Giant cell tumour (GCT) of bone is an uncommon, typically benign lesion that is known for its locally aggressive behaviour. It accounts for about 5–8% of all primary bone tumours and is most often seen in young adults after skeletal maturity, with a slight predominance in females. Classically, GCT arises in the epiphyseal region of long bones, most frequently around the knee and at the distal radius (13,15,16). Occurrence of GCT in the bones of the foot is distinctly rare, representing less than 2% of reported cases, and involvement of the metatarsals is particularly unusual. Tumours arising in the small bones of the hand and foot often behave differently from those at conventional sites. They tend to present at a younger age, progress rapidly, and frequently involve the entire length of the bone by the time of diagnosis (8,17). Because of this atypical presentation, diagnosis may be delayed or confused with other lytic lesions such as aneurysmal bone cysts, enchondroma, or chronic infection (8,16). Owing to the rarity of metatarsal involvement, there is no clear consensus on optimal management. Surgical treatment remains the mainstay, with options ranging from extended curettage with adjuvant therapy to en bloc resection, depending on the extent of bone and soft-tissue involvement. Several authors have reported a higher risk of local recurrence in GCTs of the hand and foot compared with tumors at more common locations, highlighting the importance of appropriate surgical planning and vigilant follow-up (17-19). This paper presents a case of giant cell tumourof the metatarsal and discusses its clinical presentation, radiological features, and treatment considerations in light of the existing literature.

Study Design This prospective observational study was conducted at the Department of Orthopaedics, NSCB Medical College & Hospital, Jabalpur, from November 2022 to October 2025. Institutional ethical approval was obtained from the Ethics Committee, and written informed consent was secured from patients before enrolment. Method of Sampling All patients with GCT of metatarsal who fulfilled the inclusion criteria and presented during the study period were included until the required sample size was reached. Study Participants Children aged 20 to 60 years presenting with Primary GCT of Metatarsal were included. Exclusion criteria were secondary tumour and recurrence of tumour and medical contraindications to anaesthesia or surgery. Study Procedure Preoperative evaluation consisted of history and clinical examination followed by Radiographic assessment utilized standardized anteroposterior and lateral foot and ankle (Fig. 1,2,3). MRI of the foot was done before the Biopsy to confirm the diagnosis (Fig.4) Surgical Technique A biopsy was performed, which confirmed the diagnosis of a giant cell tumour (GCT) (Fig. 10). The lesion was managed with complete excision by radical resection (Fig. 5,6). To minimize the risk of residual disease, the surgical margins were extended using hydrogen peroxide as a local adjuvant. The articular cartilage of the medial cuneiform and the proximal phalanx of the great toe was excised, and slots were created in both bones to prepare the host surfaces for arthrodesis (Fig. 5, 6). The resulting bone defect was reconstructed using primary bone grafting with a freshly harvested autogenous fibular strut graft. A 2-mm Kirschner wire was passed intramedullary through the graft and anchored proximally in the medial cuneiform and distally in the phalanges to maintain alignment and provide stability (Fig. 7,8,9). The resected specimen was sent for histopathological examination, which confirmed the diagnosis of GCT (Fig. 10). The wound was closed over a drain, and a posterior below-knee plaster slab was applied. Postoperative Care Postoperative wound care followed standard dressing protocols. Sutures were removed on the 14th postoperative day, after which a below-knee plaster of Paris cast was applied. Once postoperative pain had subsided, the patient was encouraged to begin ambulation with non-weight-bearing crutches. This was gradually progressed to partial weight bearing after k-wire removal and eventually to full weight bearing. The patient has since completed regular clinic radiological follow-up. Follow-up and Outcome Measures Patients were clinically and radiologically reviewed at cast removal i.e. 14 days, then at 2 months for K-wire removal then at 3, 6, and 12 months to assess correction and complications (Fig.11,12,13,14). Statistical Analysis Data analysis was performed using paired t-tests and ANOVA; p < 0.05 was considered statistically significant

The majority of patients 80 were between 20 and 40 years old, indicating most presentations in skeletally mature patients. There was a clear female predominance (80%) in the study cohort, most patients K- wire removal was done in 2 months, indicating this period as optimal for fixation. A minority required longer fixation. There was a significant and progressive decrease in VAS Score from preoperative values to zero by 12 months (table 1), indicating complete clinical correction of deformity and pain and satisfactory clinical outcome. Complications were minor overall like Pin tract infection, stiffness of joints etc., with pin tract infections being the most common (10%) and all manageable with conservative treatments. Preoperative Immediate Postoperative 2 Month follow up 3 Month follow up 6Month follow up 12 Month follow up 8.9 + 0.5 6.8 + 0.5 3.8 + 0.5 2.4 + 0.5 1.5+ 0.5 1 + 0.5 Table 1 showing Mean Vas Score at Different event VAS: 0 = no pain and no difficulty in walking, 10 = worst imaginable pain and difficulty in walking Fig 1 clinical photo Fig 2 Pre-operative X-ray showing a large osteolytic lesion of 3rd metatarsal right foot Fig.3 pre-operative measurement of size of tumour Fig.4 MRI cuts showing GCT involving 3rd metatarsal Fig.5 Exposure and excision of tumour Fig.6 Excised tumour mass fig.7 Fibular graft Fig.8 Post operative X-rays Fig.9 X-ray of graft harvesting site fig 10 Biopsy showing multinucleated giant cells Fig.11 1month foll ow up X-ray Fig.12- 3 month follow up X-rays after K-wire removal Fig.13- 6month follow up X-rays Fig.14-Follow up after 12-month X-ray showing graft incorporation

Giant cell tumour (GCT) of bone is a benign but locally aggressive lesion, accounting for approximately 20% of benign bone tumours, with a relatively higher incidence reported in Asian populations [9]. The tumour most commonly affects skeletally mature individuals in the second to fourth decades of life, with a peak incidence in the third decade [9,10]. GCTs characteristically arise in the epiphyseal–metaphyseal region of long bones; however, in skeletally immature patients, metaphyseal involvement is more common [1,3,4]. More than half of all GCTs occur around the knee joint, particularly involving the distal femur and proximal tibia, followed by the distal radius and sacrum [3,4]. In contrast, involvement of the bones of the foot is rare, and metatarsal localization is exceedingly uncommon. Dahlin, in his extensive series of bone tumours, did not report any cases of metatarsal GCT, emphasizing the rarity of this location [7]. Similarly, Biscaglia et al. identified only a few metatarsal cases among over 2,000 GCTs involving the hand and foot [8]. Consequently, most information regarding metatarsal GCTs is derived from isolated case reports and small case series. Several authors have suggested that GCTs involving the metatarsals tend to behave more aggressively than those in long bones [1,8]. The compact anatomy of the foot, thin cortical bone, and limited intramedullary space allow early cortical breach and rapid local expansion. Siddiqui et al. and Baker et al. reported that patients with metatarsal GCTs often present with extensive bone destruction at diagnosis, frequently due to delayed recognition and misattribution of symptoms to common foot disorders [1,2]. Pain and swelling are the most common presenting complaints, and pathological fracture may be the initial presentation in a minority of cases [2,14]. Radiological diagnosis of metatarsal GCT can be challenging, as the classical radiographic features seen in long bones may be absent or less pronounced in small bones [5]. MRI plays an important role in delineating tumour extent, cortical breach, and soft-tissue involvement, thereby assisting in surgical planning [1,3]. However, given the nonspecific clinical and radiological features, histopathological examination remains mandatory for definitive diagnosis [1,3]. The treatment of metatarsal GCT differs from that of long-bone lesions. While extended curettage with adjuvants is widely accepted for GCTs at conventional sites, this approach has been associated with high recurrence rates in small bones of the hand and foot [8]. Biscaglia et al. demonstrated significantly increased recurrence following intralesional procedures in foot GCTs, leading many authors to advocate en-mass excision for metatarsal involvement to ensure oncological clearance [8]. Malignant transformation, although rare, has been reported either de novo or following recurrence or radiotherapy, further supporting the need for adequate initial resection [12,13]. Resection of a metatarsal creates a segmental defect that compromises forefoot stability, length, and load transmission. Reconstruction is therefore essential to restore biomechanics and prevent transfer metatarsalgia. Among available options, autogenous fibular strut grafting offers several advantages. The fibula closely matches the size and contour of the metatarsal and provides excellent structural strength due to its cortical nature, allowing effective weight-bearing and load transfer [1]. Additionally, fibular grafts show reliable incorporation with minimal donor-site morbidity [6]. Previous studies have reported favourable outcomes following fibular strut graft reconstruction after metatarsal GCT excision. Siddiqui et al. achieved successful graft union without recurrence following en-mass excision of a first metatarsal GCT reconstructed with a fibular strut graft [1]. Wang et al. similarly reported good functional outcomes using graft reconstruction following wide excision [6]. Compared with ray resection or amputation, fibular strut grafting preserves foot length, alignment, and function, resulting in superior functional and cosmetic outcomes. Tumours of the foot are known to progress rapidly because of confined anatomical compartments and delayed diagnosis. According to Bos et al., delayed presentation may limit limb-salvage options and necessitate amputation, particularly when the tumour crosses anatomical compartments as described in the Enneking staging system [15]. Early diagnosis and definitive surgical management are therefore crucial. In this context, en-mass excision followed by fibular strut graft reconstruction represents an effective treatment strategy that provides oncological safety while preserving foot function. Comparison with Previously Reported Cases The present case shares clinical characteristics with previously reported metatarsal GCTs(Table 2), including delayed presentation and extensive local bone involvement [1,2]. Similar to reports by Siddiqui et al., intralesional curettage was avoided due to the high recurrence rates associated with small-bone GCTs [1]. Unlike earlier cases managed by ray resection or amputation, reconstruction with an autogenous fibular strut graft in the present case allowed restoration of metatarsal continuity and preservation of forefoot biomechanics. This outcome supports existing literature advocating fibular strut grafting as a reliable reconstructive option following en-mass excision of metatarsal GCTs [1,6]. Author (Year) Site Treatment Reconstruction Outcome Coley & Higginbotham (1938) Metatarsal Curettage None Recurrence Ralph (1961) Metatarsal Curettage None Recurrence Schajowicz (1961) Metatarsal Resection None No recurrence Masalawala et al. (1962) Metatarsal Resection Bone graft Satisfactory Marcove et al. (1978) Metatarsal Resection Arthrodesis Good function Baker et al. (2009) [2] Metatarsal Resection Bone graft No recurrence Wang et al. (2008) [6] First metatarsal Wide excision Allograft Good outcome Siddiqui et al. (2011) [1] First metatarsal En-mass excision Fibular strut graft Union, no recurrence Table 2: Reported Cases of Giant Cell Tumour of the Metatarsal

Giant cell tumour of the metatarsal is an exceptionally rare and locally aggressive lesion that can be easily overlooked due to its atypical location and nonspecific clinical presentation. Early recognition is crucial to prevent extensive bone destruction, preserve forefoot structure, and avoid more radical procedures such as ray resection or amputation. En-mass excision remains the most effective treatment to achieve complete tumour clearance and minimize the risk of recurrence. Reconstruction with an autogenous fibular strut graft not only restores metatarsal length and alignment but also maintains biomechanical stability, allowing early weight-bearing and satisfactory functional outcomes. These cases highlights that a carefully planned, limb-salvage approach can successfully balance oncological safety with functional preservation. Additionally, fibular strut grafting provides a reproducible and reliable technique for reconstructing small weight-bearing bones, which can be applied in similar cases of foot tumours. Long-term follow-up is recommended to monitor for recurrence, graft incorporation, and functional performance. Overall, en-mass excision combined with fibular strut graft reconstruction represents a preferred strategy for metatarsal GCT, offering durable outcomes and maintaining patient quality of life

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