Use of extended curettage with osteotomy and fenestration followed by reconstruction with conservation of muscle insertion in the treatment of Enneking stage II locally aggressive bone tumor of the proximal extremities: resection and treatment of bone tumors
Feiyan Chen
0
Jun Xia
0
Siqun Wang
0
Yibing Wei
0
Jianguo Wu
0
Gangyong Huang
0
Jie Chen
0
Jingsheng Shi
0
0
Department of Orthopedics, Huashan Hospital, Fudan University
,
Shanghai 200040
,
China
Background: The purpose of this study was to investigate the clinical efficacy of extended resection with osteotomy, fenestration and conservation of muscle (tendon) insertion in the treatment of bone tumors. Methods: A total of 15 patients with locally aggressive bone tumors (Enneking stage II) in the adjacent muscle (tendon) insertion of the proximal extremity were enrolled in the present study (mean age of 29 years). Extended curettage of lesions with osteotomy, fenestration and/or conservation of muscle (tendon) insertion and internal fixation with a bone graft or bone cement was performed at stage I. Postsurgical brace protection was used for 4 to 12 weeks and the patients were periodically followed-up by X-ray and functional assessment. Recurrence, postsurgical Enneking score and outcome rating were assessed. Results: Treated cases included 15 patients aged 29 7.75 years (range, 18 to 42) with a male to female ratio of 8:7. Six had a femoral tumor and nine had a humeral tumor. These tumors comprised three chondroblastomas, five giant-cell tumors and seven aneurysmal bone cysts. Follow-up for 48 12.95 months (range, 25 to 72) revealed that 13 of 15 (87%) patients exhibited no recurrence. Local recurrence was observed in a patient with an aneurysmal bone cyst (nine months) and one with a giant-cell tumor (12 months). Mean Enneking scores were 27 4.07 (range, 18 to 29). Except for the patient with the recurrent giant-cell tumor, all patients reported good (13%, 2 out of 15) or very good (80%, 12 out of 15) outcomes. Very good outcomes were reported in 92% of patients (12 out of 13) without recurrence. Conclusions: The procedures used in this study achieved high clinical efficacy, complete lesion removal, reduced recurrence and good restoration of joint function in patients with primary locally aggressive Enneking stage II bone tumors of the proximal extremities.
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Background
Locally aggressive bone tumors are a group of
commonly recurrent and metastatic bone tumors that
predominantly occur in the epiphysis of the long bone of
the adjacent joints, including giant-cell tumor (GCT) of
bone, aneurysmal bone cyst (ABC), chondroblastoma
(CBT) and osteoblastoma [1]. According to Enneking
surgical staging, progression of these tumors can be
understood in terms of tumor stage [2]. Using this scale,
stage I represents the latent phase. At stage II, tumors
become active, exhibiting expansive growth and thinning
of the bone cortex within the compartment. Stage III is
the most aggressive, with lesions piercing through the
bone cortex and involving soft tissues surrounding the
compartment. Routine treatment includes surgical
therapy with extended curettage (IC) of lesions, local
adjuvant treatment, graft implantation and effective internal
fixation [1]. Because most lesions are adjacent to the
joint and muscle (tendon) insertion, IC of lesions may
damage muscle (tendon) insertions, exerting detrimental
effects on postsurgical limb function. If protection is
limited to the muscle (tendon) insertion, a sufficient
operative field is difficult to obtain, preventing effective
curettage. Therefore, improved methods for treatment
selection are required for more effective and successful
treatment of locally aggressive musculoskeletal tumors.
The current status of treatment and recurrence of these
tumors, as discussed in the present study, are briefly
reviewed.
Treatment of aneurysmal bone cysts
ABCs are relatively rare in primary bone tumors,
constituting only 1% to 2% of all primary bone tumors.
These tumors exhibit rapid growth and high
invasiveness, and are often destructive to surrounding tissues
[3]. Ubiquitin-specific protease 6 has been implicated in
the development of ABCs [3,4], and treatment with
curettage and bone grafting or bone cementation has
been reported to achieve 70% to 90% success with 10%
to 30% recurrence rates [3,5]. IC, or aggressive curettage,
applies drills, local adjuvant therapies (such as
cauterization), phenolic therapies or cryotherapies to reduce
the rate of local recurrence [3,5,6]. ABCs of specific
sites, such as the vertebral body and pelvis, can be
treated with sclerosing therapies using percutaneous
injections of Ethibloc, ethanol and methylprednisolone.
In addition, selective arterial embolization has been
recommended as an alternative therapy [7].
Treatment of chondroblastomas
A CBT is a rare cartilage-derived bone tumor that
constitutes 1% of all benign bone tumors. It predominantly
affects young men and often exhibits invasiveness or
malignant behavior [8,9]. Following recommended surgical
treatments, the two- to three-year recurrence rate is as
high as 10% to 20%, which may partially be due to wide
application of inappropriate surgical methods [9,10]. IC,
however, has been demonstra (...truncated)