Denosumab combined with curettage after surgical dislocation of the hip in the treatment of giant cell tumors of bone in the femoral head and neck region: a single-center retrospective study.

To evaluate the mid-term clinical efficacy of microwave in situ inactivation combined with bone grafting or polymethyl methacrylate (PMMA) filling in the treatment of giant cell tumor of bone (GCTB). This is a retrospective, descriptive, and analytical study. A total of 30 GCTB patients received microwave in situ inactivation from January 2012 to January 2020, whose clinical recurrence rate was evaluated at the last follow-up after microwave in situ inactivation surgery. The Musculoskeletal Tumor Society (MSTS) function score was used to evaluate the postoperative clinical panoramic results. All patients were followed up for 21 to 110months, with an average of 63.79months. Distal femur (40%) and proximal tibia (28%) had a higher rate of GCTB incidence. Seventeen percent of tumor patients suffered from associated pathologic fracture. The rate of Campanacci classification stage III was 60%. The average MSTS score was evaluated as 27.53 points overall at the last follow-up. In terms of complications, three, two, two and one cases developed fat liquefaction, controllable tissue rejection reaction, incision infection and degenerative changes around lesion joint, respectively, without in situ recurrences and reoperation as well as distant lung metastasis. The method of microwave in situ inactivation combined with bone grafting or PMMA filling is prudently recommended as one of the options for the limb salvage treatment of giant cell tumor of long and periarticular bone. IV: case series.

Objective To restospectively analyze the treatment and efficacy of giant cell tumor(GCT) in proximal humerus, specify the indications and precautions for different surgical methods and analysis the risk factors for recurrence and shoulder dysfunction. Methods The retrospective case-control study was conducted. From January 2002 to June 2015, the complete clinical data of 27 patients with giant cell tumor of the proximal humerus in the Second Affiliated Hospital of Inner Mongolia Medical University, the 960th Hospial of PLA, Tianjin Hospital and Third Hospital of Medical University were collected. Among them, there were 15 males and 12 females, with age of 18-55(33.1±12.2) years. Twenty-seven patients with initial treatment and follow-up for more than 3 years were included in the study. There were 17 patients with pathological fracture, 14 cases with fracture displacement, 3 cases with pathological fracture but no displacement; Campanacci grade Ⅱ GCT was diagnosed in 17 patients; Campanacci grade Ⅲ GCT in 10 patients, 14 cases of curettage in the initial operation (3 cases of scraping, 11 cases of enlarged scraping), of which 10 patients were treated with plate screw internal fixation. There were 2 cases of autogenous bone grafting, 1 case of autologous plus allogeneic bone grafting, 3 cases of allogeneic bone grafting, 8 cases of bone cement filling to fill the bone defect. Thirteen cases underwent resection and reconstruction of the tumor, including 10 cases of semi-shoulder joint replacement and 3 cases of intramedullary nail fixation with large allograft. The patients were followed up regularly and the effects of upper shoulder joint function were evaluated according to the Musculoskeletal Tumor Society(MSTS) score. Statistical analysis was performed using SPSS 22.0 statistical software. The recurrence rate and complication rate, the upper limb MSTS score, the analysis of the influencing factors of surgical approach selection and the risk factors of tumor recurrence were compared by univariate analysis between the tumor segment resection group and the risk factors for tumor recurrence. Results All the patients were followed up for 36 to 180 (92.4±38.9) months. There was 1 local recurrence in each of the curettage and tumor resection, and the recurrence rate was 1/14 and 2/13. Four patients with tumor resection had postoperative complications, and the total complication rate was 14.8%(4/27). Among them, 2 patients with large segmental allografts underwent semi-shoulder arthroplasty; 1 patient with subluxation of shoulder joint; 1 patient with prosthesis loosening exposed for 36 months after surgery had to undergo revision surgery with replacement of cemented prosthesis. The incidence of complications of intracapsular curettage was lower than that of tumor resection, and the difference was statistically significant(P=0.041). Single factor analysis showed that there was no correlation between pathological fracture and surgical methods (r=-0.037, P=1.000), Campanacci grading was correlated with surgical methods (r=0.482, P 0.05). The postoperative shoulder function of the patients with scrape reconstruction was significantly better than that of the tumor reconstruction (P<0.01). Conclusions The giant cell tumor of the proximal humerus is prone to pathological fracture compared with other sites. The recurrence rate is lower after curettage or tumor resection, but the latter has high postoperative complications. The shoulder function of the scraping group was significantly better than that of the tumor segment group. Due to the high incidence of complications after resection of the tumor, especially the bone resorption after resection of large segmental allografts. Intracapsular curettage should be selected as a treatment of giant cell tumor in proximal humerus. Key words: Giant cell tumor of bone; Proximal humerus; Curettage; Resection; Multicenter study

It has been suggested that, when a patient has a giant cell tumor, subchondral bone involvement close to articular cartilage and a hyperthermic reaction from polymethylmethacrylate (PMMA) are risk factors for the development of osteoarthritis. We determined the prevalence, risk factors, and clinical relevance of osteoarthritis on radiographs after curettage and application of PMMA for the treatment of giant cell tumors around the knee. This retrospective single-center study included fifty-three patients with giant cell tumor around the knee treated with curettage and PMMA between 1987 and 2007. The median age at the time of follow-up was forty-two years (range, twenty-three to seventy years). There were twenty-nine women. Radiographic evidence of osteoarthritis was defined, preoperatively and postoperatively, as Kellgren and Lawrence grade 3 or 4 (KL3-4). We studied the influence of age, sex, tumor-cartilage distance, subchondral bone involvement (≤3 mm of residual subchondral bone), subchondral bone-grafting, intra-articular fracture, multiple curettage procedures, and complications on progression to KL3-4. Functional outcomes and quality of life were assessed with the Short Form-36 (SF-36), Musculoskeletal Tumor Society (MSTS) score, and Knee injury and Osteoarthritis Outcome Score (KOOS). After a median duration of follow-up of eighty-six months (range, sixty to 285 months), six patients (11%) had progression to KL3, two (4%) had progression to KL4, and one had preexistent KL4. No patient underwent total knee replacement. The hazard ratio for KL3-4 was 9.0 (95% confidence interval [CI] = 2.0 to 41; p = 0.004) when >70% of the subchondral bone was affected and 4.2 (95% CI = 0.84 to 21; p = 0.081) when the tumor-cartilage distance was ≤3 mm. Age, sex, subchondral bone-grafting, intra-articular fracture, multiple curettage procedures, and complications did not affect progression to KL3-4. Patients with KL3-4 reported lower scores on the KOOS symptom subscale (58 versus 82; p = 0.01), but their scores on the other KOOS subscales, the MSTS score (21 versus 24), and the SF-36 (76 versus 81) were similar to those for the patients with KL0, 1, or 2 (KL0-2). Seventeen percent of patients with giant cell tumor around the knee had radiographic findings of osteoarthritis after treatment with curettage and PMMA. A large amount of subchondral bone involvement close to articular cartilage increased the risk for osteoarthritis. The function and quality of life of the patients with KL3-4 were comparable with those for the patients with KL0-2, suggesting that radiographic findings of osteoarthritis at the time of intermediate follow-up had a modest clinical impact. Treatment with curettage and PMMA is safe for primary and recurrent giant cell tumors, even large tumors close to the joint. Therapeutic level IV. See Instructions for Authors for a complete description of levels of evidence.

Surgical dislocation of the hip is rarely undertaken. The potential danger to the vascularity of the femoral head has been emphasised, but there is little information as to how this danger can be avoided. We describe a technique for operative dislocation of the hip, based on detailed anatomical studies of the blood supply. It combines aspects of approaches which have been reported previously and consists of an anterior dislocation through a posterior approach with a 'trochanteric flip' osteotomy. The external rotator muscles are not divided and the medial femoral circumflex artery is protected by the intact obturator externus. We report our experience using this approach in 213 hips over a period of seven years and include 19 patients who underwent simultaneous intertrochanteric osteotomy. The perfusion of the femoral head was verified intraoperatively and, to date, none has subsequently developed avascular necrosis. There is little morbidity associated with the technique and it allows the treatment of a variety of conditions, which may not respond well to other methods including arthroscopy. Surgical dislocation gives new insight into the pathogenesis of some hip disorders and the possibility of preserving the hip with techniques such as transplantation of cartilage.

To investigate the long-term effectiveness of uncemented allograft-prosthesis composite (APC) for reconstruction of bone defects after proximal femur tumor resection. Between June 2007 and March 2014, 21 patients who underwent uncemented APC reconstruction of proximal femur after tumor resection were retrospectively evaluated. There were 9 males and 12 females with an average age of 33.2 years (range, 19-54 years). There were 9 cases of giant cell tumor of bone, 5 cases of osteosarcoma, 4 cases of osteoblastic osteosarcoma, 2 cases of chondrosarcoma, and 1 case of undifferentiated pleomorphic sarcoma. Thirteen cases of benign bone tumors were all classified as stage 3 by Enneking staging; and 8 cases of malignant bone tumors were classified as grade ⅡB in 7 cases and grade ⅡA in 1 case according to the American Joint Committee on Cancer (AJCC) staging system. Among them, 7 patients underwent reoperation after recurrence, and the rest were primary operations; 8 patients presented with pathological fractures. The preoperative Harris hip score (HHS) and American Musculoskeletal Tumor Society (MSTS) score was 40 (30, 49) and 9.1±3.5, respectively. The length of osteotomy was 80-154 mm, with an average of 110 mm. At 1 year after operation and last follow-up, HHS and MSTS scores were utilized to evaluate the function of hip joint; the gluteus medius strength score was used to evaluation of the hip abduction function. Image examinations were taken at 1, 3, 6, 9, and 12 months after operation and every year thereafter to assess the union of allograft-host bone interfaces. Intra- and post-operative complications were also recorded. All patients were followed up 84-163 months (mean, 123.5 months). At 1 year after operation and last follow-up, the HHS and MSTS scores significantly improved when compared with the preoperative scores ( P<0.05). However, there was no significant difference in the HHS score, MSTS score, and gluteus medius strength score between the two time points after operation ( P>0.05). Image examination showed that all allograft-host bone interfaces achieved union after 5-10 months (mean, 7.6 months). At last follow-up, all patients had bone resorption, including 11 severe cases, 4 moderate cases, and 6 mild cases; the bone resorption sites included Gruen 1, 2, and 7 regions. Complications included 10 fractures and 1 prosthetic fracture. Local recurrence occurred in 3 patients and pulmonary metastasis in 3 patients. Uncemented APC is a reliable method for the reconstruction of bone defects after proximal femur tumor resection. It has the good long-term effectiveness and possesses obvious advantages in the union at the bone-bone surface.

To determine the association between type of surgery (wide resection versus curettage with adjuvant therapy) and outcome in patients with giant cell tumour (GCT) of bone. Records of 30 male and 52 female consecutive patients aged 10 to 62 years who underwent wide resection (n=57) or curettage with adjuvant therapy (n=25) for primary GCT of bone were reviewed. The surgical decision was based on patient age, tumour location, functional demand, and patient preference. The median tumour size was 8.5 cm. Tumours were classified as stage 1 (n=4), stage 2 (n=60), and stage 3 (n=18), and 25%, 68.3%, and 83.3% of them were treated with wide resection, respectively. Functional outcome was assessed using the Musculoskeletal Tumor Society (MSTS) score; the maximum score was 30. The wide resection and curettage with adjuvant therapy groups were comparable in terms of patient age, gender, tumour size, location, symptoms, tumour stage, type of biopsy, and MSTS score. The MSTS score was excellent in 50.2% of patients, good in 38.7% of patients, and fair and poor in the remaining patients. The MSTS score was not associated with tumour stage or type of surgery. Four patients in the wide resection group had metastasis to the lung. They also had lower haemoglobin level (10.6 vs. 12.7 g/dl, p=0.020) and higher percentage of stage-3 tumour (100% vs. 17.9%, p=0.001) but had no recurrence (0% vs. 6.4%, p=0.774), compared with those without metastatsis. All died from massive haemoptysis and respiratory failure. Eight patients died; their haemoglobin level was lower than that of patients who were still living (11.2 vs. 12.7 g/dl, p=0.032). Mortality was associated with metastasis (100% vs 5.2%, p<0.001) but not recurrence or complication. Two patients in each group had recurrence; recurrence was not associated with type of surgery. There was no association between type of surgery and tumour recurrence, metastasis, or outcome. Curettage with adjuvant therapy was more commonly performed for stage 1 and 2 tumours, whereas wide resection was more for stage 3 tumours. Metastasis was associated with stage 3 tumour and mortality but not recurrence.

Non-traumatic osteonecrosis of the femoral head (ONF) is considered to be a disease that occurs primarily due to ischemia of the femoral head, while its etiology and pathology are not fully understood. It is therefore necessary to identify the characteristics of the hemodynamics of the femoral head. In this study, the hemodynamics in the ilium and proximal regions of the femur, including the femoral head, was investigated using positron emission tomography (PET). The subjects of this study consisted of 8 hip joints of four healthy male adults and 3 hip joints on the contralateral side of a femoral neck fracture, avulsion fracture of the greater trochanter and coxarthrosis (1 case each, all females) for a total of 11 hip joints of 7 subjects. The ages of the subjects ranged from 25 to 87 years (average age: 54 years). Blood flow was measured by means of the H215O dynamic study method and blood volume was measured by means of the 15O-labeled carbon monoxide bolus inhalation method. Blood flow was determined to be 9.1 +/- 4.8 ml/min/100 g in the ilium and among proximal regions of the femur (femoral head, neck and intertrochanteric region), 1.8 +/- 0.7 ml/min/100 g in the femoral head, 2.1 +/- 0.6 ml/min/100 g in the femoral neck, and 2.6 +/- 0.7 ml/min/100 g in the intertrochanteric region. In addition, blood volume was 4.7 +/- 1.3 ml/100 g in the ilium, and among proximal regions of the femur, 1.1 +/- 0.5 ml/100 g in the femoral head, 2.1 +/- 0.7 ml/100 g in the femoral neck, and 2.6 +/- 0.9 ml/100 g in the intertrochanteric region. The results showed that both blood flow and volume were lowest in the femoral head. Blood flow and volume were significantly lower in the proximal regions of the femur (femoral head, neck and intertrochanteric region) than in the ilium (p < 0.01). The present study demonstrated that the femoral head is in a hypoemic state as compared with other osseous tissue, indicating that even the slightest exacerbation of hemodynamics in the femoral head can trigger an ischemic condition culminating in ONF.

Background Giant cell tumors (GCTs) of bone around the knee are locally aggressive benign neoplasms with a tendency for recurrence and functional compromise. Surgical options include extended curettage (EC), often combined with adjuvants and internal fixation (sandwich technique), or segmental resection (SR) with megaprosthesis reconstruction. The optimal approach remains debated. This study compares oncological and functional outcomes between these two surgical strategies in a cohort of 65 patients. Methods A retrospective analysis was conducted at the Department of Orthopaedics, Indira Gandhi Institute of Medical Sciences, Patna, over six years. Patients with biopsy-confirmed GCTs around the knee who underwent EC or SR were included. Outcomes assessed included local recurrence, recurrence-free survival (RFS), Musculoskeletal Tumor Society (MSTS) scores, operative time, blood loss, hospital stay, and postoperative complications. Results Of the 65 patients (EC: 48; SR: 17), local recurrence was noted in 12.5% of the EC group and 5.9% of the SR group (p=0.762). For Grade II tumors, recurrence occurred in 4.2% of EC cases and none in SR; for Grade III tumors, recurrence rates were 8.3% (EC) and 5.9% (SR). At three years, RFS was 87.5% for EC and 94.1% for SR (p=0.604). SR involved longer surgeries (172.7 ± 36.3 vs. 119.2 ± 23.8 min, p<0.001), greater blood loss (656.8 ± 155.6 vs. 319.6 ± 127.9 mL, p<0.001), and longer hospital stays. EC demonstrated superior functional outcomes (MSTS: 25.5 ± 3.2 vs. 22.1 ± 3.8, p=0.007). Complication rates were higher in SR (35.3%) compared to EC (20.8%), though not statistically significant (p=0.268). Conclusion EC offers superior functional outcomes with a non-significant trend toward higher recurrence, whereas SR provides better local control at the cost of greater surgical morbidity. These findings suggest that patient selection should consider tumor grade, extent, and individual functional priorities. Prospective studies are needed to refine treatment algorithms and optimize outcomes.

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. 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. 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. 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.

AimsSurgical treatment of young femoral neck fractures often requires an open approach to achieve an anatomical reduction. The application of a calcar plate has recently been described to aid in femoral neck fracture reduction and to augment fixation. However, application of a plate may potentially compromise the regional vascularity of the femoral head and neck. The purpose of this study was to investigate the effect of calcar femoral neck plating on the vascularity of the femoral head and neck.MethodsA Hueter approach and capsulotomy were performed bilaterally in six cadaveric hips. In the experimental group, a one-third tubular plate was secured to the inferomedial femoral neck at 6:00 on the clockface. The contralateral hip served as a control with surgical approach and capsulotomy without fixation. Pre- and post-contrast MRI was then performed to quantify signal intensity in the femoral head and neck. Qualitative assessment of the terminal arterial branches to the femoral head, specifically the inferior retinacular artery (IRA), was also performed.ResultsQuantitative MRI revealed a mean reduction of 1.8% (SD 3.1%) of arterial contribution in the femoral head and a mean reduction of 7.1% (SD 10.6%) in the femoral neck in the plating group compared to non-plated controls. Based on femoral head quadrant analysis, the largest mean decrease in arterial contribution was in the inferomedial quadrant (4.0%, SD 6.6%). No significant differences were found between control and experimental hips for any femoral neck or femoral head regions. The inferior retinaculum of Weitbrecht (containing the IRA) was directly visualized in six of 12 specimens. Qualitative MRI assessment confirmed IRA integrity in all specimens.ConclusionCalcar femoral neck plating at the 6:00 position on the clockface resulted in minimal decrease in femoral head and neck vascularity, and therefore it may be considered as an adjunct to laterally-based fixation for reduction and fixation of femoral neck fractures, especially in younger patients.Cite this article: Bone Jt Open 2021;2(8):611–617.

Background: A giant cell tumour (GCT) is a locally invasive benign tumour of bone in young adults. Treatment includes surgical resection as first-line or denosumab pharmacotherapy in inoperable patients. However, surgical resection of distal radius GCT has produced debatable functional outcomes. Here we study the use of fibular grafts for reconstruction of surgically resected GCT of the distal radius. Methods: A total of 11 patients having Grade III GCT of the distal radius were recruited for a retrospective single-centred study. Five underwent arthrodesis with fibular shaft graft and six received arthroplasty with the proximal fibula. Functional outcomes at 6 weeks, 6 and 12 months were measured by Mayo wrist score (MWS) (>51% = good) and Revised Musculoskeletal tumor society (MSTS) score (>15 = good). Results: At 6 weeks, mean MSTS score and MWS were 23.64 and 58.64% respectively, and the length of the fibular graft was a predictor for both MSTS score (p = 0.014) and MWS (p = 0.006). At 6 months, the mean MSTS and MWS were 26.36 and 76.82%, respectively. At 6 months, the surgical procedure was a predictor in MSTS score (p = 0.02) while MWS was predicted by length of graft (p = 0.02). At 12 months, MSTS score was 28.73, and MWS remained 91.82%. Length of the fibular graft was an insignificant predictor, but a significant risk factor was surgical procedure for MWS (p = 0.04) at 12 months. No variable was found significant for MSTS score. Conclusions: Resection along with reconstruction of Grade III GCT of the radius with fibular graft was found an optimal treatment option. Also, use of the fibular head grafts and shorter length grafts are predictors for better outcomes after surgery. Level of Evidence: Level IV (Therapeutic).

ObjectivesTo 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.MethodsThis 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.ResultsAll 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.ConclusionCurettage 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.

Objective To investigate technique and effect of reconstruction with alcohol-inactivated autograft-prosthesis composite after en bloc resection of giant cell tumor of bone around the knee.Methods From January 2007 to October 2008,8 patients with Campanacci grade Ⅲ giant cell tumor of bone around the knee underwent en bloc resection of tumor and reconstruction with alcohol-inactivated autograft-prosthesis composite in our hospital.There were 5 males and 3 females,aged from 20 to 43 years (average,31years).The tumor located in distal femur in 5 cases and proximal tibia in 3 cases.There were 4 cases of primary tumor and 4 cases of recurrent tumor.Two patients combined with pathological fracture.The Musculoskeletal Tumor Society (MSTS) score was used to evaluate limb function,and the International Society of Limb Salvage (ISOLS) score was used for radiographic evaluation.Results All patients were followed up for 38 to 67 months (average,54 months).No recunrence,metastasis,prosthesis loosening were found.The mean healing time of autograft and host bone was 5.5 months.At final follow-up,the MSTS score ranged from 25 to 29 [average,26.3 (88％)]; the ISOLS score ranged from 28 to 35 [average,32.8 (88.5％)].Creeping substitution was possibly the main way of bone union.The healing time in femoral lesion was faster than that in tibial lesion.Conclusion For Campanacci grade Ⅲ giant cell tumor of bone around the knee,en bloc resection and reconstruction with alcohol-inactivated autograft-prosthesis composite is an effective method,which can provide satisfactory results. Key words: Knee joint; Giant cell tumor of bone; Salvage therapy; Treatment outcome

Background and objectivesTreatment of benign osteolytic lesions in the femoral head and neck can be extremely challenging, particularly in children with open physis or for aggressive tumors with pathological fracture. There remains the difficult management decision as to whether to perform complete excision of the involved area or only curettage. Moreover, there is no agreed consensus on the optimal approach to lesion access when performing curettage, which included the transcervical, open and direct approach. The current systematic review aims to provide guidance for selection of surgical methods in clinical practice by comparing the advantages and drawbacks of different procedures.MethodsA comprehensive literature search of PubMed, Embase and Web of Science databases were executed for human studies restricted to the English language. The search was filtered to include studies published from January 1980 to January 2020.ResultsA total of 33 articles including 274 patients were enrolled in the final analysis. The most common diagnosis was chondroblastoma (CBT) (104, 38.0%), followed by giant cell tumor (GCT) (56, 20.4%). There were 57 (20.8%) patients with pathological fracture. Intralesional curettage was performed in 257 (93.8%) patients with the local recurrence of 12.5% at the mean follow-up of 51.5 months. The patients who were presented with open physis or curetted via transcervical approach developed higher local recurrence in patients with CBT (P < 0.001). The local recurrence rate of GCT is 33.3% after curettage, while 8 of 9 (88.9%) patients with fracture were treated successfully with joint preservation. Two of 45 (4.4%) patients developed avascular necrosis (AVN) of femoral head after surgical hip dislocation. The reported Musculoskeletal Tumor Society (MSTS) Score was comparable among patients with different approaches to curettage.ConclusionThe majority of benign osteolytic lesions in the femoral head and neck can be treated with intralesional curettage with acceptable local tumor control and satisfactory function. The incidence of local recurrence might be decreased dramatically for lesion access under direct visualization. The native joint maintenance could be achieved even in patients with aggressive lesions presenting pathological fracture.

A giant cell tumor of bone is a primary benign but locally aggressive neoplasm. Malignant transformation in a histologically typical giant cell tumor of bone, without radiotherapy exposure, is an uncommon event, occurring in less than 1% of giant cell tumors of bone. Although surgery is the standard initial treatment, denosumab, a monoclonal antibody drug that inhibits receptor activator of nuclear factor-κB ligand (RANKL), has shown considerable activity regarding disease and control of symptoms in patients with recurrence, unresectable, and metastatic giant cell tumors of bone. We report the case of a 20-year-old woman with a recurrent benign, giant cell tumor of bone, who had a bone sarcoma develop while receiving denosumab treatment. To our knowledge, there have been no reports of infection or malignancy with low-dose denosumab administration for osteoporosis. However, while there are relatively few reported side effects, the safety of denosumab and adverse events seen with higher doses, as used in treatment of giant cell tumors of bone are not well defined. Denosumab has become a valuable adjunct for treatment of recurrent or unresectable giant cell tumor of bone. It is not clear if our patient's malignant transformation of a giant cell tumor of bone while receiving denosumab treatment was caused by denosumab, but it is important to be aware of the possibility if more cases occur. Future studies should focus on the safety of high-dose denosumab administration in patients with a benign unresectable giant cell tumor of bone.