Incidence and progression of osteoarthritis following curettage and cementation of giant cell tumor of bone around the knee: long-term follow-up

This study included 119 patients, 54 (45.4%) males and 65 (54.6%) females, with a mean age at presentation of 29.4 ± 9.2 (range, 15–56) years. Patients presented with pain (n = 89, 74%) or pain and swelling (n = 30, 26%). Pathological fractures were encountered in 35 (29.4%) patients.

Regarding tumor location, 70 (58.8%) lesions were located in the distal femur and 49 (41.2%) in the proximal tibia. All tumors reached the subchondral bone, and 92 (77%) tumors were in direct contact with the articular cartilage. Patients presented at our institute with de novo lesions (n = 84, 70.6%) or recurrent lesions (n = 35, 29.4%); see Table 1.

Table 1 Baseline and demographic data for the included patients

No patients had arthritis in the preoperative plain X-rays. Patients did not receive denosumab before surgery. A high-speed burr was used in all patients except 4 patients who were operated on before the adoption of the extended curettage technique. Hydrogen peroxide was used in 28 (23.5%) patients.

The mean number of bone cement packs (40 gm) used was 2.5 ± 0.95 (range, 1–5). An iliac crest bone graft towards the articular surface was used in 5 (4.2%) patients. Additional internal fixation procedures were done in 16 (13.4%) patients using Steinmann pins (n = 8) or plate osteosynthesis (n = 8). The mean operative time was 1.69 ± 0.55 (range, 1–3) h.

The mean follow-up period was 13.2 ± 3.16 (range, 10–22) years.

The mean MSTS score was 28.5 ± 1.9 (range, 20–30). Patients who developed arthritis showed a lower mean MSTS score at the final follow-up than those without arthritis: 27.3 ± 2.6 and 28.8 ± 1.4, respectively; P = 0.009.

Regarding the range of motion, 109 (91.6%) patients achieved the full range of knee flexion and extension, while 10 (8.4%) patients had a reduced range of motion of 5–110° (n = 1), 0–100° (n = 2), 0–90° (n = 2), 20–100° (n = 2), 0–80° (n = 1), 20–90° (n = 1), and 0–60° (n = 1). Four patients had flexion deformities.

Out of all the patients, 15 (12.6%) patients had occasional knee pain on prolonged walking, exertion, going upstairs or downstairs, and deep flexion, with no arthritic changes on radiographic evaluation. Those patients were classified as KL grade 0 and responded well to physiotherapy, knee exercises, and weight reduction for overweight patients. The pain was attributed to mild patellofemoral arthritis or chondromalacia patellae.

Overall, 25 (21%) patients developed variable degrees of arthritis. Out of those 25 patients, 7 (28%) patients had KL grade 1, 11 (44%) KL grade 2, 4 (16%) KL grade 3, and 3 (12%) KL grade 4. All patients had a satisfactory response to conservative measures, including weight loss, pain medications, and physiotherapy, except 4 patients (1 patient with grade 3 who had valgus deformity and 3 patients with grade 4). Those 4 patients were offered total knee replacement but only one with grade 4 accepted; the other 3 patients refused and preferred to continue with conservative measures.

Ten (8.4%) patients had a progression of arthritis with a progression of the KL grade during the follow-up period, while the remaining 15 maintained the same KL grade during the follow-up period.

The mean age at presentation of patients who developed secondary osteoarthritis was similar to that of patients who did not develop osteoarthritis: 29.3 ± 9.3 and 29.4 ± 9.3 years, respectively; P = 0.958. Moreover, other factors, including gender, presence of pathological fracture at presentation, whether the tumor was de novo or recurrent at presentation, and the tumor location, were not associated with the incidence of osteoarthritis; see Table 2.

Table 2 Factors affecting the incidence of secondary osteoarthritisFig. 1figure 1

A 29-year-old male with giant cell tumor and pathologic fracture of the distal femur treated with curettage and cementation with distal femur plate fixation. A Preoperative AP and lateral X-rays. B Preoperative coronal, sagittal, and axial MRI cuts. C Immediate postoperative AP and lateral X-rays. D Ten-year follow-up AP and lateral X-rays with KL grade 1

Fig. 2figure 2

A 25-year-old female with giant cell tumor of the distal femur treated with curettage and cementation. A Preoperative AP X-ray. B Preoperative coronal, sagittal, and axial MRI cuts. C Immediate postoperative AP and lateral X-rays. D Ten-year follow-up AP and lateral X-rays with KL grade 1

Fig. 3figure 3

A 28-year-old male with giant cell tumor and pathologic fracture of the distal femur treated with curettage and cementation with fixation using rush pins. A Preoperative AP and lateral X-rays. B Preoperative coronal, sagittal, and axial MRI cuts. C Immediate postoperative AP and lateral X-rays. D Ten-year follow-up AP and lateral X-rays with KL grade 3 arthritic changes

Other reported complications were acute deep venous thrombosis (n = 1) and deep infections with sinus (n = 2). The two patients with deep infection refused to have any surgical debridement, and they had good response to antibiotics. Two other patients were subjected to a fall and had a fracture proximal to the inserted cement. One was treated with ORIF, and the other was treated conservatively. No patients had instability.

Local recurrences occurred in 19 (15.9%) patients. Two of them had soft-tissue recurrences. All the recurrences appeared during the first 2 years of follow-up. These patients were treated by re-curettage and cementation. Patients with a soft-tissue recurrence were treated by excision. None of these patients developed any recurrence after that.

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