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Giant cell tumour of bone: Reconstruction of the index metacarpophalangeal joint with an osteochondral graft from the lateral femoral condyle
Journal of Plastic, Reconstructive & Aesthetic Surgery (2013) 66, 729e732
CASE REPORT
Giant cell tumour of bone: Reconstruction of the index metacarpophalangeal joint with an osteochondral graft from the lateral femoral condyle Alexander S. Spiro a,*, Pia Pogoda a, Michael Amling b, Norbert M. Meenen c, Jozef Zustin d, Johannes M. Rueger a, Matthias H. Priemel a a Department of Trauma-, Hand-, and Reconstructive Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany b Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany c Department of Pediatric Orthopaedic Surgery, Children’s Hospital Hamburg-Altona, Bleickenallee 38, 22763 Hamburg, Germany d Department of Pathology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany
Received 1 May 2012; accepted 27 August 2012
KEYWORDS Giant cell tumour; Digital joint; Osteochondral graft; Lateral femoral condyle
Summary We describe the successful reconstruction of the index finger metacarpophalangeal joint with an osteochondral autograft from the lateral femoral condyle following failed curettage and cementation of a giant cell tumour of the proximal phalanx base. At the 2year follow-up, a good functional outcome was noted with 0e80 range of motion of the metacarpophalangeal joint and no clinical or radiographic evidence of tumour recurrence. ª 2012 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Giant cell tumour of bone accounts for approximately 5% of all primary bone tumours.1 Typical locations are the metaepiphyseal regions of the long bones, while involvement of * Corresponding author. Tel.: þ49 40 74105 3459; fax: þ49 40 74105 4569. E-mail address: [email protected] (A.S. Spiro).
the metacarpals, phalanges or carpus is rare.2 Biscaglia et al. reported an incidence of only 0.9% in the hand in their series of 900 cases.3 Giant cell tumours in the long bones have been frequently treated by intralesional curettage and bone grafting or cementation.4 Those located in the hand appear to behave more aggressively.3 Thus, several authors
1748-6815/$ - see front matter ª 2012 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2012.08.037
730 recommend resection followed by reconstruction of the resected bone/joint or amputation.3,5e9
Case report A 31-year-old right-hand-dominant woman presented with pain and swelling of the right index finger. The symptoms had been present for several weeks with no history of antecedent trauma. Physical examination demonstrated focal tenderness and diffuse swelling at the base of the proximal phalanx. Range of motion (ROM) was limited to full extension and 30 of flexion at the metacarpophalangeal joint. Radiographs revealed a lytic and expansile lesion within the base of the proximal phalanx (Figure 1). The patient was otherwise healthy and denied taking any regular medications. Routine serological testing and a chest X-ray were inconspicuous. Computed tomography (CT) of the right index finger demonstrated thinning of the dorsal and volar cortices and the proximal phalanx articular surface. The differential diagnosis was a giant cell tumour or an aneurysmal bone cyst. Surgical treatment included curettage of the tumour, followed by burring of the inner cortex with a diamond milling cutter and cementation (polymethylmethacrylate cement, PMMA). Histopathological examination revealed a giant cell tumour. Eight months later, the patient presented with a stiff, painful metacarpophalangeal joint. Plain radiographs, CT and magnetic resonance imaging (MRI) revealed destruction of the articular surface of the proximal phalanx base, while the metacarpal head was intact. There was no sign of tumour recurrence.
Figure 1 An anteroposterior radiograph of the right index finger shows a lytic and expansile lesion within the base of the proximal phalanx.
A.S. Spiro et al. Reconstruction of the proximal phalanx metaphysis and the articular surface was then performed using an osteochondral autograft from the ipsilateral distal femoral condyle. At surgery, a mid-dorsal incision was used to expose the proximal phalanx and the metacarpophalangeal joint of the right index finger. The cement was easily removed en bloc because of the absent dorsal cortex and articular surface. Both collateral ligaments were intact. The size of the required osteochondral graft was measured at the proximal phalanx base. A hollow milling tool (Diamond Bone Cutting System, DBCS, ARTICOmed, Schlu ¨chtern, Germany) was then used to remove a cylindric osteochondral autograft with a concave articular surface (diameter: 1.045 cm, length: 2.5 cm) from the right lateral femoral condyle. The osteochondral autograft was then prepared with a bone rongeur and fitted into the proximal phalanx base (Figures 2 and 3). A single K-wire was used to fix the osteochondral autograft and the metacarpophalangeal joint. The osteochondral defect of the lateral femoral condyle was filled with a cylindric corticocancellous autograft from the right iliac crest. After surgery, the right index finger was immobilised for 6 weeks in a cast. The K-wire was then removed and active ROM was allowed. At the 2-year follow-up, the patient had a good functional outcome of the right index finger with 0e80 ROM of the metacarpophalangeal joint, no pain and stable conditions (varus and valgus stressing). Radiographs and MRI revealed that the osteochondral autograft had healed without evidence of tumour recurrence (Figure 4). Physical examination and radiographs of the right knee, pelvis and chest were normal.
Figure 2 Intraoperative photograph shows the prepared osteochondral autograft from the ipsilateral lateral femoral condyle.
Giant cell tumour of bone
Figure 3 Intraoperative photograph after implantation of the osteochondral autograft into the proximal phalanx base.
Discussion Different types of surgical treatment for phalangeal and metacarpal giant cell tumours are described. Curettage of the lesions followed by cementation or bone grafting is reported in a few studies.3,9,10 Due to the higher recurrence
731 rate of phalangeal and metacarpal giant cell tumours, several authors prefer a wide resection of the bone and reconstruction of the finger, or amputation.3,5e9 Sanjay et al. treated seven cases of metacarpal and phalangeal giant cell tumour by en bloc excision and fibular autografting or amputation.7 Tumour recurrence was reported in one case. Torpey et al. described the successful transfer of the proximal phalanx of the right fifth toe to the middle phalanx of the left ring finger to treat a recurrent giant cell tumour.5 At the 41-year follow-up, the active ROMs of the proximal and distal interphalangeal joint were 0e80 and 0e40 , respectively. Two patients with a recurrent metacarpal giant cell tumour were treated by en bloc resection and metatarsal transfer in another study.6 The functional results were satisfactory with no evidence of tumour recurrence at the 3-year follow-up. The use of an osteochondral autograft to reconstruct a digital joint after excision of a giant cell tumour has been investigated in a limited number of studies. Kanaya et al. described a vascularised metatarsophalangeal joint transfer to reconstruct the metacarpophalangeal joint, following en bloc resection of the metacarpal head and base of the proximal phalanx.8 At the 2-year follow-up, the metacarpophalangeal joint was stable with satisfactory ROM (0e85 ). These results are in line with our findings using an osteochondral autograft from the lateral femoral condyle to reconstruct the metacarpophalangeal joint. At the 2-year follow-up, no donorsite morbidity occurred in our patient, the osteochondral autograft healed and there was no evidence of tumour recurrence. To the best of our knowledge, this is the first report describing this technique for the management of a giant cell tumour in the hand. The use of an osteochondral autograft from the lateral femur condyle to reconstruct the metacarpophalangeal joint offers a viable option with respect to other described techniques, considering the limited risks at the donor site (lateral gonarthrosis; pain at the site of the harvested iliac crest autograft).
Conflict of interest statement The authors declare that they have no conflict of interest.
References
Figure 4 Radiographs at the two year follow-up revealed that the osteochondral autograft had healed with no evidence of tumor recurrence.
1. Dahlin DC, Unni KK. Bone tumors: general aspects and data on 11,087 cases. 5th ed. Philadelphia: Lippincott Williams & Wilkins; 1996. 285. 2. Campanacci M, Baldini N, Boriani S, Sudanese A. Giant-cell tumor of bone. J Bone Joint Surg Am 1987;69:106e14. 3. Biscaglia R, Bacchini P, Bertoni F. Giant cell tumor of the bones of the hand and foot. Cancer 2000;88:2022e32. 4. Becker WT, Dohle J, Bernd L, et al. Local recurrence of giant cell tumor of bone after intralesional treatment with and without adjuvant therapy. J Bone Joint Surg Am 2008;90: 1060e7. 5. Torpey B, Faierman E, Lehmann O. Phalangeal transfer for recurrent giant-cell tumor of the phalanx of a finger in a nineyear-old child. A case report with forty-one-year follow-up. J Bone Joint Surg Am 1994;76:1864e9.
732 6. Pardo-Montaner J, Pina-Medina A, Barcelo-Alcan ˜iz M. Recurrent metacarpal giant cell tumour treated by en bloc resection and metatarsal transfer. J Hand Surg Br 1998;23: 275e8. 7. Sanjay BK, Raj GA, Younge DA. Giant cell tumours of the hand. J Hand Surg Br 1996;21:683e7. 8. Kanaya K, Wada T, Kitajima K, Yamashita T. Vascularized metatarsophalangeal joint transfer for giant cell tumor of the
A.S. Spiro et al. proximal phalanx of the hand. Plast Reconstr Surg 2008;121: 354e5. 9. Ropars M, Kaila R, Cannon SR, Briggs TW. Primary giant cell tumours of the digital bones of the hand. J Hand Surg Eur Vol 2007;32:160e4. 10. Wittig JC, Simpson BM, Bickels J, Kellar-Graney KL, Malawer MM. Giant cell tumor of the hand: superior results with curettage, cryosurgery, and cementation. J Hand Surg Am 2001;26:546e55.
CASE REPORT
Giant cell tumour of bone: Reconstruction of the index metacarpophalangeal joint with an osteochondral graft from the lateral femoral condyle Alexander S. Spiro a,*, Pia Pogoda a, Michael Amling b, Norbert M. Meenen c, Jozef Zustin d, Johannes M. Rueger a, Matthias H. Priemel a a Department of Trauma-, Hand-, and Reconstructive Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany b Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany c Department of Pediatric Orthopaedic Surgery, Children’s Hospital Hamburg-Altona, Bleickenallee 38, 22763 Hamburg, Germany d Department of Pathology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany
Received 1 May 2012; accepted 27 August 2012
KEYWORDS Giant cell tumour; Digital joint; Osteochondral graft; Lateral femoral condyle
Summary We describe the successful reconstruction of the index finger metacarpophalangeal joint with an osteochondral autograft from the lateral femoral condyle following failed curettage and cementation of a giant cell tumour of the proximal phalanx base. At the 2year follow-up, a good functional outcome was noted with 0e80 range of motion of the metacarpophalangeal joint and no clinical or radiographic evidence of tumour recurrence. ª 2012 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Giant cell tumour of bone accounts for approximately 5% of all primary bone tumours.1 Typical locations are the metaepiphyseal regions of the long bones, while involvement of * Corresponding author. Tel.: þ49 40 74105 3459; fax: þ49 40 74105 4569. E-mail address: [email protected] (A.S. Spiro).
the metacarpals, phalanges or carpus is rare.2 Biscaglia et al. reported an incidence of only 0.9% in the hand in their series of 900 cases.3 Giant cell tumours in the long bones have been frequently treated by intralesional curettage and bone grafting or cementation.4 Those located in the hand appear to behave more aggressively.3 Thus, several authors
1748-6815/$ - see front matter ª 2012 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2012.08.037
730 recommend resection followed by reconstruction of the resected bone/joint or amputation.3,5e9
Case report A 31-year-old right-hand-dominant woman presented with pain and swelling of the right index finger. The symptoms had been present for several weeks with no history of antecedent trauma. Physical examination demonstrated focal tenderness and diffuse swelling at the base of the proximal phalanx. Range of motion (ROM) was limited to full extension and 30 of flexion at the metacarpophalangeal joint. Radiographs revealed a lytic and expansile lesion within the base of the proximal phalanx (Figure 1). The patient was otherwise healthy and denied taking any regular medications. Routine serological testing and a chest X-ray were inconspicuous. Computed tomography (CT) of the right index finger demonstrated thinning of the dorsal and volar cortices and the proximal phalanx articular surface. The differential diagnosis was a giant cell tumour or an aneurysmal bone cyst. Surgical treatment included curettage of the tumour, followed by burring of the inner cortex with a diamond milling cutter and cementation (polymethylmethacrylate cement, PMMA). Histopathological examination revealed a giant cell tumour. Eight months later, the patient presented with a stiff, painful metacarpophalangeal joint. Plain radiographs, CT and magnetic resonance imaging (MRI) revealed destruction of the articular surface of the proximal phalanx base, while the metacarpal head was intact. There was no sign of tumour recurrence.
Figure 1 An anteroposterior radiograph of the right index finger shows a lytic and expansile lesion within the base of the proximal phalanx.
A.S. Spiro et al. Reconstruction of the proximal phalanx metaphysis and the articular surface was then performed using an osteochondral autograft from the ipsilateral distal femoral condyle. At surgery, a mid-dorsal incision was used to expose the proximal phalanx and the metacarpophalangeal joint of the right index finger. The cement was easily removed en bloc because of the absent dorsal cortex and articular surface. Both collateral ligaments were intact. The size of the required osteochondral graft was measured at the proximal phalanx base. A hollow milling tool (Diamond Bone Cutting System, DBCS, ARTICOmed, Schlu ¨chtern, Germany) was then used to remove a cylindric osteochondral autograft with a concave articular surface (diameter: 1.045 cm, length: 2.5 cm) from the right lateral femoral condyle. The osteochondral autograft was then prepared with a bone rongeur and fitted into the proximal phalanx base (Figures 2 and 3). A single K-wire was used to fix the osteochondral autograft and the metacarpophalangeal joint. The osteochondral defect of the lateral femoral condyle was filled with a cylindric corticocancellous autograft from the right iliac crest. After surgery, the right index finger was immobilised for 6 weeks in a cast. The K-wire was then removed and active ROM was allowed. At the 2-year follow-up, the patient had a good functional outcome of the right index finger with 0e80 ROM of the metacarpophalangeal joint, no pain and stable conditions (varus and valgus stressing). Radiographs and MRI revealed that the osteochondral autograft had healed without evidence of tumour recurrence (Figure 4). Physical examination and radiographs of the right knee, pelvis and chest were normal.
Figure 2 Intraoperative photograph shows the prepared osteochondral autograft from the ipsilateral lateral femoral condyle.
Giant cell tumour of bone
Figure 3 Intraoperative photograph after implantation of the osteochondral autograft into the proximal phalanx base.
Discussion Different types of surgical treatment for phalangeal and metacarpal giant cell tumours are described. Curettage of the lesions followed by cementation or bone grafting is reported in a few studies.3,9,10 Due to the higher recurrence
731 rate of phalangeal and metacarpal giant cell tumours, several authors prefer a wide resection of the bone and reconstruction of the finger, or amputation.3,5e9 Sanjay et al. treated seven cases of metacarpal and phalangeal giant cell tumour by en bloc excision and fibular autografting or amputation.7 Tumour recurrence was reported in one case. Torpey et al. described the successful transfer of the proximal phalanx of the right fifth toe to the middle phalanx of the left ring finger to treat a recurrent giant cell tumour.5 At the 41-year follow-up, the active ROMs of the proximal and distal interphalangeal joint were 0e80 and 0e40 , respectively. Two patients with a recurrent metacarpal giant cell tumour were treated by en bloc resection and metatarsal transfer in another study.6 The functional results were satisfactory with no evidence of tumour recurrence at the 3-year follow-up. The use of an osteochondral autograft to reconstruct a digital joint after excision of a giant cell tumour has been investigated in a limited number of studies. Kanaya et al. described a vascularised metatarsophalangeal joint transfer to reconstruct the metacarpophalangeal joint, following en bloc resection of the metacarpal head and base of the proximal phalanx.8 At the 2-year follow-up, the metacarpophalangeal joint was stable with satisfactory ROM (0e85 ). These results are in line with our findings using an osteochondral autograft from the lateral femoral condyle to reconstruct the metacarpophalangeal joint. At the 2-year follow-up, no donorsite morbidity occurred in our patient, the osteochondral autograft healed and there was no evidence of tumour recurrence. To the best of our knowledge, this is the first report describing this technique for the management of a giant cell tumour in the hand. The use of an osteochondral autograft from the lateral femur condyle to reconstruct the metacarpophalangeal joint offers a viable option with respect to other described techniques, considering the limited risks at the donor site (lateral gonarthrosis; pain at the site of the harvested iliac crest autograft).
Conflict of interest statement The authors declare that they have no conflict of interest.
References
Figure 4 Radiographs at the two year follow-up revealed that the osteochondral autograft had healed with no evidence of tumor recurrence.
1. Dahlin DC, Unni KK. Bone tumors: general aspects and data on 11,087 cases. 5th ed. Philadelphia: Lippincott Williams & Wilkins; 1996. 285. 2. Campanacci M, Baldini N, Boriani S, Sudanese A. Giant-cell tumor of bone. J Bone Joint Surg Am 1987;69:106e14. 3. Biscaglia R, Bacchini P, Bertoni F. Giant cell tumor of the bones of the hand and foot. Cancer 2000;88:2022e32. 4. Becker WT, Dohle J, Bernd L, et al. Local recurrence of giant cell tumor of bone after intralesional treatment with and without adjuvant therapy. J Bone Joint Surg Am 2008;90: 1060e7. 5. Torpey B, Faierman E, Lehmann O. Phalangeal transfer for recurrent giant-cell tumor of the phalanx of a finger in a nineyear-old child. A case report with forty-one-year follow-up. J Bone Joint Surg Am 1994;76:1864e9.
732 6. Pardo-Montaner J, Pina-Medina A, Barcelo-Alcan ˜iz M. Recurrent metacarpal giant cell tumour treated by en bloc resection and metatarsal transfer. J Hand Surg Br 1998;23: 275e8. 7. Sanjay BK, Raj GA, Younge DA. Giant cell tumours of the hand. J Hand Surg Br 1996;21:683e7. 8. Kanaya K, Wada T, Kitajima K, Yamashita T. Vascularized metatarsophalangeal joint transfer for giant cell tumor of the
A.S. Spiro et al. proximal phalanx of the hand. Plast Reconstr Surg 2008;121: 354e5. 9. Ropars M, Kaila R, Cannon SR, Briggs TW. Primary giant cell tumours of the digital bones of the hand. J Hand Surg Eur Vol 2007;32:160e4. 10. Wittig JC, Simpson BM, Bickels J, Kellar-Graney KL, Malawer MM. Giant cell tumor of the hand: superior results with curettage, cryosurgery, and cementation. J Hand Surg Am 2001;26:546e55.