Abstract

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We report a case proximal femur giant cell tumor in an active young male who presented with pathological fracture. The tumor was excised with a wide margin and the defect was reconstructed successfully with a custom made endoprosthesis. After three years, the patient had an excellent functional outcome with Musculoskeletal Tumor Society Functional score of 26.7.

Introduction

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Giant cell tumor (GCT) is a benign/locally aggressive bone tumor with predilection to occur the knee joint [1, 2]. Proximal femur is a relatively rare site for the occurrence of primary GCT accounting for only 1-10% [3,4,5]. GCT in this location poses a unique challenge in management owing to difficulties in preoperative diagnosis, obtaining a safe surgical margin and reconstruction of the surgical defect, considering the complex biomechanics of the hip joint [6-9]. We report a case of GCT of proximal femur (Enneking stage II) associated with pathological fracture managed effectively by wide excision and proximal femur endoprosthesis.

Case Report(s)

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A 44-year-old man presented with history of right hip pain for 3 months. He sustained a trivial fall 2 days before and after that he could not bear weight on the affected limb. He had no history of constitutional symptoms and had no history of any congenital anomaly.

On local examination, he had an obvious external rotation deformity and tenderness over the trochanteric region. Antero-posterior radiograph of the right hip (figure 1) revealed a lytic lesion involving the proximal femur (ISOLS H2), associated with pathological fracture. Magnetic resonance imaging showed a heterogeneous high intensity on T2 weighted image involving the proximal femur (figure 2). Histopathological evaluation of the lesion on needle biopsy revealed a collection of multinucleated-osteoclastic-giant cells in a background of stromal cells. The stromal cells were mitotically active. The possibility of giant cell tumor was raised. Chest radiograph did not show any evidence of metastasis.

The histological and radiological grading of the lesion showed Enneking surgical stage II and Campanacci radiological grade 2.  It was decided to go for wide surgical excision followed by endoprosthesis implantation. The tumor was removed enbloc (figure 3). A large surgical defect was created which was reconstructed with a 270 mm long custom-made femoral-endoprosthesis with a stem diameter of 13 mm. Abductors were sutured to the endoprosthesis along with the ilio-psoas and external rotators.

Post-operatively the patient had a shortening of 1 cm on the operated side compared to the other limb. Post-operative radiograph showed a well fixed endoprosthesis. The patient was followed up every monthly for first 6 months and 3 monthly up to 3 years. He had a good functional outcome (Musculoskeletal Tumor Society Functional Score=26.7) at the end of 3 years. Chest radiograph showed no evidence of metastasis. Local radiographs showed no evidence of loosening of the implant. He was able to do his normal daily activities comfortably.

Discussion

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Giant cell tumor is notorious for local recurrence unless completely excised with adequate margin. Curettage with or without bone grafting are associated with high recurrence rates and can help a certain group of patients when carefully chosen [10-12]. Adequate (wide) tumor margin during excision seems to be an important predictor of good outcome than adjuvant therapy following curettage [5-7]. Wide excision and reconstruction with endoprosthesis for proximal femur GCT in young patients has got its own limitations considering the high rate of mechanical failure and concerns over the longevity of the implant [8]. This age group of patients comes under the high demand group, whose daily activities can mechanically load the endoprosthesis with forces beyond its stress limits. Nevertheless, wide excision and tumor endoprosthesis remains the primary treatment of choice in giant cell tumor in this region instead of using it as a secondary procedure for recurrence, non-union or other complications [10-12].

There is a higher incidence of pathological fracture associated with GCT of proximal femur than in any other areas. Pathological fracture is associated with higher recurrence rate due to tumor dissemination during fracture [4]. Pathological fracture associated with GCT of proximal femur poses a challenge in management particularly in the young active man. Achieving wide tumor margin becomes extremely difficult with intralesional excision which is compounded by the lack of stability at the fracture site with routine fixation devices.

Conclusion

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Wide margin excision of the tumor and reconstruction using a tumor endoprosthesis seems to be an adequate management for proximal femur GCT with pathological fracture while carefully following up the patient for early mechanical failure.

Authors contribution(s)

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SD managed the patient. NT, SKT and SB helped in acquisition of the data. TT reviewed the literature. All the authors have read the manuscript and approved.

References

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8. Zwart HJ, Taminiau AH, Schimmel JW et al (1994) Kottz modular femur and tibia replacement. 28 tumor cases followed for 3(1?8) years. Acta Orthop Scand 65:315?318
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10. Deheshi BM, JaVer SN, GriYn AM, Ferguson PC, Bell RS, Wunder JS (2007) Joint salvage for pathologic fracture of giant cell tumor of the lower extremity. Clin Orthop Relat Res 459:96?104.
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Source(s) of Funding

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Nil

Competing Interests

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Nil

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