Hans Kristian Nugraha, MD, SpOT, and colleagues detail the potential benefits of an arthroscopic surgical approach through a case study of a patient with giant cell tumor of bone.
As a locally aggressive primary benign tumor, giant cell tumor of bone (GCTB) presents a challenge to surgeons, as it often recurs regardless of surgical resection. This report describes a case of GCTB of the distal femur in a man, aged 39 years, treated with intralesional curettage through an arthroscopic approach. A 360° view of the tumor cavity can be achieved with the help of an arthroscope, which can help complete intralesional curettage and minimize possible larger approach-related complications. The result is favorable in terms of functional outcome and recurrence after 1-year follow-up.
Surgeons face a challenge with giant cell tumor of bone (GCTB), as it has a tendency to recur even after surgical resection. Some previous studies showed that the recurrence rate of this pathology could reach 90%, regardless of surgical treatments. Treatments vary; they include intralesional curettage, wide excision, bone grafting, adjuvant addition, and prosthetic replacement. Intralesional curettage is preferred in many cases of GCTB; however, an arthroscopic approach is rarely chosen nor reported in the literature.1,2 In this case report, we present a 39-year-old man with GCTB of the distal femur who underwent an arthroscopic intralesional curettage. Our findings indicate a positive functional outcome and low risk of recurrence.
A man, aged 39 years, came to our outpatient clinic with the chief complaint of pain in his left thigh for the previous 6 months. The pain occurred mainly with activity (eg, gardening, climbing stairs), and improved with rest. The pain was accompanied by a slow-growing lump on his left knee. One month prior to his visit, the patient had almost fallen and had used his left leg as a support to prevent himself from falling. Since then, he felt that his left knee was swollen and he had prolonged difficulty in walking. The swelling on his left knee had diminished over time, but the pain had remained. He reported no weight loss, fever, nocturnal pain, or fatigue. At presentation, the patient used 2 crutches to help him in his daily activities, including work. The patient is employed in a public health department and his knee issues were disrupting his proper job performance.
On physical examination, we found swelling over the left knee, without venectasia or shiny skin. Palpation confirmed the existence of a painful lump sized 8.5 × 8 cm at the lateral side of the left distal femur, fixed with an ill-defined border and solid consistency. The pulse of the femoral and popliteal arteries was still palpable, with normal capillary refill time and sensation. However, the active range of motion (ROM) of the left knee was limited, especially in flexion. The active ROM of the distal leg was within normal limits (Figure 1). A plain x-ray demonstrated a lytic destructive lesion of the lateral condyle femur (Figure 2).
From the clinical and radiological examination, the patient was suspected to have GCTB of the left distal femur. We, therefore, decided to do an arthroscope-assisted fixation of the fracture and intralesional curettage of the GCTB.
During the surgery, the patient was positioned supine, with the knee in 90° flexion. An incision was made for lateral portal insertion, at the soft spot above the joint line 2 cm lateral to the patellar tendon. The hematoma was drained, and an anteromedial portal was established with an outside-in technique. The joint was then irrigated with copious amounts of saline solution. A guide wire was passed from the lateral femoral condyle using a 6.5-mm drill bit. The presence of a mass on the lateral condyle of the femur was confirmed, and a sample taken for frozen section examination demonstrated a histological result in accordance with GCTB. A lateral longitudinal incision was made on the distal femur, extending up to expose the tumor. The fascia was incised to expose the lateral femoral condyle. Curettage and ablation were performed arthroscopically. A cortical window measuring 2 × 2 cm was made with an intact periosteal hinge. A 30° arthroscope with a light source was introduced through the cortical window. After the introduction of the scope, the light source cable was rotated to provide a 360° visualization of the tumor cavity. The surrounding structure of the cortical window was covered with a sterile mop to avoid spillage of the tumor cells or of irrigation fluid in the surrounding tissue. A small curette, 4.5-mm shaver tip, and high-speed burr were interchangeably used to curette the GCTB cavity. The end point of curettage was the visualization of the normal cortical bone through the arthroscope. During the curettage, copious amounts of normal saline were used for irrigation of the cavity. After curettage, the cavity was filled with polymethyl methacrylate cement. A distal femoral locking plate with 5 holes and 8 screws was then installed with the minimally invasive plate osteosynthesis (MIPO) technique. After hemostasis was achieved, the incision was closed in layers over a drain. The operation procedure and radiograph after the procedure are shown in Figure 3 and Figure 4.
Knee ROM exercises were started immediately postoperatively, as tolerated. The patient was advised to walk with 2 crutches and to not bear weight for 4 weeks, before gradually increasing weight according to his pain tolerance. He was asked to return for outpatient follow-up every month for the initial 6 months. After 1 year of follow-up, the patient has full ROM and has demonstrated no sign of recurrence on serial radiography and a satisfactory functional outcome; he has returned to his occupational and daily activities (Figure 5 and Figure 6).
GCTB was first described by Cooper and Travers in 1818 and is characterized histologically by a multinucleated giant cell tumor with a background of mononuclear stromal cells. GCTB occurs mainly (80%) in patients aged 20 to 40 years; fewer than 3% of cases occur in patients younger than 14 years, and only 13% in patients older than 50 years.3,4 GCTB accounts for 5% of all primary bone tumors and 20% of benign skeletal tumors. The 3 most common locations are the distal femur, proximal tibia, and distal radius, making it one of the differential diagnoses for radiographic lytic bone lesions in the metaphyseal-epiphyseal area of long bones.4,5
Traditionally, GCTB has been treated surgically with curettage and placement of cement (polymethyl methacrylate). As most GCTBs are benign and located near a joint, some orthopedic surgeons favor an intralesional approach that preserves the anatomy of the bone during resection. However, because the local behavior of GCTBs can be aggressive and the risk of local recurrence is substantial, other surgeons advocate wide resection and reconstruction for these grade 3 lesions, with the goal of preventing local recurrence and preserving joint function.6
The intralesional curettage method of treatment is associated with a risk of recurrence of approximately 16% to 45%, higher than that of wide resection and reconstruction. Local adjuvant therapy has been shown to help prevent recurrence,7 and some orthopedic surgeons argue that the skillfulness of the tumor removal rather than the use of adjuvant modalities is what determines the risk of recurrence. In addition, patients with extensive, aggressive, and/or incompletely-resected GCTBs are not candidates for intralesional curettage—they require wide excision and curettage.8-10 An arthroscopic approach, as in the case described here, is a challenge for surgeons, considering the proximity of the tumor to the joint and the possible injury of surrounding structures due to minimally invasive exposure. The bone cement was applied to fill the bone defect as a reconstructive measure and to decrease the possibility of recurrence. Fixation using plate and screw was also performed via the MIPO technique to minimize surgical trauma to the surrounding soft tissue and restrict the associated inflammation.
Extraarticular endoscopic resection of bone tumors was introduced in 1995 to treat chondroblastoma of the femoral head.11,12 Arthroscopic removal of GCTB was first reported later, in 2015, by Kekatpure et al at a distal femur location; results were satisfactory and no recurrence was seen at 1-year follow-up.13 An arthroscopic approach for such pathology has some advantages, including the ability to visualize the tumor directly, and in detail, as well as the opportunity to evaluate and subsequently repair possible cartilage defects. The minimal incision also allows the lesion to heal faster with minimal blood loss, lower risk of infection, and shorter length of hospital stay. However, there are some potential drawbacks: The use of block bone graft, in this case, was not feasible due to the minimal size of the portals, and bone cement should always be used cautiously, as it might damage the arthroscopy set. These potential drawbacks can be minimized when an experienced surgeon performs the procedure.2,13
At 1-year follow-up, this patient has a satisfactory range of movement and no sign of recurrence on serial radiography. The pain is diminished, and he has returned to his normal daily activities. Nonetheless, annual long-term follow-up is still required to detect any possible recurrence or metastasis.
Intralesional curettage with an arthroscopic approach for GCTB of the distal femur with the addition of bone cement and MIPO fixation shows a favorable outcome in terms of pain control, functional outcome, and recurrence at 1-year follow-up.
Hans Kristian Nugraha, MD, SpOT;1 I Gede Eka Wiratnaya, MD, PhD, SpOT(K);1 and Putu Astawa, MD, MSc, PhD, SpOT(K)1
1Department of Orthopaedic Surgery and Traumatology, Faculty of Medicine, Udayana University; Sanglah General Hospital, Bali, Indonesia
Written informed consent was obtained from the patient for being included in the study and its publication.
All authors have no conflict of interest. This report has not received any specific grant from any funding agency in the government, nor from any commercial or nonprofit entity. All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2008.