Resection-reconstruction arthroplasty for giant cell tumor of

distal radius Campanacci grade III : A case report

Anugrawan P., Arsa W., Rasyid H.N., Darmadji I.

Department of Orthopaedic & Traumatology, Faculty of Medicine – Universitas Padjadjaran / Dr. Hasan

Sadikin Hospital, Bandung

Abstract

Giant cell tumor (GCT) of bone, or osteoclastoma, is classically described as a locally invasive

tumor that occurs close to the joint of a mature bone. It is generally considered to be a benign

tumor. In our rural setup, a substantial proportion of patients seek traditional means of treatment

before medical consultation. The aim of this study is to report the result of wrist and hand

function after resection-reconstruction arthroplasty. The patient profile, a 27 year-old female

came to the hospital with extensive destruction of the right distal radius. We diagnosed as a GCT

of the right distal radius Campanacci grade III after confirmed by x-ray of the wrist. Several

options for reconstructive procedures can be considered like; vascularized and non-vascularized

fibular graft, osteo-articular allograft, ceramic prosthesis and megaprosthesis are in use for

substitution of the defect of the distal radius following resection. Here we have analyzed the

results of aggressive benign GCTs of the distal radius treated by resection and reconstruction

arthroplasty using autogenous non-vascularized fibular graft. At 6 months of follow-up, the

patient had a painless and well functioned wrist joint. There was no evidence of recurrence after

18 months of follow-up. As conclusion, the patient feel satisfied for the procedure that she had.

Key words:

Autogenous non-vascularized fibular graft, campanacci grade III, giant cell tumor, wrist joint.

Resection-reconstruction arthroplasty for giant cell tumor of

distal radius Campanacci grade III : A case report

I. Introduction

Giant cell tumor (GCT) of the distal radius is a fairly common, locally aggressive tumor of

young adults. GCT account for approximately 5-8% of all primary bone tumors. While early

tumors can be treated by curettage with or without bone grafting, recurrence rates are significant.

Once the tumor has breached the cortex, wide local excision remains the only curative treatment.

No traditional procedure can replace the wrist joint and completely restore normal morphology

and function. In view of the extensive involvement, wide resection along with hemi-arthroplasty

using the upper end of the fibula has been described as one of the procedures of choice because

the upper end of fibula has some similarity in shape to the distal radius. The upper end of the

fibula has been described both as a vascularized as well as a non-vascularized transfer. This is a

report of one cases we did, in which we were able to restore near normal functions of the hand,

using non-vascularized transfer of the upper end of the fibula.

The purpose of this study was to report the long term result of the treatment of Campanacci

III GCT of distal radius with wide resection and reconstruction with non-vascularised fibula

transfer at Hasan Sadikin Hospital of Universitas Padjadjaran.

II. Case Presentation

A 27 years-old female with chief complaint of pain at her left forearm since the last 1 year, with

swollen forearm since 8 months ago. The patient was treated elsewhere at bone setter with massage

and traditional herb. There was no history of fever, loss of appetite, loss of weight, similar

complaints in other joints or history of similar complaints in the past. The family, occupational,

recreational and drug histories were not significant. The general physical and systemic

examinations were within normal limits.

On local examination, there was a mass at the left forearm 10x8x5 cm in size, with

venectation, hard, warm, fixated to the bone beneath. All movements at the left wrist joint were

painfully restricted. Serum biochemistry studies were within normal limits. Anterior posterior

(AP) and lateral radiographs of the ankle showed a radiolucent lesion occupying the whole distal

radius. The CT scan revealed an expansible soft tissue mass in the distal radius causing cortical

destruction and extension into soft tissues. A fine needle aspiration of the mass was performed

and a provisional diagnosis of GCT was rendered. And chest radiograph showed no

intrapulmonary lesions.

The condition, its prognosis and various treatment modalities were discussed with the patient

and his family. Because of extensive involvement of distal radius, resection of almost 1/3 of

distal radius with arthroplasty using non-vascularised autologous proximal fibula was planned.

The patient was a home labourer and therefore opted for an optimum functional but painless

wrist joint. Distal radius resection was performed through an anterior approach, and arthroplasty

using autologous non-vascularised proximal fibula graft.

Fixation was achieved by open reduction and internal fixation using small narrow plate, and

added transfixing wire for distal radio-ulnar joint. The patient was advised not to used her

affected forearm and arm for 8 weeks. During 3 weeks post-operative the transfixing wire was

removed.

At 6 months of follow-up, the patient had a smooth healed scar with a painless and well

functioned wrist and no evidence of recurrence. There was no evidence of recurrence at 18

months of follow-up.

III. Discussion

GCT, also known as osteoclastoma, is a fairly common bone tumor accounting for 5% of all

the primary bone tumors. It is a benign tumor with a tendency for local aggressiveness and high

chances of recurrence. GCT is most commonly seen in the distal femur proximal tibia, distal

radius and the proximal humerus in descending order of frequency.

The clinical picture is that of insidious onset pain, which in many cases may be mismanaged

as wrist sprain and muscle strain. A history of preceding trivial trauma may be present. Other

features are non specific. radiologically; the tumor appears as an eccentric lytic lesion with

cortical thinning and expansion. There is absence of reactive new bone formation. The tumor

may erode the cortex and invade the joint. Pathological fracture may also be seen. MRI scanning

permits accurate delineation of the tumor extent and helps in deciding the line of management.

Many authors have reported satisfactory results with intralesional curettage and bone

grafting. However, curettage alone has a high rate of recurrence and adjuvants like

Methylmethacrylate (bone cement), cryotherapy and phenol have been suggested. Partial or total

resection of the distal radius may be contemplated in cases where there is extensive involvement

of the distal radius. Fresh frozen osteochondral allograft reconstruction has also been described

for an aggressive GCT of talus but there is paucity of literature on this particular modality of

treatment. The trend is towards limb salvage and amputation is reserved for recurrences and only

rarely done. In conclusion, in a case of GCT of talus presenting late with extensive involvement

and in a manual labourer, total excision and tibiocalcaneal arthrodesis is a valuable treatment

option.

IV. References

1. Eckardt JJ, Grogan TJ. Giant cell tumour of bone. Clin Orthop 1986;204:45-58.     [PUBMED]    

2. Dahlin DC, Cupps RE, Johnson EW Jr. Giant cell tumour: A study of 195 cases. Cancer 1970;25:1061-70.     [PUBMED]    

3. Goldenberg RR, Campbell CJ, Bonfiglio M. Giant cell tumour of bone. An analysis two hundred and eighty cases. J Bone Joint Surg Am 1970;52:619-64.     [PUBMED]    

4. Marcove RC, Weis LD, Vaghaiwala MR, Pearson R. Cryosurgery in the treatment of giant cell tumoue of bone - a report of 52 consecutive cases. Cancer 1978;41:957-69.         

5. Smith RJ, Mankin HJ. Allograft replacement of distal radius for giant cell tumour of distal radius. J Hand Surg Am 1977;2:299-309.     [PUBMED]    

6. Rastogi S, Prasanth I, Khan SA, Trikha V, Mittal R. Giant cell tumour of bone: Is curettage the answer? Ind J Orthop 2007; 41:109-14.         

7. Campanacci M, Baldini N, Boriani S, Sudanese A. Giant cell tumour of bone. J Bone joint Surg Am 1987;69:106-14.     [PUBMED]    

8. Getilis S, Mallin BA, Piaseccki P, Turner F. Intralesional excision compared with en bloc resection for giant cell tumour of bone. J Bone Joint Surg Am 1993;75:1648-55.         

9. McDonald DJ, Sim FH, McLeod RA, Dahlin DC. Giant cell tumour of bone. J Bone Joint Surg Am 1986;68:235-42.     [PUBMED]    

10. Vander Griend RA, Funderburk CH. The treatment of giant cell tumour of distal part of the radius. J Bone Joint Surg Am 1993;75:899-908.     [PUBMED]    

11. Walthar M. Resection de extremite inferieure du radius pour osteosarcoma geffe de I extremite superiuete du perone. Sac Chir Par Bull Mem 1911;37:739-47.         

12. Deb HK, Das NK. Resection and reconstructive surgery in giant cell tumour of bone. Ind J Orthop 1992;26:13-6.         

13. Goni V, Gill SS, Dhillon MS, Nagi ON. Reconstruction of massive skeletal defects after tumour resection. Ind J Orthop 1992;26:13-6.         

14. Aithal VK, Bhaskaranand K. Reconstruction of distal radius following excision of giant cell tumour. Int Orthop 2003;27:110-3.     [PUBMED]  [FULLTEXT]  

15. Harris WR, Lehmann EC. Recurrent giant cell tumour after en bloc excision of distal radius and fibular autograft replacement. J Bone Joint Surg Br 1983;65:618-20.     [PUBMED]  [FULLTEXT]  

16. Murray JA, Schlafly B. Giant cell tumours in the distal end of the radius. Treatment by resection and autograft interpositional arthrodesis. J Bone Joint Surg Am 1986;68:687-94.     [PUBMED]    

17. Van Demark RE Jr, Van Demark RE Sr. Non-vascularized fibular autograft to treat recurrent giant cell tumour of the distal radius. J Hand Surg Am 1988;13:671-5.     [PUBMED]    

18. Pho RW. Malignant giant cell tumour of distal end of the radius treated by a free vascularized fibular transplant. J Bone Joint Surg Am 1981;63:877-84.     [PUBMED]    

19. Weiland AJ. Vascularized free bone transplants. J Bone Joint Surg Am 1981;63:166-9.     [PUBMED]    

20. Intuwongse CS. Reconstruction following resection of a giant cell tumour of distal radius using a vascularized pedicle graft of ulna. J Hand Surg 1998;23:742-7.         

21. Enneking WF. Modification of system for the functional evaluation of surgical management of musculoskeletal tumours. In: Enneking WF, editor. Limb Salvage in Musculoskeletal Oncology. New York: Churchill Livingstone; 1987. p. 626-39.         

22. Ihara K, Doi K, Sakai K, Yamamoto M, Kanchiku T, Kawai S. Vascularized fibular graft after excision of giant cell tumour of the distal radius. a case report. J Surg Oncol 1998;68:100-3.         

23. O'Donnell RJ, Springfield DS, Motwani HK, Ready JE, Gerhart MC, Mankin HJ. Recurrence of giant cell tumours of long bones after curettage and packing with cement. J Bone Joint Surg Am 1994;76:1827-33.         

24. Cheng CY, Shih HN, Hsu KY, Hsu RW. Treatment of giant cell tumour of the distal radius. Clin Orthop 2001;383:221-8.     [PUBMED]    

25. Harness NG, Mankin HJ. Giant cell tumour of the distal forearm. J Hand Surg Am 2004;29:188-93.     [PUBMED]  [FULLTEXT]  

26. Dhamni IK, Jain AK, Maheswari AV, Singh MP. Giant cell tumours of the lower end of radius:problems and solutions. Ind J Orthop 2005;39:201-5.         

27. Lackman RD, McDonald DJ, Beckenbaugh RD, Sim FH. Fibular reconstruction for giant cell tumour of the radius. Clin Orthop 1987;218:232-8.     [PUBMED]    

28. Saraf SK, Goel SC. Complications of resection and reconstruction in giant cell tumour of distal end of radius- An analysis. Ind J Orthop 2005;39:206-11.         

29. Panchwagh Y, Puri A, Agarwal M, Anchan C, Shah M. Giant cell tumour - distal end radius: Do we know the answer. Ind J Orthop 2007;41:139-45.         

30. Puloski SK, Griffin A, Fergusson PC, Bell RS, Wunder JS. Functional outcome after treatment of aggressive tumours in the distal radius. Clin Orthop Rel Res 2007;459:154-60.         

31. Minami A, Kato H, Iwasaki N. Vascularized fibular graft after excision of giant cell tumour of the distal radius: Wrist arthroplasty versus partial wrist arthrodesis. Plast Reconstr Surg 2002;110:112-7.     [PUBMED]  [FULLTEXT]  

32. Bianchi G, Donati D, Staals EL, Mercury M. Osteoarticular allograft reconstruction of the distal radius after bone tumour resection. J Hand Surg Br 2005;30:369-73.         

33. Hatano H, Monta T, Kobayashi H, Otsuka H. A ceramic endoprostheses for the treatment of tumours of the distal radius. J Bone Joint Surg Br 2006;88:1656-8.         

34. Natarajan MV, Bose JC, Viswanath J, Balasubramanium M, Sameer M. Custom prosthetic replacement for distal radius tumours. Int Orthop 2009;33:1081-4.         

35. Tomic S, Krajcinovic O, Krajcinovic J. Illizarov reconstruction of the distal radius after resection of a giant cell tumour: A case report. Clin Orthop Reparatrice Appar Mot 2006;92:264-70.         

36. Asavamongkolkul A, Waikakul S, Phimolsarnti R, Kiatisevi P. Functional outcome following excision of a tumour and reconstruction of distal radius. Int Orthop 2009;33:203-9.     [PUBMED]  [FULLTEXT]