Journal of Orthopaedic Surgery 2008;16(1):75-9
Curettage and allograft reconstruction for
giant cell tumours
T Morii, H Yabe, H Morioka, Y Suzuki, U Anazawa, Y Toyama
Department of Orthopaedic Surgery, Keio University School of Medicine, Tokyo, Japan
ABSTRACT
Purpose. To evaluate treatment outcomes in patients
with giant cell tumours after curettage and allograft
reconstruction and to identify the risk factors for
poor oncological and functional outcome.
Methods. 29 patients with giant cell tumours of bone
who underwent curettage and allograft reconstruction
were retrospectively reviewed. The adjuvants used
were heat treatment by electrocautery and hot
water. Types of allograft used, time to bone union,
complications, functional outcomes, and risk factors
for poor function were analysed.
Results. The mean time to bone union was 2.8 (range,
15) months. In 7 patients the tumours recurred (6
within 2 years); the 5-year recurrence-free survival rate
was 77%. Three recurrences were classified as grade
III and 4 as grade II; recurrence and the Campanacci
grade showed a trend towards association (p=0.06).
Tumour in the distal femur was a risk factor for
postoperative fracture (p=0.02). Functional outcomes
were excellent in 20 patients, good in 6, fair in 2, and a
failure in one. The risk factors for poor function were
Address correspondence and reprint requests to: Dr Takeshi Morii, Department of Orthopaedic Surgery, Kyorin University,
6-20-2 Shinkawa Mitaka, Tokyo, 181-8611, Japan. E-mail: t-morii@kyorin-u.ac.jp
recurrence (p=0.002) and joint instability (p=0.008) but
not the Campanacci grade (p=0.10) or postoperative
fracture (p=0.76). Lung metastasis, infection, and
non-union were not encountered.
Conclusion. Despite a relatively high recurrence
rate (24%), 26 (90%) of the 29 patients had excellent/
good functional outcomes. We recommend the use of
adjuvants and allografts for the management of giant
cell tumours.
Key words: giant cell tumor of bone; reconstructive surgical
procedures; transplantation, homologous
INTRODUCTION
Giant cell tumours (GCTs) are locally aggressive
and prone to recur.1,2 The choice of treatment and
reconstruction remains controversial. Wide resection
with prosthesis reconstruction provides advantages
in terms of local control. The risk of recurrence is high
after curettage alone,3,4 and therefore adjuvants such as
cryosurgery, cement, phenol or a combination of these
are recommended.310 Various reconstructions using
cement, autograft, allograft,1114 and hydroxyapatite
76 T Morii et al Journal of Orthopaedic Surgery

Table 1 should be considered. Besides, allografts have no

Patient profiles adjuvant cementing effect.
We aimed to evaluate treatment outcomes in
Characteristics No. of patients patients with GCTs, after curettage and allograft
Gender reconstruction and to identify the risk factors for poor
Male 21 oncological and functional outcomes.
Female 8
Mean age (range) [years] 35 (1669)
Tumour site
Distal femur 9 MATERIALS AND METHODS
Proximal tibia 8
Proximal femur 4 Of 50 patients with GCTs of bone treated in our
Distal radius 4 hospital over the past decade, 29 who underwent
Pelvic bone 3 curettage and allograft reconstruction with at least 2
Proximal humerus 1
Campanacci grading years of follow-up (mean, 4.3 years; range, 210 years)
Grade I 6 were retrospectively reviewed (Table 1). Curettage
Grade II 19 was performed through a large cortical window.
Grade III 4 The cavity was then burred, washed, and brushed
Reconstruction materials
to remove all visible tumour tissue. Heat treatment
Allograft (chip) 26
Allograft (chip and fibula) 1 included electrocautery and filling the cavity with
Allograft and biopex 1 hot water (60C) for 5 minutes. The donor bone was
Allograft and autograft 1 sterile and preserved in a deep freezer at -80C for at
least 3 months. It was then thawed in hot water at
60C for 10 hours.
have been proposed. However, recent studies suggest The types of allograft used, times to bone union,
that reconstruction and adjuvants are not needed complications, functional outcomes, and risk factors
after careful, intensive curettage for intra-osseous for poor function were analysed. Oncological
GCTs because of low recurrence rates and fine bone complications included recurrence and distant
formation in the cavity.15 metastasis. Surgery-related complications included
In our hospital, the most popular reconstruction fracture, non-union, joint instability, and infection.
material selected for GCT patients was allograft. Its Bone union was defined as integration of the allograft
benefits include reduction in operating time, unlimited with surrounding host bone with disappearance
supply, and no donor-site morbidity. However, the of the demarcation border (Fig. 1). Tumours were
risk of contamination by viral diseases and rejection evaluated based on the Campanacci grading system.4

(a) (b) (c)

Figure 1 Radiographs of a patient with giant cell tumour in the proximal tibia: (a) preoperation, (b) after curettage and
allograft reconstruction showing sharp graft margins, and (c) 11 weeks later showing disappearance of the sharp line.
Vol. 16 No. 1, April 2008 Curettage and allograft reconstruction for giant cell tumours 77

100 100 Grade I

Recurrence-free survival rate (%)

Recurrence-free survival rate (%)

80 80
Grade II
60 60

40 40

20 20
Grade III
0 0

0 20 40 60 80 100 120 140 0 20 40 60 80 100 120 140

Time (months) Time (months)

Figure 2 The Kaplan-Meier recurrence-free survival curve Figure 3 A trend of association is present between the
showing recurrence of tumour in 6 of 7 patients within 2 Campanacci grade and recurrence.
years, the longest being 6 years.

Functional outcome was evaluated based on Mankins Table 2

method.14 Risk factors for poor function
Kaplan-Meier survival analysis, log-rank
tests, Spearmans rank correlation coefficients, Chi Risk factors Function (No. of patients)
squared tests, and Mann-Whitney U tests were used. Excellent Good Fair Failure
Differences were considered significant when a p
Campanacci
value was <0.05. grade (p=0.10)
I 6 0 0 1
II 12 4 2 0
RESULTS III 2 2 0 0
Recurrence
(p=0.0005)
The mean time to bone union was 2.8 (range, 1 Yes 2 4 1 1
5) months. In 7 patients the tumours recurred (6 No 18 2 1 0
within 2 years); the 5-year recurrence-free survival Fracture
rate was 77% (Fig. 2). Two recurrences were in the (p=0.76)
distal femur, 2 in the proximal tibia, one each in the Yes 2 0 1 0
No 18 6 1 1
proximal humerus, sacrum, distal radius, and ilium. Joint instability
In one patient the recurrence in the proximal humerus (p=0.008)
was resolved with wide resection and prosthetic Yes 0 0 2 0
reconstruction. All others underwent repeat curettage No 20 6 0 1
and allograft reconstruction. Three recurrences were
classified as grade III, and 4 as grade II; recurrence
and the Campanacci grade revealed a trend towards
association (p=0.06, Log-rank test, Fig. 3). instability (after repeat surgery). In one who underwent
Tumour in the distal femur was a risk factor for wide resection and prosthetic reconstruction for
postoperative fracture (p=0.02, Chi squared test), recurrence, it was a failure (Table 2). The risk factors
because all 3 postoperative fractures (one fixed for poor function were recurrence (p=0.0005, Mann-
internally, and 2 conservatively) occurred in the distal Whitney U test) and joint instability (p=0.008, Mann-
femur. Salvage surgery for the unstable joint was not Whitney U test) but not according to the Campanacci
performed as the patient refused. grade (p=0.10, Spearmans rank correlation coefficient)
Functional outcomes were excellent in 20 patients or presence of postoperative fracture (p=0.76, Mann-
(including the 2 with postoperative fracture treated Whitney U test). Lung metastasis, infection, and non-
conservatively), good in 6, and fair in 2 with joint union were not encountered.
78 T Morii et al Journal of Orthopaedic Surgery
DISCUSSION
Tu m o u r- a n d i n t e r v e n t i o n - re l a t e d v a r i a b l e s
determine the choice of treatment. Tumour-related
variables such as tumour size, tumour site, biologic
activity, bony cortex destruction (i.e. Campanacci
grading), and pathologic fracture are uncontrollable.
Whether interventions such as the use of adjuvants
or reconstruction options can improve treatment
outcome remains controversial.
Adjuvants reduce the risk of recurrence. Patients
with curettage alone have higher recurrence rates
than those with combined adjuvant treatment (45%
vs 18%).3 In patients treated with curettage without
adjuvants, the recurrence rate varies from 33 to
47%.4,8,16,17 The rate decreases to 5%9 to 8%7 when
cement is used, and to 2.3%5 after cryosurgery. Yet
in recent studies, recurrence rates of 12%11 and 0%18
have been reported in patients with curettage alone.
A multicentre study by a Canadian Sarcoma Group
has reported an overall recurrence rate of 17% and
claimed that the filling material or type of adjuvant
has no significant impact on recurrence.19 It has been
suggested that adjuvant is not needed for intra-
osseous GCTs,15 as the recurrence rates of Campanacci
grade-I/II and grade-III GCTs were only 7% and 29%,
respectively.
Such variation in recurrence rates is attributed
to: (1) development of cross-sectioned computed
tomographic scanning and magnetic resonance
imaging enabling accurate preoperative assessment
of the lesion, (2) concerns over recurrence leading
surgeons to undertake more aggressive curettage,
(3) variations in the grade and site of tumour among
different series, and (4) differences in surgical protocol
between hospitals and/or surgeons.
Our choice of treatment for recurrence is repeat
curettage, with a goal to preserve the joint and
function, although en bloc resection offers better local
control. Failure to salvage the joint is due to incomplete
initial surgery, delay in diagnosis of the recurrence (>6
months), and subchondral recurrence.20 The success
rate of repeat curettage is 79 to 100%.15 Our primary
goal of treatment is to enhance the quality of life of
patients rather than reduce the recurrence.
The difference in functional outcomes after 2
or more surgical procedures has been reported. In
patients treated with cryosurgery, overall function
REFERENCES
1. Unni KK. Dahlins bone tumors. General aspects and data on 11,087 cases, 5th ed. Philadelphia, New York: Lippincott
was good to excellent in 92%, moderate in 7%, and
poor in 1%,5 based on the American Musculoskeletal
Tumor Society (MSTS) system.21 In patients treated
with allografts, it was excellent/good in 78% and
fair/poor in 22%, based on a categorical scoring
system.14 Nonetheless, these single-arm studies lack
controls. The Enneking functional scores were similar
in patients treated with curettage or resection.15
Based on the MSTS system, the only risk factor for
poor function was displaced fracture; there was no
significant difference between patients treated with
cement or other types of filler.19 Pathologic fractures
affect the score for bodily pain in the Short Form-36
health survey.22 The functional outcomes using the
MSTS system, the Short Form-36, and the Toronto
Extremity Salvage Score23 were similar in the cement
and curettage groups.20 Although these studies
were not randomised control trials, they suggested
that surgical procedures do not correlate with the
functional outcomes/quality of life.
Other risk factors for poor function include
infection, fracture, recurrence, specific tumour sites,
joint instability, and metastases.14 In our study,
recurrence and joint instability were significant risk
factors, suggesting that prevention of recurrence may
improve function. Nonetheless, the latest functional
evaluation may not be affected by recurrence,
owing to the salvage effect. Removal of the graft
was considered a failure despite acceptable function
after salvage operations. In our study, although joint
instability after repeat curettage correlated with poor
function, it was because patients refused salvage
operations; had proper surgical intervention been
performed, functional outcomes of the 2 patients may
have been improved. Moreover, co-existence of joint
instability and recurrence may cause bias. Despite
relatively high recurrence rates (24%), 26 (90%) of 29
patients had excellent/good functional outcomes. We
recommend the use of adjuvants and allograft for the
management of GCT.
Our study lacked an adequate number of patients
and controls, which is common in GCT studies.
Moreover it was a retrospective review from one
hospital and limited by referral bias. A randomised
controlled trial is required to identify independent
risk factors for recurrence and poor function,
and to validate the efficacy of each adjuvant and
reconstruction method.
Vol. 16 No. 1, April 2008 Curettage and allograft reconstruction for giant cell tumours 79

Raven; 1996:26383.
2. Reid R, Banerjee SS, Sciot R. Giant cell tumor. In: Christopher DM, Fletcher DM, Unni KK, Mertens F, editors. World
Health Organization Classification of Tumours. Pathology and genetics. Tumours of soft tissue and bone. Lyon: IARCPress;
2002:3102.
3. Capanna R, Fabbri N, Bettelli G. Curettage of giant cell tumor of bone. The effect of surgical technique and adjuvants on
local recurrence rate. Chir Organi Mov 1990;75:206.
4. Campanacci M, Baldini N, Boriani S, Sudanese A. Giant-cell tumor of bone. J Bone Joint Surg Am 1987;69:106-14.
5. Malawer MM, Bickels J, Meller I, Buch RG, Henshaw RM, Kollender Y. Cryosurgery in the treatment of giant cell tumor. A
long-term follow-up study. Clin Orthop Relat Res 1999;359:17688.
6. Bickels J, Meller I, Shmookler BM, Malawer MM. The role and biology of cryosurgery in the treatment of bone tumors. A
review. Acta Orthop Scand 1999;70:30815.
7. Bini SA, Gill K, Johnston JO. Giant cell tumor of bone. Curettage and cement reconstruction. Clin Orthop Relat Res
1995;321:24550.
8. Saglik Y, Yildiz Y, Karakas A, Ogut H, Erekul S. Giant cell tumor of bone. Bull Hosp Jt Dis 1999;58:98104.
9. Gitelis S, Mallin BA, Piasecki P, Turner F. Intralesional excision compared with en bloc resection for giant-cell tumors of
bone. J Bone Joint Surg Am 1993;75:164855.
10. Ward WG Sr, Li G 3rd. Customized treatment algorithm for giant cell tumor of bone: report of a series. Clin Orthop Relat
Res 2002;397:25970.
11. Blackley HR, Wunder JS, Davis AM, White LM, Kandel R, Bell RS. Treatment of giant-cell tumors of long bones with
curettage and bone-grafting. J Bone Joint Surg Am 1999;81:81120.
12. Malek F, Krueger P, Hatmi ZN, Malayeri AA, Faezipour H, ODonnell RJ. Local control of long bone giant cell tumour using
curettage, burring and bone grafting without adjuvant therapy. Int Orthop 2006;30:4958.
13. Cheng MT, Chen TH, Chen WM, Huang CK, Chiang CC, Su YP. Periacetabular giant cell tumor treated with intralesional
excision and allograft reconstruction. J Chin Med Assoc 2004;67:53741.
14. Mankin HJ, Hornicek FJ. Treatment of giant cell tumors with allograft transplants: a 30-year study. Clin Orthop Relat Res
2005;439:14450.
15. Prosser GH, Baloch KG, Tillman RM, Carter SR, Grimer RJ. Does curettage without adjuvant therapy provide low recurrence
rates in giant-cell tumors of bone? Clin Orthop Relat Res 2005;435:2118.
16. Sung HW, Kuo DP, Shu WP, Chai YB, Liu CC, Li SM. Giant-cell tumor of bone: analysis of two hundred and eight cases in
Chinese patients. J Bone Joint Surg Am 1982;64:75561.
17. Masui F, Ushigome S, Fujii K. Giant cell tumor of bone: a clinicopathologic study of prognostic factors. Pathol Int
1998;48:7239.
18. Richardson MJ, Dickinson IC. Giant cell tumor of bone. Bull Hosp Jt Dis 1998;57:610.
19. Turcotte RE, Wunder JS, Isler MH, Bell RS, Schachar N, Masri BA, et al. Giant cell tumor of long bone: a Canadian Sarcoma
Group study. Clin Orthop Relat Res 2002;397:24858.
20. McGough RL, Rutledge J, Lewis VO, Lin PP, Yasko AW. Impact severity of local recurrence in giant cell tumor of bone. Clin
Orthop Relat Res 2005;438:11622.
21. Enneking WF, Dunham W, Gebhardt MC, Malawar M, Pritchard DJ. A system for the functional evaluation of reconstructive
procedures after surgical treatment of tumors of the musculoskeletal system. Clin Orthop Relat Res 1993;286:2416.
22. Ware JE Jr, Sherbourne CD. The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection.
Med Care 1992;30:47383.
23. Davis AM, Bell RS, Badley EM, Yoshida K, Williams JI. Evaluating functional outcome in patients with lower extremity
sarcoma. Clin Orthop Relat Res 1999;358:90100.