An improved total en bloc spondylectomy for L5 vertebral giant cell tumor through a single-stage posterior approach

PURPOSE

Although total en bloc spondylectomy (TES) is strongly recommended for spinal giant cell tumor (GCT), it is extremely difficult to excise a L5 neoplasm intactly through the single-stage posterior approach. Given the risk of neurological and vascular injury, intralesional curettage (IC) is usually recommended for the treatment of L5 GCT. In this study, we presented our experience with the use of an improved TES to treat L5 GCT through the single-stage posterior approach.

METHODS

This study included 20 patients with L5 GCT who received surgical treatment in our department between September 2010 and April 2021. Of them, seven patients received improved TES without iliac osteotomy, and the other 13 patients received IC (n = 8), sagittal en bloc resection (n = 1), TES with iliac osteotomy (n = 3), and TES with radicotomy (n = 1) as control.

RESULTS

The mean operative time was 331.43 ± 92.95 min for improved TES group and 365.77 ± 85.17 min for the control group (p = 0.415), with the mean blood loss of 1142.86 ± 340.87 ml vs. 1969.23 ± 563.30 ml (p = 0.002). Postoperative treatment included bisphosphonates in nine patients and denosumab in 12 patients including one patient who changed from bisphosphonates to denosumab. Three patients who received IC experienced local recurrence, and no relapse was observed in improved TES group.

CONCLUSION

Single-stage posterior TES for L5 GCT was previously considered impossible. In this study, we presented our experience with the use of an improved surgical technique for L5 TES through the single-stage posterior approach, which has proved to be superior to the conventional procedures in terms of blood loss control and complication and recurrence rates.

LEVEL OF EVIDENCE

IV.

Recurrent chondroblastoma of the talus: A case report and literature review of recurrent lesions in the foot and ankle

INTRODUCTION AND IMPORTANCE

Chondroblastoma is a benign cartilaginous tumour that usually presents in the epiphysis of long bones in patients aged 10-20 years old. Only 4 % of primary chondroblastoma occur in the talus. Recurrence is rare, especially in the foot and ankle and there is no consensus regarding how it is best managed. This unique case and literature review add to a limited evidence base.

CASE PRESENTATION

A 21-year-old male was referred to our elective orthopaedic clinic with persistent anterior ankle pain exacerbated by weight-bearing. Radiographs and MRI revealed a 2.5 cm non-homogenous mass in the anteromedial talus with expansion of overlying bone consistent with chondroblastoma-ABC. Our patient was initially managed by intralesional curettage and autologous bone grafting but had recurrence 4.5 months postoperatively. Subsequent en bloc resection of the talar neck with talonavicular and calcaneocuboid joint fusion resulted in excellent functional outcomes and disease-free survival at 2 years follow-up.

CLINICAL DISCUSSION

There are few reports discussing treatment options for recurrence in the foot and ankle. Successful treatment of primary and recurrent lesions depends on complete local resection. Repeat curettage or en bloc resection are effective options depending on tumour size and location. Type of bone graft or void filler should be considered on a case-by-case basis. Novel therapies (e.g. phenol instillation) may be beneficial.

CONCLUSION

This case details successful management of recurrent chondroblastoma with en bloc resection of the talar neck and hindfoot reconstruction. We review the efficacy and outcomes of all previously reported recurrent chondroblastoma in the foot and ankle. We highlight multiple potential treatment options.

Intraoperative three-dimensional navigation for surgical treatment of osteoid osteoma in the foot and ankle - A series of 14 cases

BACKGROUND

The surgical treatment for osteoid osteoma (OO) in the foot and ankle is challenging. It is difficult to locate the lesion and the anatomy is crowded by sensitive structures. The purpose of this study was to describe the outcomes of navigated mini open-intralesional curettage (NMIC) or navigated minimally invasive radiofrequency ablation (NMRFA) in treating these lesions.

METHODS

All patients who underwent surgery for OO in the foot and ankle between 2015 and 2020 were included. O-arm navigation was used in All procedures. The choice of NMIC versus NMRFA was made by the surgeon according to the location of the lesion and its proximity to sensitive anatomic structures.

RESULTS

Fourteen patients were included. Ten were operated by NMRFA and 4 by NMIC. All patients' symptoms related to OO resolved following a single procedure. Average AOFAS score increased by 18.7 (P < .001). Three patients had the following complications: pathologic fracture, superficial infection and transient deep peroneal nerve sensory loss.

CONCLUSION

Navigated surgical treatment of OO in the foot and ankle is accurate, efficient and safe.

Curettage versus wide resection followed by arthrodesis/arthroplasty for distal radius Giant cell tumours: A meta-analysis of treatment and reconstruction methods

Purpose

Primary aim of this review was to compare the two treatment modalities-curettage and wide excision (WE)- of Giant cell tumours of distal radius along with the methods of reconstruction viz. arthrodesis (AD) and arthroplasty (AP), and determine which had a better outcome.

Methods

PubMed and Cochrane library databases were systematically searched using a well-defined search strategy by two independent reviewers. Inclusion/exclusion criteria were predetermined using the PICO format. MINORS tool was used to evaluate study quality. Recurrence rate (RR) was the chief oncological determinant whereas range of motion, grip strength, disability of arm, shoulder and hand (DASH) and musculoskeletal tumour society (MSTS) scores and complication rates were the functional outcome measures used.

Results

For the first part, a total of 11 articles (284 patients) were analysed. The second half- AP versus AD-included four studies (71 patients). Quantitative analysis revealed a significantly higher RR (Odds ratio (OR) 8.6 [95% CI, 3.4, 21.75]) with curettage. WE, on the other hand, was associated with a higher complication rate (OR 0.3[ 95% CI, 0.14, 0.62]) and lower grip strength (Standard Mean Difference (SMD) 18.08[95% CI, 13.78, 22.37]). Complication rates were also significantly higher with wrist AP (OR 6.36[ 95% CI, 1.72, 23.52]). Remaining functional parameters failed to show any significant difference between either group.

Conclusion

WE is the preferred surgical strategy in terms of lower RR and functionally equivalent results. In terms of the choice of reconstruction following WE, there is a trend towards higher patient satisfaction after wrist AD.

Management of giant cell tumors of the distal radius: a systematic review and meta-analysis

PURPOSE

The treatment of giant cell tumors (GCT) of the distal radius remains challenging, with no consensus on the optimal surgical management. Surgical management remains the mainstay of treatment with options including intralesional curettage and en-bloc resection with reconstruction. The objective of this systematic review and meta-analysis was to evaluate and compare the outcomes of these two procedures.

METHODS

Using OVID-Medline and Embase databases, a systematic literature search was performed. Comparative studies, assessing intralesional curettage and en-bloc resection in patients with GCTs of the distal radius, were included. Data regarding rates of local recurrence, metastasis, overall complications, and functional outcomes, were collected and analyzed. The ROBINS-I tool was utilized for risk of bias appraisal within each study outcome.

RESULTS

Thirteen studies (n = 373 patients) reporting on 191 intralesional curettage procedures and 182 en-bloc resections were included in the analysis. The average age of participants was 31.9 (SD ± 2.4) years and average follow-up was 7.1 (SD ± 3.6) years. Patients that underwent intralesional curettage were more likely to develop local recurrence (Risk Ratio (RR) 3.3, 95% CI, [2.1, 5.4], p < 0.00001) when compared to patients that underwent en-bloc resection. In Campanacci grade 3 lesions, the risk for local recurrence was 5.9 (95% CI, [2.2, 16.3], p = 0.0006) times higher in patients that received intralesional curettage. Patients that underwent intralesional curettage showed an 84% reduction in the relative risk of developing overall complications compared to en-bloc resection (95% CI, [0.1, 0.4], p < 0.00001), and a larger decrease in Visual Analog Scale and lower Disabilities of the Arm, Shoulder, and Hand (DASH) scores (p < 0.00001). Risk ratio for developing a local recurrence, with PMMA versus bone graft following an intralesional procedure was not significant (RR 1.2, 95% CI, [0.6, 2.6], p = 0.62).

CONCLUSIONS

In the surgical management of GCT of the distal radius, intralesional curettage increased local recurrence compared to en-bloc resection with reconstruction, particularly in grade 3 tumors. However, it led to significantly fewer operative complications, lower pain scores, and improved functional outcomes compared to en-bloc resection. Both treatment options remain relevant in the contemporary management of GCTs of the distal radius. Surgical decision making should include both patient and tumor factors when determining the optimal treatment strategy for these patients. LEVEL 3 EVIDENCE: Meta-analysis of Level 3 studies.

Aneurysmal bone cyst of the foot: A series of 10 cases

BACKGROUND

Aneurysmal bone cyst (ABC) is a benign, locally aggressive tumor that occurs in childhood and early adulthood. It usually affects the metaphysis of long bones but can also occur in the foot.

METHODS

This single-center study is a retrospective review of ten patients with primary ABCs of the foot which underwent an intralesional curettage or a polidocanol instillation.

RESULTS

After intralesional curettage a local recurrence was observed in 3/5 cases. The instillation of polidocanol showed a significant reduction of the initial cyst volume (p=0.0267). In the instillation subgroup a primary complete healing was achieved in three cases. Due to a persisting disease two cases were converted to intralesional curettage without local recurrence in the follow-up.

CONCLUSIONS

Percutaneous instillation of polidocanol is a minimally invasive treatment option for ABCs of the foot and especially for small bones. Nevertheless, several sequential instillations and a conversion to intralesional curettage can be necessary.

Intralesional curettage versus prosthetic replacement for bone tumors - a finite element analysis case of limb salvage simulation in biomechanics

BACKGROUND AND OBJECTIVES

To compare mechanical properties of femoral tumor treatments so that better operative strategy for limb tumors surgery is optimized.

METHODS

Fourteen femoral CT images were randomly selected to rebuild 3D models by MIMICS. They were then executed by reverse engineering softwares for simulative modes. Mode #1: Intralesional curettage with cement filled plus fixator; Mode #2: Distal femur resection with tumorous prosthesis replaced. Finally, the mechanical aspects such as stress and displacement were compared by finite element analysis.

RESULTS

Analyzed by AnSys, the observation indexes were measured as follows: for displacement of femurs, d=1.4762 (< a=3.9042 < c=3.9845 < b=4.1159) in mm is the most staple of all models; for displacement of implants (fixators or prostheses), it's similar to the behavior of femurs and with no significant difference; for stresses of femurs, no significant difference was found among all models; the stresses of implants (fixations and prostheses) were observed as d=39.6334 (< a=58.6206 < c=61.8150 < b=62.6626) in MPa correspondently, which is the least; for stresses of the general system, the average of peak values for integrated devices of all models are: d=40.8072 (< a=58.6206 < c=61.7831< b=62.6626) in MPa, which is also the least. As a final result, both maximum values for displacement and stress of mode 2 are lower than those of mode 1.

CONCLUSIONS

Our finite element analysis of limb salvage simulation in biomechanics proved that, to treat distal femoral bone tumors, prosthetic replacement is more efficient than intralesional curettage.

Chondroblastoma: Is intralesional curettage with the use of adjuvants a sufficient way of therapy?

•

Chondroblastoma represents a rare pathology.

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An aggressive intralesional curettage leads to low recurrence rates.

•

Hydrogen peroxide as adjuvant lowers the risk of local recurrence.

Background

Chondroblastoma is a rare benign cartilaginous bone tumor that represents 1–2% of all primary bone tumors. It is characterized by aggressive growth, possible recurrence after surgical treatment and, in rare cases, metastasis. Surgical management is the primary treatment and includes intralesional curettage with or without adjuvants. Local recurrence rates vary between less than 10% up to more than 30%.

Methods

In this retrospective study between 2009 and 2020 we analysed 38 cases of chondroblastoma with a mean follow-up of 27.9 months who underwent a surgical treatment in our institution. Epidemiological data, radiographic and histological examinations, different surgical techniques, complications and local recurrence were evaluated to comment on the question if curettage with or without adjuvants is a sufficient way of therapy.

Results

The study includes 25 male (65.8%) and 13 female (34.2%) patients with a mean age of 17.2 (11–51) years. The most common location of manifestation was the proximal epiphyseal humerus (34.2%), followed by the proximal tibia (26.3%) and the distal femur (15.8%). Joint involvement occurred in 28 patients (73.7%). In all cases intralesional curettage was performed; in 25 cases (65.8%) the resulting cavity was filled with bone substitute, in 7.9% (3 cases) with bone cement and in 10.5% (4 cases) with autogenous bone graft. Adjuvant hydrogen peroxide was used in 64.9% of the cases. The overall recurrence rate was 39.5% (15 cases). The following subgroup analysis showed a recurrence rate of 100% (4/4 cases) after curettage and defect reconstruction with autogenous bone. In the case of intralesional curettage and filling of the cavity with bone substitute but without use of adjuvant the recurrence rate was 50% (4/8 cases). A low recurrence rate of 11.8% (2 cases) was observed in the case of intralesional curettage, using hydrogen peroxide as adjuvant (17 cases) and bone substitute for defect reconstruction.

Conclusions

Chondroblastoma represents a rare pathology. Therapeutically an aggressive intralesional curettage with use of hydrogen peroxide as adjuvant and filling up the defect with bone substitute leads to low recurrence rates.

Adjuvant therapy by high-speed burr may cause intraoperative bone tumor seeding: an animal study

Background

Bone tumors are often treated with intralesional curettage. High-speed burring, an adjuvant therapy, was performed to maximize the tumor cell killing; however, tumor recurrence might still occur, which may be caused by residual tumor or local tumor spread during surgery.

Methods

A porcine cadaver (femur) was utilized to determine whether the use of a high-speed burr causes bone cement spray. To mimic residual tumor after curettage, luminescent cement was smeared on two locations of the bone cavity, the wall and the bottom. The cavity in the femoral bone was then placed in the middle of a sheet of drawing paper featuring 10 cm, 20 cm, and 30 cm concentric circles. The luminescent cement was then burred totally with a high-speed burr.

Results

The intensity of the area in the wall in circle I was 72.6% ± 5.8%; within circle II, it was 22.1% ± 4.2%; and within circle III, it was 5.4% ± 1.5%. The intensity of the area within the bottom of the femoral bone within circle I was 66.5% ± 6.1%, within circle II was 28.1 ± 4.8%, and within circle III, it was 5.4% ± 1.4%. The amount of luminescent cement seeding decreased with distance, but there was no difference while burring at different locations of the bone cavity. Under the handpiece cover, a greater amount of cement spray was retained in circle I during burring of the cement in the bottom of the cavity and less was sprayed out in circle III.

Conclusions

High-speed burring may cause explosive bone cement spray, which could extend to 20 cm. The intensities of spray did not decrease, even when the handpiece cover was used. The wide range of bone cement spray caused by high-speed burr was inspected in this pilot study, which may lead to tumor seeding.

Level of evidence

Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Retrospective cohort study of 68 sacral giant cell tumours treated with nerve-sparing surgery and evaluation on therapeutic benefits of denosumab therapy

AIMS

To investigate the benefits of denosumab in combination with nerve-sparing surgery for treatment of sacral giant cell tumours (GCTs).

METHODS

This is a retrospective cohort study of patients with GCT who presented between January 2011 and July 2017. Intralesional curettage was performed and patients treated from 2015 to 2017 also received denosumab therapy. The patients were divided into three groups: Cohort 1: control group (n = 36); cohort 2: adjuvant denosumab group (n = 9); and cohort 3: neo- and adjuvant-denosumab group (n = 17).

RESULTS

There were 68 patients within the study period. Six patients were lost to follow-up. The mean follow-up was 47.7 months (SD 23.2). Preoperative denosumab was found to reduce intraoperative haemorrhage and was associated with shorter operating time for tumour volume > 200 cm³. A total of 17 patients (27.4%) developed local recurrence. The locoregional control rate was 77.8% (7/9) and 87.5% (14/16) respectively for cohorts 2 and 3, in comparison to 66.7% (24/36) of the control group. The recurrence-free survival (RFS) rate was significantly higher for adjuvant denosumab group versus those without adjuvant denosumab during the first two years: 100% vs 83.8% at one year and 95.0% vs 70.3% at two years. No significant difference was found for the three-year RFS rate.

CONCLUSION

Preoperative denosumab therapy was found to reduce intraoperative haemorrhage and was associated with shorter operating times. Adjuvant denosumab was useful to prevent early recurrence during the first two years after surgery. Cite this article: Bone Joint J 2020;102-B(2):177-185.

Giant Cell Tumor of the Sacrum: Series of 19 Patients and Review of the Literature

There are still some debates regarding the best treatment of Giant Cell Tumor (GCT) of the sacrum. Since GCT of this location is rare, therapeutic strategies are mainly based on the treatment of GCT in other anatomic locations. The objective of this study was to evaluate the oncologic and clinical results of surgical management of sacral GCT with and without local adjuvant therapy. Medical records of 19 patients diagnosed with GCT of the sacrum, were retrospectively reviewed. Sixteen patients were treated by intralesional curettage and three patients with marginal resection. Musculoskeletal tumor society (MSTS) score was used for the evaluation of functional outcome. Prolonged pain was the most common complication after treatment. Mean Pre and post-operative pain based on visual analogue scale (VAS) was 6.1 ± 1.99 and 3.05 ± 1.64, respectively. Postoperative neurologic deficit appeared in six patients. In addition, infection occurred in five patients. One case of spinopelvic instability was also observed after surgery. At average follow up of 158.5 ± 95.9 months (25 to 316 months), recurrence was seen in eight (42.7%) out of seventeen patients treated by intralesional curettage. The size of the tumor significantly correlated with the tumor recurrence (r=0.654, P=0.001). Mean MSTS score was 74.7 ± 16.78. Those patients, in whom sacral nerve roots remained intact before and after surgery, had better functional outcome. Preservation of sacral nerve roots is associated with better functional outcome and less pain. Although an acceptable surgical outcome was observed in our cohort, the problem of local recurrence still warrants further investigations for better local control of the tumor.

Is intralesional resection suitable for central grade 1 chondrosarcoma: A systematic review and updated meta-analysis

BACKGROUND

The surgical choice for grade 1 chondrosarcoma has been debated for decades. Intralesional resection can minimize the damage caused by surgery and offer better functional outcome. However, controversy remains about whether it will result in higher rates of local recurrence and metastasis, fewer complications, and better functional outcome compared with resection with wide margin. This systematic review and updated meta-analysis therefore compared intralesional resection and resection with wide margin in terms of local recurrence, metastasis, complications, and functional outcome.

METHODS

Medline, Embase, and the Cochrane Library were comprehensively searched in December 2016 to identify studies comparing intralesional resection and resection with wide margin for central grade 1 chondrosarcoma. Data of interest were extracted and analyzed using Review Manager 5.3.

RESULTS

Ten studies involving 394 patients were included, with 214 patients who had intralesional resection and 180 patients who had resection with wide margin for grade 1 chondrosarcoma. Intralesional resection was associated with lower complication rates (P < 0.0001) and better Musculoskeletal Tumor Society score (MSTS). There were no significant differences in terms of overall local recurrence (P = 0.27), local recurrence based on adjuvant therapies (P = 0.22), local recurrence in studies that included lesions of the hand, foot, pelvis, and axial skeleton (P = 0.55), and metastasis (P = 0.74) between groups.

CONCLUSION

Intralesional resection provides lower complications and better functional outcome with no significant increase in the risk of recurrence and metastasis. We think it is a suitable treatment for central grade 1 chondrosarcoma.

Surgery methods and soft tissue extension are the potential risk factors of local recurrence in giant cell tumor of bone

Background

Various treatments of giant cell tumor of bone (GCTB) included in curettages and resections and with adjuvant are exerted, but the best treatment is controversial. The aim of the study was the identification of individual risk factors after various treatments in GCTB.

Methods

A total of 179 patients treated for GCTB between 1998 and 2010 were concluded in the retrospective study. All patients were treated with intralesional curettage, extensive curettage, or wide resection. Mean follow-up was 60.2 ± 18.7 months (36~112 months). Age, gender, tumor location, Campanacci grade, soft tissue extension, pathological features, and surgical methods were performed to univariate Kaplan-Meier survival analysis and multivariate Cox regression analysis.

Results

The local recurrence rates of intralesional curettage (41.9 %) and extensive curettage (19.0 %) were significantly higher than that of wide resection (7.7 %). The higher risk of local recurrence was found for soft tissue extension (hazard = 7.921, 95 % CI 1.107~56.671), compared with no statistical significances between gender, location, Campanacci grade, pathologic fracture, and local recurrences, which were shown by Kaplan-Meier analysis. However, recurrence-free survival (RFS) of patients younger than 30 was significantly lower than that of patients older than 30. The RFS of pathologic fracture patients with soft tissue extension was significantly lower than that of pathologic fracture patients without soft tissue extension. Multivariate Cox regression analysis indicated that the independent variable that contributed to recurrence-free survival was soft tissue extension and surgical methods. The RFS of extensive curettage had no statistically significant difference with wide resection and was significantly higher than that of intralesional curettage. Use of high-speed burring and bone cement significantly decreased the local recurrence rate.

Conclusions

Age (below 30 years), gender, tumor location, Campanacci grade, and pathologic fracture have no statistically significant influence on local recurrences. Soft tissue extension and intralesional curettage of surgical methods increased the RFS. The results of the present study suggested that compared with curettage and wide section, treatment of GCTB by extensive curettage could provide the favorable local control and functional recovery.

Electronic supplementary material

The online version of this article (doi:10.1186/s12957-016-0871-z) contains supplementary material, which is available to authorized users.

Recurrent Spinal Giant Cell Tumors: A Study of Risk Factors and Recurrence Patterns

Study Design

Retrospective study.

Purpose

To highlight risk factors, recurrence patterns and multimodal treatment in management of recurrent giant cell tumors (GCTs).

Overview of Literature

GCTs of the spine are rare and challenging entities. Recurrences are very common and warrant complex management to prevent multiple recurrences. Gross total resection is preferred over subtotal procedures to prevent recurrences. However, resection is associated with morbidity and mortality. Proper understanding of risk factors and a high index of suspicion helps to spot recurrences early and aids in subsequent management.

Methods

Ten patients (six females, four males) with recurrent GCTs underwent 17 interventions. There were six lesions in the thoracic spine, two in the cervical spine and two in the lumbar spine. Recurrences were managed with preoperative digital subtraction embolization, intralesional curettage and postoperative radiotherapy.

Results

The average age at intervention was 31.3 years. The average duration of recurrence in patients following index surgery in a tertiary care hospital and surgery elsewhere was 7.3 years and was 40 months, respectively. The minimum recurrence-free interval after the last recurrent surgery was 10 years.

Conclusions

Our study reports the largest recurrence-free interval for GCTs. Recurrent GCTs are challenging entities. Understanding of risk factors and meticulous planning is required to prevent recurrences. Intralesional surgery could be a safer and effective modality in managing recurrences.