title: Giant cell tumor with pathologic fracture: should we curette or resect?
abstract: BACKGROUND
  Approximately one in five patients with giant cell tumor of bone presents with a pathologic fracture. However, recurrence rates after resection or curettage differ substantially in the literature and it is unclear when curettage is reasonable after fracture.
  
  
  OBJECTIVE
  We therefore determined: (1) local recurrence rates after curettage with adjuvants or en bloc resection; (2) complication rates after both surgical techniques and whether fracture healing occurred after curettage with adjuvants; and (3) function after both treatment modalities for giant cell tumor of bone with a pathologic fracture.
  
  
  METHODS
  We retrospectively reviewed 48 patients with fracture from among 422 patients treated between 1981 and 2009. The primary treatment was resection in 25 and curettage with adjuvants in 23 patients. Minimum followup was 27 months (mean, 101 months; range, 27-293 months).
  
  
  RESULTS
  Recurrence rate was higher after curettage with adjuvants when compared with resection (30% versus 0%). Recurrence risk appears higher with soft tissue extension. The complication rate was lower after curettage with adjuvants when compared with resection (4% versus 16%) and included aseptic loosening of prosthesis, allograft failure, and pseudoarthrosis. Tumor and fracture characteristics did not increase complication risk. Fracture healing occurred in 24 of 25 patients. Mean Musculoskeletal Tumor Society score was higher after curettage with adjuvants (mean, 28; range, 23-30; n = 18) when compared with resection (mean, 25; range, 13-30; n = 25).
  
  
  CONCLUSIONS
  Our observations suggest curettage with adjuvants is a reasonable option for giant cell tumor of bone with pathologic fractures. Resection should be considered with soft tissue extension, fracture through a local recurrence, or when structural integrity cannot be regained after reconstruction.
  
  
  METHODS
  Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
authors.affiliation: Department of Orthopaedic Surgery, Leiden University Medical Center, Postzone J11-R70, PO Box 9600, 2300 RC Leiden, The Netherlands. lizzvanderheijden@gmail.com
authors.forename: Lizz
authors.initials: L
authors.lastname: van der Heijden
authors.forename: P D Sander
authors.initials: PD
authors.lastname: Dijkstra
authors.forename: Domenico A
authors.initials: DA
authors.lastname: Campanacci
authors.forename: C L Max H
authors.initials: CL
authors.lastname: Gibbons
authors.forename: Michiel A J
authors.initials: MA
authors.lastname: van de Sande
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D001859:Bone Neoplasms / Q000150:complications / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D002648:Child; D003475:Curettage / Q000009:adverse effects / Q000401:mortality; D018572:Disease-Free Survival; D005060:Europe; D005260:Female; D005592:Fracture Fixation; D017102:Fracture Healing; D005598:Fractures, Spontaneous / Q000209:etiology / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D018212:Giant Cell Tumor of Bone / Q000150:complications / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D009364:Neoplasm Recurrence, Local; D010027:Osteotomy / Q000009:adverse effects / Q000401:mortality; D016016:Proportional Hazards Models; D019651:Plastic Surgery Procedures / Q000009:adverse effects / Q000401:mortality; D012189:Retrospective Studies; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D055815:Young Adult