Giant cell tumor (GCT) of the bone represents ~5% of primary bone tumor types and 20% of benign bone tumor types (1). The disease often occurs in adults between the ages of 20- and 40-years-old, with a higher incidence in females (2,3). GCTs are generally composed of mononuclear histiocytic cells, multinucleated giant cells resembling osteoclasts and neoplastic stromal cells that are the predominant proliferating cell population (4,5). The disease is generally recognized as a border or low-grade, with a certain degree of invasive characteristics, demonstrated by biological behavior (6,7). The predominant problem in the management of GCT is local recurrence following surgical treatment: 27–65% following isolated curettage; 12–27% following curettage with adjuvants such as high-speed burr, phenol, liquid nitrogen, or polymethylmethacrylate; and 0–12% after en bloc resection (6).

The distal radius and ulna is the fourth most common location for GCT of the bone, after the distal femur, proximal tibia and proximal femur, accounting for ~9% of cases (8,9). Numerous previous studies have identified the distal radius and ulna as being particularly prone to recurrence. To date, the ideal treatment methods for GCTs of the distal ulna and radius remain controversial (10–12). En bloc resection of GCT provides lower rates of recurrences, which also sacrifices the joint, results in a major reconstruction, and the functional outcomes are questionable. Intralesional excision (curettage) preserves the joint; however, has a reasonably high risk of local recurrence even if used in combination with surgical adjuvants, including liquid nitrogen, phenol or cement (8,10,13). Therefore, the effect of different surgical modalities on tumor recurrence and postoperative wrist function remains unclear. The aim of the present study was to assess the clinical effects of three surgical approaches for GCT of the distal radius and ulna, including curettage plus inactivated tumor bed plus allogeneic bone graft/bone cement augmentation, simple en bloc resection, and en bloc resection and reconstruction with non-vascularized fibular autograft/allogeneic bone graft segment.

Currently, no consensus has been reached regarding the optimal treatment approach for GCTs that occur in the distal radius. Although almost 100% local control can be achieved with en bloc resection (16), limb function is usually offset (17). Intralesional excision with curettage is the standard method of treatment; however, it is associated with the rates of local recurrence ranging between 10 and 40% (18–21). As a result, topical adjuvant agents, including hydrogen peroxide, phenol and alcohol, have been used to decrease the recurrence rates (9). Liu et al (10) reported that patients in the intralesional excision group exhibited a higher recurrence rate, particularly for Campanacci's III Grade GCT compared with the en bloc resection group (10). Pazionis et al (11) reported that the odds of local recurrence were three times less in the en bloc resection group (n=60) compared with the intralesional excision group (n=81). Considering the high local recurrence risk of curettage, the 23 patients with Campanacci's grade II and III GCT of the distal radius and ulna were all treated with en bloc resection, and only one patient (1/23; 4.3%) relapsed. However, 6 months after secondary surgery, the patient developed pulmonary metastasis, which may be associated with the high invasiveness. Considering the limited lesions of Campanacci's grade I GCT, the present study selected the curettage plus inactivated tumor bed and allogeneic bone graft (1 case)/bone cement augmentation (3 cases) for Campanacci's grade I GCT of the distal radius and ulna, which can theoretically guarantee the safety boundary. However, the incidence of the postoperative recurrence of patients was 50% (2/4), which is higher compared with that reported previously, which may be due to limited sample size. It can also partially reflect that the application of bone cement augmentation cannot reduce the risk of the recurrence of GCT (9). A previous report suggested that wrist joint can still reach 75% grasp strength and 80% range of motion following distal ulnar resection (22). Therefore, in the present study, en bloc resection without reconstruction for Campanacci's grade II and III GCT of the distal ulna was selected. Following surgery, no statistically significant difference was revealed regarding the incidence of the postoperative recurrence of the GCT in distal ulna and radius (14.3 vs. 10%). Although no statistically significant difference was found in the present study regarding the incidence of the postoperative recurrence among the three surgical approaches for the GCT on distal ulna and radius, a >10-fold higher difference was revealed regarding the incidence of the postoperative recurrence of curettage when compared with that of en bloc resection. Further studies with a larger number of samples are warranted.

Various surgical approaches for GCT of the distal radius and ulna can produce different rates of postoperative complications. Previous reports suggested that en bloc resection was associated with a relatively high rate of major complications (range, 29–100%) (23–27). These complications included nonunion at the graft-radius junction (12–38%) (26–28), fracture of graft (13–29%) (26,27), subluxation (12–67%) (23,26), arthritis (13–50%) (23,28) and postsurgical pneumonia (24). Notably, in the present study, 1 case (5.6%) experienced postoperative infection, which may be associated with rich blood supply and rapid tissue healing. Additionally, 2 cases of internal fixation fracture (11.2%) and 1 case of nonunion (5.6%) occurred. These patients received reconstruction with allogeneic bone graft. This may be associated with the slow creeping substitution of allografts and premature functional exercise. These 3 patients underwent with fibulo-scapholunate arthrodesis and thereafter no postoperative infection or nonunion was noted. Overall, the postoperative complications observed in the present study were lower compared with that in the aforementioned reports.

Patients with GCT of the distal radius and ulna can have long-term survival, unless the incidence of pulmonary metastasis occurs; therefore, functional recovery of the wrist is extremely important. In the present study, patients undergoing allogeneic bone graft were all treated with individual customized allografts with the preservation of the articular aspect of the distal radius. The overall excellent and good rate of en bloc resection and reconstruction was 70.4%, which is not statistically different compared with that of curettage. The present study suggested that en bloc resection and reconstruction can be used as the standard initial treatment method for Campanacci's grade II and III GCT. Wysocki et al (12) suggested that curettage can be considered for the initial treatment for Campanacci's grade II and III GCT of the distal radius, since en bloc resection can be performed if tumor recurrence occurred. However, secondary surgery not only increases the expense of the patients, it also increases the risk of postoperative complications. Therefore, the present study suggested that en bloc resection can be used as the standard initial treatment method for Campanacci's grade II and III GCT, whereas curettage can be used for Campanacci's I Grade GCT.

In conclusion, in order to achieve the best clinical effects for patients with GCT on distal radius and ulna, individualized treatment regimens must be designed according to the different Campanacci's grades and tumor locations.