Limb salvage with wide resection and endoprosthetic reconstruction for giant cell tumour of proximal tibia: a case report

INTRODUCTION

Giant cell tumour of bone giant cell tumour (GCT) of bone is a benign but locally aggressive primary bone tumour that commonly affects skeletally mature individuals, typically in the third to fourth decade of life, with a predilection for the epiphyseo-metaphyseal region of long bones around the knee.¹ The proximal tibia is one of the most frequently involved sites and presents unique challenges due to its subarticular location, thin soft tissue coverage, and critical role in weight- bearing across the knee joint.² Although histologically benign, GCT exhibits aggressive biological behaviour characterized by cortical destruction, local invasion, and a significant risk of recurrence.³ Various surgical modalities have been described for the management of GCT, with the primary goal being complete tumour removal while preserving joint function.⁴ Extended intralesional curettage with the use of high-speed burrs and adjuvant agents such as phenol, hydrogen peroxide, and polymethylmethacrylate (PMMA) cement remains the standard treatment for most Campanacci grade I and II lesions.⁵ Reconstruction following curettage using techniques such as the sandwich technique, bone grafting beneath the subchondral bone, and cement augmentation with internal fixation has shown good functional outcomes in proximal tibial lesions.⁶ Despite advances in intralesional surgery, recurrence remains a significant concern, particularly in tumours around the knee joint.⁷ Factors such as cortical breach, soft tissue extension, and inadequate curettage contribute to higher recurrence rates.⁸ In cases with extensive bone loss, recurrent disease, or pathological fractures, more radical procedures such as wide resection and limb salvage reconstruction using custom or modular mega-prostheses may be required.⁹ Adjuncts in the management of GCT have also evolved, with denosumab emerging as a useful option in selected cases, particularly in advanced, recurrent, or unresectable tumours, by reducing tumour burden and facilitating surgical management.¹⁰ Although GCT most commonly involves long bones, rare presentations in locations such as the spine have also been reported, where diagnosis and management become more complex due to anatomical constraints and potential neurological involvement.¹¹ Overall, management of proximal tibial GCT requires an individualized, multidisciplinary approach to achieve optimal oncological control and functional outcomes.¹²

CASE REPORT

A41-year-old female presented to the orthopaedic outpatient department with complaints of pain and swelling around the left knee joint associated with difficulty in weight bearing for three months. There was no history of trauma, fever, or systemic illness. On clinical examination, swelling was noted over the proximal aspect of the left tibia. There was no local rise in temperature. Tenderness was present over the proximal tibia. The range of motion of the left knee joint was painful and terminally restricted.

Plain radiographs of the left knee revealed a lytic lesion involving the proximal tibia suggestive of an aggressive bone lesion. MRI of the left knee demonstrated features consistent with a giant cell tumour of the proximal tibia with posterior extension into adjacent soft tissues. Considering the extent of the lesion, the patient was planned for wide excision of the tumour with limb salvage reconstruction.

Surgical procedure

A longitudinal midline incision extending approximately 4-5 cm above and 4-5 cm below the knee joint was made. Careful dissection was carried out to expose the tumour. The posterior vascular pedicle was carefully dissected and preserved.

After separation of the giant cell tumour from surrounding soft tissue attachments, the tibia was osteotomized approximately 5 cm distal to the inferior margin of the tumour. The tumour-bearing segment of the proximal tibia was excised en bloc and sent for histopathological examination. Reconstruction was performed using a proximal tibial endoprosthesis. The tibial canal was reamed up to size 11. The distal femur was prepared with a box cut and freshening of the bone surface. Trial components were placed to assess alignment and stability.

The final prosthetic components consisted of femoral component size 11 with ring, proximal tibial component size 11 10×110 mm collar stem cemented into the tibia using bone cement the patellar tendon was sutured to the tibial component to restore extensor mechanism function. The wound was closed in layers after adequate histopathology.

Histopathological examination of the excised specimen confirmed the diagnosis of giant cell tumour of bone, characterized by numerous multinucleated giant cells dispersed among mononuclear stromal cells.

DISCUSSION

Giant cell tumour (GCT) of bone is a benign but locally aggressive primary bone tumour characterized by proliferation of mononuclear stromal cells and osteoclast-like multinucleated giant cells.¹¹ It typically affects skeletally mature individuals in the third to fifth decades of life with a slight female predominance.² The tumour most commonly arises in the epiphyseal region of long bones, with a strong predilection for the distal femur and proximal tibia around the knee joint.³

Clinically, patients usually present with insidious onset of pain, swelling, and restriction of joint movements.⁴ In advanced disease, cortical destruction with soft-tissue extension may lead to joint instability, functional impairment, and difficulty in weight-bearing.⁵ Radiologically, GCT appears as an eccentric, expansile, lytic lesion involving the epiphysis with cortical thinning and absence of mineralized matrix.⁶ MRI plays a key role in delineating intraosseous extent, soft-tissue involvement, and articular cartilage status, thereby guiding surgical planning.⁷

The primary goal of management is complete tumour removal while preserving joint function whenever feasible.⁸

Extended intralesional curettage with the use of high-speed burrs and local adjuvants such as phenol, hydrogen peroxide, and polymethylmethacrylate (PMMA) cement is the standard treatment for most Campanacci grade I and Ⅱ lesions.⁹ Reconstruction following curettage using techniques such as the sandwich technique, subchondralbone grafting, and cement augmentation with internal fixation has shown good functional outcomes, particularly in proximal tibial lesions.¹⁰

Despite advances in intralesional surgery, recurrence remains a significant concern, with reported rates ranging from 10%to 25%.¹¹ Recurrence is more common in lesions with cortical breach, soft-tissue extension, or inadequate initial curettage.¹² In such aggressive or recurrent cases, wide excision may be required to achieve adequate oncological control.¹³

Wide resection, however, results in substantial bone loss and necessitates reconstruction for limb salvage.¹⁴ Endoprosthetic reconstruction has emerged as an effective option following resection of aggressive periarticular GCTs, particularly around the knee joint, as it allows immediate stability and early mobilization.¹⁵ Reconstruction of the proximal tibia requires special attention to restoration of the extensor mechanism, which is critical for achieving satisfactory functional outcomes.¹

Adjunctive therapies have expanded treatment options in recent years, with denosumab showing effectiveness in reducing tumour size and facilitating surgery in selected advanced cases.² However, surgical excision remains the definitive treatment in most cases.³ In the present case, the patient presented with an aggressive proximal tibial GCT with posterior soft-tissue extension. Considering the extent of disease, wide excision followed by proximal tibial endoprosthetic reconstruction was performed, allowing adequate oncological clearance and functional limb preservation. Postoperatively, the patient achieved stable knee reconstruction with satisfactory early functional recovery. Overall, management of aggressive proximal tibial GCT requires individualized planning, balancing oncological safety with functional preservation. Wide resection with endoprosthetic reconstruction remains a reliable limb salvage option in selected cases with extensive local disease.^4-6

CONCLUSION

Giant cell tumor of the proximal tibia can be effectively managed with wide excision and limb salvage reconstruction when there is extensive bone destruction or soft tissue extension. Endo prosthetic reconstruction offers a reliable method for restoring knee function and enabling early rehabilitation while achieving adequate tumor clearance.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: Not required

REFERENCES

1. 1. Roy M, Reddy HV, Bhikshavarthimath SA, Dwidmuthe SC, Tiwari V. Rare coexistence: Giant cell tumor recurrence and infection in the proximal tibia – A case report. J Orthop Case Rep. 2025;15(1):26-30.
2. 2. Harishkumar M, Choudhary BM, Ganesh A, Lourdes K. Advanced surgical management of proximal tibia giant cell tumor using extended curettage and sandwich technique: A case report. J Orthop Case Rep. 2025;15(8):158-63.
3. 3. Gupta VA, Tomar A, Katkani A, Modi L, Desai SM. Modular custom prosthetic reconstruction of proximal tibia giant cell tumor: A case report and review of the literature. Int J Res Orthop. 2025;11(3):635-8.
4. 4. Roy A, Vadakke Puthiyottil SS, Edayattil A. Denosumab in giant cell tumour of bone: A case series with review of literature. Asian Pac J Cancer Care. 2026;11(2):293-301.
5. 5. Govindaraj V, Chellamuthu S, Vemuri MB, Rajesh NG. Giant-cell tumor of dorsal vertebra presenting as a posterior mediastinal mass: A rare case report. Indian J Chest Dis Allied Sci. 2024;66(2):64-7.
6. 6. Gundavda MK, Agarwal MG. Extended curettage for giant cell tumors of bone: A surgeon's perspective. JBJS Essent Surg Tech. 2021;11(1):e20.00040.
7. 7. Meena AM, Jain P, Dayma RL. Retrospective study of function outcome in giant cell tumor treated by sandwich technique with internal fixation. Int J Orthop Sci. 2017;3(2):817-22.
8. 8. Moaiyadi AH, Wankhede AK, Badole CM, Patond KR. Case of giant cell tumour of proximal tibia treated with intra-lesion curettage with adjuvant therapy and reconstruction with the sandwich technique fixation. Int J Res Orthop. 2023;9(1):213-6.
9. 9. Chawla S, Mehta S, Agarwal R. Management of giant cell tumor around the knee: A retrospective analysis from an Indian tertiary care centre. Indian J Orthop. 2021;55(5):1204-11.
10. 10. Sharma V, Batra S, Kapoor SK. Surgical management of giant cell tumor around the knee joint: Functional outcomes and recurrence rate. J Clin Orthop Trauma. 2020;11(4):674-8.
11. 11. Natarajan MV, Kumar R, Rajkumar N. Limb salvage surgery for bone tumors using custom mega prosthesis: Experience from an Indian center. Indian J Orthop. 2020;54(3):311-8.
12. 12. Agarwal MG, Gundavda MK. Current concepts in the management of giant cell tumor of bone. Indian J Orthop. 2022;56(2):167-75.
13. 13. Sharma S, Maheshwari AV, Jain VK. Surgical treatment and recurrence pattern of giant cell tumor around the knee. J Orthop Surg (Hong Kong). 2021;29(3):1-7.
14. 14. Singh S, Kumar D, Tiwari A. Giant cell tumor of proximal tibia treated with curettage and bone cement: A case report. Int J Orthop Sci. 2020;6(3):345-8.
15. 15. Patel A, Shah K, Desai N. Management of giant cell tumor of bone with extended curettage and bone cement: Experience from a tertiary hospital in India. Cureus. 2023;15(5):e42132.