Bone and Joint Unit, Hôtel Dieu teaching medical center, place A.-Ricordeau, 44093 Nantes cedex, France.
Orthop Traumatol Surg Res. 2009 Oct;95(6):402-6. doi: 10.1016/j.otsr.2009.07.004. Epub 2009 Sep 19.
Giant cell tumors (GCT) of bone are benign tumors with local aggressiveness that most of the time occur around the metaphyseal area of long bones, often in contact with the articular cartilage. Their treatment remains controversial because of their high recurrence rate. The authors report a retrospective series of 30 cases treated using curettage followed by cementation. They suggest demonstrating the mechanical and functional benefit of this technique, its benefit controlling the risk of recurrence, and of osteoarthritis potential.
Between 1992 and 2005, 30 patients with GCT were treated using curettage and cementation. Twenty-six of these tumors were present around the knee: 14 at the distal femur and 12 at the proximal tibia. Preoperative radiological evaluation with standard X-rays showed that the tumor measured a mean 71x45mm, for a mean volume of 78cm(3). Seventy-three percent of these GCT were in direct contact with the articular cartilage and 40% extended to the soft tissues as seen on the CAT scan and/or MRI. All patients were treated with curettage and cementation, 16 additional internal fixation procedures were performed. The mean follow-up of this series was 6 years and 4 months. All patients continue to be monitored, with none lost to follow-up.
In all our cases, nine recurrences (30%) were observed during the first 2 years. Six patients were treated with a new curettage and cementation procedure and three underwent a total knee arthroplasty. None of these lesions had recurred at the last follow-up. The MSTS score, reflecting the function of the operated limb was a mean 93.33% (28 + or - 2/30). Standard radiological assessment showed a thin scalable border on four patients and was normal for the all-total arthroplasty cases. Two cases of minor osteoarthritis progression were noted (one less than 50% and a simple densification of subchondral bone), requiring no specific treatment. Three complications were noted: one leg deep venous thrombosis, one hematoma, and one deep infection without impacting the initial treatment outcome over the long term.
The curettage and cementation technique is usual practice in GCT treatment. Simple and reproducible, this technique has a lower rate of complication than other treatment options such as cryotherapy. It produces a lower rate of recurrence with the dual benefit of excellent mechanical and functional qualities. Diagnosis of recurrence can be made earlier because of the thin scalable border at the bone-cement interface. This technique does not generally cause osteoarthritis, which was found in only two cases with no evidence of the cement having a direct effect. The 30% recurrence rate observed in this series shows that the benefit provided by the cement as an adjuvant preservative remains modest.
The cement mechanical and cytotoxic properties as well as its innocuity and its ease of handling make curettage and cementation one of the top-ranking GCT treatment options. An even lower rate of recurrence may be obtained through development of additional adjuvant treatments such as calcitonin and bisphosphonates.
Level IV; Therapeutic study.
骨巨细胞瘤（GCT）是一种具有局部侵袭性的良性肿瘤，通常发生在长骨的干骺端区域，常与关节软骨接触。由于其高复发率，其治疗仍存在争议。作者报告了 30 例采用刮除术联合骨水泥填充治疗的回顾性系列病例。他们建议证明该技术在控制复发风险和潜在骨关节炎方面的机械和功能优势。
1992 年至 2005 年间，30 例 GCT 患者采用刮除术联合骨水泥填充治疗。其中 26 例肿瘤位于膝关节周围：14 例位于股骨远端，12 例位于胫骨近端。术前 X 线检查显示肿瘤平均大小为 71x45mm，平均体积为 78cm³。这些 GCT 中有 73%与关节软骨直接接触，40%延伸至 CAT 扫描和/或 MRI 所见的软组织。所有患者均采用刮除术联合骨水泥填充治疗，其中 16 例患者额外进行了内固定治疗。本系列的平均随访时间为 6 年 4 个月。所有患者均持续接受监测，无失访病例。
在所有病例中，前 2 年内观察到 9 例（30%）复发。6 例患者接受了新的刮除术联合骨水泥填充治疗，3 例患者接受了全膝关节置换术。在最后一次随访时，这些病变均未复发。反映手术肢体功能的 MSTS 评分平均为 93.33%（28+/-2/30）。标准影像学评估显示 4 例患者有薄的可刮除边界，所有全膝关节置换病例均正常。注意到 2 例轻度骨关节炎进展（1 例小于 50%，单纯软骨下骨致密化），无需特殊治疗。注意到 3 例并发症：1 例下肢深静脉血栓形成，1 例血肿，1 例深部感染，长期来看，这些并发症均未影响初始治疗效果。
刮除术联合骨水泥填充技术是 GCT 治疗的常规方法。该技术简单且可重复，其并发症发生率低于冷冻治疗等其他治疗方法。它具有较低的复发率，同时具有优异的机械和功能质量。由于在骨水泥界面处存在薄的可刮除边界，因此可以更早地诊断复发。这种技术通常不会引起骨关节炎，在本系列中仅发现 2 例，且没有证据表明骨水泥有直接影响。本系列观察到的 30%的复发率表明，水泥作为辅助防腐剂的益处仍然有限。
骨水泥的机械和细胞毒性特性以及其无害性和易于处理性使其成为 GCT 治疗的首选方法之一。通过开发额外的辅助治疗方法，如降钙素和双膦酸盐，可能会获得更低的复发率。
IV 级；治疗性研究。
