Giant cell tumor with pathologic fracture: should we curette or resect?

Abstract

Background: Approximately one in five patients with giant cell tumor of bone presents with a pathologic fracture. However, recurrence rates after resection or curettage differ substantially in the literature and it is unclear when curettage is reasonable after fracture.

Questions/purposes: We therefore determined: (1) local recurrence rates after curettage with adjuvants or en bloc resection; (2) complication rates after both surgical techniques and whether fracture healing occurred after curettage with adjuvants; and (3) function after both treatment modalities for giant cell tumor of bone with a pathologic fracture.

Methods: We retrospectively reviewed 48 patients with fracture from among 422 patients treated between 1981 and 2009. The primary treatment was resection in 25 and curettage with adjuvants in 23 patients. Minimum followup was 27 months (mean, 101 months; range, 27-293 months).

Results: Recurrence rate was higher after curettage with adjuvants when compared with resection (30% versus 0%). Recurrence risk appears higher with soft tissue extension. The complication rate was lower after curettage with adjuvants when compared with resection (4% versus 16%) and included aseptic loosening of prosthesis, allograft failure, and pseudoarthrosis. Tumor and fracture characteristics did not increase complication risk. Fracture healing occurred in 24 of 25 patients. Mean Musculoskeletal Tumor Society score was higher after curettage with adjuvants (mean, 28; range, 23-30; n = 18) when compared with resection (mean, 25; range, 13-30; n = 25).

Conclusions: Our observations suggest curettage with adjuvants is a reasonable option for giant cell tumor of bone with pathologic fractures. Resection should be considered with soft tissue extension, fracture through a local recurrence, or when structural integrity cannot be regained after reconstruction.

Level of evidence: Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Fig. 1

Surgical treatment of a primary giant cell tumor of bone (GCTB) with a pathologic fracture and subsequent recurrences. * Patients with a followup of less than 2 years (n = 10), other primary treatment (n = 2), or axial location (n = 2) were excluded.

Fig. 2

Recurrence-free survival (RFS) after curettage with adjuvants (with 95% confidence interval) and en bloc resection for giant cell tumor of bone with a pathologic fracture. After curettage with adjuvants, the RFS was lower (p = 0.003) than after resection and was estimated at 74% and 70% at 2 and 5 years postoperatively, respectively. After resection, the RFS was 100%.