Extensive Curettage Research Articles

Chondromyxoid Fibroma of Pelvis, Surgical Management of 8 Cases.

Chondromyxoid fibroma is a rare benign primary bone tumor of cartilaginous origin, which most commonly involves the metaphyseal bone of proximal tibia and distal femur. The purpose of the study is to report our experience with diagnosis and surgical management of Chondromyxoid fibroma in the pelvic region. Eight consecutive patients with a final diagnosis of pelvic Chondromyxoid fibroma were treated from 2001 to 2010. We considered the presentations and outcome for surgical complications and local recurrence after extended curettage and allogenic corticocancellous bone grafting. Three patients were female and five were male. The median follow up period was 72 (30-126) months. The mean age of cases was 31.9 (20-41) years. Five patients had left side involvement and in the remaining three, the right side was involved. Four involved periacetabulum, two involved the ilium and the remaining two cases were ischiopubic. The mean Musculoskeletal Tumor Society Score was 94.1%. The major complications were recurrence in one case and herniation after pubic rami resection in another case. Chondromyxoid fibroma should be distinguished from chondrosarcoma. Management recommendation includes extensive curettage and corticocancellous bone grafting. We also advocate use of fibular strut allograft for reconstruction of pubic rami after its resection to prevent hernia in cases with pubic rami involvement.

Simple bone cyst with pathological fracture of humerus treated with extensive curettage followed by incorporation of fibular strut-graft

A simple bone cyst is an intramedullary cyst usually filled with serous and serosanguinous fluid. We hereby present a case of a 16-year-old male patient with simple bone cyst with pathological fracture of left humerus, who underwent extensive curettage of the lesion followed by incorporation of autogenous nonvascularized fibular strut-graft taken from ipsilateral limb. Simple bone cyst complicated with pathological fracture may be treated with cortical bone grafting with fibular strut-graft and synthetic fillers. Additional internal fixation with suitable implant is required to fix the pathological fracture. Therefore, by this methodology, we can take care of the disease and its complications as well in a same sitting reducing patient's morbidity.

Meta-analysis of risk factors of recurrence in patients with giant cell tumor on extremities

To explore the risk factors of giant cell tumor on extremities for patients with postoperative recurrence. The literature reports published before June 2014 were searched in the electronic databases of CBM, CNKI, PUBNED, MEDLINE and EMBASE. Meta-analysis was performed by software Review Manager (Version 5.3). The odds ratios (OR) of gender, age, tumor site, Campanacci Classification, pathological fracture, selection of treatment and soft tissue invasion were analyzed with heterogeneity test. Publication bias were tested by funnel plot and fail-safe number.Sensitivity analysis was performed to assess the stability. A total of 15 case-control studies were identified. Age, location and type of surgery were associated with tumor recurrence. The combined OR (95%CI) was 1.83 (1.04-3.24) P = 0.04 for aged <20 years, 0.52(0.31-0.86) P = 0.01 for aged >40 years, 1.60 (1.06-2.42) P = 0.02 for distal radius, 0.35 (0.14-0.90) P = 0.03 for proximal humerus, 3.64 (1.88-7.04) P = 0.0001 for curettage,0.56 (0.35-0.91) P = 0.02 for curettage with PMMA, 1.79 (1.11-2.88) P = 0.02 for curettage with bone graft and adjuvant and 0.29 (0.12-0.66) P = 0.003 for resection respectively. There were not significant relationship between tumor recurrence and gender, tumor location (distal femur, proximal femur, distal tibia, proximal tibia), Jaffe staging, Campanacci classification,Enneking classification, pathological fracture, soft tissue invasion, extensive curettage, curettage with bone graft, curettage with polymethylmethacrylate and adjuvant (P > 0.05). Youth (aged <20 years), distal radius, curettage and curettage with bone graft and adjuvant are the risk factors for recurrence of giant cell tumor.However, advanced age (aged >40 years), proximal tibia, curettage with PMMA and resection appear to have lower risks for tumor recurrence.

Adjuvant treatment with zoledronic acid after extensive curettage for giant cell tumours of bone

BackgroundGiant cell tumours (GCT) of bone are benign neoplasms associated with a high rate of local recurrence after extensive intra-lesional curettage. Recently, understanding of the biological molecular availability of strong anti-osteoclastic drugs has suggested their potential value in reducing local recurrences after curettage. Through a phase II clinical trial, we investigated the effect of a short treatment with zoledronic acid (ZOL) after intra-lesional curettage of GCT, as well as local recurrence and tolerance of the treatment. Methods and patientsTwenty-four patients were enrolled in a multicentre, phase 2 study. The patients were treated with extensive intra-lesional curettage followed by five courses of ZOL (4mg IV every 3weeks).The clinical and biological tolerance of each patient was assessed. Patients were reviewed clinically and by X-ray every 6months until the end of the study (36months). ResultsEighteen out of 20 patients reported side-effects with ZOL, mainly grade 1 and 2 effects. The local recurrence rate was 15%; three patients had a recurrence, one at 4months (huge GCT of the sacrum), one at 24months (patient who discontinued the treatment after the first course of ZOL), and one after the observational period, at 58months. Finally, local relapse-free survival was 82±9% at 60months. ConclusionShort adjuvant treatments with ZOL after extensive intra-lesional curettage of GCT were associated with a low rate of recurrence but did not prevent local recurrence in this study. No serious general adverse effects were observed. More studies are needed to evaluate the potential benefit of medical bisphosphonate injections combined with intra-lesional curettage in the treatment of GCTB.

English

Aneurysmal Bone cyst is a benign solitary lesion of unknown etiology. It occurs mostly in long bones, very rarely (3% of cases) it occurs in the foot bones that too in the calcaneum, it is extremely rare. CASE: A twenty-one years old male with history of a slow growing swelling on right heel since two years and dull aching pain over the swelling. There was history of trivial trauma to same heel for which patient was treated with a boot cast by a local doctor. Investigations were done and X-ray showed central multiloculated lytic lesion with bone destruction and no new bone formation with trabeculations. FNAC revealed blood elements indicating towards Aneurysmal bone cyst. Excision was planned and per-operative finding was welling of blood at operation site. Extensive curettage followed by corticocancellous bone grafting was done and patient was discharged with a boot cast. On follow-up the grafts were taken up well. Weight bearing was started after 10 weeks. Patient was followed up for 2 years. There was no sign of recurrence. The lytic lesion healed well. CONCLUSION: ABC of calcaneum along with pathological fracture is very rare.

Analysis of the risk factors for local recurrence of giant cell tumor of long bone

The aim of the present study was to investigate the outcome of surgical management in patients with giant cell tumor (GCT) of extremity long bone and the risk factors for recurrence. Clinicopathological data of 145 patients with giant cell tumor of long bone treated in our hospital from 2002 to 2008 were retrospectively reviewed. There were 79 male and 66 female patients. The mean age at first diagnosis was 29 (11-66) years. There were 45 GCTs localized in the distal femur, followed by 36 in the proximal tibia, 22 in the proximal femur, 19 in the distal radius, 8 in the proximal fibula, 8 in the proximal humerus, 4 in the distal tibia and one in the distal fibula, distal humerus and proximal radius, for each. Surgical treatment included extensive curettage in 81 cases and resection in 64 cases. The possible risk factors for recurrence included age, gender, tumor location, Campanacci grading, pathologic fracture and types of surgery. The patients were followed up with a mean duration of 50 months ranging from 36 to 104 months. The correlation of age, gender, tumor location, Campanacci grading, pathologic fracture and types of surgery with the risk for recurrence was analyzed. The overall local recurrence rate was 4.8% (7/145) and the mean duration for recurrence was 20 months ranging from 4 to 52 months. The local recurrence rate was 7.4% (6/81) in the extensive curettage group and 1.6% (1/64) in the resection group (P = 0.134). The difference was not statistically significant. Age, gender, tumor location, Campanacci grading, pathologic fracture and types of surgery were not risk factors for recurrence. The results of the present study suggest that clinical and imaging features and types of surgery are not affecting factors for recurrence of giant cell tumor of long bone. Extensive curettage provides similar favorable local control of the tumor as resection. We would recommend extensive curettage while resection should be done following indications.

Tuberculous Tenosynovitis Presenting As Ganglion Of Wrist

Tuberculosis (TB) is still endemic in many developed countries. Involvement of the hand and wrist at presentation is extremely rare, and the diagnosis is often missed. 57 years old male presented with swelling over the left wrist since 3 years. Three swellings over dorsal aspect of the left wrist, soft in consistency, non tender, non compressible mobile at right angles to the plane of the wrist joint. ESR: 45 mm in 1 hr and rest blood investigation were normal. Ultrasonography showed Giant-cell tumor of Extensor Digitorum sheath. Xray: soft tissue swelling MRI suggestive of Extensor Tendon sheath Extraskeletal Synovial Koch’s or Giant cell tumor of tendon sheath. Then planed for excision of swelling and intra-operative fi nding were rice bodies. Histopathological examination showed caseous necrosis with granuloma formation. Patient put on DOT1 therapy. Tuberculous tenosynovitis was first described by Acrel in 1777. Rice bodies occurring in joints affected by tuberculosis were first described in 1895 by Reise Rice bodies will be diagnosed on plain radiographs when mineralization occurs. More than 50% of cases recur within 1 year of treatment. The currently recommended 6-month course is often adequate with Extensive curettage, lavage and synovectomy should be performed. Surgery is essential, but the extent of surgical debridement is still debatable. The surgeon has to be aware of the significance of loose bodies when performing routine excision of innocuous looking wrist ganglia. SAARC Journal of Tuberculosis, Lung Diseases &amp; HIV/AIDS; 2013; X(2); 45-47 DOI: http://dx.doi.org/10.3126/saarctb.v10i2.9713

Extensive curettage using a high-speed burr versus dehydrated alcohol instillation for the treatment of enchondroma of the hand

The purpose of this retrospective study was to compare the clinical and radiological outcomes of patients treated with different adjuvant methods after curettage for enchondromas of the hand. Sixty-two patients with enchondroma were treated with high-speed burring (29 patients) or alcohol instillation (33 patients) after curettage. The mean follow-up was 40.8 months. No significant differences in the visual analogue scale, Disabilities of the Arm, Shoulder, and Hand scores, total range of active motion, grip strength, and complete healing time were observed between the groups. The distribution of the results of the formula by Wilhelm and Feldmeier were not significantly different between the groups. No surgery-related complications, postoperative pathological fractures, or recurrence was found in either group. For the treatment of enchondroma in the metacarpal and proximal phalanx, alcohol instillation immediately after curettage was as effective as extensive curettage using a high-speed burr.

Lower recurrence rate in chondroblastoma using extended curettage and cryosurgery

Various methods for the treatment of chondroblastoma of bone have been used including simple curettage, or combined with bone grafting, in addition to the use of adjuvant therapy. However, local recurrence still represents a challenge in the management of this aggressive tumour. This study focuses on evaluating the role of intraregional extended curettage together with the use of adjuvant cryotherapy and autogenous bone grafting in the treatment of benign chondroblastoma of bone aiming to decrease the recurrence rate. All patients with chondroblastoma included in this study underwent intralesional extended curettage, adjuvant cryotherapy using liquid nitrogen, and autogenous iliac crest bone grafting. Follow up for healing of chondroblastoma lesions and detection of any local recurrence was assessed on clinical and radiological bases. The functional outcome was assessed by the Musculoskeletal Tumour Society scoring system. The mean follow-up period was 49 months. The average time for bone healing was 7.4 months. Our rate of local recurrence is 7.1 %. Two patients (14.3 %) developed physeal growth arrest. One patient had superficial skin sloughing (7.1 %). None of the cases had pathological fracture. The mean Musculoskeletal Tumour Society functional score was 92.7 %. Chondroblastoma is an aggressive benign bone tumour with a high rate of recurrence. The use of high-speed burr combined with adjuvant intralesional cryotherapy and iliac crest autogenous bone grafting is a reliable method of treatment with a low rate of recurrence.

Subchondral bone grafting reduces degenerative change of knee joint in patients of giant cell tumor of bone

Background Giant cell tumors (GCTs) most commonly occur around the knee. The most beneficial procedure for this disease has been extensive curettage with reconstruction. However, since many GCTs may compromise the subchondral bone, surgery can further jeopardize the articular cartilage and result in secondary osteoarthritis. In this study, we aimed to determine the factors associated with the development of degenerative arthritis and the effect of bone grafting on the prevention of secondary osteoarthritis. Methods We retrospectively analyzed 76 patients with GCT around the knee. The mean age at first diagnosis was 31.1 years. Surgical treatments included extensive curettage and cementation with or without bone grafting in the subchondral bone. Patient follow-up was a median duration of 35 months, ranging from 18 to 113 months. Results The local recurrence rate was 5.3% (4/76). Secondary degenerative changes occurred in 30.3% (23/76) of the patients. Less than 10 mm of the residual thickness of the remaining subchondral bone was correlated with secondary degenerative changes in 57 patients (P &lt;0.001). Of these 57 patients, 56.5% (13/23) treated with bone cement reconstruction alone developed secondary degenerative changes; following bone grafting, the rate decreased to 29.4% (10/34), with a statistically significant difference (P=0.041). Conclusions GCT patients with less residual thickness of the subchondral bone are more likely to develop degenerative arthritis after curettage. Bone grafting in the subchondral bone area is recommended when the residual thickness of the subchondral bone is less than 10 mm.

Giant Cell Tumor of the Extremity

There are no recent reports of giant cell tumors of bone in a large series of Chinese people. The present study was designed to review the epidemiological characteristics and outcomes of surgical management in a large series of Chinese patients with giant cell tumor of an extremity, treated at a single institution. The records and images of 621 patients in whom a benign giant cell tumor in an extremity was treated between 1989 and 2009 were reviewed retrospectively. There were 359 male and 262 female patients. The mean age at diagnosis was 31.4 years (range, eleven to seventy-one years). Sixty-six percent of the giant cell tumors were localized around the knee. Surgical treatments primarily included curettage, extensive curettage, and resection. The median duration of follow-up was forty-nine months (range, eighteen to 256 months). Giant cell tumor accounted for 13.7% of all primary bone tumors treated at our institution. Multivariate Cox regression analysis indicated that the only variable that contributed to recurrence-free survival was the type of surgical treatment. The local recurrence rate after extensive curettage was 8.6%, which was significantly lower than the 56.1% recurrence rate after curettage alone. Bone-grafting did not affect local tumor control after extensive curettage; the local recurrence rate was 11.1% if bone graft was used. Recurrent giant cell tumor can be treated by further curettage or resection, with acceptable re-recurrence rates of 6.7% and 9.3% respectively. The Musculoskeletal Tumor Society Score for patients treated with extensive curettage was 92.6%, which was significantly higher than that for patients treated with resection. Twenty-one (3.4%) of the 621 patients developed benign pulmonary metastasis, with a favorable outcome, and three patients presented with multifocal giant cell tumors. The incidence of giant cell tumor in the Chinese population may be higher than that in Western countries, and it has a male predilection. The results of the present study suggest that extensive curettage provides favorable local control and satisfactory functional outcomes.

Tuberculous Tenosynovitis Presenting as Ganglion of Wrist

Tuberculosis (TB) is still endemic in many developed countries. Involvement of the hand and wrist at presentation is extremely rare, and the diagnosis is often missed. A 57 years old male presented with swelling over the left wrist since 3 years Three swellings over dorsal aspect of the left wrist Soft in consistency Non tender Non compressible Mobile at right angles to the plane of the wrist joint. ESR: 45 mm in 1 hr and rest blood investigations were normal. Ultrsonography showed giant cell tumor of Extensor Digitorum sheath. X-ray: soft tissue swelling and MRI was suggestive of extensor tendon sheath extraskeletal synovial Koch's, or giant cell tumor of tendon sheath. Excision of swelling was planned and intraoperatively, rice bodies were seen inside it. Histopathological examination showed caseous necrosis with granuloma formation. Patient was put on DOT1 therapy. Tuberculous tenosynovitis was first described by Acrel in 1777. Rice bodies occurring in joints affected by tuberculosis were first described in 1895 by Reise. Rice bodies will be diagnosed on plain radiographs when mineralization occurs. More than 50% of cases recur within 1 year of treatment. The currently recommended 6-month course is often adequate with extensive curettage lavage and synovectomy should be performed. Surgery is essential, but the extent of surgical debridement is still debatable. The surgeon has to be aware of the significance of loose bodies when performing routine excision of innocuous looking wrist ganglia.

Osteofibrous dysplasia–an unusual presentation of rare entity

Correspondence: Dr. Vineet Jain, H. No. 194, Sector 21-C, Faridabad, Haryana – 121001. E-mail: vineet.ortho@gmail.com doi: 10.1016/S0976-5662(11)60056-8 last 15 days. On clinical examination right hip was tender and all movements at right hip were severely painful and restricted. Radiographs (Figures 1 and 2) revealed a well circumscribed osteolytic metaphyseal lesion with diaphyseal extension and surrounding sclerotic rim, involving neck, trochanter and extending up to subtrochantric region of femur. There was fracture of neck of femur. On the basis of above finding differential diagnosis of Fibrous dysplasia, Non-ossifying fibroma, Giant cell tumor and Admantinoma with pathological fracture neck of femur were considered. Under spinal anesthesia through lateral approach to hip, pathological site was approached and extensive curettage and cauterization was performed. Fixation was done with 4-hole dynamic hip screw. About 6 cm ipsilateral fibula was harvested and inserted through trochanter to neck region superior to lag screw of dynamic hip screw and rest of the area was filled with cancellous bone graft taken from iliac crest. Histopathological examination of curetted material showed osteofibrous dysplasia (Figure 3). Patient was kept on bed rest for 3 weeks, followed by nonweight-bearing crutch walking for 6 weeks, toe touch crutch walking for 8 weeks. Fracture united and bone graft was incorporated in about 4 months’ time. Subsequently patient was Osteofibrous dysplasia—an unusual presentation of rare entity

Joint Preservation after Extensive Curettage of Knee Giant Cell Tumors

Joint Preservation after Extensive Curettage of Knee Giant Cell Tumors

Prognostic effect of inadvertent curettage without treatment delay in osteosarcoma

Unplanned primary surgery has been known to have a negative prognostic impact in osteosarcoma. We identified 20 osteosarcoma patients that had undergone inadvertent surgery followed by adequate treatment without delay, and compared the clinicopathologic characteristics of these 20 case patients with those of 365 patients who underwent incisional biopsy. For survival analysis, 40 control patients matched for tumor size at presentation, tumor location, age and gender were selected from these 365 patients. Unusual initial clinicopathologic characteristics were frequently observed in the case patients, such as, an older age, a small tumor size, an unusual tumor location, and a lytic radiographic pattern. The 5-year overall survival rate in the case group was 89.4 +/- 7.1% and in the control group was 83.9 +/- 6.1%, and the 5-year event-free survival rate in the case group was 90.0 +/- 6.7% and in the control group was 76.8 +/- 6.8%. The log rank test revealed no survival difference between the case and control groups. As is the case for soft tissue sarcoma, inadvertent extensive curettage with no ensuing treatment delay was found to have no detrimental effect on overall- or event-free survival in osteosarcoma. Further study using a larger sample size is needed to confirm our results.

Joint Preservation after Extensive Curettage of Knee Giant Cell Tumors

Curettage is the most attractive procedure for surgically treating a giant cell tumor because it preserves joint function. However, since many giant cell tumors compromise subchondral bone this technique can jeopardize the articular surface with subsequent fractures or collapse. We asked whether intralesional curettage of a giant cell tumor close to the knee that combined morselized bone and cortical structural allograft would preserve joint function. We retrospectively reviewed 22 patients treated with that approach. The minimum followup was 2 years (average, 48 months; range, 24-80 months). The distal femur was involved in 12 patients and proximal tibia in 10. Complications and failures were recorded and functional results evaluated with Musculoskeletal Tumor Society score. We determined survivorship using the Kaplan-Meier technique using removal of the implant as the endpoint. The survival was 85% and the average functional score 28 points. Three of the 22 patients had a local tumor recurrence and one had a partial subchondral collapse not requiring further treatment. Among the remaining patients, none had fracture, infection, or knee instability. The combination of fragmented and cortical allograft allows reconstructing the bone defect and ligaments created after extensive curettage of a knee giant cell tumor obtaining normal joint function and a high survival rate with minimal complications in a high percentage of the patients. Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

One Stage Management with Curettage and Bone Graft of Chronic Osteomyelitis Preceded by Surgical Treatment of Calcaneal Fracture: Report of Three Cases

Several methods for treatment of the chronic calcaneal osteomyelitis has been reported. Soft tissue flaps were used to fill the dead space after curettage. And then autogenous bone grafting is performed to maintain mechanical integrity as a second procedure in case of large bony defect. So at least two operations have to be done and the total duration of treatment is long. We hereby report three cases of chronic osteomyelitis of the calcaneus preceded by surgical treatment of calcaneal fracture which were treated successfully through simultaneous operation of extensive curettage and bone graft. Pin tract infection around Steinmann pin used for axial fixation occurred in two out of three cases.

Methotrexate Eluted From Bone Cement

The effectiveness of methotrexate eluted from polymethylmethacrylate on cell lines established from giant cell tumor of bone was investigated in vitro to determine the possible efficacy of this treatment. Elation of methotrexate from polymethylmethacrylate beads and boluses was shown in vitro to be dose dependent and limited by the size of the bolus. Cytocidal activity of methotrexate elated from polymethylmethacrylate beads prepared without monomer and of boluses of polymethylmethacrylate with the same dose of methotrexate prepared with monomer against 2 human giant cell tumor cell lines was statistically significant at 24 hours in culture. Statistical significance occurred at 24 hours in culture. Activity was maintained in vitro after 17 days. These experiments showed that eluted methotrexate remained effective against tumor cells after exposure to thermal changes during polymerization of polymethylmethacrylate. While extensive curettage of giant cell tumor of bone followed by filling in the defect with polymethylmethacrylate has become a common treatment, a local adjuvant is necessary to reduce further risk of local recurrence. A potential alternative to cryosurgery or instillation of phenol is the use of methotrexate impregnated polymethylmethacrylate to treat residual microscopic disease after curettage. This method may provide locally effective chemotherapy without the risks of systemic toxicities.

Open quiz: Case report 806

Fig. 1 A-C. Chronological radiographic sequences of the fight fifth metacarpal bone during the different stages of disease. A lyric and expansile lesion within the medullary canal is seen (A, C). After treatment, a sclerosing reparative pattern is present (B) of fracture or cortical interruption. A subchondral location was noted. Enchondroma was the clinical and radiographic diagnosis. Extensive curettage of the medullary canal was performed, after which the cavity was packed with a cancellous bone graft obtained f rom the right iliac crest. During the curettage a thick fluidlike material was observed, and the bone fragments obtained were submitted for histological analysis. A radiological study performed 3 months later revealed a trabecular, sclerosing reparative pat tern (Fig. 1 B). Three years later, in January 1992, a new roentgenogram disclosed an expansile lytic lesion in the same anatomical zone, very similar radiographically to the original lesion (Fig. 1 C). Curettage was performed at that time. Periodic skeletal surveys were unremarkable except for the findings in the hand.

小児頚椎に発生したＡｎｅｕｒｙｓｍａｌ ｂｏｎｅ ｃｙｓｔの２例

Aneurysmal bone cysts (ABC) arising from the cervical spine in children is relatively rare. Two cases with aneurysmal bone cysts arising from the cervical spine were successfully operated on in order to achieve radical tumor resection and reconstruction cervical spine stability were reported.Case1: A five year-old boy with neck pain and limitation of cervical movements. Clinical and histological investigation revealed ABC at the body of C4. Extensive curettage and bone grafting from C3 to C5 spine were carried out. Complete bony union was achieved. At six years follw-up, no tumor recurrence was seen, the spinal canal had normal growth and the patient had returned to normal activity.Case 2: A twelve year-old girl. Radiological examination and histological findings revealed ABC extensively occupying the body and lamina of C4. Staged resection and reconstruction were done. In the first stage, wide curettage through the posterior approach followed by bone grafting with Luque instrumentation were done. Two weeks later extensive curettage of the C4 lesion, cervical interbody fusion with bone grafting and plating from C3 to C5 were carried out. At three years follow-up, complete bony union was observed with no recurrence of the lesion, nor any disturbance of spinal canal growth.