GCT is most commonly found in the epi-metaphyseal region of long bones. Numerous studies have reported a slight female predominance, with a peak incidence in young adults aged 20-50 years [4, 7, 9,10,11, 16, 26, 27]. The results of patients with fractures in the GTOC was in complete accordance with the reported literatures. The widely accepted consensus of most authors is that pathologic fractures cause adjacent tissue contamination, causing the development of a surrounding tissue mass [3, 4, 21, 28,29,30,31,32]. Our study is not only in accord with the reported literatures, but also indicates that soft tissue mass increases with the aggravation of complexity of fractures.
Metastases after GCT of bone are relatively rare, occurring in only 1-4% of patients [4, 7, 10, 20, 24, 31, 33]. In our research, the overall metastatic rate was 2.3% (3/130). This suggests that fractures do not increase the risk of metastasis. Although GCTs have rarely been reported to metastasize, due to their potential for aggressiveness, joint salvage operations are not often considered. GCT, as an osteolytic bone tumour, has been reported to be a relatively frequent complication of pathologic fractures [4, 10, 11, 34]. It is also commonly believed that pathologic fractures are associated with a higher recurrence risk [4, 11, 21, 26, 34, 35]. Thus, resection has been the preferred primary treatment for GCTs with pathologic fractures [3, 20, 21, 36]. However, a few studies could not confirm that pathologic fractures are a risk factor for local recurrence [21, 34, 35]. Furthermore, it has been reported that articular resection may result in functional impairment [3, 9, 27, 37]. These findings have motivated further studies to investigate the indications of surgery for GCT with pathologic fractures. Deheshi et al. compared the recurrence and functional outcomes after curettage for patients both with and without pathologic fractures, and they found that the outcomes were similar [6]. Jeys et al. evaluated the treatment methods for different types of fractures and concluded that curettage can be a safe method for cortical breach, but discrete fractures very often require resection [27]. There was a consensus found in our research: The significant results of our study revealed that resection and reconstruction with joint replacement is performed more often in patients with complex fractures, while joint salvage (curettage and excision with internal fixation) is performed more often in more patients with simple fractures. Our results also showed that the local recurrence rate was significantly higher in the group with intralesional procedures than in the group with resection reconstructed with joint replacement. So, the Kaplan–Meier survival curves practically based on the two surgical methods revealed that the recurrence rate significantly decreased as the extent of surgery increased, which is consistent with the reported literature [9, 18, 22, 35].
A limited number of studies have compared the local recurrence and complications rates of patients with and without pathologic fractures due to GCT [3, 4, 6, 21, 26]. Moreover, no studies have compared prognostic outcomes based on the different degrees of pathologic fracture due to GCT. The existing data provide evidence to support that there is no significant difference in the recurrence-free survival rates between the fracture group and nonfracture group [10, 11, 34]. However, our results indicated that the simple fracture group had significantly higher recurrence-free survival rates than the complex fracture group. The overall recurrence rate was 15.4% (20/130) in our study, which were lower than those reported in literatures [6, 9, 11, 12, 14, 21, 34, 38]. The reasons we considered to explain this difference were mainly related to the surgical methods, and fracture itself is an important factor for surgery that determines the surgical extent. Perhaps the results were also affected by the follow-up data obtained via telephone, as it has low reliability and may not exactly represent the true results for local recurrence.
Only few articles have reported on complications after surgical treatments for cases of GCT specifically with pathologic fracture [3, 18, 27]. In the literature, complications were even more frequent after resection and reconstruction with prostheses than after joint salvage. Heijden et al. pointed out in their study that the major complication rate was higher after resection than after curettage (16% versus 4%). Although we did not evaluate the complication rates after the treatment of GCT in patients without pathologic fracture in this study, our results indicated that the group with simple fractures had lower complication rates than the group with complex fractures [4]. We consider this to be due to the fact that resection and reconstruction with joint replacement is performed more often in patients with complex fractures.
The number of studies assessing functional outcomes after treatment for GCT with scoring systems are also limited in the literature. Available reports indicate that better functional outcomes can be achieved with joint salvage than with resection [4, 11, 21, 39]. We found that the group with simple fractures had better outcomes, with higher MSTS and TESS scores, than the group with complex fractures. We consider this difference to be caused by the different surgical methods used between the two groups. However, Prosser et al. found the mean functional scores were similar after curettage and primary resection in their research [40].
The limitations of our study include the following: (1) Patients were recruited from multiple centres, and the quality control methodology was not unified. (2) During follow-up, we found that the compliance of patients was poor; therefore, we used telephone calls instead of outpatient visits to complete our follow-up for some patients. The low recurrence and complication rates might have some relations with our follow-ups adopted. (3) Even though our response rate during follow-up was as high as 86.1%, it sorely stands for the features of our study group.