Giantcell Tumour Surgical Technique

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intralesional curettage+cementing is gold standard

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Giantcell Tumour Surgical Technique

  1. 1. Giantcell tumour Surgical Technique of Curettage Vinod Naneria, G. Yeotikar, A. Wadhwani Choithram Hospital & Research Centre, Indore, India
  2. 2. The Crux of Tx <ul><li>Curettage + Curettage + Curettage. </li></ul><ul><li>Wide Window. </li></ul><ul><li>Dental Burr. </li></ul><ul><li>Electric Cauterization. </li></ul><ul><li>Adjuvant therapy – H2O2 / phenol / Liquid Nitrogen /Argon beam Laser / Alcohol. </li></ul><ul><li>Cementing / Bone grafting. </li></ul><ul><li>Radiation for inaccessible sites. </li></ul><ul><li>Bisphosphonates. </li></ul>
  3. 3. Intra-lesional Curettage and Wide Window cementing
  4. 4. Why Cement? <ul><li>It is simple. </li></ul><ul><li>there is no need for bone grafting. </li></ul><ul><li>Immediate fixation and stabilization is obtained. </li></ul><ul><li>joint function is preserved. </li></ul><ul><li>local control is better by thermal & cyto-toxic effect of cement. </li></ul><ul><li>local recurrence is easily to detect. </li></ul>
  5. 5. Intralesional surgery should be the first choice in most giant cell tumors, even in the presence of a pathological fracture. After thorough evacuation, the cavity should be filled with cement. Acta Orthop. 2008 Feb;79(1):86-93. Cement is recommended in intralesional surgery of giant cell tumors: a Scandinavian Sarcoma Group study of 294 patients followed for a median time of 5 years. Kivioja AH , Blomqvist C , Hietaniemi K , Trovik C , Walloe A , Bauer HC , Jorgensen PH , Bergh P , Follerås G . Cement is recommended Acta Orthop. 2008 Feb
  6. 6. Use of polymethylmethacrylate as an adjuvant appears to be the therapy of choice for primary as well as recurrent giant cell tumors of bone. J Bone Joint Surg Am. 2008 May;90(5):1060-7. Local recurrence of giant cell tumor of bone after intralesional treatment with and without adjuvant therapy. Arbeitsgemeinschaft Knochentumoren , Becker WT , Dohle J , Bernd L , Braun A , Cserhati M , Enderle A , Hovy L , Matejovsky Z , Szendroi M , Trieb K , Tunn PU . Cement as Adjuvant Therapy J Bone Joint Surg Am. 2008 May
  7. 7. Complications - Cement <ul><li>May form a radiolucent zone at the bone-cement interface up to 2.5 mm in width. </li></ul><ul><li>Osteoarthritis of the knee joint in patient with an intraarticular fracture at initial presentation. </li></ul><ul><li>A stress fracture. </li></ul><ul><li>J Orthop Sci. 2002;7(2):194-8. </li></ul><ul><li>Complications associated with bone cementing for the treatment of giant cell tumors </li></ul><ul><li>of bone. </li></ul><ul><li>Wada T , Kaya M , Nagoya S , Kawaguchi S , Isu K , Yamashita T , Yamawaki S , Ishii S .   </li></ul>
  8. 8. Cementing & O.A.Knee J Bone Joint Surg Br. 2007 March <ul><li>Follow up of nine patients at a mean period of 11 years (6 to 16) after curettage and cementing of a giant-cell tumour around the knee showed no evidence that the long-term presence of cement close to the knee joint was associated with the development of degenerative osteoarthritis. </li></ul><ul><li>J Bone Joint Surg Br. 2007 Mar;89(3):361-5. </li></ul><ul><li>Giant-cell tumour of the knee: the condition of the cartilage after treatment by curettage and cementing. </li></ul><ul><li>von Steyern FV , Kristiansson I , Jonsson K , Mannfolk P , Heinegård D , Rydholm A . </li></ul><ul><li>Department of Orthopaedics, Centre for Medical Imaging and Physiology, Lund University Hospital, Lund, Sweden. </li></ul>
  9. 9. Heat above 60 ° produced during polymerization lasted for about 10 min. After heat treatment at 60 ° for 10 min, no cells could have survived. This study has clarified the tumoricidal effect of methyl methacrylate by hyperthermia from the heat caused by polymerization. Heat Of Polymerization of Cement Arch Orthop Trauma Surg (1993)
  10. 10. Curettage, high-speed burring with added phenol/liquid nitrogen treatment and cementation is a useful and safe method in the treatment of giant cell tumors. The advantages include a low recurrence rate, as well as immediate stabilization allowing early mobilization. Patients who have Campanacci grade I tumors have the highest chance of being disease-free after the first operation. Ann Acad Med Singapore. 2005 Apr;34(3):235-7. Treatment of benign giant cell tumors of bone in Singapore. Lim YW , Tan MH . Department of Orthopaedic Surgery, Changi General Hospital, Singapore. yeow_1@yahoo.com Intralesional Curettage
  11. 11. A 30yr, female with biopsy proved Giantcell tumour
  12. 13. Under Tourniquet
  13. 14. Skin Incision
  14. 22. Dental Burr
  15. 25. Pulse Lavage + H2O2
  16. 28. Cementing
  17. 30. Post-op X-ray
  18. 31. 1997
  19. 34. Stress fracture
  20. 35. 2006
  21. 65. The Key To Success - literature <ul><li>Adequate removal of the tumour seems to be a more important predictive factor for the outcome of surgery than the use of phenol as an adjuvant therapy. </li></ul><ul><li> Eur J Surg Oncol. 2001 Mar;27(2):200-2. </li></ul><ul><li>Recurrence of curetted and bone-grafted giant-cell tumours with and without adjuvant phenol therapy. </li></ul><ul><li>Trieb K , Bitzan P , Lang S , Dominkus M , Kotz R . </li></ul>
  22. 66. Curettage is the key - literature <ul><li>CONCLUSIONS: Curettage plus cement reconstruction is safe and effective in treating local GCT of limbs. The key of the method is aggressive curettage of the lesion via a bone window. Cement is adjuvant therapy only. </li></ul><ul><li> Zhonghua Wai Ke Za Zhi. 1999 Dec;37(12):730-2. </li></ul><ul><li>[Curettage plus cement reconstruction for treating giant cell tumor of limbs] </li></ul><ul><li>Zhang Q , Cai Y , Niu X , Hao L . </li></ul><ul><li>Department of Orthopaedic Oncology, Beijing Jishuitan Hospital, Beijing 100035. </li></ul>
  23. 67. The most important factor for local recurrence appeared to be inadequate curettage with similar recurrence rates regardless of the type of bone graft used. A careful approach to the surgical margin including use of a dental burr and local adjuvant treatment with phenol, the rate of local recurrence may be decreased. Changgeng Yi Xue Za Zhi. 1996 Mar;19(1):16-23. Treatment of giant cell tumor of long bone. Shih HN , Chen YJ , Huang TJ , Ho WP , Hsueh S , Hsu RW . Department of Orthopedic Surgery, Chang Gung Medical College, Taoyuan, Taiwan, R.O.C. Prevention of recurrence – literature
  24. 68. Prevention of recurrence - literature <ul><li>Use of polymethylmethacrylate as an adjuvant significantly reduces the recurrence rate following intralesional treatment of benign giant cell tumors, and it appears to be the therapy of choice for primary as well as recurrent giant cell tumors of bone. </li></ul><ul><li>J Bone Joint Surg Am. 2008 May;90(5):1060-7. </li></ul><ul><li>Local recurrence of giant cell tumor of bone after intralesional treatment with and without adjuvant therapy. </li></ul><ul><li>Arbeitsgemeinschaft Knochentumoren , Becker WT , Dohle J , Bernd L , Braun A , Cserhati M , Enderle A , Hovy L , Matejovsky Z , Szendroi M , Trieb K , Tunn PU . </li></ul><ul><li>Orthopädische Klinik Volmarstein, Universität Witten/Herdecke, Wetter, Germany. w.becker@gmx.com </li></ul>
  25. 69. This study demonstrates that either curettage and packing with cement or wide resection are effective in treatment of giant cell tumor of bone. There is, however, a better functional result after curettage and packing with cement than following wide resection. We recommend curettage and cement packing for giant cell tumor of bone whenever it is technically feasible Changgeng Yi Xue Za Zhi. 1998 Mar;21(1):37-43. Treatment of giant cell tumor of bone: a comparison of local curettage and wide resection. Liu HS , Wang JW . Recommendation - literature
  26. 70. DISCLAIMER <ul><li>Information contained and transmitted by this presentation is based on personal experience and collection of cases at Choithram Hospital & Research centre, Indore, India, during last 25 years. It is intended for use only by the students of orthopaedic surgery. Views and opinion expressed in this presentation are personal opinion. Depending upon the x-rays and clinical presentations viewers can make their own opinion. For any confusion please contact the sole author for clarification. Every body is allowed to copy or download and use the material best suited to him. I am not responsible for any controversies arise out of this presentation. For any correction or suggestion please contact naneria@yahoo.com </li></ul>

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