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Distal femoral Giant cell tumour of bone- intra-lesional curettage and stabilisation

    Overview

    Learn the Distal femoral Giant cell tumour of bone: intra-lesional curettage and stabilisation surgical technique with step by step instructions on OrthOracle. Our e-learning platform contains high resolution images and a certified CME of the Distal femoral Giant cell tumour of bone: intra-lesional curettage and stabilisation surgical procedure.
    Giant cell tumour of bone is a rare, benign primary bone tumour arising in the meta-epiphyseal region of bones in young adults.This tumour classically arises in the meta-epiphyseal region as a radiolucent lesion most commonly affecting the distal femur, proximal tibia, proximal humerus and distal radius.
    Surgical treatment involves intralesional curettage with or without internal fixation or en-bloc resection and limb-salvage reconstruction. The decision on the type of surgical treatment to undertake in a patient with GCTB depends on a variety of factors including the Campanacci staging at diagnosis, articular involvement and anatomical location.
    Denosumab has recently played a role in the management of GCTB but the optimal use of denosomab has yet to be identified. Denosumab is a monoclonal antibody to RANK ligand recommended as the first option in inoperable or metastatic GCTB. Denosumab has also been used pre-operatively to downstage tumours with large soft tissue extension to allow for less morbid surgery.

    Indications

    INDICATIONS
    Giant-cell tumor of bone (GCTB) is a benign but aggressive skeletal neoplasm that is often seen in young adults and may rarely present with pulmonary metastases. This tumour classically arises in the meta-epiphyseal region as a radiolucent lesion most commonly affecting the distal femur, proximal tibia, proximal humerus and distal radius. Soft tissue extension may be found at diagnosis in 25% – 29% of the cases (https://www.researchgate.net/profile/Michiel_Van_de_Sande/publication/230748239_Giant_Cell_Tumor_With_Pathologic_Fracture_Should_We_Curette_or_Resect/links/0912f50a65b9986187000000.pdf), and in 15 to 25% of the patients pathological fractures are identified at diagnosis.
    Giant cell tumor of bone contains histiocytic cells, multinucleated giant cells, and neoplastic mono-nuclear stromal cells. Overexpression of receptor activator nuclear factor kappa-B ligand by stromal cells promotes the recruitment of multinucleated osteoclast-like giant cells responsible for the osteolysis seen in GCTB.
    The decision on the type of surgical treatment to undertake in a patient with GCTB depends on a variety of factors including the Campanacci staging at diagnosis, articular involvement and anatomical location. The Campanacci classification describes completely intraosseous tumours (Stage 1), tumours demonstrating cortical erosion without destruction (Stage 2) and those with cortical destruction and with a soft tissue extension (Stage 3) (Campanacci M, Baldini N, Boriani S, Sudanese A. Giant cell tumor of bone. J Bone Joint Surg Am 1987;69:106–114). The majority of GCTs are stage 2 or 3 at presentation.
    SYMPTOMS & EXAMINATION
    Patients present with pain and swelling and upto 25% of presentations may have pathological fractures. Examination may reveal localised pain and swelling with limitation of the adjacent joint. Neurovascular examination is usually normal.
    IMAGING
    Plain radiography classically demonstrates an eccentric, expansile, lobulated lytic lesion with a narrow zone of transition. Tumours have extended into the soft tissues at presentation and a soft-tissue mass, sometimes covered by a thin layer of sclerosis, can be seen on X-ray. GCTs usually have little or no discernible matrix calcification and little new bone formation or periosteal reaction. They are typically located within the metaphysis and are one of the few lesions to involve the epiphysis, abutting the subchondral plate. CT gives an accurate estimation of cortical bone involvement, and MRI demonstrates ow signal on T1 and intermediate to high signal on T2 sequences with areas of heterogeneity.
    ALTERNATIVE OPERATIVE TREATMENT
    The management options for patients with GCTB fall into four categories. The first and least invasive option is intralesional curettage, with or without adjuvant therapy and internal fixation; second, wide resection of the affected bone with or without reconstruction; third & fourth options are to postpone surgery and commence denosumab therapy and thereafter perform intralesional curettage or en-bloc resection and reconstruction, respectively.
    NON-OPERATIVE MANAGEMENT
    Denosumab is a monoclonal antibody to RANK ligand recommended as the first option in inoperable or metastatic GCTB. Denosumab has also been used pre-operatively to downstage tumours with large soft tissue extension to allow for less morbid surgery. The role of denosumab for conventional limb GCTB is yet to be defined (https://clinicalsarcomaresearch.biomedcentral.com/articles/10.1186/s13569-016-0056-0). The response of the tumour can be dramatic but the side-effect profile can result in significant morbidity, including hypocalcaemia, osteonecrosis of the jaw and atypical stress fractures (https://clinicalsarcomaresearch.biomedcentral.com/articles/10.1186/s13569-016-0056-0). However, the cumulative and long term incidence of these toxicities remains to be accurately reported.
    Other non-operative interventions include radiotherapy and bisphosphonates and embolisation for inoperable tumours.
    CONTRAINDICATIONS
    To surgery include spinal, sacral and pelvic tumours when the morbidity of surgical resection outweighs the risk of long-term medical (denosumab) therapy.

    Setup

    Operation – 1

    This AP radiograph shows a 7x7cm eccentrically located expansile lesion involving the medial femoral condyle extending to the subchondral bone. The appearances are in keeping with a giant cell tumour of bone. This 22 year old male patient presented with a 12-month history of gradually worsening discomfort in the left knee. There was no significant past medical history. The X-ray appearances are classical for a giant cell tumour of bone (GCTB) but malignant primary bone tumours, although teleangiectatic osteosarcoma needs to be excluded.

    This shows a T1-weighted MRI sequence of the whole left femur showing the same low signal lesion in the distal femoral metaphysis. This is solitary lesion with nothing else evident in the remaining femur.

    T1 Axial image highlighting the involvement of the subchondral bone of the trochlea groove and intercondylar notch of the distal femur.

    Fluoroscopic AP radiograph at the time of needle core biopsy. The differential diagnosis based on imaging in a 22-year-old male at this anatomical site includes a telangiectatic osteosarcoma.
    The needle has been inserted via an anterior approach avoiding the rectus femoris tendon so that should the patient require en-bloc resection of a malignant primary bone tumour, the excised biopsy tract would not compromise the resection and reconstruction of the extensor mechanism.

    Patient positioning, skin preparation and draping.The patient is positioned in theatre with a thigh high tourniquet and alcoholic chlorhexidine skin preparation and draping with Ioban incisional drapes with the foot excluded using a bowel bag. The hip is allowed to externally rotate with the knee flexed to provide good access to the medial side of the distal femur in a ‘figure four’ position.

    Medial longitudinal skin incision distal thigh.Clinical photograph taken looking at the medial side of the knee: the longitudinal skin incision is made in line with the femur overlying the vastus medialis.

    Incise deep fascia to identify vastus medialis.After incision of skin, fat and deep fascia the (VM) vastus medialis muscle is revealed underneath.

    Mobilise the posterior border of vastus medialis off the inter-muscular septumThe posterior border of the (VM) vastus medialis is mobilised off the (IMS) inter-muscular septum. A small Cobb elevator is preferred to elevate in one layer without splitting the muscle, which could lead to bleeding, muscle necrosis and therefore infection.

    Identify and ligate vessels perforating Hunter’s canal supplying vastus medialis.Care is taken to identify and ligate the muscular branches to the (VM) vastus medialis traversing the inter-muscular septum from the common femoral vessels. The adductor canal (subsartorial or Hunter’s canal) extends from the inferior apex of the femoral triangle to the opening in adductor magnus, called the adductor hiatus. The adductor canal is bordered by the vastus medialis laterally and sartorial anteromedially and adductors magnus and longus posteriorly. The contents include the femoral artery, femoral vein, the nerve to vastus medialis and the saphenous nerve. The saphenous nerve is a sensory nerve arising from the femoral nerve supplying the distal thigh, knee and medial lower leg.

    Elevate vastus medialis to expose the medial distal femur.Using bone levers placed carefully over the anterior portion of the femur the (VM) vastus medialis has been elevated and retracted using two Hohmann’s retractors to expose the (DF) distal femur and periosteum.

    Mark the cortical bone window to be osteotomised.The planned window in the medial aspect of the (DF) has been marked with a sterile marker pen prior to the use of an (O) osteotome to cut a window in the medial cortex to gain access to the tumour cavity. No extra-osseous component of the tumour is evident.

    Drill the corners of the planned cortical bone window.Drill holes are made using a 2.5mm drill in the corners of the planned cortical bone window to facilitate osteotomising the medial cortex without causing any fracture propagation.

    Osteotomise between drill holes to open bone window.Using the osteotome the bone window is cut between the four drill holes to open the bone window.

    The cut window is levered open using the Cobb elevator or an osteotome to reveal the tumour cavity beneath.

    The pale core of the tumour inside the metaphysis is evident and the bone window flap is shown anterior to the window.

    This shows evidence of tumour on the deep surface of the bone window on the back table.

    Curettage of the giant cell tumour of bone.Using curettes and spoons the tumour cavity is emptied.

    Large fragments of tumour are removed using the spoon from the metaphysis.

    Smaller spoons are used for detailed intralesional curettage of the residual cavity. In order to remove the tumour cells which have permeated into the host bone the cavity is enlarged leaving only host bone at all the margins of the cavity.

    Smaller spoons are used for detailed intralesional curettage of the residual cavity.

    Send tissue for histological analysis.Fragments of bone and tumour saved for histological analysis on the back table.

    Use fluoroscopy to confirm all areas of the tumour have been curetted.Fluoroscopic AP radiograph showing the centre of the tumour cavity and the position of the curette used to debride it. Although these tumours do not invade the articular surface they can weaken the subchondral bone to the point of intra-articular fracture. This risk increases peri-operatively so the fluoroscopy is useful to confirm no fractures or iatrogenic joint breaches have occurred.

    Lavage of the tumour cavity.Thorough lavage of the cavity removes any residual macroscopic tumour fragments and clot.

    This shows the cavity after lavage ready for cementation and stabilisation.

    Apply plate sub-muscularly and drill holes for distal femoral locking plate stabilisation.A contralateral distal femoral locking plate applied to the medial aspect of the left distal femur and held with K-wire. We use the contralateral plate as it is a sided lateral distal femoral plate which contours better with the medial cortex if you use the contralateral side in our experience.

    Operation – 2

    Locking screws are inserted proximally and distally to stabilise the distal femur to prevent any fracture and deformity.

    The plate insitu bridging the cortical bone window. The cortical fragment removed cannot be replaced due to the tumour contamination evident.

    Retrograde cement filling of tumour cavity.After completion of the plate stabilisation palacos cement (4 mixes) is inserted in a retrograde fashion in to the tumour cavity.

    The window in the tumour cavity has been filled with bone cement. Whilst the cement cures further screws are placed through the cement for additional fixation in the metaphyseal region.

    Confirm satisfactory check images.AP fluoroscopic radiograph showing the cement filling the cavity of the tumour and the distal half of the plate and five locking screws.

    Cover plate with vastus medialis.The vastus medialis muscle is allowed to flap across the plate and distal femur at the time of closure. This approach enables adequate plate coverage to minimise the risk of infection without denervating the muscle.

    After interrupted tacking sutures using No 1 Vicryl of the vastus medialis to the intramuscular septum, the plate has been covered with soft tissues. A drain exiting distally from the wound margin is evident which is lying deep to the fascia.

    Layered closure.The deep fascia is closed using interrupted No 1 Vicryl.

    Skin closure and dressings.The dermis is closed with a continuous 2:0 Vicryl suture and clips are inserted into the skin, followed by an aquacel dressing, wool and crepe bandages and a tri-panel splint. The splint reduces movement in the immediate post-operative period to reduce pain and swelling and aid wound healing.

    Post-operative AP radiograph of the distal femur and knee showing skin clips and the right-sided distal femoral locking plate in the left distal femur on the medial side with cement in the cavity and locking screws.

    Post Operative

    VTE prophylaxis: LMWH for four weeks and anti-thrombotic stockings for six weeks
    3 doses of post-op intravenous antibiotics (flucloxacillin)
    Check X-rays AP lateral pre-discharge
    Toe touch weight bearing left side for six weeks
    Full flexion extension permitted after removal of the triple-panel splint and wool & crepe bandaging at 36-48 hours
    Drain removal when output is <80ml/24 hours
    Home when safe
    GP to remove clips in two weeks
    X-rays on arrival to outpatient clinic in six weeks when progressive weight bearing can be started

    Recommended Reading

    The decision on the type of surgical treatment to undertake in a patient with GCTB depends on a variety of factors including the Campanacci staging at diagnosis, articular involvement and anatomical location.
    In the majority of stage 1 and 2 lesions, extended intralesional curettage with a detailed debridement of the lesional wall will be effective. Recurrence rates vary depending on the use of adjuvant treatments at the time of curettage (including phenol, bone cement,liquid nitrogen) but a commonly accepted rate of local recurrence is in the order of 15%. We have preferred less invasive surgery in most patients due to (young) age and the desire to preserve the native bone, joint and function.
    The use of cement to fill the cavity halves the risk of local recurrence and consequently reduces the risk of revision surgery to a total joint arthroplasty in the long-term (https://online.boneandjoint.org.uk/doi/pdf/10.1302/0301-620x.93b12.27663).
    However, our experience suggests that the risk of recurrence and subsequent failure of intralesional curettage surgery is very high in patients with Campanacci stage 3 tumours. this view is supported by recent literature from van der Heijden et al. (van der Heijden L, Dijkstra PD, Campanacci DA, Gibbons CL, van de Sande MA. Giant cell tumor with pathologic fracture: should we curette or resect? Clin Orthop Relat Res. 2013 Mar;471(3):820-9) , and Cheng DD et al. (Cheng DD, Hu T, Zhang HZ, Huang J, Yang QC. Factors Affecting the Recurrence of Giant Cell Tumor of Bone After Surgery: A Clinicopathological Study of 80 Cases from a Single Center. Cell Physiol Biochem. 2015;36(5):1961-70.), who reported comparable rates of local recurrence in this group of patients.
    Downstaging of Campanacci 3 GCTB with neoadjuvant denosumab is thought to reduce the risk of local recurrence following local excision: Rutkowski et al. analysed this effect in 115 patients in whom 89 had surgery after neoadjuvant denosumab. 39 had excision and 50 had intralesional curettage with rates of recurrence of 7.7% vs 32% respectively (https://link.springer.com/article/10.1245/s10434-015-4634-9).


    Reference

    • orthoracle.com

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