International
International Orthopaedics (SICOT) (1990) 14:129-133
Orthopaedics © Springer-Verlag 1990
Is bone graft necessary? Analysis of twenty cases of giant cell tumour of bone treated by curettage without graft M. A. Waldram and R. S. Sneath Bone Tumour Treatment Service, Royal Orthopaedic Hospital, Birmingham, England
Twenty cases o f giant cell tumour o f bone treated over an eleven year period were analysed. The minimum follow-up time was two years with an average o f six years. Primary treatment consisted o f a detailed curettage alone, without bone graft. A recurrence rate o f 35% (7 patients) was recorded. Cases o f recurrence were suitable for resection and endoprosthetic replacement. We conclude that detailed curettage alone, without bone graft, is an effective primary treatment f o r patients with giant cell tumour o f bone.
Summary.
R~sum~. Analyse de 20 cas de tumeurs osseuses
cellules gbantes traitbes durant une pdriode de onze ans. Le recul minimal est de 2 ans, avec une moyenne de 6 ans. Le traitement initial a consistb en un curettage soigneux simple, sans comblement par greffe osseuse. On a notd un taux de rbcidive de 35% (7 malades). Ces cas de r~cidive sont l'indication d'une r~section avec remplacement prothdtique. On peut conclure que le curettage simple, sans greffe associ~e, constitue un traitement primitif efficace pour les sujets atteints de tumeurs osseuses cellules gbantes.
Introduction G i a n t cell t u m o u r s o f b o n e w e r e first d e s c r i b e d b y C o o p e r a n d T r a v e r s in 1818 [2]. T h e s e l e s i o n s have always been challenging and controversial. W h i l s t g i a n t cell t u m o u r s a r e p l a c e d at t h e m o r e benign end of the spectrum of bone tumours, their tendency to recur, unpredictable behaviour and
Qffprint requests to: M. A. Waldram
rare potential for malignant transformation dem a n d a t h o r o u g h a p p r o a c h to t h e i r p r i m a r y t r e a t m e n t a n d f o l l o w - u p ( F i g . 1). B e c a u s e o f t h e i r rarity, most reports from the English literature are b a s e d o n o n l y a f e w cases. G o l d e n b e r g et al. [5] d e s c r i b e 218 cases. D a h l i n a n d J o h n s o n [21 195 c a s e s a n d m o r e r e c e n t l y S u n g a n d Li [18] 208 c a s e s f r o m C h i n a . T h e B r i t i s h l i t e r a t u r e w a s rev i e w e d b y M c G r a t h a n d P y m b l e [12] w h o rep o r t e d 52 c a s e s f r o m t h e B r i s t o l b o n e t u m o u r r e g istry. T h e p u r p o s e o f t h i s r e p o r t is to p r e s e n t o u r experience with a relatively small number of pat i e n t s [20] w h o s e p r i m a r y s u r g i c a l t r e a t m e n t c o n sisted of detailed curettage without bone graft. T h e m e t i c u l o u s m e t h o d o f c u r e t t a g e is e m p h a s ized.
Clinical material and method All of the patients were treated at the Royal Orthopaedic Hospital by one of the authors (R.S.S.), although referral or initial treatment may have started elsewhere. All patients had giant cell tumours of bone, confirmed by biopsy, and satisfying the criteria of Jaffe et al. [8]. No patient with a follow-up of less than two years is included. Most of the patients are still under review. The primary surgery after biopsy consisted of exposure of the bony part affected. The cortex was then fenestrated adequately to allow removal of the tumour bulk and full visualisation of the internal walls. Detailed curettage was then undertaken. Attention was paid to removing all macroscopic tumour tissue especially that concealed in the crevices and trabeculated pockets of the walls of the cavity. A set of fine curettes and dental burrs and brushes attached to a compressed air drill unit were considered essential. Noxythiolin and Amethocaine hydrochloride (Noxyflex 2%) solution was used for irrigation. No bone graft was placed in the cavity. Cryotherapy and electrical or chemical coagulation were not used in this technique. Postoperatively patients remained nonweight bearing for six weeks. They then commenced gradual increase in
130
M. A. Waldram and R. S. Sneath: Bone curettage Age 8, sex distribution 9 8
Male 9 Femate 11
7
u5
Z
2
10-19
20-29
30-39 40-49 Age (decade)
50-59
60-69
Fig. 3. Age and sex distribution of twenty cases of osteoclastoma of bone
Fig. 1 a, b. Radiographs of a typical giant cell tumour of bone at the lower end of the femur before curettage
weightbearing over two to three months. The rate of increase was governed by both the x-ray appearance and the amount of discomfort at the operation site. Cases of recurrence were confirmed by biopsy.
is seen in T a b l e 1. Seventeen patients (85%) had t u m o u r s a r o u n d the knee. Most patients p r e s e n t e d with a history o f pain and swelling o f the affected part for some months. Sometimes m i n o r t r a u m a resulted in p r e s e n t a t i o n as a pathological fracture. O n l y one patient has died in this series, and d e a t h was f o u n d at post m o r t e m to be f r o m unrelated causes. N o patient has d e v e l o p e d metastases or died f r o m the disease. Eight patients d e v e l o p e d local r e c u r r e n c e following p r i m a r y curettage without b o n e graft. One o f these d e v e l o p e d a rec u r r e n c e in the scar (Case no. 5). T h e r e were t h e r e f o r e seven patients (35%) w h o d e v e l o p e d a true b o n y recurrence, (Table 1). T w o o f these were treated b y repeat curettage. (Case nos 17, 20). One, (Case no. 17), had the a d d i t i o n o f a fibular strut graft on the s e c o n d curretage. A further rec u r r e n c e three years later resulted in e n d o p r o s thetic replacement, a n d a subsequent a m p u t a t i o n for infection some seven years later. Five cases o f r e c u r r e n c e were treated b y e n d o p r o s t h e t i c rep l a c e m e n t (Case nos 4, 6, 13, 14, 9). One o f these resulted in a m p u t a t i o n eighteen m o n t h s after the p r o c e d u r e . The choice o f e n d o p r o s t h e t i c replacem e n t for m a n a g i n g r e c u r r e n c e was m a d e when cortical b r e a k t h r o u g h or t u m o u r extension resulted in a loss o f b o n e too great to be treated by curettage alone.
Results
Discussion
The age a n d sex distribution is s h o w n in Fig. 3. The sex ratio was a p p r o x i m a t e l y equal. The largest g r o u p o f patients was in the ten to nineteen year decade. The y o u n g e s t patient was 16 a n d the oldest 60. The skeletal distribution o f the t u m o u r s
In this series o f twenty patients the r e c u r r e n c e rate after detailed curettage without b o n e grafting was 35%. This c o m p a r e s f a v o u r a b l y with other reports. Curettage without b o n e graft for osteoclast o m a has been described before, but the detailed
Fig. 2 a, b. Radiographs of same tumour as in Fig. 1, 4 years after curettage without bone graft
M. A. Waldram and R. S. Sneath: Bone curettage
131
Table 1. Case No
Sex M or F
Age at presentation
Tumour location side L or R
Size cm
Cortical breakthrough stage ( 1 - 3 )
Ref. 4
Local recurrence: treatment follow up. NSR = no sign recurrence
1
F
18
Distal tibia (R)
3x 3
Yes
2
NSR
12 yrs.
2
F
23
Distal femur (R)
3x6
Yes
2
NSR
8 yrs.
3
F
19
Distal femur (L)
5x 6
Yes
2
NSR
2 yrs.
4
M
18
Distal femur (L)
9x7
Yes
3
Recurrence 11 months. Endoprosthetic Replacement. NSR 9 yrs since recurrence.
5
M
29
Distal femur (L)
4x7
Yes
2
Scar recurrence excised NSR 4 yrs since recurrence.
6
M
60
Distal femur (R)
9x7
Yes
2
Recurrence 5 months. Endoprosthetic Replacement. Died after 5 yrs. Unrelated cause.
7
F
19
Distal femur (L)
8
F
59
Left ilium (L)
9
M
34
Proximal tibia (L)
7x 5
No
2
NSR
7 yrs.
10 x 12
Yes
3
NSR
6 yrs.
5x 6
No
2
Recurrence 3 yrs. Endoprosthetic Replacement. Infection. Amputation 7 yrs. NSR 18 months since amputation.
10
M
40
Proximal tibia (L)
5x 4
No
2
NSR
7 yrs.
11
F
18
Distal femur (R)
4x7
Yes
2
NSR
7 yrs.
12
M
59
Proximal tibia (L)
12 x 7
No
2
NSR
5 yrs.
13
M
17
Proximal tibia (L)
5x 6
Yes
2
Recurrence 6 months. Endoprosthetic Replacement. NSR 3 yrs since recurrence.
14
F
23
Distal femur (L)
5x 7
Yes
2
Recurrence 12 months. Endoprosthetic Replacement. NSR 4 yrs since recurrence.
15
F
21
Distal femur (R)
6x6
Yes
2 with fracture
NSR
5 yrs. 3 yrs.
16
M
18
Proximal tibia (R)
5 x 10
Yes
2
NSR
17
M
32
Proximal tibia (L)
5x 7
No
2
Recurrence 18 months. Further curettage with fibular strut graft. Further recurrence 3 yrs. Endoprosthetic Replacement. Amputation for infection at 5 yrs. NSR 7 yrs since amputation.
18
F
16
Distal femur (L)
5x 5
No
2
NSR
5 yrs.
19
F
19
Proximal humerus (R)
4x 5
No
2
NSR
5 yrs.
20
F
35
Proximal tibia (L)
5x 6
No
2
Recurrence 12 months. Repeat curettage. NSR 4 yrs since recurrence.
method and time taken over curettage has not been stressed. Mnaymneh [11] gave details of eight patients undergoing curettage alone; six recurred (75%). He noted that chemical cautery with carbolic acid made no difference to the recurrence rate. In Goldenberg's large series of two
hundred and eighteen patients [51, forty-five underwent curettage without bone graft. Thirtyseven of these (82%) recurred. Johnson [9] described seventy-one patients undergoing curettage. He observed that additional bone graft, cautery or irradiation did not alter the recurrence
132
M . A . Waldram and R. S. Sneath: Bone curettage
Fig. 4 a, b. Giant cell tumour of left ilium involving acetabulum Appearances before (a) and 3 years after curettage without bone graft (b)
rate. Johnson also noted an increase in the recurrence rate the longer patients were followed up. There was 30% recurrence at one year which rose to 54% at five years, confirming the need for long term follow up in these patients. Other series report a variable rate of recurrence. The lowest, 8%, was observed by Marcove [10] who instilled liquid nitrogen as an adjuvent to curettage. Most of his patients underwent a routine second look biopsy to exclude recurrence. However, eryotherapy may lead to problems of skin necrosis and wound infection. Goldenberg's larger series reports an overall 35% recurrence rate after curettage and grafting. Sung [18] noted a 41% recurrence rate after curettage and grafting, which fell to 7% with resection and fusion. Persson described the method of curettage with acrylic cementation and recorded a low recurrence rate (13%). All but one of our patients (Case no 18) had reached skeletal maturity. Most were in the ten to nineteen age group, but none was below sixteen years of age. Reckling [17] reviewed 1100 cases from twenty-two separate series and noted a 2% incidence of giant cell tumour in the under fifteen age group. The x-ray of any giant cell tumour of bone may be confused with an aneurysmal bone cyst, fibrous dysplasia, chondroblastoma or brown turnout of hyperparathyroidism. There is not much stippling or calcification of the lesion within the lesion since a giant cell tumour possesses no osteogenic capacity. The x-ray appearance following curettage without a bone graft consists not so much of a filling in of the cavity, but rather a gradual consolidation and thickening of the side walls and trabeculae sufficient to give full strength. The cortex may be thinned and breached by tumour escaping into the surrounding soft tissue. This does not invalidate the method of curettage
unless the tumour tissue cannot be visualised for adequate removal (Fig. 4). Most tumours in this series occured around the knee (85%). Bone grafting was not used after curettage. The added complications of using an autogenous graft are donor site pain, non-union of the graft and infection. Grafting may later lead to confusion when assessing x-rays, especially when recurrence is suspected. Detailed curettage without bone graft is an effective primary treatment for giant cell tumour of bone. Acknowledgments. We would like to thank Mrs P Bradford for her secretarial assistance and the Department of Medical Illustration at the Birmingham Accident Hospital for the illustrations. References 1. Cooper, Astley, Travers B (1818) Surgical essays, vol 1. Cox and Son and Longman and Co., London, pp 186-208 2. Dahlin DC, Cupps RE, Johnson EW (1970) Giant cell tumour: A study of 195 cases. Cancer 25:1061 3. Ellis F (1949) Treatment of osteoclastoma by radiation. J Bone Joint Surg 31 : 268 4. Enneking WF (1983) Musculoskeletal tumour surgery. Vol 1: 87-88; vol. 2: 1439-1422. Churchill Livingstone, Edinburgh 5. Goldenberg RR, Campbell CJ, Bonfiglio M (1970) Giant cell tumour of bone. J Bone Joint Surg 5 2 : 6 1 9 - 6 6 3 6. Harris WR, Lehmann ECH (1983) Recurrent giant-cell tumour after en bloc excision of the distal radius and fibular autograft replacement. J Bone Joint Surg 65:618 7. Jaffe HL (1953) Giant-cell tumour (Osteoclastoma) of bone: Its pathological delineation and the inherent clinical implications. Ann R Coll Surg Engl 13:343 8. Jaffe HL, Lichtenstein L, Portis RB (1940) Giant-cell Tumour of bone. Its pathological appearance, grading, supposed variants and treatment. Arch Pathol 30:993 9. Johnson EW, Dahlin DC (1959) Treatment of giant-cell tumour of bone. J Bone Joint Surg 41:895 10. Marcove RC, Lyden JP, Huvos AG, Bullough PB (1973) Giant-cell tumours treated by Cryosurgery. J Bone Joint Surg 55:1633
M. A. Waldram and R. S. Sneath: Bone curettage I I. Mnaymneh WA, Dudley HR, Mnaymneh L G (1964) Giant-cell turnout of bone. Analysis and follow-up of the forty-one cases observed at the Massachusetts General Hospital between 1925 and 1960. J Bone Joint Surg 46:63 12. McGrath PJ, Pymble (1972) Giant-cell tumours of bone. J Bone Joint Surg 54:216 13. Nascimento AG, Huvos AG, Margove RC (1979) Primary malignant giant cell tumour of bone. Cancer 44:1393 14. Persson BM, Ekellund L, L6vdahl R, Gunterber B (1984) Favourable results of acrylic cementation for giant cell tumours. Acta Orthop Scand 55:209-214 15. Pho RW (1981) Malignant giant-cell tumour of the distal end of the radius treated by a free vascularized fibular transplant. J Bone Joint Surg 63:877
133 16. Prossor TM (1949) Treatment of giant-cell tumours of bone. J Bone Joint Surg 31:241 17. Reckling FW, Gurtler RA, Mantz FA (1979) Recurrent giant-cell tumour of bone in a thirteen-year-old girl. J Bone Joint Surg 61 : 281 18. Sung HW, Kuo DP, Shu WP, Chai YB, Liu CC, LI SM (1982) Giant-cell tumour of bone: analysis of two hundred and eight cases in chinese patients. J Bone Joint Surg 64: 755 19. Wearne WM (1968) Giant cell tumour of bone. J Bone Joint Surg 50:676 20. Windeyer BW, Woodyatt PB (1949) Osteoclastoma. A study of thirty-eight cases. J Bone Joint Surg 31 : 252
International Orthopaedics (SICOT) (1990) 14:129-133
Orthopaedics © Springer-Verlag 1990
Is bone graft necessary? Analysis of twenty cases of giant cell tumour of bone treated by curettage without graft M. A. Waldram and R. S. Sneath Bone Tumour Treatment Service, Royal Orthopaedic Hospital, Birmingham, England
Twenty cases o f giant cell tumour o f bone treated over an eleven year period were analysed. The minimum follow-up time was two years with an average o f six years. Primary treatment consisted o f a detailed curettage alone, without bone graft. A recurrence rate o f 35% (7 patients) was recorded. Cases o f recurrence were suitable for resection and endoprosthetic replacement. We conclude that detailed curettage alone, without bone graft, is an effective primary treatment f o r patients with giant cell tumour o f bone.
Summary.
R~sum~. Analyse de 20 cas de tumeurs osseuses
cellules gbantes traitbes durant une pdriode de onze ans. Le recul minimal est de 2 ans, avec une moyenne de 6 ans. Le traitement initial a consistb en un curettage soigneux simple, sans comblement par greffe osseuse. On a notd un taux de rbcidive de 35% (7 malades). Ces cas de r~cidive sont l'indication d'une r~section avec remplacement prothdtique. On peut conclure que le curettage simple, sans greffe associ~e, constitue un traitement primitif efficace pour les sujets atteints de tumeurs osseuses cellules gbantes.
Introduction G i a n t cell t u m o u r s o f b o n e w e r e first d e s c r i b e d b y C o o p e r a n d T r a v e r s in 1818 [2]. T h e s e l e s i o n s have always been challenging and controversial. W h i l s t g i a n t cell t u m o u r s a r e p l a c e d at t h e m o r e benign end of the spectrum of bone tumours, their tendency to recur, unpredictable behaviour and
Qffprint requests to: M. A. Waldram
rare potential for malignant transformation dem a n d a t h o r o u g h a p p r o a c h to t h e i r p r i m a r y t r e a t m e n t a n d f o l l o w - u p ( F i g . 1). B e c a u s e o f t h e i r rarity, most reports from the English literature are b a s e d o n o n l y a f e w cases. G o l d e n b e r g et al. [5] d e s c r i b e 218 cases. D a h l i n a n d J o h n s o n [21 195 c a s e s a n d m o r e r e c e n t l y S u n g a n d Li [18] 208 c a s e s f r o m C h i n a . T h e B r i t i s h l i t e r a t u r e w a s rev i e w e d b y M c G r a t h a n d P y m b l e [12] w h o rep o r t e d 52 c a s e s f r o m t h e B r i s t o l b o n e t u m o u r r e g istry. T h e p u r p o s e o f t h i s r e p o r t is to p r e s e n t o u r experience with a relatively small number of pat i e n t s [20] w h o s e p r i m a r y s u r g i c a l t r e a t m e n t c o n sisted of detailed curettage without bone graft. T h e m e t i c u l o u s m e t h o d o f c u r e t t a g e is e m p h a s ized.
Clinical material and method All of the patients were treated at the Royal Orthopaedic Hospital by one of the authors (R.S.S.), although referral or initial treatment may have started elsewhere. All patients had giant cell tumours of bone, confirmed by biopsy, and satisfying the criteria of Jaffe et al. [8]. No patient with a follow-up of less than two years is included. Most of the patients are still under review. The primary surgery after biopsy consisted of exposure of the bony part affected. The cortex was then fenestrated adequately to allow removal of the tumour bulk and full visualisation of the internal walls. Detailed curettage was then undertaken. Attention was paid to removing all macroscopic tumour tissue especially that concealed in the crevices and trabeculated pockets of the walls of the cavity. A set of fine curettes and dental burrs and brushes attached to a compressed air drill unit were considered essential. Noxythiolin and Amethocaine hydrochloride (Noxyflex 2%) solution was used for irrigation. No bone graft was placed in the cavity. Cryotherapy and electrical or chemical coagulation were not used in this technique. Postoperatively patients remained nonweight bearing for six weeks. They then commenced gradual increase in
130
M. A. Waldram and R. S. Sneath: Bone curettage Age 8, sex distribution 9 8
Male 9 Femate 11
7
u5
Z
2
10-19
20-29
30-39 40-49 Age (decade)
50-59
60-69
Fig. 3. Age and sex distribution of twenty cases of osteoclastoma of bone
Fig. 1 a, b. Radiographs of a typical giant cell tumour of bone at the lower end of the femur before curettage
weightbearing over two to three months. The rate of increase was governed by both the x-ray appearance and the amount of discomfort at the operation site. Cases of recurrence were confirmed by biopsy.
is seen in T a b l e 1. Seventeen patients (85%) had t u m o u r s a r o u n d the knee. Most patients p r e s e n t e d with a history o f pain and swelling o f the affected part for some months. Sometimes m i n o r t r a u m a resulted in p r e s e n t a t i o n as a pathological fracture. O n l y one patient has died in this series, and d e a t h was f o u n d at post m o r t e m to be f r o m unrelated causes. N o patient has d e v e l o p e d metastases or died f r o m the disease. Eight patients d e v e l o p e d local r e c u r r e n c e following p r i m a r y curettage without b o n e graft. One o f these d e v e l o p e d a rec u r r e n c e in the scar (Case no. 5). T h e r e were t h e r e f o r e seven patients (35%) w h o d e v e l o p e d a true b o n y recurrence, (Table 1). T w o o f these were treated b y repeat curettage. (Case nos 17, 20). One, (Case no. 17), had the a d d i t i o n o f a fibular strut graft on the s e c o n d curretage. A further rec u r r e n c e three years later resulted in e n d o p r o s thetic replacement, a n d a subsequent a m p u t a t i o n for infection some seven years later. Five cases o f r e c u r r e n c e were treated b y e n d o p r o s t h e t i c rep l a c e m e n t (Case nos 4, 6, 13, 14, 9). One o f these resulted in a m p u t a t i o n eighteen m o n t h s after the p r o c e d u r e . The choice o f e n d o p r o s t h e t i c replacem e n t for m a n a g i n g r e c u r r e n c e was m a d e when cortical b r e a k t h r o u g h or t u m o u r extension resulted in a loss o f b o n e too great to be treated by curettage alone.
Results
Discussion
The age a n d sex distribution is s h o w n in Fig. 3. The sex ratio was a p p r o x i m a t e l y equal. The largest g r o u p o f patients was in the ten to nineteen year decade. The y o u n g e s t patient was 16 a n d the oldest 60. The skeletal distribution o f the t u m o u r s
In this series o f twenty patients the r e c u r r e n c e rate after detailed curettage without b o n e grafting was 35%. This c o m p a r e s f a v o u r a b l y with other reports. Curettage without b o n e graft for osteoclast o m a has been described before, but the detailed
Fig. 2 a, b. Radiographs of same tumour as in Fig. 1, 4 years after curettage without bone graft
M. A. Waldram and R. S. Sneath: Bone curettage
131
Table 1. Case No
Sex M or F
Age at presentation
Tumour location side L or R
Size cm
Cortical breakthrough stage ( 1 - 3 )
Ref. 4
Local recurrence: treatment follow up. NSR = no sign recurrence
1
F
18
Distal tibia (R)
3x 3
Yes
2
NSR
12 yrs.
2
F
23
Distal femur (R)
3x6
Yes
2
NSR
8 yrs.
3
F
19
Distal femur (L)
5x 6
Yes
2
NSR
2 yrs.
4
M
18
Distal femur (L)
9x7
Yes
3
Recurrence 11 months. Endoprosthetic Replacement. NSR 9 yrs since recurrence.
5
M
29
Distal femur (L)
4x7
Yes
2
Scar recurrence excised NSR 4 yrs since recurrence.
6
M
60
Distal femur (R)
9x7
Yes
2
Recurrence 5 months. Endoprosthetic Replacement. Died after 5 yrs. Unrelated cause.
7
F
19
Distal femur (L)
8
F
59
Left ilium (L)
9
M
34
Proximal tibia (L)
7x 5
No
2
NSR
7 yrs.
10 x 12
Yes
3
NSR
6 yrs.
5x 6
No
2
Recurrence 3 yrs. Endoprosthetic Replacement. Infection. Amputation 7 yrs. NSR 18 months since amputation.
10
M
40
Proximal tibia (L)
5x 4
No
2
NSR
7 yrs.
11
F
18
Distal femur (R)
4x7
Yes
2
NSR
7 yrs.
12
M
59
Proximal tibia (L)
12 x 7
No
2
NSR
5 yrs.
13
M
17
Proximal tibia (L)
5x 6
Yes
2
Recurrence 6 months. Endoprosthetic Replacement. NSR 3 yrs since recurrence.
14
F
23
Distal femur (L)
5x 7
Yes
2
Recurrence 12 months. Endoprosthetic Replacement. NSR 4 yrs since recurrence.
15
F
21
Distal femur (R)
6x6
Yes
2 with fracture
NSR
5 yrs. 3 yrs.
16
M
18
Proximal tibia (R)
5 x 10
Yes
2
NSR
17
M
32
Proximal tibia (L)
5x 7
No
2
Recurrence 18 months. Further curettage with fibular strut graft. Further recurrence 3 yrs. Endoprosthetic Replacement. Amputation for infection at 5 yrs. NSR 7 yrs since amputation.
18
F
16
Distal femur (L)
5x 5
No
2
NSR
5 yrs.
19
F
19
Proximal humerus (R)
4x 5
No
2
NSR
5 yrs.
20
F
35
Proximal tibia (L)
5x 6
No
2
Recurrence 12 months. Repeat curettage. NSR 4 yrs since recurrence.
method and time taken over curettage has not been stressed. Mnaymneh [11] gave details of eight patients undergoing curettage alone; six recurred (75%). He noted that chemical cautery with carbolic acid made no difference to the recurrence rate. In Goldenberg's large series of two
hundred and eighteen patients [51, forty-five underwent curettage without bone graft. Thirtyseven of these (82%) recurred. Johnson [9] described seventy-one patients undergoing curettage. He observed that additional bone graft, cautery or irradiation did not alter the recurrence
132
M . A . Waldram and R. S. Sneath: Bone curettage
Fig. 4 a, b. Giant cell tumour of left ilium involving acetabulum Appearances before (a) and 3 years after curettage without bone graft (b)
rate. Johnson also noted an increase in the recurrence rate the longer patients were followed up. There was 30% recurrence at one year which rose to 54% at five years, confirming the need for long term follow up in these patients. Other series report a variable rate of recurrence. The lowest, 8%, was observed by Marcove [10] who instilled liquid nitrogen as an adjuvent to curettage. Most of his patients underwent a routine second look biopsy to exclude recurrence. However, eryotherapy may lead to problems of skin necrosis and wound infection. Goldenberg's larger series reports an overall 35% recurrence rate after curettage and grafting. Sung [18] noted a 41% recurrence rate after curettage and grafting, which fell to 7% with resection and fusion. Persson described the method of curettage with acrylic cementation and recorded a low recurrence rate (13%). All but one of our patients (Case no 18) had reached skeletal maturity. Most were in the ten to nineteen age group, but none was below sixteen years of age. Reckling [17] reviewed 1100 cases from twenty-two separate series and noted a 2% incidence of giant cell tumour in the under fifteen age group. The x-ray of any giant cell tumour of bone may be confused with an aneurysmal bone cyst, fibrous dysplasia, chondroblastoma or brown turnout of hyperparathyroidism. There is not much stippling or calcification of the lesion within the lesion since a giant cell tumour possesses no osteogenic capacity. The x-ray appearance following curettage without a bone graft consists not so much of a filling in of the cavity, but rather a gradual consolidation and thickening of the side walls and trabeculae sufficient to give full strength. The cortex may be thinned and breached by tumour escaping into the surrounding soft tissue. This does not invalidate the method of curettage
unless the tumour tissue cannot be visualised for adequate removal (Fig. 4). Most tumours in this series occured around the knee (85%). Bone grafting was not used after curettage. The added complications of using an autogenous graft are donor site pain, non-union of the graft and infection. Grafting may later lead to confusion when assessing x-rays, especially when recurrence is suspected. Detailed curettage without bone graft is an effective primary treatment for giant cell tumour of bone. Acknowledgments. We would like to thank Mrs P Bradford for her secretarial assistance and the Department of Medical Illustration at the Birmingham Accident Hospital for the illustrations. References 1. Cooper, Astley, Travers B (1818) Surgical essays, vol 1. Cox and Son and Longman and Co., London, pp 186-208 2. Dahlin DC, Cupps RE, Johnson EW (1970) Giant cell tumour: A study of 195 cases. Cancer 25:1061 3. Ellis F (1949) Treatment of osteoclastoma by radiation. J Bone Joint Surg 31 : 268 4. Enneking WF (1983) Musculoskeletal tumour surgery. Vol 1: 87-88; vol. 2: 1439-1422. Churchill Livingstone, Edinburgh 5. Goldenberg RR, Campbell CJ, Bonfiglio M (1970) Giant cell tumour of bone. J Bone Joint Surg 5 2 : 6 1 9 - 6 6 3 6. Harris WR, Lehmann ECH (1983) Recurrent giant-cell tumour after en bloc excision of the distal radius and fibular autograft replacement. J Bone Joint Surg 65:618 7. Jaffe HL (1953) Giant-cell tumour (Osteoclastoma) of bone: Its pathological delineation and the inherent clinical implications. Ann R Coll Surg Engl 13:343 8. Jaffe HL, Lichtenstein L, Portis RB (1940) Giant-cell Tumour of bone. Its pathological appearance, grading, supposed variants and treatment. Arch Pathol 30:993 9. Johnson EW, Dahlin DC (1959) Treatment of giant-cell tumour of bone. J Bone Joint Surg 41:895 10. Marcove RC, Lyden JP, Huvos AG, Bullough PB (1973) Giant-cell tumours treated by Cryosurgery. J Bone Joint Surg 55:1633
M. A. Waldram and R. S. Sneath: Bone curettage I I. Mnaymneh WA, Dudley HR, Mnaymneh L G (1964) Giant-cell turnout of bone. Analysis and follow-up of the forty-one cases observed at the Massachusetts General Hospital between 1925 and 1960. J Bone Joint Surg 46:63 12. McGrath PJ, Pymble (1972) Giant-cell tumours of bone. J Bone Joint Surg 54:216 13. Nascimento AG, Huvos AG, Margove RC (1979) Primary malignant giant cell tumour of bone. Cancer 44:1393 14. Persson BM, Ekellund L, L6vdahl R, Gunterber B (1984) Favourable results of acrylic cementation for giant cell tumours. Acta Orthop Scand 55:209-214 15. Pho RW (1981) Malignant giant-cell tumour of the distal end of the radius treated by a free vascularized fibular transplant. J Bone Joint Surg 63:877
133 16. Prossor TM (1949) Treatment of giant-cell tumours of bone. J Bone Joint Surg 31:241 17. Reckling FW, Gurtler RA, Mantz FA (1979) Recurrent giant-cell tumour of bone in a thirteen-year-old girl. J Bone Joint Surg 61 : 281 18. Sung HW, Kuo DP, Shu WP, Chai YB, Liu CC, LI SM (1982) Giant-cell tumour of bone: analysis of two hundred and eight cases in chinese patients. J Bone Joint Surg 64: 755 19. Wearne WM (1968) Giant cell tumour of bone. J Bone Joint Surg 50:676 20. Windeyer BW, Woodyatt PB (1949) Osteoclastoma. A study of thirty-eight cases. J Bone Joint Surg 31 : 252
