| Abstract|| |
Background: Giant cell tumors of bone are aggressive, potentially malignant lesions. Juxtaarticular giant cell tumours of lower end radius are common and present a special problem of reconstruction after tumor excision. Out of the various reconstructive procedures described, use of nonvascularised fibular autograft has been widely used with satisfactory functional results.
Methods: Sixteen patients with a mean age of 20.2 years, with either Campanacci grade II or III histologically proven giant cell tumours of lower end radius were treated with wide excision and reconstruction with ipsilateral nonvascularised proximal fibular autograft. Host graft junction was fixed with intramedullary nail in 12 cases and DCP in last 4 cases. Wrist ligament reconstruction and fixation of the head of fibula with carpal bones using K-wires and primary cancellous iliac crest grafting at graft host junction with DCP was done in last 2 cases.
Results: The follow up ranges from 2 - 5 years (mean 3.5 years). At last follow up, the average combined range of motion was 110° with range varying from 60-125°. The average grip strength was 39% in comparison to the contralateral side (range 21-88%). The average union time was 8 months (range 4-12 months). Sound union occurred in 5 months, where DCPs were used. There were 5 nonunions, one resorption of graft, 10 wrist subluxations (2 painful), one recurrence, 3 superficial infections, one wound dehiscence and one amputation. There was no case of graft fracture, metastasis, death or significant donor site morbidity. A total of 10 secondary procedures were required.
Conclusions: Enbloc resection of giant cell tumours of lower end radius is a widely accepted method. Reconstruction with nonvascularised fibular graft, internal fixation with DCP with primary corticocancellous bone grafting with transfixation of the fibular head and wrist ligament reconstruction minimizes the problem and gives satisfactory functional results.
Keywords: Giant cell tumor; Lower end radius; Nonvascularised fibular autograft.
|How to cite this article:|
Dhammi I K, Jain A K, Maheshwari AV, Singh M P. Giant cell tumors of lower end of the radius : Problems and solutions. Indian J Orthop 2005;39:201-5
|How to cite this URL:|
Dhammi I K, Jain A K, Maheshwari AV, Singh M P. Giant cell tumors of lower end of the radius : Problems and solutions. Indian J Orthop [serial online] 2005 [cited 2015 Apr 17];39:201-5. Available from: http://www.ijoonline.com/text.asp?2005/39/4/201/36569
| Introduction|| |
Giant cell tumors of bone are aggressive, potentially malignant lesions. They are recognized for variable clinical behavior, which is not always related to radiographic or histological appearance . They represent 3-8% of all bone tumors and are more common in China and India, where they constitute about 20% of all bone tumors. The lower end of radius is the third most common site (almost 50% of the lesions are found in distal femur and proximal tibia), accounting for about 10% of these tumors  . These predominantly affect adults in the third and fourth decade of life (70-80%)  . Statistically 80% of the giant cell tumours have a benign course, with a local rate of recurrence of 20-50%. About 510% undergo malignant transformation and 1-4% give pulmonary metastasis even in case of benign histology  .
The management of giant cell tumours involving the distal end of radius has always been a difficult problem with controversies  . Curettage and bone grafting has a high rate of recurrence (30-50%). Curettage and adjuvant therapy with liquid nitrogen, methylmethacrylate, phenol, hydrogen peroxide or alcohol has lowered down the recurrence rate (030%). This high recurrence rate can be controlled by enbloc resection (0-5% in primary lesions)  . Although amputation would be curative, it would seem unwarranted for a lesion which rarely metastasizes. Thus enbloc resection, where feasible, appears to be the treatment of choice, especially for that lesion which is high grade, has recurred, has pathological fracture, has enlarged rapidly, or is frankly malignant  . Complete excision of tumor offers best chance of cure but sacrifices the articular surface and presents complex reconstructive problems  . This may lead to complications, repeat surgeries and decreased quality of life. Although the method of resection of giant cell tumours has been fairly uniform in literature, the methods of reconstruction have varied. Proximal fibular autograft (vascularised and nonvascularised) have been widely used with good results ,,,,,,,,,,,, .
In this study we will discuss the complications faced and their solutions, after wide resection and non-vascularised fibular autograft in giant cell tumours of lower end of radius.
| Materials and Methods|| |
This study comprised of sixteen cases having giant cell tumour of lower end of radius, which were operated from 1986 to 2001. All these cases were histologically proven. The diagnosis was ascertained by FNAC in 14 cases and open biopsy in 1 case (as FNAC was inconclusive). One case presented with recurrence 18 months after his initial curettage and cementing (done elsewhere) and was carrying his previous histopathological slides. The age ranged from 1742 years (mean 20.2 years). There was no side or sex predilection. All the patients presented with mild pain and, or, enlarging swelling around the wrist. Twelve patients gave a history of trauma to the region. The duration of symptoms before the patient reported to us ranged from 6 weeks to 16 months (mean 11 weeks). Eight of the patients had taken some treatment from quacks.
On roentgenogram, tumor was found as an expansile radiolucent lesion located in epiphyseal end plate. All were Campanacci  grade II (n=12) or III (n=4) [Figure - 1]. The hematological and skeletal surveys were normal in all cases. All the cases underwent surgery. Informed consent was taken in each case. The tumor was excised enbloc with 1 cm safety margin. The defect, thus created in the radius was bridged by ipsilateral non-vascularised fibula in 15 cases and iliac crest graft in one case. Host graft junction was fixed with intramedullary nail in 12 cases and dynamic compression plate (DCP) in 4 cases. Wrist ligament reconstruction and fixation of the head of fibula with carpal bones using K-wires and primary cancellous iliac crest grafting at graft host junction with DCP was done in last 2 cases. No tumor invaded the wrist joint so as to excise any carpal bone. Postoperatively, an above elbow cast immobilization was given in all cases for 3 months. Then a below elbow splint was applied till union. K-wires were removed at 8 weeks. The nail was removed between 6-12 months depending on the union.
| Results|| |
The cases were followed up at every 6 weekly interval till 6 months, then 3 monthly interval till one year and then at 6 months interval. At every follow up, clinicoradiological assessment was done. Clinically, range of motion (by goniometer) and grip strength (by dynamometer) were assessed, while radiologically, X-rays of the local part and chest were assessed. The follow up ranged from 2 - 5 years (mean 3.5 years). At last follow up, the average combined range of motion was 110° (supination, pronation, dorsiflexion, palmar flexion, ulnar deviation and radial deviation) with range varying from 60-125°. The average grip strength was 39% in comparison to the contralateral side (range 21-88%). The average union time was 8 months (range 4-12 months). Sound union occurred in 5 months, where DCPs were used (last 4 cases). This was further reduced to 4 months when primary bone grafting was done (last 2 cases).
Non union occurred in 5 cases at graft host junction and all of these required secondary bone grafting [Figure - 2] . The graft resorption occurred at three months in the case, where iliac crest graft was used [Figure - 3]. The patient then developed a manus valgus deformity and was successfully treated by fibular grafting. Fibular head subluxation was noticed in 10 cases. This usually occurred after intramedullary nail removal [Figure - 4]. However, function wise, the wrists were stable. Two patients developed painful subluxations, and they eventually required arthrodesis of wrist. In both these cases, arthrodesis was done after one year and the fibular end was found bleeding. Wrist functions were restricted in all cases.
Recurrence occurred in one patient after 2 years at the graft host junction. This was one of the two patients who had undergone wrist arthrodesis for painful subluxation. This patient was planned for revision fibular grafting. But due to prolonged intolerable morbidity, she opted for a below elbow amputation. Superficial infection occurred in 3 cases, which healed on antibiotics and local wound care. Wound gap occurred in one case, which ultimately required a split thickness skin graft. This patient had presented with recurrence, following curettage and bone grafting. We had done an enbloc excision with non vascularised fibular autograft reconstruction. There was no graft fracture, metastasis, death or significant donor site morbidity in our patients. Overall, 10 secondary procedures were required (5 bone grafting for non-unions, one fibular grafting for absorbed iliac graft, 2 wrist arthrodesis for painful subluxation, one amputation and one skin grafting).
| Discussion|| |
Giant cell tumour is an aggressive lesion with a high rate of recurrence  . The problem of selecting the proper treatment is complicated by the failure of its histologic appearance to indicate its biologic behavior  . Inspite of controversies, it is generally agreed that for a giant cell tumour of lower end radius, the extent of surgical procedure and subsequent functional deficit must be weighed against the chance of recurrence  . Although benign recurrence can occur after long latent time, most recurrences take place within the first two years. Secondary malignancy, if any, usually occurs beyond the third year , . There are reports that giant cell tumour in the lower end of radius is more aggressive and metastasizes more often to the lungs  . The behavior of pulmonary relapse is unpredictable and only infrequently fatal. Thus every effort should be made to totally eradicate the primary lesion during the initial surgical treatment  . Thus enbloc resection is strongly recommended, especially in high grade tumors and those which have recurred, have pathological fracture, have enlarged rapidly, or are frankly malignant  . Reconstruction is necessary after adequate resection of tumor to preserve the function and alignment. Many techniques have been described for reconstruction and include iliac crest graft, corticocancellous tibial graft, centralization of ulna, distal radial allograft, vascularised or non vascularised fibular graft and prosthesis ,,,,,,,,,,,,,,,.
Reconstruction with corticocancellous iliac or tibial graft and centralization of ulna sacrifices the wrist and the forearm motion. Nearly half of these grafts suffer stress fracture . Although use of radial allograft has shown encouraging results, there are many associated problems. Selection of suitable donors, the method of obtaining and preserving the graft, and the technique of allograft reconstruction deserves particular attention. The surgeon must consider the risks of infection, or graft rejection, delayed healing and functions of the wrist joint ,17] . Vascularised fibular autograft is technically more demanding with use of microsurgical techniques. All complications of vascularised free bone graft are possible. Skin closure of forearm also poses problems ,, . The potentially increased operative time, effort, expense and associated complications must be shown to decrease the morbidity and late fracture problems, before they can be considered superior  . Prosthesis gives poor results and is a non biological solution, not possible in all settings.
Non vascularised proximal fibular graft is reasonably congruous with distal radius. Its incorporation as an autograft is more rapid and predictable. Moreover, it is easily accessible without significant donor site morbidity. The wrist functions are clinically acceptable. It is also a biological solution and an average orthopaedic surgeon can perform this surgery in an average set up. Complications and disabilities do not result in unacceptable limitations compared with other sites under similar circumstances  .
Non vascularised fibular autograft was first used in 1945 for congenital absence of radius  . Later, fibular transplants were used by various authors for tumors of the lower end radius ,,11], . This reconstruction technique has yielded good functional results for giant cell tumour of lower end of radius in various series, though large series with longer follow ups are few ,,, . But this procedure also has problems like delayed union, non union, stress fractures, bone resorption, deformities, ulnar impingement, carpal degenerative changes, donor site morbidity ,,, . Very often prolonged immobilization is required before healing is complete. We also faced almost similar problems in our series. But major problem faced was nonunion at host-graft junction (5 cases), which required secondary bone grafting. Lackman had reported 2 nonunions (n=12), while Murray reported 5 (n=18), all of which required secondary procedures , . We observed union time to be less in cases where DCP was used (average 5 months as compared to 8 months for all cases) and even lesser (4 months) if corticocancellous graft was used primarily at the graft host junction. In Murray's series (fibular interpositional arthrodesis), it was noted to be average 8.6 months for all cases and 7.1 months for uncomplicated cases. He also reported one case of graft resorption. We also had one case of primary iliac crest graft resorption, which required secondary fibular grafting. We noted one case of recurrence, in which arthrodesis after centralization of ulna was done. Recurrence was reported to be nil by Chiang (n=8)  , 5 by Murray and one by Lackman. There was no case of graft fracture, metastasis, death or significant donor site morbidity in our series. One patient demanded amputation because of prolonged intolerable morbidity. Murray had found donor site morbidity to be frequent, which included pain, weakness, lateral instability and transient peroneal nerve palsy. Lackmann had reported 3 fractures, one metastasis but no significant donor site morbidity. In our series, wrist subluxation occurred in 10 patients after nail removal and 2 of them subsequently required arthrodesis for pain. Lackmann had noted volar displacement and radial deviation in one case each in his series. He remarked that all patients show radiological distortion of radioulnar joint and degenerative fibulocarpal changes on follow up. Similarly, Chiang observed 4 cases of radioulnar diastasis, one case each of manus varus and volar tilt of carpals. We had 10 secondary procedures, while Murray had 15. Our average grip strength was 39% as compared to the contralateral side and our combined range of motion was 110°. This has been shown in literature to vary from 40 - 77 O and 70-185° respectively ,,,, . Most of our cases are of duration, when we were still finding the solution of our initial problems, and thus our results can improve now (the average grip in last 4 cases was 47% with an average total range of motion of 138°). Keeping these observations, we now routinely use DCP with primary bone grafting at the host-graft junction. The fibular head is transfixed to carpus and lower end of ulna with Kwires. The wrist ligaments are reconstructed. Utmost care is taken to preserve the integrity and articular surface of the graft [Figure - 5].
To conclude, considering the fact that one can be certain that resection of a giant cell tumour in the lower end of radius will cure more than half of the patient (even recurrence can be treated similarly with a good chance of success)  , the recommended treatment is resection, with as wide a margin as possible, that will not preclude a functional reconstruction. Reconstruction with nonvascularised fibular graft, internal fixation with DCP with primary corticocancellous bone grafting with transfixation of the fibular head and wrist ligament reconstruction minimizes the problem and gives satisfactory functional results.
| References|| |
|1.||Szendroi M. Giant cell tumor of bone. J Bone Joint Surg (Br). 2004; 86: 5-12. |
|2.|| Lee MLH, Sandeman JC. Fibular autograft survival following resection of osteoclastoma of radius. Postgrad Med J. 1969; 45: 266-71. |
|3.|| De Palma AT, Ahmad I, Flanney G. Treatment of giant cell tumors in bone. Clin Orthop. 1974; 100: 232-7. |
|4.|| Smith RJ, Mankin HJ. Allograft replacement of distal radius for giant cell tumor. J Hand Surg (Am). 1977; 2(4): 299-309. |
|5.|| Parker SM, Hastings DE, Fornasier VL. Giant cell tumor of distal end radius replaced by massive fibular autograft: a case report. Can J Surg. 1974; 17:266-8. |
|6.|| Bajec J, Gang RK. Bone reconstruction with a free vascularized fibular graft after giant cell tumor resection. J Hand Surg (Br). 1993; 18(5): 565-7. |
|7.|| Ben AH, Zouari M, KarrayS, Zehi K, Litaiem T, Douik M. Giant cell tumors of the distal end of the radius treated by resection arthrodesis. Acta Orthop Belg. 1998; 64(1): 41-6. |
|8.|| Campanacci M, Baldini N, Boriani S, Sudanese A. Giant cell tumor of bone. J Bone Joint Surg (Am). 1987; 69: 106-14. |
|9.|| Chiang IM, Chen TH, Shih LY, Lo WH. Nonvascularized proximal fibular autograft to treat giant cell tumors of the distal radius. Zhonghua Yi Xue Za Zhi. 1995; 56(5): 331-7. |
|10.|| Lackman RD, McDonald DJ, Beckenbaugh RD, Sim FH. Fibular reconstruction for Giant cell tumour of the radius. Clin Orthop. 1987; 218: 232- 8. |
|11.|| Lawson TL. Fibular transplant for osteoclastoma of radius. J Bone Joint Surg (Br). 1952; 34-B (1): 74-5. |
|12.||Minami A, Kato H, Iwasaki N. Vascularizes fibular graft after excision of giant cell tumor of the distal radius: wrist arthroplasty versus partial wrist arthrodesis. Plast Reconstr Surg. 2002; 110(1): 112-7. |
|13.|| Murray JA, Schlafly B. Giant cell tumors in the distal end of the radius. Treatment by resection and fibular autograft interpositional arthroplasties. J Bone Joint Surg (Am). 1986; 68: 687-94. |
|14.|| Parrish FF. Treatment of bone tumors by total excision and replacement with massive autologous and homologous grafts. J Bone Joint Surg (Am). 1966; 48: 968-90. |
|15.|| Pho RWH. Malignant giant cell tumor or the distal end or the radius treated by a free vascularized fibular transplant. J Bone Joint Surg (Am). 1981; 63: 877-84. |
|16.|| Unni KK. General aspects and data on 11087 cases. In: Dahlins' bone tumors, 5th edition. Philadelphia: Lippincott-Raven Publishers. 1996; 263-87. |
|17.|| Mund DF, Yao L, Fu YS, Eckardt JJ. Case report 826. Skeletal Radiol. 1994; 23: 139-41. |
|18.|| Starr DE. Congenital absence of radius; method of surgical correction. J Bone Joint Surg. 1945; 27: 572. |
A K Jain
Department of Orthopaedics, University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi-110095
Source of Support: None, Conflict of Interest: None
[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5]