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Management of giant cell tumors of the distal radius: a systematic review and meta-analysis

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Abstract

Purpose

The treatment of giant cell tumors (GCT) of the distal radius remains challenging, with no consensus on the optimal surgical management. Surgical management remains the mainstay of treatment with options including intralesional curettage and en-bloc resection with reconstruction. The objective of this systematic review and meta-analysis was to evaluate and compare the outcomes of these two procedures.

Methods

Using OVID-Medline and Embase databases, a systematic literature search was performed. Comparative studies, assessing intralesional curettage and en-bloc resection in patients with GCTs of the distal radius, were included. Data regarding rates of local recurrence, metastasis, overall complications, and functional outcomes, were collected and analyzed. The ROBINS-I tool was utilized for risk of bias appraisal within each study outcome.

Results

Thirteen studies (n = 373 patients) reporting on 191 intralesional curettage procedures and 182 en-bloc resections were included in the analysis. The average age of participants was 31.9 (SD ± 2.4) years and average follow-up was 7.1 (SD ± 3.6) years. Patients that underwent intralesional curettage were more likely to develop local recurrence (Risk Ratio (RR) 3.3, 95% CI, [2.1, 5.4], p < 0.00001) when compared to patients that underwent en-bloc resection. In Campanacci grade 3 lesions, the risk for local recurrence was 5.9 (95% CI, [2.2, 16.3], p = 0.0006) times higher in patients that received intralesional curettage. Patients that underwent intralesional curettage showed an 84% reduction in the relative risk of developing overall complications compared to en-bloc resection (95% CI, [0.1, 0.4], p < 0.00001), and a larger decrease in Visual Analog Scale and lower Disabilities of the Arm, Shoulder, and Hand (DASH) scores (p < 0.00001). Risk ratio for developing a local recurrence, with PMMA versus bone graft following an intralesional procedure was not significant (RR 1.2, 95% CI, [0.6, 2.6], p = 0.62).

Conclusions

In the surgical management of GCT of the distal radius, intralesional curettage increased local recurrence compared to en-bloc resection with reconstruction, particularly in grade 3 tumors. However, it led to significantly fewer operative complications, lower pain scores, and improved functional outcomes compared to en-bloc resection. Both treatment options remain relevant in the contemporary management of GCTs of the distal radius. Surgical decision making should include both patient and tumor factors when determining the optimal treatment strategy for these patients.

Level 3 Evidence

Meta-analysis of Level 3 studies.

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Funding

There was no funding or financial support utilized to carry out this research.

Author information

Authors and Affiliations

  1. Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada

    Robert Koucheki

  2. Institute of Biomedical Engineering, Toronto, ON, Canada

    Robert Koucheki

  3. Division of Orthopaedic Surgery, McMaster University, Hamilton, ON, Canada

    Aaron Gazendam

  4. Royal National Orthopaedic Hospital NHS Trust, Greater London, UK

    Jonathan Perera

  5. Department of Orthopaedic Surgery, Mount Sinai Hospital, Toronto, ON, Canada

    Aaron Gazendam, Anthony Griffin, Peter Ferguson, Jay Wunder & Kim Tsoi

  6. Division of Orthopaedic Surgery, University of Toronto, Toronto, ON, Canada

    Peter Ferguson, Jay Wunder & Kim Tsoi

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  1. Robert Koucheki
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Correspondence to Robert Koucheki.

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Appendices

Appendix 1 Sample search strategy

Search Terms

1. Giant cell tumor.mp. or exp Giant Cell Tumors/

2. Exp “Giant Cell Tumor of Bone”/ or giant cell tumour.mp

3. Distal radius.mp

4. 1 or 2

5. 3 and 4

6. Curettage.mp. or exp Curettage/

7. Intralesional excision.mp

8. Resection.mp

9. Wrist arthrodesis.mp

10. 6 or 7 or 8 or 9

11. 5 and 10

12. Limit 11 to (english language and humans)

Appendix 2 PRISMA flow diagram

figure a

Appendix 3 Additional characteristics of the included studies

 

Denosumab

Intra-operative adjuvants

Defect fill following curettage

Reconstruct following resection

Vander Griend [26]

No

High-speed burn, combined more recently with pulsating lavage and electrocautery + PMMA

Packing with cement

#6—non-vascularized autogenous bone graft from the fibula

#4—the adjacent ulna

#1—the iliac crest

Sheth [27]

No

Liquid nitrogen

#9—bone graft

#7—PMMA cement

#2—no form of reconstruction

The selection of bone for arthrodesis varied from tibial cortex, tricortical iliac crest, ulna, or fibula

Cheng [28]

No

High speed burr and phenol

#6—Autogenous cancellous bone graft, which was harvested from the iliac crest

#4—osteoarticular allograft

#2—fibular autograft

Harness [29]

No

Burring or phenolization and insertion of PMMA

#5—Autograft

#26—PMMA cement

NS

Panchwagh [30]

No

Phenol

#5—bone graft

#4—Cement

#2—no form of reconstruction

Proximal fibular graft wrist arthrodesis

Kang [21]

No

High-speed burring of the endosteal cavity, followed by irrigation, drying, and electrocautery coagulation ± liquid nitrogen

Antibiotic-laden PMMA cement

#5—Patients with vascularized or non-vascularized intercalary fibula autogenous graft arthrodesis

#1—Total wrist arthroplasty/allograft composite

Wysocki [31]

No

#20—Burr exteriorization

#10—Phenol

#12—Electrocautery

#4—Argon beam

#19—Polymethylmethacrylate

#1—Cancellous allograft

NS

#6—Non-vascularized fibular autograft

#3—Distal radius allograft

#3—Ulnar transposition

#3—Fibular allograft

Zhang [32]

No

95% ethanol was used to inactivate the tumor bed

Allogeneic bone graft/bone cement augmentation

Autologous fibular graft/allogeneic bone graft

Mozaffarian [53]

No

High-speed burring

Irrigation with saline and filling with bone cement

Proximal fibular autograft

Zou [22]

For 8 patients (21.1%), which were all Campanacci grade III, pre-operative denosumab was given subcutaneously at dosage of 120 mg on day 1, day 8, day 15 and day 29 as the loading dosage for the first month, 120 mg per four weeks thereafter.

Adjuvant treatments included high speed burring, iodine tincture, electrocautery.

#9—PMMA cement

#8—cancellous allograft

#4—autograft

#26—fibular autograft

#6—distal allograft

#5—PMMA

Atalay [33]

No

Adjuvant burr was applied to the lesion site with both cauterization and burring for grind lesions after curettage. Then 95% ethanol was used to neutralize the tumor site.

Autologous fibular graft, allogeneic bone graft segment, iliac graft or combinations

Allograft fibula + iliac autograft

Abuhejleh [9]

Two patients had a third recurrence, and the first was managed with denosumab only, while the second underwent repeated curettage with adjuvant radiotherapy

Burring followed by inconsistent use of adjuvant and followed with jet wash

#23—bone cement

#10—bone graft

#1—empty

#7—vascularized fibular autografts

#16—non-vascularized autograft

Jiao [34]

No

Microwave ablation

Bone cement filling

Non-vascularized autologous fibula reconstruction

Appendix 4 Funnel plots: (A) recurrence (B) complications (C) metastasis (D) recurrence in grade 3 tumors

figure b

Appendix 5 Forest plot depicting the comparison of rates of metastasis between intralesional curettage and en-bloc resection

figure c

Appendix 6 Description of types of complications

Study

Intralesional curettage

Resection

Sheth [27]

1/4 superficial skin necrosis and infection

3/4 collapse of the radiocarpal joint

3/4 non-union

1/4 traumatic fracture

Zou [22]

None

3/12 displacements of the wrist joint, including carpal subluxation (1 patient) and separation of the distal radioulnar joint (2 patients)

5/12 nonunions in cases of en-bloc resection with fibular autograft reconstruction

2/12 Fractures of bone graft

2/12 infections

Abuhejle [9]

None

4/7 Infections

1/7 malunion

1/7 non-union

1/7 fracture

Cheng [28]

None

None

Vander Griend [26]

None

Not Clear

Kang [21]

1/1 irritability of a branch of the superficial radial nerve

1/1 postoperative

pneumonia

Zhang [32]

None

1/4 of postoperative infection

2/4 implant breakage and postoperative fracture

1/4 nonunion

Mozaffarian [53]

None

None

Atalay [33]

1/1 fracture

1/1 nonunion

Appendix 7 Forest plot depicting the comparison of rates of recurrence between PMMA versus bone graft

figure d

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Koucheki, R., Gazendam, A., Perera, J. et al. Management of giant cell tumors of the distal radius: a systematic review and meta-analysis. Eur J Orthop Surg Traumatol 33, 759–772 (2023). https://doi.org/10.1007/s00590-022-03252-9

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