Resection Of Giant Cell Tumor Research Articles

Effectiveness of the Use of Denosumab When Performing Intralesional Surgery in Patients with Gigant Cell Tumors of the Bones of the Knee Joint

In intralesional resection of giant cell tumors, local recurrence rate can be as high as 60–65 %. Some authors attribute recurrences to the presence of an extraosseus component and pathologic fractures, others focus on the effectiveness of bone cavity processing. Currently, denosumab is widely used in treatment of giant cell tumors of the bone. Most frequently, it is used in neoadjuvant regimen at dose 120 mg. This regimen allows to decrease the volume of extraosseous tumor component, form bone margins, and, as a result, make radical resection easier. However, the number of publications on increased risk of local tumor recurrence after neoadjuvant denosumab administration has been growing.Aim. To evaluate the effectiveness of various denosumab administration regimens in intralesional tumor resection in patients with giant cell tumors of the bones forming the knee joint.Materials and methods. The prospective study included outcomes of integrated treatment of 65 patients (34 (52.3 %) women and 31 (47.7 %) men) who underwent surgery at the Division of Bone Oncology of the National Scientific Research Center for Traumatology and Orthopedics named after R.R. Vreden due to giant cell tumors of the knee joint between 2017 and 2023. Mean patient age was 37.5 ± 9.79 years (95 % confidence interval 35.11–39.96; range 19–61 years). Mean follow-up duration was 40.2 ± 13.3 months (95 % confidence interval 36.87–43.46; range 18–68 months). To perform comparative analysis, the patients were divided into 2 groups depending on treatment type. The Group 1 (control) included 32 patients who subcutaneously received 120 mg denosumab prior to surgery (4 injections once a week and then once a month; total number of injections was 6 or more) with subsequent intralesional tumor resection, defect reconstruction with cement in combination with external fixation using a lockable condylar plate. The Group 2 (treatment) included 33 patients who underwent the same surgery as patients of Group 1 and then received subcutaneous injections of 120 mg denosumab (1 injection once a month for 3 months after surgery). Classification and analysis of complications were performed using the International Society of Limb Salvage (ISOLS) 2014 system. Functional outcomes were evaluated using the Musculoskeletal Tumor Society Score (MSTS) at 3, 6, and 12 months.Results. Mean time of recurrence diagnosis in the Group 1 was 9.1 months, in the Group 2 – 14.3 months. Evaluation of the probability of local tumor recurrence depending on treatment type showed statistically significant differences (p = 0.001). Odds of local recurrence in the Group 2 were 10.6 times lower than in the Group 1, and odds of revision surgical intervention in this patient group was 14.5 times higher (with higher probability, this surgery involved oncological endoprosthesis) (p = 0.011). No statistically significant differences in development of distant metastases and probability of death depending on treatment type were found (p = 0.492). According to the obtained data, there are statistically significant differences in functioning of the knee joint per the MSTS scale in the Groups 1 and 2 at 6 and 12 months (p = 0.021 and p = 0.021, respectively). Functional outcomes were better in the Group 2. No significant differences in knee joint functioning per the MSTS scale at 3 months depending on treatment type were found (p = 0.764).Conclusion. Administration of denosumab in the postoperative period allows to improve oncological outcomes due to decreased number of local recurrences (2 (6.1 %) cases), maintenance of excellent local control and good functional results, and to decrease the probability of revision surgical intervention to a minimum. In our study, administration of this drug prior to surgery (intralesional tumor resection) significantly increased the risk of local tumor recurrence (p = 0.001).

A novel technique of reconstruction of the distal tibia using allograft after resection of giant cell tumor: A case report with literature review

Giant cell tumor (GCT) of the distal tibia can result in significant bone loss and soft tissue compromise, which can present a challenge for reconstruction. Various techniques have been described for the reconstruction of large defects, including the use of allografts. In this article, we describe a novel technique of reconstruction of a large defect in the distal tibia using two femoral head allografts after resection of GCT. The technique involves using two femoral head allografts, which are shaped to fit the defect and secured with a locking plate and screws. Using this technique, we present a case report of a patient with GCT of the distal tibia who underwent resection and reconstruction. At the 18-month follow-up, the patient had good functional outcomes and no evidence of tumor recurrence. This technique offers a viable option for reconstructing large defects in the distal tibia after GCT resection, particularly in cases where autograft is not available or not feasible. Further studies are needed to evaluate the long-term outcomes and complications associated with this technique.

Primary Cooperative Application of a LARS® Tube and 3D‐Printed Prosthesis for Reconstruction of the Distal Radius after en bloc Resection of Giant Cell Tumor of Bone: A Comparative Retrospective Study

Using a fibula autograft (FA) to reconstruct defects after en bloc resection of giant cell tumor of bone (GCTB) in the distal radius is classic but has high complication rates. We describe a novel reconstruction method employing the cooperative application of LARS® and a 3D-printed prosthesis (L-P) and investigate whether it improves postoperative outcomes. From April 2015 to August 2022, 14 patients who underwent the cooperative L-P reconstruction method after en bloc resection of distal radial GCTBs and 31 patients who received FA reconstruction were enrolled as two retrospective cohorts in this comparative study. The properties of the implants and critical surgical techniques were elaborated in the L-P group. Preoperative function, intraoperative data, and postoperative clinical, functional, and radiographic outcomes of all patients were recorded and compared between the two groups. The grip strength and range of wrist motion, including extension, flexion, radial deviation, and ulnar deviation, were measured. The Mayo modified wrist and Musculoskeletal Tumor Society scores were chosen to assess wrist function and surgical functional outcomes, respectively. Kaplan-Meier curves were generated to analyze the significant differences in complication rates and implant survival between the two groups. In both groups, all 45 patients underwent the operation without complication with similar average osteotomy lengths and bleeding volumes, while a shorter operative duration was achieved in the L-P group (201.43 ± 22.87 min vs. 230.16 ± 51.44 min, P=0.015). At a mean follow-up of 40.42 ± 18.43months (range, 14-72months), both reconstruction methods effectively ameliorated postoperative function. Patients who received L-P showed higher postoperative modified Mayo wrist scores (81.43 ± 5.49 vs. 71.13 ± 16.10, P=0.003), Musculoskeletal Tumor Society scores (27.64 ± 1.34 vs. 25.06 ± 2.95, P=0.004), and grip strength on the normal side (68.71% ± 8.00% vs. 57.81% ± 12.31%, P=0.005) than the FA group. Better wrist extension (63.21° ± 8.99° vs. 45.32° ± 14.53°, P < 0.001) and flexion (45.36° ± 7.90° vs. 30.48° ± 12.07°, P < 0.001) were also observed in the L-P group. The complication rate was significantly higher in the FA group (29/31, 93.55%) than in the L-P group (1/14 7.14%, P < 0.001). The L-P group showed higher implant survival than the FA group, but the difference was not statistically significant. The cooperative application of LARS® and 3D-printed prostheses is an effective modality for reconstructing musculoskeletal defects after en bloc resection of distal radial GCTBs, which can improve functional outcomes, diminish complication rates, and promote wrist joint stability and motion.

Carbon fiber lumbopelvic reconstruction following sacral giant cell tumor resection: illustrative case.

The use of carbon fiber or polyetheretherketone spine constructs has proven to be a safe and effective alternative to standard metal alloy. The mechanical properties of carbon fiber while unique provide a construct that is comparable in strength to previous titanium-based constructs and have additionally shown greater fatigue resistance. These constructs have been especially useful for the mechanical stabilization of the spine following tumor resection. The subsequent interference seen when imaging a patient with a traditional metallic construct is reduced and allows for improved tumor surveillance after the procedure, and a more accurate delivery of radiotherapy when indicated. This case report details the treatment of a 25-year-old female diagnosed with a sacral giant cell tumor. The authors discuss the use of a carbon fiber-reinforced polyetheretherketone for lumbopelvic reconstruction. Carbon fiber-reinforced polyetheretherketone with its radiolucency and rigidity is a reliable option for complex spinal reconstruction after tumor resection.

Wide resection and reconstruction of giant cell tumor of the distal humerus with favorable outcomes in 3 months: A case report

Introduction and importanceA giant cell tumor is a locally aggressive tumor with low-risk progression into malignant and rarely metastasize, but a high risk of recurrence and notable disturbance of bony architecture in peri-articular locations. Wide resection provides a more advantageous therapy option, but the functional outcome is often hampered.Case presentationA 36-years old woman came with a lump on the left elbow as chief of complaint since a year ago that kept growing bigger with pain, local tenderness, and limited motion. She underwent several examinations and was diagnosed with a giant cell tumor in the distal humerus. Wide excision and reconstruction surgery using megaprosthesis, rotational flap, nerve graft, and skin graft were done. After 3 months follow-up, the patient had favorable functional outcomes.Clinical discussionThe primary aim of treating giant cell tumors is wide resection with good functional than cosmesis outcomes. This manner was common and expected to reduce the potential risk of infection.ConclusionReconstruction with megaprosthesis, nerve and skin graft, is a reasonable option after wide resection of the giant cell tumor in the left humerus with favorable functional outcomes within 3 months compared with other treatment modalities.

Outcome Analysis of En bloc Resection and Reconstruction by Non-vascularized Proximal Fibular Autograft in Giant Cell Tumor of Distal Radius supplemented with Brachytherapy.

Giant cell tumors of the bone are aggressive and potentially malignant lesions. Juxtaarticular giant cell tumors of the lower end radius are common and is a challenge for reconstruction after tumor excision. Several reconstructive procedures like vascularized and non-vascularized fibular graft, osteoarticular allograft, ceramic prosthesis, and megapros thesis are in use for substitution of the defect in the distal radius following resection. Here, we have analyzed the results of aggressive benign Giant cell tumor of the distal radius treated by en bloc excision and reconstruction using autogenous non-vascularized fibular graft along with brachytherapy. Eleven patients with either Campanacci Grade II or III histologically proven giant cell tumors of lower end radius were treated with en bloc excision and reconstruction with ipsilateral non-vascularized proximal fibular autograft. Host graft junction was fixed with low contact dynamic compression plate (LC-DCP) in all cases. Fixation of the head of the fibula with carpal bones and distal end of the ulna, if not resected, using K-wires at graft host junction was done. Brachytherapy was given in all 11 cases. Routine radiographs and clinical assessments regarding pain, instability, recurrence, hand grip strength, and functional status were done using Mayo modified wrist score at regular intervals. The follow-up ranged from 12 to 15 months. At last follow-up, the average combined range of motion was 76.1%. The average union time was 19 weeks. Out of 11 patients, two patients had good results, five patients had fair results, and four patient had poor results. There was no case of graft fracture, metastasis, death, local recurrence, or significant donor site morbidity. En bloc resection of giant cell tumors of the lower end radius is a widely accepted method. Reconstruction with non-vascularized fibular graft and internal fixation with LC-DCP along with brachytherapy minimizes the problem and gives satisfactory functional results with no recurrence.

Reconstruction with a Custom made Prosthetic Wrist Arthrodesis after Bone Tumor Resections of the Distal Radius. Single Centre Experience.

Objective The present study aimed at analyzing the clinical, radiological and functional results of the reconstruction of the distal radius after tumor resection with a custom-made metal arthrodesis implant and compare them with other types of distal radius reconstruction, as presented in the literature. To our best knowledge, this is the first article describing this particular type of implant and patient functionality. Methods Functional outcomes of reconstruction of the distal radius were assessed in a series of 4 patients. Three of the patients having had resection of giant cell tumors (GCTs), one patient having had resection of osteosarcoma. Results There were no major implant-related complications like infection, nonunion or loosening. Two patients had to undergo further surgery for protruding metalwork. Overall function was good according to the Musculoskeletal Tumor Society MSTS and Disabilities of the Arm, Shoulder, and Hand (DASH) scores. Conclusion The present study shows that custom-made metal arthrodesis implant benefits from the fact that it can be used as a salvage option when other treatments have failed, or it can be used as a primary option in cases in which there is limited bone stock after distal radius tumor resection.

Vascularized Ulnar Transposition and Radioulnoscapholunate Fusion With Volar Locking Plate in a Dorsal Position Following Resection of Giant Cell Tumor of the Distal Radius.

Giant cell tumor of the distal radius is a rare, locally destructive, and frequently recurrent tumor. We present a case of Campanacci Grade III giant cell tumor of the distal radius with pathologic fracture and cortical destruction which was treated with neoadjuvant denosumab. This facilitated en-bloc resection of the entire distal radius, including the articular surface, while minimizing tumor contamination. Reconstruction was accomplished using a vascularized ulnar transposition flap to facilitate radioulnoscapholunate fusion, which was fixated using a long-stem contralateral variable angle locking volar distal radius plate in a dorsal position. This case illustrates multidisciplinary management of a challenging reconstructive problem and demonstrates a novel strategy for fixation which repurposes familiar and readily available hardware to provide optimal osteosynthesis.

Wrist Arthrodesis and Osteoarticular Reconstruction in Giant Cell Tumor of the Distal Radius

The aim of this multi-institutional retrospective study was to compare osteoarticular graft reconstruction (OA) and wrist arthrodesis (WA) after distal radius resection for giant cell tumor. Sixty-seven patients affected by giant cell tumor of the distal radius underwent resection and reconstruction with OA (47 patients) or WA (20 patients). The mean age was 40 years (range, 13-74 years). Grafts included fresh-frozen allograft or nonvascularized fibular autograft. Complications requiring surgical revision were recorded. Clinical outcome was assessed with the Musculoskeletal Tumour Society Score (MSTS) and Disabilities of the Arm, Shoulder, and Hand (DASH) score. Fifteen patients developed a local recurrence after a median of 12 months (range, 6-137 months). Sixteen patients required revision surgery for complications. Of these, 10 were graft-related complications (7 in the OA group and 3 in the WA group). Among OA, 2 patients with painful instabilities and 4 with severe arthritis required conversion into WA after a mean of 26 months (range, 13-38 months) At a median follow-up of 105 months (range, 12-395 months), similar functional outcome (MSTS and DASH score) was observed between OA and WA. Our results did not show any advantage of OA or WA over the other technique. A patient-by-patient decision should be taken both regarding the type of reconstruction (OA or WA) and the type of graft (allograft or autograft). The reconstructive choice should also consider the patient's functional expectations. Therapeutic IV.

Radical Resection of a Recurrent Giant Cell Tumor of the Distal Ulna and Immediate Reconstruction With a Distal Radio-Ulnar Joint Implant Arthroplasty

Background: Giant cell tumors (GCTs) of the distal ulna are rare. Despite being benign, they can be locally aggressive and may recur following conventional treatment by curettage and bone grafting. Salvage reconstructive options after failed conventional treatment include Darrach resection, Suave-Kapandji procedure, hemi-arthroplasty, or total joint arthroplasty. Methods: We discuss reconstruction options for the distal radio-ulnar joint following tumor resection, and present the outcomes of a constrained distal radio-ulnar prosthesis in a 29-year-old male following resection of a distal ulna GCT. Results: Reconstruction of the distal radio-ulnar joint by a constrained prothesis yielded excellent functional outcomes following resection of a GCT of the distal ulna. Conclusions: This case demonstrates that successful oncologic and functional outcomes can be achieved by radical resection of a recurrent GCT of the distal ulna and reconstruction with a constrained total joint arthroplasty.

Циркулярная резекция локтевой кости при гигантоклеточной опухоли с одномоментной пластикой васкуляризированным фрагментом малоберцовой кости

Циркулярная резекция локтевой кости при гигантоклеточной опухоли с одномоментной пластикой васкуляризированным фрагментом малоберцовой кости

Endoscopic Resection of Giant Cell Tumor of the Extensor Tendon of the Foot

The localized form of giant cell tumor of the tendon sheath is one of the most common soft tissue tumors of the foot and ankle region. It is characteristically a benign, sharply localized peritendinous fibrous mass in the synovial or tendinous spaces. The purpose of this Technical Note is to present the technical details of endoscopic resection of giant cell tumor of the extensor tendon of the foot with preservation of the tendon. It is indicated in the localized form of giant cell tumor of the extensor tendon at the foot dorsum. It is contraindicated in cases with a diffuse giant cell tumor, a giant cell tumor of the extensor tendon at the phalangeal level, or involvement of the flexor tendon.

Clinical Outcome of En-Bloc Resection of Distal Radius Giant Cell Tumor And Reconstruction by Non Ascularized Fibular Graft &amp;Transossious Augmentation of Wrist By PalmarishLongusTendon,An Improvise Technique

Introduction: Giant cell tumor (GCT) of bone is a benign but locally aggressive tumor with tendency for local recurrence. Usually it can be treated by en-bloc resection and reconstruction arthroplasty using autogenous non-vascularizedipsilateral proximal fibular graft. Fibulo-carpal subluxation can be prevent by transossiouspamarishlongus tendon. This improvise technique found useful in preserving the movements and functions as well as stability of the wrist. Materials and Methods: Ten patients with a mean age of 33 years, witheither Campanacci grade II or III histologically proven giant cell tumours of lower end radiuswere treated with wide excision and reconstruction with ipsilateral non-vascularised proximalfibularautograft. Host graft junction was fixed with dynamic compression plate (DCP) in allcases. Wrist ligament reconstruction and fixation of the head of the fibula with carpal bonesand distal end of the ulna using K-wires along with pamarishlongus tendon reinforcement throw transeossiciousroot and primary cancellous iliac crest grafting at grafthost junction was done in all cases. Results: The follow-up ranged from 30 to 60 months (mean,46.8). At last follow-up, the average combined range of motion was 100° with range varyingfrom 60° to 125°. The average union time was 7 months (range, 4 to 12). Non-union occurredin 1 case. Graft resorption occurred in another case. Localised soft tissue recurrence occurredin another case after 3 years and was treated by excision. There was no case of graft fracture,metastasis, death, local recurrence or signifi cant donor site morbidity. A total of 3 secondaryprocedures were required. Conclusions: Enbloc resection of giant cell tumours of the lowerend radius is a widely accepted method. Reconstruction with non-vascularised fibular graft,internal fixation with DCP with primary corticocancellous bone grafting with transfixation of the fibular head and wrist ligament reconstruction minimises the problem and gives satisfactoryfunctional results.

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?

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. (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? 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. 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°). 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 IV, therapeutic study.

Ten-Year Follow-Up of Desarthrodesis of the Knee Joint 41 Years after Original Arthrodesis for a Bone Tumor.

Introduction. The main indication for knee arthrodesis in tumor surgery is a tumor that requires an extensive resection in which the joint surface cannot be preserved. We report a patient that had knee desarthrodesis 41 years after giant cell tumor resection followed by a knee arthrodesis. This is the longest reported follow-up after desarthrodesis and conversion to total knee arthroplasty (TKA), almost ten years. Case Report. A 71-year-old man with a distal femoral giant cell tumor had undergone a resection of the distal femur and knee arthrodesis using Kuntscher nail in 1962. In July 2003 he experienced gradually increasing pain of his left knee. We performed a desarthrodesis and conversion to TKA in 2005. The postoperative period passed uneventfully as his pain and gait improved, with gradually increasing range of motion (ROM) and no infection. He now walks independently, with no brace or contractures. Conclusion. Desarthrodesis of the knee joint and conversion to TKA are a difficult surgical choice with a high complication risk. However, our patient's life style has improved, he has no pain, and he can ascend and descend stairs more easily. The surgeon has to be very meticulous in selecting a patient for knee arthrodesis and counseling them to realize that their expectations may not be achievable.

Is intralesional treatment of giant cell tumor of the distal radius comparable to resection with respect to local control and functional outcome?

A giant cell tumor is a benign locally aggressive tumor commonly seen in the distal radius with reported recurrence rates higher than tumors at other sites. The dilemma for the treating surgeon is deciding whether intralesional treatment is adequate compared with resection of the primary tumor for oncologic and functional outcomes. More information would be helpful to guide shared decision-making. We asked: (1) How will validated functional scores, ROM, and strength differ between resection versus intralesional excision for a giant cell tumor of the distal radius? (2) How will recurrence rate and reoperation differ between these types of treatments? (3) What are the complications resulting in reoperation after intralesional excision and resection procedures? (4) Is there a difference in functional outcome in treating a primary versus recurrent giant cell tumor with a resection arthrodesis? Between 1985 and 2008, 39 patients (39 wrists) were treated for primary giant cell tumor of the distal radius at two academic centers. Twenty patients underwent primary intralesional excision, typically in cases where bony architecture and cortical thickness were preserved, 15 underwent resection with radiocarpal arthrodesis, and four had resection with osteoarticular allograft. Resection regardless of reconstruction type was favored in cases with marked cortical expansion. A specific evaluation for purposes of the study with radiographs, ROM, grip strength, and pain and functional scores was performed at a minimum of 1 year for 21 patients (54%) and an additional 11 patients (28%) were available only by phone. We also assessed reoperations for recurrence and other complications via chart review. With the numbers available, there were no differences in pain or functional scores or grip strength between groups; however, there was greater supination in the intralesional excision group (p=0.037). Tumors recurred in six of 17 wrists after intralesional excision and none of the 15 after en bloc resection (p=0.030). There was no relationship between tumor grade and recurrence. There were 12 reoperations in eight of 17 patients in the intralesional excision group but only one of 11 patients (p=0.049) who underwent resection arthrodesis with distal radius allograft had a reoperation. There were no differences in functional scores whether resection arthrodesis was performed as the primary procedure or to treat recurrence after intralesional excision. Resection for giant cell tumor of the distal radius with distal radius allograft arthrodesis showed a lower recurrence rate, lower reoperation rate, and no apparent differences in functional outcome compared with joint salvage with intralesional excision. Because an arthrodesis for recurrence after intralesional procedures seems to function well, we believe that intralesional excision is reasonable to consider for initial treatment, but the patient should be informed about the relative benefits and risks of both options during the shared decision-making process. Because arthrodesis after recurrence functions similar to the initial resection and arthrodesis, an initial treatment with curettage remains a viable, and likely the standard, mode of treatment for most giant cell tumors of the distal radius unless there is extensive bone loss. Level III, therapeutic study.

Reconstruction of the distal radius with non-vascularised fibular graft after resection of giant cell tumour of bone.

To evaluate outcomes of wide resection and reconstruction of the distal radius with non-vascularised autogenous fibular grafts for giant cell tumour (GCT) of bone. Medical records of 7 men and 5 women aged 22 to 47 (mean, 31) years who underwent wide resection of the distal radius and reconstruction with non-vascularised autogenous fibular grafts for GCT of bone were reviewed. The mean length of the resected radius was 9 (range, 7-11) cm. The ipsilateral proximal fibula with a small portion of attached ligament was harvested. The articular surface of the graft was fixed to the scapholunate articular surface by Kirschner wires, and the ligament of the fibular head was sutured to the carpal ligaments. The graft was fixed to the proximal radius with a small dynamic compression plate. Iliac cancellous bone graft was added. Pain, instability, and functional status were assessed. Wrist joint movements were measured using a goniometer. The grip strength was measured. The operated and contralateral sides were compared. The mean follow-up was 24 (range, 20-27) months. All patients achieved radiological union after a mean of 16 (range, 14-20) weeks. The mean active range of movement in the operated wrists was 32º dorsiflexion, 38º palmar flexion, 15º radial deviations, 12º ulnar deviations, 50º supination, and 60º pronation. Compared with the contralateral wrists, the operated wrists regained 60% of the function, with satisfactory grip strength, and normal finger and thumb movements and hand sensation. No patient had recurrence after 2 years. Two patients had minor dorsal subluxation, which was resolved with a wrist brace. Three patients had superficial infection, which was resolved with intravenous antibiotics and dressings. Two patients had peroneal nerve palsy, which recovered completely in 12 weeks. Non-vascularised fibular grafts for reconstruction of the distal radius after resection of a GCT of bone achieved good cosmetic and functional outcomes.

Commentary on: "L4 and L5 Spondylectomy for En Bloc Resection of Giant Cell Tumor and Review of the Literature".

Giant cell tumor (GCT; also known as osteoclastoma) is a locally aggressive, intermediate primary bone tumor characterized by osteoclast-like, multinucleated giant cells and the overexpression of receptor activator of nuclear factor kB ligand (RANKL) produced by stromal tumor cells. The tumorigenesis seemed to be associated with mutations of a histone (H3F3A) gene. Prevalence of GCT can be different in different regions/ethnical groups; e.g., GCT is rare in the United States—approximately 4 to 5% of primary bone tumors—but more often occurs in China where it is 10 to 20%.1 Local recurrence is common in surgically treated cases. Globally, malignant transformation has been described in 10% of cases, and lung metastases have been described in 1 to 4% of cases. Metastasizing can occur in benign, primary lesions as well and more frequently in recurrent GCTs and in spinal lesions.2 3 According to the Enneking surgical staging system, GCT is rarely S1 (latent); in 90% of cases, it is S2 (active with extensive cortical thinning and bulging) or S3 (aggressive with soft-tissue component). Management of GCT is often challenging and requires a multidisciplinary approach. In the spine, the osteolytic lesion can result in pathological fracture and consequential instability. Furthermore, the locally aggressive expansion of the tumor can cause neurological symptoms even in its early stage. The Enneking appropriate, en bloc resection of an S3 spinal lesion is a technically challenging surgery with high risk for perioperative complications and functional loss. The case report of Santiago-Dieppa et al demonstrates the complexity of such a surgery. Regarding the differential diagnosis, on one hand, the imaging studies present the typical diagnostic findings in the case of spinal GCT: lytic, aggressive tumor in L4–L5 with local extension across the L4–L5 disc and to the spinal canal. On the other hand, the patient was 58 years old. That age is not typical for the appearance of a GCT, which is usually diagnosed in the second to fourth decade. The patient had local and irradiating pain but no neurological symptom. Considering the unpredictable nature of the tumor and the high risk for local recurrence, the authors performed an en bloc L4–L5 spondylectomy followed by lumbopelvic reconstruction. The description of the technical details of the two-stage surgery clearly shows the difficulty of the management of such a patient; however, more data on the total time of the surgery, blood loss, and hospital stay would have been more informative. In the reported case, the sagittal alignment is properly reconstructed, but I would have been also interested about the bone-grafting procedure, which is the key element of the long-term stability of the lumbopelvic reconstruction. Despite the proper surgical technique and the careful perioperative care, complications occur in almost all of these patients. The reported deep wound infection and CSF leak are the most common complications after en bloc lumbar spondylectomies and lumbopelvic stabilization procedures. However, in some cases, the short- and long-term outcome of extended spinal surgery is not as good as in this patient. The recently described pathological importance of the RANKL in the tumorigenesis of GCT led to human trials of the anti-RANKL monoclonal antibody (denosumab) in the management of the disease. Osteoclasts and their progenitors are dependent on RANKL, and the giant cells in the tumor produce unknown factors important for the survival of the stromal tumor cells. Denosumab was originally developed for the treatment of osteoporosis, but its inhibitory effect on osteoclasts blocks the bone resorption and the tumor progression in GCT. Moreover, in the absence of RANKL, the less cellular stroma starts to produce new osteoid matrix. After the successful phase 1 and 2 trials, denosumab was recently registered for the treatment of unresectable GCTs. Most of these studies comprised patients with GCT in the appendicular skeleton. The first report, with medium-term follow-up, about the use of denosumab in spinal GCT has been recently published by Mattei et al who treated successfully a 22-year-old female with a C2 GCT, applying denosumab after a posterior stabilization procedure.4 The open-label, parallel-group, phase-2 study about the safety and efficacy of denosumab in GCT also included 75 spinal cases (26.5%).5 In the overall cohort, use of the drug was associated with the inhibition of tumor progression and the reduced need for morbid surgery with an acceptable safety profile. Unfortunately, sub-analysis of spinal cases was not reported in this study, despite the importance of the possible surgical morbidity–reducing effect. The first results promise to bring significant changes to the current therapeutic standards, but further multicentric studies on the effect of denosumab in spinal GCT are required to include the drug into the first-line treatment.

Giant cell tumors of bone: nonsurgical factors associated with local recurrence.

To determine the rate of giant cell tumor (GCT) recurrence and evaluate the factors associated with its recurrence in patients who underwent surgery and submitted to only one adjuvant method. Forty-one patients (22 female, 19 male; mean age: 34.22 ± 9.70 years) with GCT, who underwent surgical and one adjuvant treatment, were evaluated after a mean follow-up period of 40.17 ± 22.08 months. The average tumor size was 8.51 ± 3.69 cm. The tumors in 18 patients (43.9%) were grade II and in 23 patients (56.1%) grade III, according to the system developed by Campanacci et al. The surgical margin was intralesional resection and curettage in 60.9% of the patients, and marginal or wide resection in 39.1%. Nine (22%) of the 41 patients had recurrence. None of the gender (p=0.436), age (p=0.310), site of the tumor (p=0.940), surgical margins (p=0.400) and the type of the filling material (PMMA or autograft) (p=0.680) had an association with recurrence. However, Campanacci grade III (p=0.028) and the size of the tumor (p=0.034) was associated with the recurrence. Tumor size and tumor grade III according to the Campanacci system appear to be risk factors for local recurrence after the local resection of GCT.

English

The elbow and distal humerus are unusual sites for primary bone tumours or metastatic disease.1 Before the advent of limb-salvage surgery around 1980s, amputation or arthrodesis was the primary treatment for tumours of the upper limb and the ultimate result was not usually satisfactory. The outcome after reconstructive surgery improved with advances in imaging, staging of the bone tumours, chemotherapy and advancements in the prosthesis designs for arthroplasty. Now preservation of the upper limb with functional reconstruction with arthroplasty has become the standard treatment for patients with bone tumours. 2, 3 Total elbow arthroplasty has been used extensively for malignancy, rheumatoid arthritis, osteoarthritis and trauma.4–6 Total elbow arthroplasty has continued to evolve over time. Elbow implants may be linked or unlinked. Unlinked implants are attractive for patients with relatively well preserved bone stock and ligaments, but many favor linked implants, since they prevent instability and allow replacement for a wider spectrum of indications.7–9 We present our experience of reconstruction with a custom-made elbow endoprosthesis (Bakshi's floppy Hinge Semi-constrained linked Prosthesis) after resection of giant cell tumour of the distal humerus with follow up of 6 and half years. CASE HISTORY: 40 year old female patient, farmer by occupation presented to us with gross swelling and pain over Left elbow and gradually aggravating since last 6 months. There was no history of trauma, high grade fever and weight loss. Radiograph was suggestive of Companacci Grade III GCT and diagnosis was conformed on histopathologically. Patient was posted for total elbow arthroplasty. Bakshi’s floppy Hinge prosthesis with bone cement used which was cost effective and readily available. OPERATIVE TECHNIQUE: General anaesthesia administered. Postero-lateral approach and excision of tumor and radial head was done. Sub-articular ‘L’ shaped cut at proximal ulna taken. Reaming of ulna and humerus was done. Component fixation at desired length with bone cement was done. Reconstruction of distal end humerus with cement was done. Components were assembled with hinged screw and locked. Post-operatively limb was immobilised in plaster of paris slab for 3 weeks and gradually elbow mobilization started over 6 weeks. Range of movement 10° to 130° with terminal mild discomfort achieved after 8 weeks. Patient could do routine activity of daily living and light wok with comfort. Patient was happy and satisfied with final outcome. Patient was followed for 6 and half years with no recurrence of bone tumour. IMPLANTS DESIGN: Linked constrained and unlinked unconstrained implants are available. The difference is the physical linking of the hinge between humeral and ulnar components in order to