Rethinking Reconstruction: Successful Outcomes of En-Bloc Resection for Giant-Cell Tumor of the Distal Ulna – A Case Report

Rethinking Reconstruction: Successful Outcomes of En-Bloc Resection for Giant-Cell Tumor of the Distal Ulna – A Case Report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Rethinking Reconstruction: Successful Outcomes of En-Bloc Resection for Giant-Cell Tumor of the Distal Ulna – A Case Report Gaurav Vatsa, Saurabh Suman This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5198420/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 17 You are reading this latest preprint version Abstract Background: Giant cell tumour (GCT) of bone is a benign yet locally aggressive neoplasm affecting mainly young adults. It is known for local recurrence, rare pulmonary metastases, and occasional malignant transformation. Although the distal femur and proximal tibia are typical sites, involvement of the distal ulna is extremely rare (0.5–2.9% of cases). This rarity, combined with the unique anatomy of the distal ulna, creates challenges in treatment, prompting exploration of alternatives to standard distal radius management. Case Presentation: A 48-year-old female experienced six months of pain and swelling on the ulnar aspect of her left distal forearm, aggravated by minor trauma. Clinical examination identified a firm, tender mass (10×6×4 cm) with limited wrist mobility and diminished grip strength. Radiographs and MRI revealed a multilobular, lytic “soap bubble” lesion. Histopathology confirmed the diagnosis of GCT. After thorough preoperative counseling, the patient underwent en-bloc resection with a 2 cm tumor-free margin and soft tissue stabilization through reattachment of the extensor and flexor carpi ulnaris tendons. Discussion: The anatomical constraints of the distal ulna limit conventional reconstructive techniques. Extensive resection precludes options like the Sauvé-Kapandji procedure, making soft tissue stabilization a simpler, yet effective, solution. En-bloc resection with soft tissue stabilization is a viable treatment for aggressive distal ulna GCT, ensuring oncological safety and preserved wrist function while avoiding complex reconstruction. Continued follow-up is essential for long-term assessment. Giant-Cell Tumor of bone (GCT of bone) Distal ulna En-bloc resection Wrist function Reconstruction Bone tumors case report Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Background Giant-Cell Tumor of bone (GCT of bone) is a prevalent bone tumor, comprising 20% of biopsy-confirmed benign lesions, primarily affecting young adults aged 18 to 40, with a slight predominance in females. 1 Although GCT of bone is generally benign, its potential for local recurrence, rare benign pulmonary metastases, and very rare malignant transformation have led to some complexity in management decisions. 2 The distal femur and proximal tibia are the most frequently affected sites, representing around 60% of cases, while distal ulna involvement is rare, occurring in only 0.5–2.9% of all GCT of bones. 3,4,5,6 The primary principle in managing GCT of bone is complete tumor removal while preserving joint function, with intralesional resection suited for Campanacci stage 1 and 2 GCT of bones, despite a recurrence rate of up to 17%, while wide resection, typically for stage 3, often compromises joint function. 4,7,8,9 Giant-Cell Tumors of bone of the distal radius or ulna are challenging to treat, primarily due to their close proximity to the carpal bones. 10,11,12 While the distal radius, more commonly affected, has been thoroughly addressed in literature with well-established procedures for reconstructing defects post-resection, including arthrodesis or proximal fibular interposition, 3,8,13 distal ulnar resections have received less attention, primarily due to their rarity and limited clinical experience, with the literature offering conflicting recommendations ranging from no reconstruction to soft tissue stabilization or bone graft augmentation. Omitting reconstruction after resection may lead to complications like a painful wrist, reduced grip strength, and impaired pronation and supination due to radioulnar convergence. 6,14,15,16,17 While curettage with surgical adjuvants like liquid nitrogen, phenol, or cement preserves the joint but carries a higher risk of local recurrence, en-bloc resection of a Giant-Cell Tumor of bone (GCT of bone) of the distal ulna reduces recurrence but may compromise the joint, necessitating significant reconstruction; thus, the impact of different surgical approaches on tumor recurrence and postoperative wrist function remains uncertain. 18,19,20 Although well-established techniques exist for managing giant cell tumors of the distal radius, those affecting the distal ulna remain exceptionally rare. This scarcity has resulted in a limited body of literature on their management. Even though en bloc resection for distal ulna lesions has been discussed in previous studies, every additional case provides valuable insights, helping to refine treatment protocols and encouraging further research in this understudied area. In presenting this straightforward approach, we aim to demonstrate that a basic procedure like this can offer significant advantages over more complex reconstruction techniques namely, reduced morbidity, lower complication rates, and stable, pain-free wrist function with a full range of motion, thereby challenging the traditional notion that reconstruction is always necessary in such cases. Herein, we present a case of a 48-year-old female with distal ulna GCT of bone, treated via en-bloc resection with Extensor Carpi Ulnaris (ECU) and Flexor Carpi Ulnaris (FCU) stabilization, resulting in painless wrist movement within 3 weeks and full forearm function within 6 months, documented in accordance with the Consensus Surgical CAse REport (SCARE) criteria. 21 Case presentation A 48-year-old female presented with a six-month history of pain and swelling on the ulnar side of her left distal forearm. The condition worsened following a bike fall 20 days prior, prompting her to seek conservative treatment, including a Below Elbow slab and analgesics, at a private clinic. Despite this initial management, she continued to experience persistent pain and swelling in her left wrist, leading her to consult a traditional bone setter and undergo several massage therapies. The mass, initially the size of a lemon, grew to the size of a baseball and became increasingly painful before she sought further medical attention. She reported no systemic symptoms, and her family, occupational, and medical histories were unremarkable. General physical and systemic examinations were unremarkable. The patient exhibited a hard, non-mobile, tender oval mass on the dorsomedial aspect of the left distal ulna, measuring 10 × 6 × 4 cm (Fig. 1). The overlying skin appeared normal, with no scars, sinuses, or prominent veins, and was pinchable, suggesting it was not adhered to the mass. There was no localized increase in temperature, but the mass was firmly attached to the underlying bone. Despite experiencing pain (Visual Analog Score 2), the patient was able to move the left wrist, though both active and passive ranges of motion were reduced compared to the opposite wrist. Preoperative supination limited to 40° and pronation to 50°, whereas the contralateral side exhibited 80° and 85°, respectively. Preoperatively, palmar flexion was 30° and dorsiflexion was 35°, compared to 70° and 75° on the contralateral side. Preoperatively, the patient’s handshake on the affected side was noticeably weak, with a soft grip and reduced resistance compared to the contralateral side. There was a clear lack of firmness, indicating compromised grip strength. Neurovascular function remained intact, and the severity of the condition was indicated by a DASH score of 49.2, reflecting considerable disability. Conventional radiography identified a multi-lobular, radiolucent area with typical ‘soap bubble’ appearance with distinct margins in the distal metadiaphyseal ulna, with no signs of fracture (Fig. 2). The T1 MRI image revealed a well-defined, hypo-intense 8 × 4 cm lesion in the distal ulna, primarily affecting the metaepiphysial ulna with a subarticular location. Fat-suppressed images showed a hyper-intense, expansile lesion at the distal end of the ulna, with the articular surface remaining intact. The lesion was eccentrically placed, lytic, and lacked a sclerotic margin, while the subchondral bone was preserved. A chest X-ray showed no evidence of pulmonary metastases. Histopathological examination of the core biopsy identified a multinucleated giant cell containing over 20 nuclei, a hallmark of a Giant-Cell Tumor of bone (GCT of bone). Additionally, mononuclear stromal cells resembling interstitial fibroblasts were observed. The analysis highlighted three distinct cell types: Giant-Cell Tumor of bone stromal cells, mononuclear histiocytic cells, and multinucleated giant cells. A comprehensive preoperative discussion was conducted with the patient to ensure informed decision-making. The nature of the tumor, its locally aggressive behavior, and the risks of inadequate treatment were explained in detail. The patient was informed of the available surgical options, along with the benefits and risks of each approach. Particular attention was given to discussing potential postoperative functional outcomes, such as the expected recovery timeline, the necessity of physical therapy, and the likelihood of preserving wrist function. The possibility of complications, including reduced grip strength, altered wrist biomechanics, and potential instability, was also addressed. Ultimately, the surgical decision was guided by the need to achieve complete tumor removal while optimizing functional recovery. Under general anesthesia, the patient was positioned supine to allow optimal access to the distal forearm. A meticulous 15 cm longitudinal incision was made along the dorsomedial aspect of the distal ulna, while minimizing disruption to adjacent neurovascular structures (Fig. 3a). The skin and subcutaneous tissues were incised and gently retracted. Once the superficial tissues were adequately mobilized, the deeper layers were carefully dissected to expose both the proximal and distal extents of the lesion (Fig. 3b). The neurovascular bundle was identified and carefully protected. A preoperative Allen test confirmed radial arterial dominance. The TFCC and the joint capsule over the ulnar side was excised along with the resected bone due to tumor involvement. A generous margin of approximately 2 cm of normal, tumor-free tissue was delineated circumferentially around the tumor. The decision to include a 2 cm bone margin was based on oncological principles to minimize recurrence risk. While soft tissue margins in bony GCT excisions vary, bone involvement necessitates a wider margin due to potential microscopic tumor spread, ensuring complete tumor clearance while preserving function. Following en-bloc resection of the distal ulna, the distal ends of both the Extensor Carpi Ulnaris (ECU) and Flexor Carpi Ulnaris (FCU) tendons were mobilized and prepared for reattachment. Using robust non-absorbable sutures, we secured the tendons to the periosteum of the residual proximal ulna and adjacent soft tissue structures. This transosseous suture technique ensured that proper tension was maintained, preventing tendon subluxation and contributing to the overall stability of the wrist. Intraoperative assessments confirmed that the repair provided adequate stability through a full range of wrist motion. Subsequently, an osteotomy was performed using an oscillating saw, with the cut executed precisely along the predetermined resection line. Throughout this process, careful attention was paid to preserving the surrounding soft tissue attachments and maintaining hemostasis, thereby optimizing the conditions for a successful reconstruction of the remaining anatomical structures. The resected segment measured 10 cm in length, and a 2 cm margin of healthy tissue was confirmed to ensure complete tumor removal (Fig. 3c). After the tumor was removed, stabilization of the Extensor Carpi Ulnaris (ECU) and Flexor Carpi Ulnaris (FCU) tendons was performed to maintain wrist function and stability. The distal portion of the ulna was removed without any form of biological reconstruction, such as bone grafting. This approach was chosen to focus solely on tumor removal and immediate stabilization, foregoing additional reconstructive measures. An above-elbow slab with a window for dressing the incision site was applied, and limb elevation was advised. Sutures were removed on postoperative day 12, with the slab removed at 4 weeks. Physiotherapy began after slab removal, leading to a gradual recovery of strength and movement. Follow-ups were conducted at 3 months, 6 months, and 1 year. Six months post-surgery, the DASH score was 4, indicating minimal disability. The patient was expected to resume normal daily activities without issues. At six months, supination improved to 55° and pronation to 60°, demonstrating near-complete restoration. Palmar flexion and dorsiflexion of the wrist were also measured. By six months postoperatively, palmar flexion improved to 45° and dorsiflexion to 50°, indicating substantial functional recovery. Radiographs in Fig. 5a. After one year, the wrist demonstrated a near-complete functional range of motion, with palmar flexion at 65°, dorsiflexion at 70°, and supination/pronation at 75° and 80°, respectively (Fig. 6). Postoperatively, at six months, the handshake felt significantly stronger and firmer, with improved resistance, closely resembling the unaffected side. By one year, the patient exhibited a confident and nearly symmetrical handshake, reflecting substantial recovery in grip strength and functional use of the hand. Radiographs in Fig. 5b. There were no signs of carpal instability or tumour recurrence, confirming a successful surgical outcome. Regular follow-up examinations every six months were recommended to monitor for signs of recurrence, given the high recurrence rate of Giant-Cell Tumor of bones. A one-year follow-up is relatively short for fully capturing the long-term oncological outcomes, particularly concerning recurrence and sustained functional stability. Although our early results are encouraging, with excellent functional recovery and no signs of recurrence during this period, we agree that extended follow-up is essential to draw more definitive conclusions about the durability of these outcomes. Discussion The reported incidence of Giant-Cell Tumor of bones (GCT of bone) in the distal ulna varies across studies. Harness et al 12 noted an incidence as low as 0.5%, while Campanacci 1 observed a 1.2% incidence, and Blackley reported a higher rate of 2.9% 5 . Reports of patients with primary distal ulna Giant-Cell Tumor of bones (GCT of bones) are uncommon, though numerous case studies advocate different approaches, including excision alone, 6,16 soft tissue stabilization, 14 or excision with bone grafting. 22 Given that these additional procedures can increase morbidity, complication rates, and require advanced technical expertise and equipment, we sought to evaluate whether these interventions are truly warranted. The distal ulna is essential for wrist stability and effective hand grip, owing to its interactions with the distal radius, carpal bones, and the Triangular Fibro Cartilage Complex (TFCC). Consequently, excising the distal ulna may theoretically lead to the ulnar translocation of carpal bones. Furthermore, the attachment of the pronator quadratus presents potential complications post-excision: lower-level resections might cause impingement symptoms due to muscular tension, while higher-level resections could result in instability and an overly prominent ulnar stump. Even the Darrach procedure, 23 which offers excellent functional outcomes by enabling painless supination and pronation in patients with distal radioulnar joint (DRUJ) dysfunction, has been criticized for causing ulnar stump instability and radio-ulnar convergence, leading to pain and clicking during wrist rotational movements. 17,24,25 Two studies have examined the functional outcomes following en bloc resection of the distal ulna without reconstruction. Cooney et al. 6 assessed patients with both malignant (3 cases) and benign (5 cases) neoplasms of the distal ulna, with a mean follow-up of 7.5 years. Wolfe et al. 16 evaluated the results in 9 patients who had pain after DRUJ excision and 3 patients with neoplastic conditions. Both studies concluded that a significant portion of the distal ulna can be excised without leading to instability, ulnar translocation of the carpus, or radioulnar convergence. 26 Follow-up radiographs revealed no scalloping of the ulnar border of the distal radius, effectively ruling out radiological evidence of radio-ulnar convergence. The patient did not experience wrist instability, even when lifting heavy objects. A notable aspect of our study was the unusually large size of the distal ulnar Giant-Cell Tumor of bones (GCT of bones) encountered, likely due to delayed presentation combined with the aggressive nature of the tumors. This may also relate to the local site characteristics, which might not favor intraosseous growth, leading to early cortical expansion. The tumor was classified as Campanacci stage II GCT of bone. During the resection of the distal ulna for tumor excision, achieving adequate oncological margins was prioritized over anatomical and functional considerations to prevent recurrence. Ulna reconstruction using a fibula graft with the Sauvé-Kapandji technique for pronation-supination could not be successfully performed due to several factors that rendered the approach impractical in this case. The primary challenge arose from the nature of the en-bloc resection performed for the giant cell tumor of the distal ulna, which resulted in the removal of a significant portion of the ulna along with critical stabilizing structures of the distal radioulnar joint (DRUJ). The Sauvé-Kapandji procedure relies on the fusion of the DRUJ while creating a pseudarthrosis of the ulna proximal to the fusion site to permit forearm rotation; however, the loss of the distal ulna in this instance made the technique difficult to implement effectively. Although the concept of using a fibula graft for reconstruction was theoretically appealing due to its structural compatibility, it presented several limitations in practice. Unlike distal radius reconstructions, where the fibula graft integrates well, its use to replace the excised ulna did not yield the desired functional outcome. A major concern was the inability to restore a stable yet mobile DRUJ. The success of the Sauvé-Kapandji technique depends on maintaining a well-aligned DRUJ with the remaining ulna stump properly stabilized by soft tissues. After the tumor resection, however, the soft tissue attachments critical for joint stability, such as the triangular fibrocartilage complex (TFCC), were compromised. Without these stabilizing structures, any attempt at reconstruction with a fibula graft would have risked instability, painful radioulnar convergence, and reduced forearm rotation. Moreover, with a completely resected distal ulna, no natural stump remained, making the technique unsuitable. In summary, the decision to forgo the fibula graft reconstruction with the Sauvé-Kapandji technique was justified by the patient’s favorable postoperative progress. The en-bloc resection, combined with appropriate soft tissue stabilization of the remaining structures, allowed the patient to regain full forearm function without incurring the risks associated with an unnecessary and potentially problematic reconstruction. The patient demonstrated an excellent functional outcome, with no complaints of ulnar snapping or painful clicking during wrist movements, which are key indicators of radio-ulnar convergence. Grip strength was strong, and there was no significant carpal translocation, as confirmed by follow-up radiographs. Literature suggests that the satisfactory functional outcome after en bloc resection of the distal ulna may be attributed to the intact central band of the interosseous membrane, which is crucial for maintaining the stability of the remaining ulna. Conclusion En-bloc resection may be the preferred treatment for Giant-Cell Tumor of bone (GCT of bone) of the distal ulna, as demonstrated by significant improvement in DASH scores within six weeks post-surgery in our case. Given the rarity of distal ulna Giant Cell Tumors, large-scale studies may not be feasible. However, individual case reports and small series provide valuable insights, offering lessons and surgical considerations. While such studies have inherent limitations, they help refine treatment strategies and contribute to clinical knowledge In conclusion, distal ulnar resection should be the primary approach for aggressive GCT of bones of the distal ulna. Postoperative outcomes showed that none of our patients needed to change their profession, and they maintained a painless, stable wrist with a full functional range of motion and no painful ulnar snapping. This suggests that reconstruction may not be necessary after extraperiosteal distal ulnar resections for aggressive GCT of bones. Declarations Ethics approval and Consent: This study was conducted in accordance with the principles of the Declaration of Helsinki after obtaining an Ethics clearance from Institutional Ethics Committee of Gopal Narayan Singh University. Informed consent was obtained from all individual participants included in the study. Participants were informed about the study's objectives, and benefits. They were assured of the confidentiality of their personal data and their right to withdraw from the study at any time without any consequence. For publication purposes, written consent was also obtained from the patients for the use of their anonymized data in research publications and presentations. Competing Interests: All the authors declare that they have no competing interests. Funding This research received no external funding. Author’ s Contributions: This study is the culmination of the dedicated efforts of GV and SS, along with the entire Department of Orthopaedics. Together, they encountered a highly rare case of Giant-Cell Tumor of bone (GCT of bone) of the ulna. GV: Conceptualized the study, analyzed the surgical outcomes of en-bloc resection without reconstruction, and played a leading role in drawing conclusions regarding the necessity of reconstruction in cases of GCT of bone of the distal ulna. GV also supervised the clinical management of the patient and contributed to the manuscript preparation. SS: Participated in data collection, literature review, and assisted with the analysis of postoperative outcomes. Also provided critical revisions to the manuscript and supported the overall development of the research findings. All authors read and approved the final manuscript. Acknowledgement: I would like to express my deepest gratitude to our co-author, Dr. Saurabh Suman, for his invaluable contributions and dedication throughout this research. His expertise and insights were integral to the success of this study. I also extend our heartfelt thanks to all the members of the Department of Orthopaedics for their support and assistance in various aspects of the research. Your collective efforts and collaboration have been crucial in bringing this work to fruition. Availability of Data and Materials: All the supporting data with respect to this article have been provided in this study. Furthermore, if any data is required in future, it will be made available as per the requirements. References Campanacci M, Campanacci M. Giant-Cell Tumor of bone: Giant-Cell Tumor of bone of Bone, Osteoclastoma. 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Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5198420","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":434393351,"identity":"cb154e6a-4ce6-44b7-bfa4-2a01a3fe9ecc","order_by":0,"name":"Gaurav Vatsa","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA/UlEQVRIiWNgGAWjYLCDw38qgCQzcwMBdcxwFuMDnjMgAUbitTAb8LaBteLXYnD8/OEPP37ZJW5vP2MmITmvNpq/HajlR8U23FrOJLNJ9vYlJ845k2MmYbjteO6Mw4wNjD1nbuPUItmQzMbA28OcOIMhLU0icdux3AagFmbGNjxa+h8zf/zbU584g/9ZmsTBOcdy5xPSwi+RzCDN8+Nw4gyJ5MOGjQ01uRsIa3lsJi3bcNx4hsTjg48Zjh3I3QjUchCfX9j4Ex9/fPOnWnYGf2LDYYaautx55w8ffPCjArcWMGBsgzMPg8kD+NWDwB84q46w4lEwCkbBKBhxAABEO14R1J86TQAAAABJRU5ErkJggg==","orcid":"","institution":"Narayan Medical College \u0026 Hospital","correspondingAuthor":true,"prefix":"","firstName":"Gaurav","middleName":"","lastName":"Vatsa","suffix":""},{"id":434393352,"identity":"8c8be837-0fa2-4cda-ab8b-5742229ed771","order_by":1,"name":"Saurabh Suman","email":"","orcid":"","institution":"Narayan Medical College \u0026 Hospital","correspondingAuthor":false,"prefix":"","firstName":"Saurabh","middleName":"","lastName":"Suman","suffix":""}],"badges":[],"createdAt":"2024-10-03 12:53:11","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5198420/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5198420/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":79336460,"identity":"c9c4e72d-9f01-43e5-8b80-084f24b9be44","added_by":"auto","created_at":"2025-03-27 07:58:11","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":34473,"visible":true,"origin":"","legend":"\u003cp\u003eClinical pre-operative picture of the swelling\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5198420/v1/90fd4bae8361981bba6afd03.jpg"},{"id":79336461,"identity":"c5fc9a6b-d89c-42dc-b3d6-0f42a399a48f","added_by":"auto","created_at":"2025-03-27 07:58:11","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":40531,"visible":true,"origin":"","legend":"\u003cp\u003eX-ray showing lytic lesion of distal ulna\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5198420/v1/3e51f2295fb16b7f8dbf857e.jpg"},{"id":79336463,"identity":"97fca04e-75e8-49bc-8a5e-1c1aef6d9b6b","added_by":"auto","created_at":"2025-03-27 07:58:11","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":162037,"visible":true,"origin":"","legend":"\u003cp\u003eIntraoperative image showing (a) dorsomedial incision; (b) en bloc resection of the tumor (c) completely excised tumor measuring 10 cm in length with 2 cm of margin\u003c/p\u003e","description":"","filename":"3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5198420/v1/8d1bfd8bc5d2d7bf33d1e27d.jpg"},{"id":79336466,"identity":"f238d9ed-1cf8-439e-a4d2-d85ada216f3b","added_by":"auto","created_at":"2025-03-27 07:58:11","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":67658,"visible":true,"origin":"","legend":"\u003cp\u003eImmediate Post-operative X-ray with slab and drain in situ\u003c/p\u003e","description":"","filename":"4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5198420/v1/f7961a2787122e2556ae3f9f.jpg"},{"id":79336469,"identity":"e3e725ba-ea26-4630-9782-a210059acf72","added_by":"auto","created_at":"2025-03-27 07:58:11","extension":"jpg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":88218,"visible":true,"origin":"","legend":"\u003cp\u003ePost operative radiographs: (a) 6 months (b) 1 year\u003c/p\u003e","description":"","filename":"5.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5198420/v1/1e00abea3994cf171fbccabb.jpg"},{"id":79336474,"identity":"76610e48-f173-4aa7-af16-6108778d4002","added_by":"auto","created_at":"2025-03-27 07:58:11","extension":"jpg","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":98831,"visible":true,"origin":"","legend":"\u003cp\u003e1 year follow up Range of Movements\u003c/p\u003e","description":"","filename":"6.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5198420/v1/a642a5fbeb2b18483c2d3b6b.jpg"},{"id":79338165,"identity":"4c38c225-fa36-4c9c-acf6-031e48c8be34","added_by":"auto","created_at":"2025-03-27 08:14:16","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":871829,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5198420/v1/887cb682-a5b5-41a8-9ee6-1730331e93cf.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Rethinking Reconstruction: Successful Outcomes of En-Bloc Resection for Giant-Cell Tumor of the Distal Ulna – A Case Report","fulltext":[{"header":"Background","content":"\u003cp\u003eGiant-Cell Tumor of bone (GCT of bone) is a prevalent bone tumor, comprising 20% of biopsy-confirmed benign lesions, primarily affecting young adults aged 18 to 40, with a slight predominance in females.\u003csup\u003e1\u003c/sup\u003e Although GCT of bone is generally benign, its potential for local recurrence, rare benign pulmonary metastases, and very rare malignant transformation have led to some complexity in management decisions.\u003csup\u003e2\u003c/sup\u003e The distal femur and proximal tibia are the most frequently affected sites, representing around 60% of cases, while distal ulna involvement is rare, occurring in only 0.5\u0026ndash;2.9% of all GCT of bones.\u003csup\u003e3,4,5,6\u003c/sup\u003e The primary principle in managing GCT of bone is complete tumor removal while preserving joint function, with intralesional resection suited for Campanacci stage 1 and 2 GCT of bones, despite a recurrence rate of up to 17%, while wide resection, typically for stage 3, often compromises joint function.\u003csup\u003e4,7,8,9\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eGiant-Cell Tumors of bone of the distal radius or ulna are challenging to treat, primarily due to their close proximity to the carpal bones.\u003csup\u003e10,11,12\u003c/sup\u003e While the distal radius, more commonly affected, has been thoroughly addressed in literature with well-established procedures for reconstructing defects post-resection, including arthrodesis or proximal fibular interposition,\u003csup\u003e3,8,13\u003c/sup\u003e distal ulnar resections have received less attention, primarily due to their rarity and limited clinical experience, with the literature offering conflicting recommendations ranging from no reconstruction to soft tissue stabilization or bone graft augmentation. Omitting reconstruction after resection may lead to complications like a painful wrist, reduced grip strength, and impaired pronation and supination due to radioulnar convergence.\u003csup\u003e6,14,15,16,17\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eWhile curettage with surgical adjuvants like liquid nitrogen, phenol, or cement preserves the joint but carries a higher risk of local recurrence, en-bloc resection of a Giant-Cell Tumor of bone (GCT of bone) of the distal ulna reduces recurrence but may compromise the joint, necessitating significant reconstruction; thus, the impact of different surgical approaches on tumor recurrence and postoperative wrist function remains uncertain.\u003csup\u003e18,19,20\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eAlthough well-established techniques exist for managing giant cell tumors of the distal radius, those affecting the distal ulna remain exceptionally rare. This scarcity has resulted in a limited body of literature on their management. Even though en bloc resection for distal ulna lesions has been discussed in previous studies, every additional case provides valuable insights, helping to refine treatment protocols and encouraging further research in this understudied area. In presenting this straightforward approach, we aim to demonstrate that a basic procedure like this can offer significant advantages over more complex reconstruction techniques namely, reduced morbidity, lower complication rates, and stable, pain-free wrist function with a full range of motion, thereby challenging the traditional notion that reconstruction is always necessary in such cases.\u003c/p\u003e \u003cp\u003eHerein, we present a case of a 48-year-old female with distal ulna GCT of bone, treated via en-bloc resection with Extensor Carpi Ulnaris (ECU) and Flexor Carpi Ulnaris (FCU) stabilization, resulting in painless wrist movement within 3 weeks and full forearm function within 6 months, documented in accordance with the Consensus Surgical CAse REport (SCARE) criteria.\u003csup\u003e21\u003c/sup\u003e\u003c/p\u003e"},{"header":"Case presentation","content":"\u003cp\u003eA 48-year-old female presented with a six-month history of pain and swelling on the ulnar side of her left distal forearm. The condition worsened following a bike fall 20 days prior, prompting her to seek conservative treatment, including a Below Elbow slab and analgesics, at a private clinic. Despite this initial management, she continued to experience persistent pain and swelling in her left wrist, leading her to consult a traditional bone setter and undergo several massage therapies. The mass, initially the size of a lemon, grew to the size of a baseball and became increasingly painful before she sought further medical attention. She reported no systemic symptoms, and her family, occupational, and medical histories were unremarkable.\u003c/p\u003e\n\u003cp\u003eGeneral physical and systemic examinations were unremarkable. The patient exhibited a hard, non-mobile, tender oval mass on the dorsomedial aspect of the left distal ulna, measuring 10 \u0026times; 6 \u0026times; 4 cm (Fig.\u0026nbsp;1). The overlying skin appeared normal, with no scars, sinuses, or prominent veins, and was pinchable, suggesting it was not adhered to the mass. There was no localized increase in temperature, but the mass was firmly attached to the underlying bone. Despite experiencing pain (Visual Analog Score 2), the patient was able to move the left wrist, though both active and passive ranges of motion were reduced compared to the opposite wrist. Preoperative supination limited to 40\u0026deg; and pronation to 50\u0026deg;, whereas the contralateral side exhibited 80\u0026deg; and 85\u0026deg;, respectively. Preoperatively, palmar flexion was 30\u0026deg; and dorsiflexion was 35\u0026deg;, compared to 70\u0026deg; and 75\u0026deg; on the contralateral side. Preoperatively, the patient\u0026rsquo;s handshake on the affected side was noticeably weak, with a soft grip and reduced resistance compared to the contralateral side. There was a clear lack of firmness, indicating compromised grip strength. Neurovascular function remained intact, and the severity of the condition was indicated by a DASH score of 49.2, reflecting considerable disability.\u003c/p\u003e\n\u003cp\u003eConventional radiography identified a multi-lobular, radiolucent area with typical \u0026lsquo;soap bubble\u0026rsquo; appearance with distinct margins in the distal metadiaphyseal ulna, with no signs of fracture (Fig.\u0026nbsp;2). The T1 MRI image revealed a well-defined, hypo-intense 8 \u0026times; 4 cm lesion in the distal ulna, primarily affecting the metaepiphysial ulna with a subarticular location. Fat-suppressed images showed a hyper-intense, expansile lesion at the distal end of the ulna, with the articular surface remaining intact. The lesion was eccentrically placed, lytic, and lacked a sclerotic margin, while the subchondral bone was preserved. A chest X-ray showed no evidence of pulmonary metastases.\u003c/p\u003e\n\u003cp\u003eHistopathological examination of the core biopsy identified a multinucleated giant cell containing over 20 nuclei, a hallmark of a Giant-Cell Tumor of bone (GCT of bone). Additionally, mononuclear stromal cells resembling interstitial fibroblasts were observed. The analysis highlighted three distinct cell types: Giant-Cell Tumor of bone stromal cells, mononuclear histiocytic cells, and multinucleated giant cells.\u003c/p\u003e\n\u003cp\u003eA comprehensive preoperative discussion was conducted with the patient to ensure informed decision-making. The nature of the tumor, its locally aggressive behavior, and the risks of inadequate treatment were explained in detail. The patient was informed of the available surgical options, along with the benefits and risks of each approach. Particular attention was given to discussing potential postoperative functional outcomes, such as the expected recovery timeline, the necessity of physical therapy, and the likelihood of preserving wrist function. The possibility of complications, including reduced grip strength, altered wrist biomechanics, and potential instability, was also addressed. Ultimately, the surgical decision was guided by the need to achieve complete tumor removal while optimizing functional recovery.\u003c/p\u003e\n\u003cp\u003eUnder general anesthesia, the patient was positioned supine to allow optimal access to the distal forearm. A meticulous 15 cm longitudinal incision was made along the dorsomedial aspect of the distal ulna, while minimizing disruption to adjacent neurovascular structures (Fig.\u0026nbsp;3a). The skin and subcutaneous tissues were incised and gently retracted. Once the superficial tissues were adequately mobilized, the deeper layers were carefully dissected to expose both the proximal and distal extents of the lesion (Fig.\u0026nbsp;3b). The neurovascular bundle was identified and carefully protected. A preoperative Allen test confirmed radial arterial dominance. The TFCC and the joint capsule over the ulnar side was excised along with the resected bone due to tumor involvement.\u003c/p\u003e\n\u003cp\u003eA generous margin of approximately 2 cm of normal, tumor-free tissue was delineated circumferentially around the tumor. The decision to include a 2 cm bone margin was based on oncological principles to minimize recurrence risk. While soft tissue margins in bony GCT excisions vary, bone involvement necessitates a wider margin due to potential microscopic tumor spread, ensuring complete tumor clearance while preserving function.\u003c/p\u003e\n\u003cp\u003eFollowing en-bloc resection of the distal ulna, the distal ends of both the Extensor Carpi Ulnaris (ECU) and Flexor Carpi Ulnaris (FCU) tendons were mobilized and prepared for reattachment. Using robust non-absorbable sutures, we secured the tendons to the periosteum of the residual proximal ulna and adjacent soft tissue structures. This transosseous suture technique ensured that proper tension was maintained, preventing tendon subluxation and contributing to the overall stability of the wrist. Intraoperative assessments confirmed that the repair provided adequate stability through a full range of wrist motion.\u003c/p\u003e\n\u003cp\u003eSubsequently, an osteotomy was performed using an oscillating saw, with the cut executed precisely along the predetermined resection line. Throughout this process, careful attention was paid to preserving the surrounding soft tissue attachments and maintaining hemostasis, thereby optimizing the conditions for a successful reconstruction of the remaining anatomical structures.\u003c/p\u003e\n\u003cp\u003eThe resected segment measured 10 cm in length, and a 2 cm margin of healthy tissue was confirmed to ensure complete tumor removal (Fig.\u0026nbsp;3c). After the tumor was removed, stabilization of the Extensor Carpi Ulnaris (ECU) and Flexor Carpi Ulnaris (FCU) tendons was performed to maintain wrist function and stability. The distal portion of the ulna was removed without any form of biological reconstruction, such as bone grafting. This approach was chosen to focus solely on tumor removal and immediate stabilization, foregoing additional reconstructive measures.\u003c/p\u003e\n\u003cp\u003eAn above-elbow slab with a window for dressing the incision site was applied, and limb elevation was advised. Sutures were removed on postoperative day 12, with the slab removed at 4 weeks. Physiotherapy began after slab removal, leading to a gradual recovery of strength and movement. Follow-ups were conducted at 3 months, 6 months, and 1 year. Six months post-surgery, the DASH score was 4, indicating minimal disability. The patient was expected to resume normal daily activities without issues. At six months, supination improved to 55\u0026deg; and pronation to 60\u0026deg;, demonstrating near-complete restoration. Palmar flexion and dorsiflexion of the wrist were also measured. By six months postoperatively, palmar flexion improved to 45\u0026deg; and dorsiflexion to 50\u0026deg;, indicating substantial functional recovery. Radiographs in Fig. 5a.\u003c/p\u003e\n\u003cp\u003eAfter one year, the wrist demonstrated a near-complete functional range of motion, with palmar flexion at 65\u0026deg;, dorsiflexion at 70\u0026deg;, and supination/pronation at 75\u0026deg; and 80\u0026deg;, respectively (Fig.\u0026nbsp;6). Postoperatively, at six months, the handshake felt significantly stronger and firmer, with improved resistance, closely resembling the unaffected side. By one year, the patient exhibited a confident and nearly symmetrical handshake, reflecting substantial recovery in grip strength and functional use of the hand. Radiographs in Fig.\u0026nbsp;5b. There were no signs of carpal instability or tumour recurrence, confirming a successful surgical outcome. Regular follow-up examinations every six months were recommended to monitor for signs of recurrence, given the high recurrence rate of Giant-Cell Tumor of bones.\u003c/p\u003e\n\u003cp\u003eA one-year follow-up is relatively short for fully capturing the long-term oncological outcomes, particularly concerning recurrence and sustained functional stability. Although our early results are encouraging, with excellent functional recovery and no signs of recurrence during this period, we agree that extended follow-up is essential to draw more definitive conclusions about the durability of these outcomes.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe reported incidence of Giant-Cell Tumor of bones (GCT of bone) in the distal ulna varies across studies. Harness et al\u003csup\u003e12\u003c/sup\u003e noted an incidence as low as 0.5%, while Campanacci\u003csup\u003e1\u003c/sup\u003e observed a 1.2% incidence, and Blackley reported a higher rate of 2.9%\u003csup\u003e5\u003c/sup\u003e. Reports of patients with primary distal ulna Giant-Cell Tumor of bones (GCT of bones) are uncommon, though numerous case studies advocate different approaches, including excision alone,\u003csup\u003e6,16\u003c/sup\u003e soft tissue stabilization,\u003csup\u003e14\u003c/sup\u003e or excision with bone grafting.\u003csup\u003e22\u003c/sup\u003e Given that these additional procedures can increase morbidity, complication rates, and require advanced technical expertise and equipment, we sought to evaluate whether these interventions are truly warranted.\u003c/p\u003e \u003cp\u003eThe distal ulna is essential for wrist stability and effective hand grip, owing to its interactions with the distal radius, carpal bones, and the Triangular Fibro Cartilage Complex (TFCC). Consequently, excising the distal ulna may theoretically lead to the ulnar translocation of carpal bones. Furthermore, the attachment of the pronator quadratus presents potential complications post-excision: lower-level resections might cause impingement symptoms due to muscular tension, while higher-level resections could result in instability and an overly prominent ulnar stump. Even the Darrach procedure,\u003csup\u003e23\u003c/sup\u003e which offers excellent functional outcomes by enabling painless supination and pronation in patients with distal radioulnar joint (DRUJ) dysfunction, has been criticized for causing ulnar stump instability and radio-ulnar convergence, leading to pain and clicking during wrist rotational movements.\u003csup\u003e17,24,25\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eTwo studies have examined the functional outcomes following en bloc resection of the distal ulna without reconstruction. Cooney et al.\u003csup\u003e6\u003c/sup\u003e assessed patients with both malignant (3 cases) and benign (5 cases) neoplasms of the distal ulna, with a mean follow-up of 7.5 years. Wolfe et al.\u003csup\u003e16\u003c/sup\u003e evaluated the results in 9 patients who had pain after DRUJ excision and 3 patients with neoplastic conditions. Both studies concluded that a significant portion of the distal ulna can be excised without leading to instability, ulnar translocation of the carpus, or radioulnar convergence.\u003csup\u003e26\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eFollow-up radiographs revealed no scalloping of the ulnar border of the distal radius, effectively ruling out radiological evidence of radio-ulnar convergence. The patient did not experience wrist instability, even when lifting heavy objects. A notable aspect of our study was the unusually large size of the distal ulnar Giant-Cell Tumor of bones (GCT of bones) encountered, likely due to delayed presentation combined with the aggressive nature of the tumors. This may also relate to the local site characteristics, which might not favor intraosseous growth, leading to early cortical expansion. The tumor was classified as Campanacci stage II GCT of bone. During the resection of the distal ulna for tumor excision, achieving adequate oncological margins was prioritized over anatomical and functional considerations to prevent recurrence.\u003c/p\u003e \u003cp\u003eUlna reconstruction using a fibula graft with the Sauv\u0026eacute;-Kapandji technique for pronation-supination could not be successfully performed due to several factors that rendered the approach impractical in this case. The primary challenge arose from the nature of the en-bloc resection performed for the giant cell tumor of the distal ulna, which resulted in the removal of a significant portion of the ulna along with critical stabilizing structures of the distal radioulnar joint (DRUJ). The Sauv\u0026eacute;-Kapandji procedure relies on the fusion of the DRUJ while creating a pseudarthrosis of the ulna proximal to the fusion site to permit forearm rotation; however, the loss of the distal ulna in this instance made the technique difficult to implement effectively. Although the concept of using a fibula graft for reconstruction was theoretically appealing due to its structural compatibility, it presented several limitations in practice. Unlike distal radius reconstructions, where the fibula graft integrates well, its use to replace the excised ulna did not yield the desired functional outcome. A major concern was the inability to restore a stable yet mobile DRUJ. The success of the Sauv\u0026eacute;-Kapandji technique depends on maintaining a well-aligned DRUJ with the remaining ulna stump properly stabilized by soft tissues. After the tumor resection, however, the soft tissue attachments critical for joint stability, such as the triangular fibrocartilage complex (TFCC), were compromised. Without these stabilizing structures, any attempt at reconstruction with a fibula graft would have risked instability, painful radioulnar convergence, and reduced forearm rotation. Moreover, with a completely resected distal ulna, no natural stump remained, making the technique unsuitable.\u003c/p\u003e \u003cp\u003eIn summary, the decision to forgo the fibula graft reconstruction with the Sauv\u0026eacute;-Kapandji technique was justified by the patient\u0026rsquo;s favorable postoperative progress. The en-bloc resection, combined with appropriate soft tissue stabilization of the remaining structures, allowed the patient to regain full forearm function without incurring the risks associated with an unnecessary and potentially problematic reconstruction.\u003c/p\u003e \u003cp\u003eThe patient demonstrated an excellent functional outcome, with no complaints of ulnar snapping or painful clicking during wrist movements, which are key indicators of radio-ulnar convergence. Grip strength was strong, and there was no significant carpal translocation, as confirmed by follow-up radiographs. Literature suggests that the satisfactory functional outcome after en bloc resection of the distal ulna may be attributed to the intact central band of the interosseous membrane, which is crucial for maintaining the stability of the remaining ulna.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eEn-bloc resection may be the preferred treatment for Giant-Cell Tumor of bone (GCT of bone) of the distal ulna, as demonstrated by significant improvement in DASH scores within six weeks post-surgery in our case. Given the rarity of distal ulna Giant Cell Tumors, large-scale studies may not be feasible. However, individual case reports and small series provide valuable insights, offering lessons and surgical considerations. While such studies have inherent limitations, they help refine treatment strategies and contribute to clinical knowledge\u003c/p\u003e \u003cp\u003eIn conclusion, distal ulnar resection should be the primary approach for aggressive GCT of bones of the distal ulna. Postoperative outcomes showed that none of our patients needed to change their profession, and they maintained a painless, stable wrist with a full functional range of motion and no painful ulnar snapping. This suggests that reconstruction may not be necessary after extraperiosteal distal ulnar resections for aggressive GCT of bones.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and Consent:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conducted in accordance with the principles of the Declaration of Helsinki after obtaining an Ethics clearance from Institutional Ethics Committee of Gopal Narayan Singh University. Informed consent was obtained from all individual participants included in the study. Participants were informed about the study's objectives, and benefits. They were assured of the confidentiality of their personal data and their right to withdraw from the study at any time without any consequence.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFor publication purposes, written consent was also obtained from the patients for the use of their anonymized data in research publications and presentations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll the authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research received no external funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor’\u003c/strong\u003e\u003cstrong\u003es Contributions:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study is the culmination of the dedicated efforts of GV and SS, along with the entire Department of Orthopaedics. Together, they encountered a highly rare case of Giant-Cell Tumor of bone (GCT of bone) of the ulna.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eGV: Conceptualized the study, analyzed the surgical outcomes of en-bloc resection without reconstruction, and played a leading role in drawing conclusions regarding the necessity of reconstruction in cases of GCT of bone of the distal ulna. GV also supervised the clinical management of the patient and contributed to the manuscript preparation.\u003c/p\u003e\n\u003cp\u003eSS: Participated in data collection, literature review, and assisted with the analysis of postoperative outcomes. Also provided critical revisions to the manuscript and supported the overall development of the research findings.\u003c/p\u003e\n\u003cp\u003eAll authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgement:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eI would like to express my deepest gratitude to our co-author, Dr. Saurabh Suman, for his invaluable contributions and dedication throughout this research. His expertise and insights were integral to the success of this study. I also extend our heartfelt thanks to all the members of the Department of Orthopaedics for their support and assistance in various aspects of the research. Your collective efforts and collaboration have been crucial in bringing this work to fruition.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of Data and Materials:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll the supporting data with respect to this article have been provided in this study. Furthermore, if any data is required in future, it will be made available as per the requirements.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eCampanacci M, Campanacci M. Giant-Cell Tumor of bone: Giant-Cell Tumor of bone of Bone, Osteoclastoma. Bone and soft tissue tumors: clinical features, imaging, pathology and treatment. 1999:99\u0026ndash;142.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJaffe HL. Giant-Cell Tumor of bone of bone. Its pathologic appearance, grading, supposed variants and treatment. Arch Path. 1940;30(5):993\u0026ndash;1031.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEnneking WF. A system of staging musculoskeletal neoplasms. Clinical Orthopaedics and Related Research (1976\u0026ndash;2007). 1986;204:9\u0026ndash;24.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTurcotte RE, Wunder JS, Isler MH. Giant cell tumour of long bone: A Canadian Sarcoma Group study. Clin Orthop Relat Res 2002 ; 397 : 248\u0026ndash;258.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBlackley HR, Wunder JS, Davis AM, White LM, Kandel R, Bell RS. Treatment of Giant-Cell Tumor of bones of long bones with curettage and bone-grafting. JBJS. 1999;81(6):811\u0026ndash;20.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCooney WP, Damron TA, Sim FH, Linscheid RL. En bloc resection of tumors of the distal end of the ulna. JBJS. 1997;79(3):406\u0026ndash;12.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBloodgood JC. The conservative treatment of giant-cell sarcoma, with the study of bone transplantation. Annals of Surgery. 1912;56(2):210\u0026ndash;39.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eECKARDT JJ, GROGAN TJ. Giant-Cell Tumor of bone of bone. Clinical Orthopaedics and Related Research (1976\u0026ndash;2007). 1986;204:45\u0026ndash;58.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWard Sr WG, Li III G. Customized treatment algorithm for Giant-Cell Tumor of bone of bone: report of a series. Clinical Orthopaedics and Related Research\u0026reg;. 2002;397:259\u0026ndash;70.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAthanasian EA, Wold LE, Amadio PC. Giant-Cell Tumors of bone of the bones of the hand. The Journal of hand surgery. 1997;22(1):91\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCheng CY, Shih HN, Hsu KY, Hsu RW. Treatment of Giant-Cell Tumor of bone of the distal radius. Clinical Orthopaedics and Related Research (1976\u0026ndash;2007). 2001;383:221\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHarness NG, Mankin HJ. Giant-Cell Tumor of bone of the distal forearm. The Journal of hand surgery. 2004;29(2):188\u0026ndash;93.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCampbell CJ, Akbarnia BA. Giant-Cell Tumor of bone of the radius treated by massive resection and tibial bone graft. JBJS. 1975;57(7):982\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGainor BJ. Lasso stabilization of the distal ulna after tumor resection: a report of two cases. The Journal of hand surgery. 1995;20(2):324\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKayias EH, Drosos GI, Anagnostopoulou GA. Resection of the distal ulna for tumours and stabilisation of the stump. A case report and literature review. Acta orthopaedica belgica. 2006;72(4):484.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWolfe SW, Mih AD, Hotchkiss RN, Culp RW, Kiefhaber TR, Nagle DJ. Wide excision of the distal ulna: a multicenter case study. The Journal of hand surgery. 1998;23(2):222\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBell MJ, Hill RJ, McMurtry RY. Ulnar impingement syndrome. The Journal of Bone \u0026amp; Joint Surgery British Volume. 1985;67(1):126\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMinami A, Iwasaki N, Nishida K, Motomiya M, Yamada K, Momma D. Giant-Cell Tumor of the Distal Ulna Treated by Wide Resection and Ulnar Support Reconstruction: A Case Report. Case reports in Medicine. 2010;2010(1):871278.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePrabowo Y, Abubakar I. Reconstruction Giant-Cell Tumor of bone of the right proximal humerus Campanacci 3 with pedicle and rod system: a case report. International Journal of Surgery Case Reports. 2018;52:67\u0026ndash;74.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhang J, Li Y, Li D, Xia J, Li S, Yu S, Liao Y, Li X, Li H, Yang Z. Clinical effects of three surgical approaches for a Giant-Cell Tumor of bone of the distal radius and ulna. Molecular and clinical oncology. 2016;5(5):613\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAgha RA, Franchi T, Sohrabi C, Mathew G, Kerwan A, Thoma A, Beamish AJ, Noureldin A, Rao A, Vasudevan B, Challacombe B. The SCARE 2020 guideline: updating consensus surgical CAse REport (SCARE) guidelines. International Journal of Surgery. 2020;84:226\u0026ndash;30.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWurapa RK, Whipple R. Distal radioulnar allograft reconstruction after Giant-Cell Tumor of bone resection. American Journal of Orthopedics (Belle Mead, NJ). 2003;32(8):397\u0026ndash;400.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDarrach W. Partial excision of the lower shaft of the ulna for deformity following Colles fracture. Ann Surg. 1913;57:764\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMoore EM. Three Cases Illustrating Luxation of the Ulna, in Connection with Colles' Fracture. Standard Steam Book and Job Printing House; 1880.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLau FH, Chung KC. William Darrach, MD: his life and his contribution to hand surgery. The Journal of Hand Surgery. 2006;31(7):1056-e1.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"discover-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Discover Medicine](https://link.springer.com/journal/44337)","snPcode":"44337","submissionUrl":"https://submission.springernature.com/new-submission/44337/3","title":"Discover Medicine","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Giant-Cell Tumor of bone (GCT of bone), Distal ulna, En-bloc resection, Wrist function, Reconstruction, Bone tumors, case report","lastPublishedDoi":"10.21203/rs.3.rs-5198420/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5198420/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eGiant cell tumour (GCT) of bone is a benign yet locally aggressive neoplasm affecting mainly young adults. It is known for local recurrence, rare pulmonary metastases, and occasional malignant transformation. Although the distal femur and proximal tibia are typical sites, involvement of the distal ulna is extremely rare (0.5–2.9% of cases). This rarity, combined with the unique anatomy of the distal ulna, creates challenges in treatment, prompting exploration of alternatives to standard distal radius management.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase Presentation:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA 48-year-old female experienced six months of pain and swelling on the ulnar aspect of her left distal forearm, aggravated by minor trauma. Clinical examination identified a firm, tender mass (10×6×4 cm) with limited wrist mobility and diminished grip strength. Radiographs and MRI revealed a multilobular, lytic “soap bubble” lesion. Histopathology confirmed the diagnosis of GCT. After thorough preoperative counseling, the patient underwent en-bloc resection with a 2 cm tumor-free margin and soft tissue stabilization through reattachment of the extensor and flexor carpi ulnaris tendons.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDiscussion:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe anatomical constraints of the distal ulna limit conventional reconstructive techniques. Extensive resection precludes options like the Sauvé-Kapandji procedure, making soft tissue stabilization a simpler, yet effective, solution. En-bloc resection with soft tissue stabilization is a viable treatment for aggressive distal ulna GCT, ensuring oncological safety and preserved wrist function while avoiding complex reconstruction. Continued follow-up is essential for long-term assessment.\u003c/p\u003e","manuscriptTitle":"Rethinking Reconstruction: Successful Outcomes of En-Bloc Resection for Giant-Cell Tumor of the Distal Ulna – A Case Report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-03-27 07:58:06","doi":"10.21203/rs.3.rs-5198420/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-07-15T17:12:41+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-12T11:41:18+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-10T13:48:29+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"82081131943091852302509598986354740975","date":"2025-07-09T01:44:56+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"16544673045160246579144353805396923081","date":"2025-07-08T20:32:35+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-07T15:37:58+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"238624898415241214956339360225859333534","date":"2025-07-07T13:46:15+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-06T17:23:15+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"150100785518222566935977452673521079048","date":"2025-07-06T16:45:55+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"164537186398345791409890720565589539178","date":"2025-07-06T12:43:41+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"162699533028970205415383178151305994370","date":"2025-07-04T04:15:43+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"240039883389759959038647073211357381479","date":"2025-07-04T02:12:09+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"290612714406022437329014267653279013442","date":"2025-07-04T00:25:26+00:00","index":"hide","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-04-09T07:44:22+00:00","index":"","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-03-26T15:19:35+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-03-25T04:41:50+00:00","index":"","fulltext":""},{"type":"submitted","content":"Discover Medicine","date":"2025-03-15T07:32:38+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"discover-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Discover Medicine](https://link.springer.com/journal/44337)","snPcode":"44337","submissionUrl":"https://submission.springernature.com/new-submission/44337/3","title":"Discover Medicine","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"6ea8bde4-d798-4cb2-9d0e-6730d823e111","owner":[],"postedDate":"March 27th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-11-19T08:53:54+00:00","versionOfRecord":[],"versionCreatedAt":"2025-03-27 07:58:06","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5198420","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5198420","identity":"rs-5198420","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}