The patient

A 25-year-old woman presented with recurrent left second metacarpal giant cell tumor of bone. She previously was treated with extensive curettage, bone graft substitute placement and Kirschner wire fixation. Giant cell tumor of bone is a benign aggressive tumor with a high rate of local recurrence and development of lung metastases in approximately 1% to 2% of patients.

This patient developed recurrent pain, stiffness and mass. Magnetic resonance imaging (MRI) and radiographs revealed evidence of recurrence, the extent of which was difficult to determine due to artifact from prior bone grafting.

The challenge

Despite medication, the patient had persistent symptoms and did not want to continue lifelong systemic therapy. She did not wish to have amputation without another attempt to salvage her index finger, but the allograft and free flap options discussed have high complication rates and unreliable functional outcomes.

Since 1999, the orthopedic oncology group at Kanazawa University in Japan has pioneered the use of liquid nitrogen-treated tumor-bearing autografts for malignant and benign aggressive bone tumors. Freezing has been found to kill the tumor cells without impairing bone healing potential as is seen with autoclaving and gamma irradiation. They developed a pedicle technique in which the tumor-bearing bone is frozen in the sterile field while still attached to the adjacent joint, thus preserving the articular blood supply and ligamentous stability. The published long-term results have been excellent with respect to both function and local tumor control. The technique has been widely adopted throughout Asia, although it is rarely used in North America.

The solution

After thorough informed consent, the patient elected resection of the soft tissue tumor component and frozen pedicle autograft reconstruction of the second metacarpal.

Resection of the soft tissue component was facilitated by the prior denosumab treatment, which had increased the ossification of the soft tissue component.

Osteotomy through the second metacarpal was performed proximal to the tumor, and the metacarpal canal was curetted to remove all gross tumor tissue. Distally, the index metacarpal ulnar collateral ligament was transected, permitting rotation of the tumor-bearing second metacarpal from the wound on the intact radial collateral ligament. The bone was bathed in liquid nitrogen on the sterile field. After warming with normal saline, the osteotomy was repaired with plate and screws and the ulnar collateral ligament with sutures.

The result

Postoperatively, the patient experienced superficial thermal damage to the skin (from proximity to the liquid nitrogen), numbness to the index finger (likely due to traction during dissection or thermal injury) and stiffness of the digit. All of these resolved within three months. She had dramatic improvement in both pain and function. She resumed her prior occupation.

There has been no evidence of local recurrence at three years postoperatively.

Treatment and results may not be representative of all similar cases.