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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 3  |  Issue : 1  |  Page : 17-21

Recurrence of giant cell tumor in fibular graft after resection of distal end radius


Department of Orthopaedics, IGIMS, Patna, Bihar, India

Date of Submission30-Nov-2019
Date of Decision20-Mar-2020
Date of Acceptance22-Mar-2020
Date of Web Publication30-Apr-2020

Correspondence Address:
Ritesh Runu
Department of Orthopaedics, IGIMS, Patna, Bihar
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JODP.JODP_19_19

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  Abstract 


Giant cell tumor (GCT) of the distal radius accounts for 10% of skeletal GCTs, next to distal femur and proximal tibia. It has high propensity for recurrence. Treatment consists of extended curettage or en bloc resection of the lesion with subsequent reconstructions. We report a case of a 31-year-old female with recurrence of tumor in the well-united grafted ipsilateral fibula used for reconstruction of the wrist after excision of GCT in the left distal radius. Surgical plan of the ulnar translocation was changed to carpus centralization and wrist arthrodesis due to intraoperative radial artery injury. Computed tomographic angiography must be done before planning as single artery is contraindicated for ulnar translocation.

Keywords: Free fibula graft, giant cell tumor, recurrence, wrist arthrodesis, wrist reconstruction


How to cite this article:
Kashyap N, Subhash A, Runu R, Kumar A, Khemka G. Recurrence of giant cell tumor in fibular graft after resection of distal end radius. J Orthop Dis Traumatol 2020;3:17-21

How to cite this URL:
Kashyap N, Subhash A, Runu R, Kumar A, Khemka G. Recurrence of giant cell tumor in fibular graft after resection of distal end radius. J Orthop Dis Traumatol [serial online] 2020 [cited 2020 Jul 5];3:17-21. Available from: http://www.jodt.org/text.asp?2020/3/1/17/283676




  Introduction Top


Giant cell tumor (GCT) of the bone is a benign but locally aggressive tumor, with increased propensity of recurrence.[1] Distal radius is the third most common site of skeletal GCTs (10%), next to distal femur and proximal tibia.[2] The tumor removal and reconstruction of the defect in the distal radius are relatively difficult due to epiphyseal–metaphyseal location and presence of radial artery and median nerve in proximity.[3] Different surgical modalities have been advocated for the management of GCT of the distal radius.[1],[3],[4],[5] Curettage and bone grafting is the most frequently done procedure. En bloc resection of the tumor and reconstruction of the distal radius by ipsilateral (I/L) proximal fibula (vascularized/nonvascularized) are done for large tumors. The centralization of the wrist over the distal ulna with arthrodesis or ulnar translocation without complete detachment from surrounding soft tissues is also done as salvage procedure.[6] Recurrence of tumor is one of the major complications of procedures. It is rarely reported in the fibular graft. We discuss the management of recurrence and review of literature.


  Case Report Top


A 31-year-old female presented in our outpatient department in 2017 with pain, swelling in the left distal forearm, and inability to work for 6 months. Pain was localized over the left wrist, insidious in onset, and gradually progressive in severity. It was relieved with analgesics. The swelling was 5 cm × 3 cm bony hard, fixed to underlying distal radius, with well-defined margin, irregular surface, overlying skin mobile, local temp normal and distal neurovascular status intact. Range of motion (ROM) of the wrist was restricted and painful. Routine hematological investigations were within normal limits. X-ray of the left wrist showed lytic expansile lesion abutting the distal radius articular cartilage with multiple ill-defined septa and cortical breach [Figure 1]. Fine-needle aspiration cytology revealed GCT. After written informed consent, en bloc excision of the distal radius was done and reconstruction with I/L free proximal fibular graft applied through volar approach [Figure 2], [Figure 3], [Figure 4]. Postoperatively, above elbow plaster of Paris (POP) slab was applied. The postoperative period was uneventful. Stitch was removed on the 14th day and the cast was continued for 6 weeks. Further, bracing was continued for 6 weeks. At 12 weeks, the fibular graft was united and distal K-wire was removed. Wrist movement was good, grip strength was moderate, and she was able to do light daily activities with her left hand [Figure 5], [Figure 6], [Figure 7].
Figure 1: Preoperative X-ray

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Figure 2: Resected distal radius

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Figure 3: Postoperative X-ray

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Figure 4: Postoperative X-ray of the leg

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Figure 5: Postoperative united fibular graft

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Figure 6: Clinical photograph of the fore arm and wrist

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Figure 7: Clinical photograph of the leg

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Two years postoperatively, she presented with painful swelling over the operated area with restriction of movement of the wrist. It was relieved by analgesics. X-ray showed lytic expansile lesion in previously grafted fibula [Figure 8]. Bone scan showed localized hot spot with suspicion of recurrence of tumor in the grafted fibula [Figure 9].
Figure 8: Recurrence of tumor in grafted fibula

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Figure 9: Bone scan for metastasis

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We planned for the removal of implant followed by excisional biopsy of previously grafted fibula, ulnar osteotomy, and translocation of distal ulna through dorsal approach. However, during complete removal of tumor, radial artery was injured and planning shifted to centralization of wrist joint and wrist arthrodesis [Figure 10]. Above elbow POP slab was applied. Stitch removal was done on the 14th day, and above elbow cast was done for 6 weeks. Cast was removed after radiographic union at 8 weeks postoperatively; ROM and grip strengthening exercise were advised. Now, she is able to do light work and grip strength is moderate [Figure 11], [Figure 12].
Figure 10: Intraoperative photograph

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Figure 11: Postoperative X-ray wrist arthrodesis

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Figure 12: Postoperative clinical photograph

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  Discussion Top


GCTs are aggressive benign lesions known for their variable clinical behavior that is often unrelated to their radiological and histological appearance.[7] In distal radius, after curettage and bone grafting, the local recurrence rate is 27%–54%.[8] Hence, resection and reconstruction by free fibular graft are preferred. It was first described by Waltharin in 1911.[9] Recurrence has been reported with nonunion and in soft tissues.[10],[11]

Aithal and Bhaskaranan[12] studied the effect of four different surgical procedures in giant cell tumour of distal radius. There were ten recurrences, which could not be correlated with Campanacci's radiological or Jaffe's histological grading. The recurrences were treated by below elbow amputation in four cases, wide excision and arthrodesis in five cases, and one patient was lost to follow-up. The patients' developing recurrences in the grafted fibula were not elaborated regarding any other associated complications such as nonunion or delayed union at host graft junction. Their management of recurrence in the fibular graft was not described. Several authors elaborated the factors affecting recurrences.

Hu et al.[13] found that local recurrence rate was higher in 20–39 years of age group. They also found that recurrence was higher in patients treated with intralesional curettage. Distal radius recurrence rate was 20%–88.9%. High recurrence rate was seen in high-grade tumors.

Prosser et al.[14] found that cortical bone is a predictor of recurrence. If broken, then recurrence rate is 29%, while 7% if cortex is intact.

Balke et al.[8] found that the involvement of soft tissue around the tumor has major role. If involved, the recurrence is 29%, while only 16% if not involved. Highest recurrence was seen in the distal end of the radius. They concluded after study of 214 cases out of which 66 had recurrence at the median time of 12.4 months. Both the authors did not study the rate of recurrence in the grafted fibula.

Panchwagh et al.[3] noted recurrences in six cases out of 19 patients at 17 months of follow-up. Previously treated group had a recurrence rate of 36% and those freshly treated had 25%. It was more in Campanacci's Grade III. One case of recurrence was noted in ulnar strut graft but no recurrence in fibular graft seen. Recurrence in the fibular head arthroplasty was NIL (zero).

Dhammi et al.[12] noted one recurrence out of 16 cases of distal radius GCT treated with excision and fibular grafting in 15 cases. Recurrence was seen in one case at 2 years which was treated with below elbow amputation. Other complications noted with fibular graft were nonunion at graft host junction, delayed union, wrist subluxation, and infection.

Saini et al.[10] studied 15 cases of GCT of the distal end radius. No recurrence was noted in the graft; soft tissue recurrence was noted in one case which was excised. The results of fibular graft were better.


  Conclusion Top


Recurrence of GCT in the grafted fibula is rare. Very few authors have noted this complication. The treatment of this complication is resection of tumor and centralization of carpus with wrist arthrodesis or below elbow amputation. To retain the function of otherwise normal hand, centralization of the wrist joint and wrist arthrodesis is good option. Computed tomographic angiography and color Doppler are essential to plan for carpal centralization or ulnar translocation as single artery is contraindication to ulnar translocation.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Eckardt JJ, Grogan TJ. Giant cell tumour of bone. Clin Orthop Rel Res 1986;(204):45-58  Back to cited text no. 1
    
2.
Campanacci M, Baldini N, Boriani S, Sudanese A. Giant-cell tumor of bone. J Bone Joint Surg Am 1987;69:106-14.  Back to cited text no. 2
    
3.
Panchwagh Y, Puri A, Agarwal M, Anchan C, Shah M. Giant cell tumor-distal end radius: Do we know the answer? Indian J Orthop 2007;41:139-45.  Back to cited text no. 3
[PUBMED]  [Full text]  
4.
Liu YP, Li KH, Sun BH. Which treatment is the best for giant cell tumors of the distal radius? A meta-analysis. Clin Orthop Relat Res 2012;470:2886-94.  Back to cited text no. 4
    
5.
Klenke FM, Wenger DE, Inwards CY, Rose PS, Sim FH. Giant cell tumor of bone: risk factors for recurrence. Clin Orthop Relat Res 2011;469:591-9.  Back to cited text no. 5
    
6.
Seradge H. Distal ulnar translocation in the treatment of giant-cell tumors of the distal end of the radius. J Bone Joint Surg Am 1982;64:67-73.  Back to cited text no. 6
    
7.
Lausten GS, Jensen PK, Schiødt T, Lund B. Local recurrences in giant cell tumour of bone. Long-term follow up of 31 cases. Int Orthop 1996;20:172-6.  Back to cited text no. 7
    
8.
Balke M, Schremper L, Gebert C, Ahrens H, Streitbuerger A, Koehler G, et al. Giant cell tumor of bone: treatment and outcome of 214 cases. J Cancer Res Clin Oncol 2008;134:969-78.  Back to cited text no. 8
    
9.
Campanacci M. Giant cell tumour and chondrosarcoms: grading, treatment and results (studies of 209 and 131 cases). Recent results cancer research 1976;54:257-61.  Back to cited text no. 9
    
10.
Saini R, Bali K, Bachhal V, Mootha AK, Dhillon MS, Gill SS. En bloc excision and autogenous fibular reconstruction for aggressive giant cell tumor of distal radius: A report of 12 cases and review of literature. J Orthop Surg Res 2011;6:14.  Back to cited text no. 10
    
11.
Dhammi IK, Jain AK, Maheshwari AV, Singh MP. Giant cell tumours of lower end of the radius: Problems and solutions. Ind J Orthop 2005;39:201-15.  Back to cited text no. 11
    
12.
Aithal VK, Bhaskaranand K. Reconstruction of the distal radius by fibula following excision of giant cell tumor. Int Orthop 2003;27:110-3.  Back to cited text no. 12
    
13.
Hu P, Zhao L, Zhang H, Yu X, Wang Z, Ye Z, et al. Recurrence rates and risk factors for primary giant cell tumors around the knee: A multicentre retrospective study in China. Sci Rep 2016;6:36332.  Back to cited text no. 13
    
14.
Prosser GH, Baloch KG, Tillman RM, Carter SR, Grimer RJ. Does curettage without adjuvant therapy provide low recurrence rates in giant-cell tumors of bone? Clin Orthop Relat Res 2005;435:211-8.  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12]



 

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