or death.

CONCLUSIONS

EIC is an effective alternative to wide resection-arthrodesis following treatment of distal radius GCT, with the advantage of preserving the distal radius and wrist joint function, but with a higher risk of local recurrence. Most local recurrences following initial treatment by EIC could be managed with iterative curettage and joint preservation. Wide excision and arthrodesis were associated with a significantly lower risk of tumour recurrence but was technically challenging and associated with more frequent post-operative complications. EIC was associated with better functional scores. Resection should be reserved for the most severe grade 3 tumours and recurrent and complex cases not amenable to treatment with EIC and joint salvage.

LEVEL OF EVIDENCE

III, retrospective comparative trial.

Radius' Giant Cell Tumor: Allograft with Conservation of Distal Radioulnar Joint

Purpose  Giant cell tumor of the distal radius are frequent lesions, and different types of surgeries have been described. Functional results, after conservative treatment or arthrodesis, often find a decreased strength and range of motion. The sacrifice of the distal radioulnar joint could be one of the causes. We report the case of a 26-year-old patient who presented with a Campanacci Grade III giant cell tumor of the distal radius. We managed his case by the association of en bloc resection and allograft reconstruction with the preservation of distal radioulnar joint. Hypothesis  This procedure could improve functional results, without increasing the risk of recurrence at 2 years follow-up. Case Report  The originality of our technique was the possibility of distal radioulnar joint conservation. We preserved a long portion of cortex bone all through the ulnar side of the distal radius. We then used an allograft of distal radius, fixed by a reconstruction anatomical plate. Results  At 2 years follow-up, the range of motion was 100° with 60° of palmar flexion, 40° of extension, 75° of pronation, and 70° of supination. Radial and ulnar inclination were 10 and 15°, respectively. MTS (Musculoskeletal Tumor Society Score) 1993 was 88% and DASH score was 6. Concerning grip strength, it was measured at 85% in comparison with the other side. Pronation and supination strengths were 80 and 73%, respectively, in comparison with the other side. At follow-up, standard X-rays showed no recurrence. The allograft was well integrated. Conclusion  Conservative treatment of the distal radioulnar joint allowed an almost ad integrum recovery, concerning strengths and range of motion. It allows a better functional recovery, without increasing the risk of recurrence.

How to optimize the therapeutic effect of free autogenous fibula graft and wrist arthroplasty for giant cell tumors of distal radius?

Objective

The purpose of this study is to retrospectively analyze the clinical efficacy of free fibula autograft and wrist arthroplasty in the treatment of giant cell tumors (GCT) of distal radius.

Methods

We retrospectively reviewed 26 patients with GCT of distal radius who underwent free autogenous fibula graft and wrist arthroplasty for repairing residual defect after en-block resection. The length of the fibula graft was 8.2 cm (6–10 cm). Postoperative follow-up regularly for an mean of 66.9 months. Bone healing was assessed by radiographs, pain was assessed by Visual Analog Scale (VAS) score and limb function was evaluated by Musculoskeletal Tumor Society (MSTS) score and disabilites of the arm, shoulder and hand (DASH) score. The range of motion (ROM) of wrist and grip strength were also evaluated.

Result

There were four males and 22 females with an mean age of 36.7 years (19–60 years); the mean length of lesions was 4.8 cm (2.3–6.6 cm); 21 primary cases and five recurrent cases; eight cases of Campanacci Grade II, 18 cases of Grade III. We had no postoperative lung metastasis and only one case had a local recurrence, three cases (11%) with subluxation of lower ulnoradial joints and five cases (19%) showed narrowing of wrist joint space. The mean postoperative VAS pain score was 0.7 ± 0.7 and grip strength retained 71% of the normal hand, MSTS score was 27.7 ± 1.1 and DASH score was 9.0 ± 3.7. The ROM of the involved wrist only slightly restricted and no donor complications. Postoperative wrist joint function was significantly improved.

Conclusion

Strict surgical resection boundary and solid reconstruction of wrist joint capsule are the key to achieving excellent oncological prognosis and function of distal radius GCT.

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.

Giant cell tumour of the distal radius/ulna: response to pre-operative treatment with short-term denosumab

Background

Treatment of giant cell tumour of bone (GCTB) of the distal radius/ulna poses a surgical challenge, as complex reconstructive surgery may be required. This study evaluates the clinical, radiological and pathological findings in five cases of GCTB of the distal forearm where a 3 month course of denosumab was given prior to surgery.

Methods

Patients with biopsy proven distal forearm GCTB, treated for 3 months with denosumab, followed by salvage surgery (curettage and cementation) were included. Wrist pain and function were assessed using the modified Mayo Wrist Score (MMWS). Plain radiographs, MRI and PET/CT were performed pre-treatment and 2 months after initiation of denosumab therapy. Histological comparison was made between the original biopsy and surgical curettage specimens.

Results

Five patients with an average age of 25 years were included in the study. Improvement in wrist pain and function was seen in all patients with the average MMWS increasing from 30 pre-treatment to 85 at 3 months. Plain radiographs demonstrated marginal sclerosis in all cases with reconstitution of cortical and subarticular bone by 2 months; internal matrix sclerosis and osseous consolidation was more variable. Increased tumour heterogeneity and low signal were observed on T2-weighted MR images. PET/CT revealed a decrease in average SUV from 14.8 pre-treatment to 4.7 at 2 months. Histology showed disappearance of osteoclasts and increased fibro-osseous tissue. Denosumab treatment has the potential to facilitate salvage surgery, thus avoiding bone resection and graft reconstruction. A good outcome was achieved apart from local recurrence in one case. Follow up ranged from 17 to 54 months.

Conclusion

Distal forearm GCTB responds clinically, radiologically and histologically to a short course of pre-operative denosumab therapy, which has the potential to facilitate salvage 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.

Does Wrist Arthrodesis With Structural Iliac Crest Bone Graft After Wide Resection of Distal Radius Giant Cell Tumor Result in Satisfactory Function and Local Control?

BACKGROUND

Many techniques have been described for reconstruction after distal radius resection for giant cell tumor with none being clearly superior. The favored technique at our institution is total wrist fusion with autogenous nonvascularized structural iliac crest bone graft because it is structurally robust, avoids the complications associated with obtaining autologous fibula graft, and is useful in areas where bone banks are not available. However, the success of arthrodesis and the functional outcomes with this approach, to our knowledge, have only been limitedly reported.

QUESTIONS/PURPOSES

(1) What is the success of union of these grafts and how long does it take? (2) How effective is the technique in achieving tumor control? (3) What complications occur with this type of arthrodesis? (4) What are the functional results of wrist arthrodesis by this technique for treating giant cell tumor of the distal radius?

METHODS

Between 2005 and 2013, 48 patients were treated for biopsy-confirmed Campanacci Grade III giant cell tumor of the distal radius. Of those, 39 (81% [39 of 48]) were treated with wrist arthrodesis using autogenous nonvascularized iliac crest bone graft. Of those, 27 (69% [27 of 39]) were available for followup at a minimum of 24 months (mean, 45 months; range, 24-103 months). During that period, the general indications for this approach were Campanacci Grade III and estimated resection length of 8 cm or less. Followup included clinical and radiographic assessment and functional assessment using the Disabilities of the Arm, Shoulder and Hand (DASH) score, the Musculoskeletal Tumor Society (MSTS) score, grip strength, and range of motion at every followup by the treating surgeon and his team. All functional results were from the latest followup of each patient.

RESULTS

Union of the distal junction occurred at a mean of 4 months (± 2 months) and union of the proximal junction occurred at a mean of 9 months (± 5 months). Accounting for competing events, at 12 months, the rate of proximal junction union was 56% (95% confidence interval [CI], 35%-72%), whereas it was 67% (95% CI, 45%-82%) at 18 months. In total, 11 of the 27 patients (41%) underwent repeat surgery on the distal radius, including eight patients (30%) who had complications and three (11%) who had local recurrence. The mean DASH score was 9 (± 7) (value range, 0-100, with lower scores representing better function), and the mean MSTS 1987 score was 29 (± 1) (value range, 0-30, with higher scores representing better function) as well as 96% (± 4%) of mean MSTS 1993 score (value range, 0%-100%, with higher scores representing better function). The mean grip strength was 51% (± 23%) of the uninvolved side, whereas the mean arc of forearm rotation was 113° (± 49°).

CONCLUSIONS

Reconstruction of defects after resection of giant cell tumor of the distal radius with autogenous structural iliac crest bone graft is a facile technique that can be used to achieve favorable functional results with complications and recurrences comparable to those of other reported techniques. We cannot show that this technique is superior to other options, but it seems to be a reasonable option to consider when other reconstruction options such as allografts are not available.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

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.

Clinical effects of three surgical approaches for a giant cell tumor of the distal radius and ulna

The aim of the present study was to assess the curative effects of three surgical approaches for a giant cell tumor (GCT) of the distal radius and ulna. A total of 27 patients with GCT on distal radius and ulnas (7 and 20, respectively), confirmed by biopsy, were treated with individualized treatment regimens, according to the Campanacci's grade system: i) Curettage plus inactivated tumor bed and allogeneic bone graft/bone cement augmentation for Campanacci's grade I GCT of the distal radius and ulna (Group A); ii) simple en bloc resection for Campanacci's grade II and III GCT of the distal ulna (Group B); iii) en bloc resection and reconstruction with non-vascularized fibular autograft/allogeneic bone graft for Campanacci's II and III GCT of the distal radius (Group C). Postoperative recurrence and complications were recorded. The Musculoskeletal Tumor Society Score was used to assess functional results. The mean follow-up time was 25 months (range, 9-125 months). A total of 3 patients exhibited tumor recurrence at 9, 11 and 15 months following surgery (1 case succumbed to pulmonary metastasis at 27 months). Overall, the incidence of the postoperative recurrence of the GCT of the distal ulna and radius were 14.3 (1/7) and 10% (2/20), respectively, with a statistical P-value of 0.762. No statistically significant difference was observed regarding the incidence of the postoperative recurrence, postoperative complications and MSTS results among the three surgical approaches for the GCT on distal ulna and radius (all P>0.05). However, statistically significant differences were noted when the incidence of the postoperative recurrence of curettage (Group A) was compared with that of en bloc resection (Groups B and C) (P=0.024). In conclusion, in order to achieve the best clinical effects for patients with GCT on distal radius and ulna, individualized treatment regimens must be designed according to the different Campanacci's grades and tumor locations.

Advantages of Pressurized-Spray Cryosurgery in Giant Cell Tumors of the Bone

BACKGROUND

Giant Cell Tumor is considered a benign, local and aggressive tumor. Although considered a benign bone tumor, it is still the subject of discussion and research because of the associated local bone destruction, as well as high rates of recurrence and distant metastases. Options are being developed for both surgical techniques and adjuvant therapies.

AIMS

The present study evaluated the administration of cryotherapy via a pressurized-spray technique in giant cell tumors of the bone.

STUDY DESIGN

Cross-sectional study.

METHODS

The study included 40 patients who were treated with extensive curettage and cryotherapy at various locations during the period from February 2006 to December 2013. Informed consent forms were obtained from the participants and ethics committee approval was taken from the local ethics committee of Ondokuz Mayıs University. The pressurized-spray technique was performed using liquid nitrogen. The patients were evaluated with respect to age, gender, radiological appearance, treatment modality, duration of follow-up, skin problems and recurrence.

RESULTS

Twenty-one patients were female; 19 were male. The average age of the patients was 33 years (range: 16-72 years), and the average duration of follow-up was 43 months (range: 12-80 months). The average time from the onset of the complaints to the diagnosis was 6 months (range: 2-12 months). Based on the Campanacci classification: 9 patients were Grade I; 25 patients were Grade II; six patients were Grade III. The lesion was located in the femur in 14 patients, in the tibia in 11 patients, in the radius in 5 patients, in the pelvis in 4 patients, in the fibula in 3 patients, in the metatarsal in 2 patients and in the phalanges of the hand in one patient. One patient had postoperative early fracture. None of the patients had skin problems and infection. Three (7.5%) of the patients had recurrence.

CONCLUSION

It was found that cryotherapy was highly effective in the lesions, especially those located in the femur and tibia and remained insufficient in the lesions expanded outside the cortex. Wound healing problems, infection and fracture risk are lower with this technique.

Distal radius reconstruction with vascularized proximal fibular autograft after en-bloc resection of recurrent giant cell tumor

Background

Giant cell tumors (GCTs) located in the distal radius are likely to recur, and the treatment of such recurrent tumors is very difficult. Here, we report our clinical experience in distal radius reconstruction with vascularized proximal fibular autografts after en-bloc excision of the entire distal radius in 17 patients with recurrent GCT (RGCT) of the distal radius.

Methods

All 17 patients with RGCT in distal radius underwent plain radiography and/or magnetic resonance imaging (MRI) of the distal radius as the initial evaluation after hospitalization. Then the distal radius were replaced by vascularized proximal fibular autografts after en-bloc RGCT resection. We assessed all patients by using clinical examinations, plain radiography of the wrist and chest, and Mayo wrist scores in the follow-ups.

Results

After an average follow-up of 4.3 years (range: 1.5–10.0 years), no lung metastasis or local recurrence was detected in any of the 17 patients. In total, 14 patients had excellent or good functional wrist scores, 16 were pain free or had occasional pain, and 15 patients returned to work. The mean range of motion of the wrist was 101° (flexion-extension), and the mean grip strength was 77.2 % of the contralateral normal hand.

Conclusion

En-bloc excision of the entire distal radius and distal radius reconstruction with a vascularized proximal fibular autograft can effectively achieve local tumor control and preserve wrist function in patients with RGCT of the distal radius.

Arthroscope assisted intralesional curettage of GCT

Introduction:

Incomplete intralesional curettage remains the most important factor contributing to the recurrence of the GCT tumor. A 360 degree view of the tumor cavity can be achieved with the help of an arthroscope, which can aid complete intralesional curettage.

Case Report:

This technical note describes the use of arthroscope assisted curettage of the distal femur GCT.

Conclusion:

Use of an arthroscope can improve the visibility for intralesional curettage 5 of Giant Cell tumor.

[New therapy approaches for giant cell tumors]

BACKGROUND

Giant cell bone tumors (GCT) are benign but partially locally aggressive osteolytic tumors which typically occur around the knee joint in the epiphysis and metaphysis of long bones after maturation of the skeleton is completed. Due to the locally aggressive growth behavior with destruction of the bone structure, the rare possibility of pulmonary metastases in recurrent cases and a very rare possibility of malignancy, GCTs were previously also described as semimalignant bone tumors.

THERAPY

The established therapy of these tumors at the typical locations consists of intralesional curettage, extension of resection margins using a high speed trephine and defect reconstruction with bone cement. The local recurrence rate is high (10-40 %) and lowest after using thermal extension of resection margins with a high speed trephine and defect reconstruction with bone cement. For uncommon localizations, such as the spinal column and the sacrum as well as in cases of recurrence, surgical treatment is more complicated.

HISTOLOGY

Histologically, GCTs consist of osteoclastic giant and oval-shaped stromal cells which show a high expression of receptor activator of nuclear factor-κB ligand (RANKL) and decisively contribute to the osteolytic activity of the tumor. Novel pharmaceutical therapy approaches with human monoclonal RANKL antibodies interfere in this osteodestructive process in an inhibitory manner and can represent alternative treatment options just as the osteosupportive therapy with bisphosphonates.

CONCLUSION

After unsatisfactory attempts at surgical treatment of GCT patients, the new treatment option with denosumab is a promising alternative due to its effect as a monoclonal RANKL inhibitor.

A modified ulnar translocation reconstruction technique for Campanacci grade 3 giant cell tumors of the distal radius using a clover leaf plate

BACKGROUND

Campanacci grade 3 giant cell tumors of the distal radius are locally aggressive and in close proximity to the median nerve, articular cartilage, flexor and extensor tendons, and the radial artery. Although several reconstructive techniques have been described, it is unclear to what degree these procedures restore function.

DESCRIPTION OF TECHNIQUE

We present a modified ipsilateral ulna translocation technique using a clover leaf plate, for reconstruction of en bloc resected distal radius. This has the theoretical advantage of ensuring a solid, pain-free wrist arthrodesis, while preserving the forearm rotational axis and minimizing functional loss, without the associated donor site morbidity or allograft rejection issues of other reconstructive techniques.

PATIENTS AND METHODS

Between 2006 and 2013, 3 patients underwent this procedure for Campanacci grade 3 giant cell tumors. All patients were right hand-dominant females, aged 24, 35, and 46 years, respectively. Two cases involved the right radius. Patients were reviewed retrospectively with clinical examination, functional assessment [the Toronto Extremity Salvage Score (TESS) for upper limb], and radiographs. The review period was 30, 51, and 41 months, respectively.

RESULTS

The length of distal radius resected was 70, 50, and 35 mm, respectively. All achieved clear margins. There were no complications and there have been no recurrences. All ulnocarpal translocations achieved radiographic fusion. Patient's averaged 80-degree pronation, 70-degree supination, and clinical TESS scores of 86 at most recent follow-up.

CONCLUSIONS

This technique achieved a painless and functional wrist arthrodesis with partially restored wrist motion, without complications. This technique has the advantage of negating remote donor site morbidity and/or allograft rejection issues of other techniques.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Effects of thermoablation with or without caffeine on giant cell tumour of bone

PURPOSE

To evaluate the effect of caffeine on the apoptosis rate of giant cell tumour of bone cells during thermoablation.

METHODS

Giant cell tumour of bone tissue (2 cm3) was collected from 10 patients. Cells were incubated at 37ºC, 40ºC, 45ºC, 50ºC, 52.5ºC, and 55ºC for 20 minutes (3 tubes for each temperature). Caffeine was added to the tubes in amounts of 0 μg/ml (control), 50 μg/ml, and 100 μg/ml. The apoptotic effect of thermoablation with or without caffeine was evaluated.

RESULTS

In all test conditions, the apoptotic rate of tumour cells increased when the temperature increased. Compared with controls (no caffeine), adding 50 or 100 μg/ml of caffeine did not increase the apoptotic rate significantly at 40ºC to 52.5ºC. Caffeine had no enhancing effect at any temperature. Conversely, at 55ºC, the apoptotic rate was lower when 100 μg/ml of caffeine was added than when no or 50 μg/ml of caffeine added (p=0.045).

CONCLUSION

Thermoablation at 40ºC to 52.5ºC for 20 minutes increased the apoptosis rate of giant cell tumour of bone cells. Caffeine had no enhancing effect at any temperature. Conversely, at 55ºC, caffeine had cytoprotective effects on the tumour cells against thermoablation.

Clinical outcome of en-block resection and reconstruction with nonvascularized fibular autograft for the treatment of giant cell tumor of distal radius

BACKGROUND

Although giant cell tumor (GCT) is considered to be a primary benign bone tumor, its aggressive behavior makes its diagnosis and treatment, difficult and challenging. This is especially true in distal radius where GCT appears to be more aggressive and difficult to control locally. We report our clinical outcome of en-block resection and reconstruction with non-vascularized fibular autograft in 15 patients with distal radius GCT.

MATERIALS AND METHODS

We retrospectively reviewed 15 patients with GCT (Grade 2 and 3) of distal radius who were treated with en-block resection and non-vascularized fibular autograft. Five of 15 were recurrent GCT treated initially with extended curettage; local adjuvant therapy and filling the cavity with cement or bone graft. We followed the patients for mean 7.2 years post operation (range: 4-11 years). Patients were evaluated post operation with clinical examination, plain radiography of distal radius and chest X-ray and/or computed tomography scan. Furthermore pain, function, range of motion and grip strength of the affected limb were evaluated and mMayo wrist score was assessed.

RESULTS

A total of 11 patients were women and 4 were men. Mean age of patients was 29 years (range: 19-48). We had no lung metastasis and bony recurrence occurred in one patient (6.6%). Nearly 53.3% of patients had excellent or good functional wrist score, 80% of the patients were free of pain or had only occasional pain and 80% of patients returned to work. Mean range of motion of the wrist was 77° of flexion-extension and mean grip strength was 70% of the normal hand.

CONCLUSION

En-block resection of distal radius GCT and reconstruction with non-vascularized fibular autograft is an effective technique for treatment in local control of the tumor and preserving function of the limb.

Partial wrist arthrodesis versus arthroplasty for distal radius giant cell tumours

PURPOSE

The purpose of this study was to evaluate the clinical efficacy of using the proximal fibular graft for partial wrist arthrodesis or arthroplasty after the resection of giant cell tumours of the distal radius.

METHODS

Between February 2006 and August 2010, 14 patients (seven males, seven females; average age, 35.7 years) with grade II and III giant cell tumours of the distal radius were treated by tumour resection and autologous proximal fibular grafts to reconstruct the wrist in our hospital. Seven patients each were treated by wrist arthroplasty and partial wrist arthrodesis, and were followed up for 2.2-6.8 years (average, 3.9 years).

RESULTS

All patients achieved primary healing. No tumour recurrence was observed during follow-up in any of the patients. No statistically significant difference in forearm rotation was observed between patients undergoing the two different treatments. However, wrist flexion-extension activities were significantly better and the wrist grip strengths were significantly worse in the arthroplasty group than in the arthrodesis group. The Musculoskeletal Tumour Society score did not significantly differ between the groups.

CONCLUSIONS

Overall, joint arthroplasty remains a favourable treatment with regard to the functional outcome for giant cell tumours of the distal radius; however, some of these patients may have a weaker grip strength. In comparison, partial wrist fusion appears to provide a durable and stable wrist with good long-term functional outcome.

Contemporary adjuvant polymethyl methacrylate cementation optimally limits recurrence in primary giant cell tumor of bone patients compared to bone grafting: a systematic review and meta-analysis

Background

Reports of recurrence following restructuring of primary giant cell tumor (GCT) defects using polymethyl methacrylate (PMMA) bone cementation or allogeneic bone graft with and without adjuvants for intralesional curettage vary widely. Systematic review and meta-analysis were conducted to investigate efficacy of PMMA bone cementation and allogeneic bone grafting following intralesional curettage for GCT.

Methods

Medline, EMBASE, Google Scholar, and Cochrane databases were searched for studies reporting GCT of bone treatment with PMMA cementation and/or bone grafting with or without adjuvant therapy following intralesional curettage of primary GCTs. Pooled risk ratios and 95% confidence intervals (CIs) for local recurrence risks were calculated by fixed-effects methods.

Results

Of 1,690 relevant titles, 6 eligible studies (1,293 patients) spanning March 2008 to December 2011 were identified in published data. Treatment outcomes of PMMA-only (n = 374), bone graft-only (n = 436), PMMA with or without adjuvant (PMMA + adjuvant; n = 594), and bone graft filling with or without adjuvant (bone graft + adjuvant; n = 699) were compared. Bone graft-only patients exhibited higher recurrence rates than PMMA-treated patients (RR 2.09, 95% CI (1.64, 2.66), Overall effect: Z = 6.00; P <0.001), and bone graft + adjuvant patients exhibited higher recurrence rates than PMMA + adjuvant patients (RR 1.66, 95% CI (1.21, 2.28), Overall effect: Z = 3.15, P = 0.002).

Conclusions

Local recurrence was minimal in PMMA cementation patients, suggesting that PMMA is preferable for routine clinical restructuring in eligible GCT patients. Relationships between tumor characteristics, other modern adjuvants, and recurrence require further exploration.

A Systematic Review and Meta-Analysis of En-Bloc vs Intralesional Resection for Giant Cell Tumor of Bone of the Distal Radius

Introduction:

Surgical management of Giant Cell Tumor of Bone of the distal radius (GCTDR) remains controversial due to risk of local recurrence (LR) offset by functional limitations which result from en-bloc resection. This study aims to determine the oncologic and functional outcomes of wide excision (WE) vs intralesional curettage (IC) of GCTDR.

Methods:

A complete search of the applicable literature was done. Included studies reported on patients from the same cohort who were surgically treated for GCTDR with WE or IC. Two reviewers independently assessed all papers. The primary outcome measure was LR.

Results:

One-hundred-forty-one patients from six studies were included: 60 treated with WE, and 81 with IC. Five WE patients (8%) suffered LR whereas 25 IC patients (31%) did. The odds of LR were three times less in the WE group vs the IC group. MSTS1993 scores, where available, were on average 'good' with WE and 'excellent' with IC.

Conclusions:

Within statistical limitations the data support an attempt, where feasible, at wrist joint preservation and superior function with IC. Intralesional curettage is reasonable when the functional benefit outweighs the risk of recurrence as is the case in many cases of GCT of the distal radius.