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Centralisation Of Ulna For Recurrence In Reconstructed Lower End Radius Giant Cell Tumor

 Pradip Bhargava*, Anand Ajmera**, Suryaprakash Nagariya***, Vikram Chatrath ***

* Professor & Head
** Assistant Professor
*** Senior Registrar
MGM MedicalCollege, Indore

Address for Correspondence:  
Dr Pradip Bhargava
Professor & Head
Department of orthopaedics
MGM MedicalCollege, Indore


Giant cell tumors have been extensively studied but the debate still continues on the ideal management. Treatment modalities range from simple curettage followed by packing of cavity with bone cement or grafts to more radical surgeries like enbloc resection with reconstruction. More radical procedures are associated with much higher patient morbidity. All the procedures are associated with recurrence and there is no consensus on the treatment of local recurrence.

We present the case report of a 21 year male with Giant cell tumor distal radius treated initially by wide excision and reconstruction using autologous non vascularized fibula who had recurrence 2 years after the initial surgery

J.Orthopaedics 2008;5(2)e3

Giant cell tumor, Radius, Recurrence

Giant cell tumor (GCT) of bone is a benign but locally aggressive tumor involving the ends of long bones. It constitutes about 20% of all benign bone tumors and 5% of all bone tumors 1. It is usually seen in young adults (females more than males) between 20 to 40 years of age 1,5,10. Its location is typically metaphysio epiphyseal; often extending up to the sub-chondral plate or even lies alongside the cartilage. Its most frequent locations are, in the distal femur, the proximal tibia, the distal radius and the sacrum, occurring in that order 1,5,10. Other less frequent sites include the fibular head, the proximal femur, the proximal humerus and the spine. In the long bones it is more frequently eccentric, but in several cases it may be central. Various treatment protocols have been advocated in the management of recurrent GCT. Traditionally, wide en bloc resection 2,3,6 and reconstruction done using fibular transfer (for distal radius), allograft, and endoprosthesis. No guidelines are described if recurrence of tumour occurs after reconstruction.

Case Report :

The patient, a 21 year male presented initially with complaints of pain and swelling left wrist and distal forearm which was progressively increasing. Patient was initially treated by a local practitioner without relief and presented to us 6 months after onset of initial symptoms. Local examination revealed fusiform swelling on distal forearm and wrist predominantly on dorsal and lateral aspects. Wrist range of movements restricted only at extremes.

Investigations - X ray of the wrist and forearm showed an osteolytic, expansile, lesion with ballooning of the walls over the lower end of radius (metaphysioepiphyseal region). It appeared geographic with well-defined borders and without sclerosis or new bone formation or calcification, commensurate with features of Giant cell tumor. An incisional biopsy was done which confirmed the diagnosis of Giant cell tumor. (Fig-1). 

Initial treatment - Considering the size and extent of the tumor, a wide excision with a 3cm healthy margin of distal radius was performed using Henry’s volar approach. Intraoperatively the tumor capsule was found breached on the dorsal side with the tumor tissue protruding out. The excised distal radius was reconstructed using ipsilateral proximal fibula. The fibula was fixed to radial stump using Dynamic compression plate and fixed to the carpus and distal ulna using K wires. The extremity was protected in a plaster splint for about 4 months till radiological signs of union at radio fibular junction were seen. The K wires were removed at 6 weeks. Patient was put on physiotherapy regimen and gained full elbow movements. At the wrist he had 20 deg dorsiflexion, 30 deg palmarflexion and about 10 deg side to side movements. Grip strength was about 70 % of opposite side. Patient was not given any chemotherapy postoperatively. (Fig 2,3 shows immediate post-op and follow-up x-rays).


Management after recurrence- 2 years later he returned with increasing pain and swelling near the same wrist. X ray showed osteolytic lesions in the transplanted fibula although the radiofibular junction was well consolidated. A repeat biopsy was done and came out as Giant cell tumor proving it to be a recurrence. After proper workup and finding no obvious secondaries, patient was operated. A wide excision was performed. The distal ulna dissected free and centralized into a notch prepared in the carpus after denuding the distal articular surface of ulna. Fixation was done using an intramedullary nail passed into the carpus. Limb was protected in plaster splint. Post operative period was uneventful. At 2 months the ulna-carpal arthrodesis was progressing satisfactorily. The appearance of forearm was good. Patient had no wrist movements. At 3 months patient gained full elbow movements and was satisfied with outcome. Follow-up at 2 years shows no local problems, good elbow movements and satisfactory ulno-carpal union (Fig 4,5). 


Functional Outcome- Elbow and wrist range of movement in both flexion and extension were assessed. Elbow flexion was 0-140 deg while extension is 140-0 degree. No wrist movement was present. Scar on both volar and dorsal side is also acceptable.

Discussion :

Giant cell tumor distal radius is a common entity and wide excision followed by reconstruction using ipsilateral fibula is a standard procedure that has been giving satisfactory results but as mentioned earlier there is no consensus on the management of local recurrences after such reconstruction. Various authors have used procedures like repeat curettage and cementing 4, wide excision with reconstruction using the second fibula (vascularized / non vascularized) 7,8,11, reconstruction using artificial prosthesis, translocation of distal ulna into the radial gap. F.Vult von Steyern et al studied 19 patients of local recurrence after primary curettage and cementing of which 13 had satisfactory results with repeat curettage and cementing.

We have used centralization of ulna into the carpus as a salvage procedure for recurrence after reconstruction using ipsilateral fibula with satisfactory results. The disadvantage of the procedure is a loss of pronation and supination movements at the elbow. The procedure has got several advantages like being much simpler to perform, no donor site morbidity, good union rate at the ulnocarpal junction site. Translocation of distal ulna into radius does preserve the pronation and supination at elbow but involves lot of mobilization of the translocated ulnar fragment with a risk of jeopardizing the vascularity and also the fact that union has to be attained at two sites – between the tanslocated ulna to radius and between translocated ulna to carpus 9.

We conclude that centralization of ulna is a simple and effective salvage procedure for recurrence of Giant cell tumor distal radius.

Reference :

  1. Bridge JA, Neff JR, Mouron BJ. Giant cell tumour of bone: chromosomal analysis of 48 specimens and review of literature. Cancer Genet Cytogenet 1992; 58:2-13.

  2. Campanacci M, Giunti A, Olmi R.Giant cell tumours of bone. A study of 209 cases with long term follows up in 130. Ital J Orthop Trauma 1975; 1:53-80.

  3. Campanacci M, Baldini N, Boriani S,et al. Giant cell tumour of bone. J Bone Joint Surg Am 1987; 69:105-44.

  4. F.Vult von Steyern, H.C.F. Bauer, C. Trovik, A. Kivioja, P. Bergh, P. Holmberg Jorgensen, G. Folleras, A. Rydholm. Treatment of local recurrences of giant cell tumor in long bones after curettage and cementing. JBJS (British) Vol 88-B, Issue 4; 2006; 531-535.

  5. Huvos AG. Bone tumours: Diagnosis, treatment and prognosis. 2nd edition Philadelphia: saunders Co.; 1991

  6. Liu HS, Wang JW. Treatment of giant cell tumour of bone: A comparison of local Curettage and wide resection. Chang Keng I Hsuey 1998; 21: 37-43.

  7. Minider S. Kocher, Mark C. Gebhardt, Henry J. Mankin. Reconstruction of the Distal Aspect of the Radius with Use of an Osteoarticular allograft after excision of a Skeletal Tumor. JBJS 80; 1998: 407-19.

  8. Murray J A, Schalfy B. Giant cell tumors in the distal end of the radius. Treatment by resection and fibular autograft interpositional arthrodesis. JBJS Vol. 68-A, No. 5; June 1986; 687 – 694

  9. Serdage H. Distal ulnar translocation in the treatment of giant cell tumors of the distal end of radius. JBJS; Vol. 64-A, No.1; Jan 1982; 67-73

  10. Unni KK. Dahlin’s bone tumors: General aspect and data on 11087 cases. 5th edition. Philadelphia: Lippincott- Raven: 1998.

  11. Vander Griend R.A, Funderburk C.H. The treatment of Giant Cell Tumors of the distal part of the Radius. JBJS Vol.75-A; No.6; June 1993; 899-908

This is a peer reviewed paper 

Please cite as : Pradip Bhargava : Centralisation Of Ulna For Recurrence In Reconstructed Lower End Radius Giant Cell Tumor

J.Orthopaedics 2008;5(2)e3





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