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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 5  |  Issue : 2  |  Page : 83-88

A study of 40 patients of chondroblastoma of extremities treated with curettage and reconstruction with bone graft or bone graft substitute or bone cement: What were the outcomes?


1 Orthopedic Surgeon, Harikrupa Orthopedic Hospital, Ahemdabad, India
2 Orthopedic Surgeon, Kerala, India
3 Orthopedic Oncosurgeon, Gujarat Cancer Research Institute, Ahemdabad, India
4 Orthopedic Surgeon, MM Demmed University, Haryana, India

Date of Submission09-Dec-2021
Date of Decision09-Mar-2022
Date of Acceptance16-Mar-2022
Date of Web Publication28-May-2022

Correspondence Address:
Abhijeet Ashok Salunke
Orthopedic Oncosurgeon, Gujarat Cancer Research Institute, Ahemdabad
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jodp.jodp_39_21

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  Abstract 


Introduction: The purpose of this study was to evaluate the outcomes of surgical management of chondroblastoma in appendicular skeleton treated with curettage and reconstruction. Materials and Methods: This retrospective study included 40 patients of chondroblastoma treated with intralesional curettage and filling of defect with bone graft or bone graft substitute or bone cement. The patients were prospectively followed to consolidation of bone graft or bone graft substitute. The mean age of presentation was 14 years (13–32 years). There were 24 were male and 16 were female patients. The mean follow-up was 11 years (4–17 years). Results: The location of chondroblastoma was proximal tibia in 12 patients, distal femur in 14 patients, proximal femur in 8 patients, and proximal humerus in six patients. The physis was found open (8), closing (12), and closed (20) patients. The tumour was of Enneking grade of tumour was 1 in 22, II in 14 and III in 4 patients. The mean union time in bone graft group and bone graft substitute group 3 months and 4 months, respectively. There was local recurrence in six patients (3 in bone graft group and 2 in bone graft substitute group, 1 in bone cement group). The other complications were surgical site infection (two cases). The mean Musculoskeletal Tumor Society score in both groups was 27. Conclusion: Intralesional curettage provides excellent functional outcomes with preservation of adjacent joint mobility. The methods of reconstruction with bone graft, bone graft substitute, and bone cement provide optimal results, and the outcomes were comparable in all these groups.

Keywords: Bone cement, bone graft substitute, bone grafting, chondroblastoma, curettage


How to cite this article:
Amin P, Pandit J, Menon P, Salunke AA, Pathak S. A study of 40 patients of chondroblastoma of extremities treated with curettage and reconstruction with bone graft or bone graft substitute or bone cement: What were the outcomes?. J Orthop Dis Traumatol 2022;5:83-8

How to cite this URL:
Amin P, Pandit J, Menon P, Salunke AA, Pathak S. A study of 40 patients of chondroblastoma of extremities treated with curettage and reconstruction with bone graft or bone graft substitute or bone cement: What were the outcomes?. J Orthop Dis Traumatol [serial online] 2022 [cited 2022 Jul 3];5:83-8. Available from: https://jodt.org/text.asp?2022/5/2/83/346214




  Introduction Top


Chondroblastoma is a bone tumor arising from cartilage growth plate occurring in young patients and has an incidence of 1% of benign bone tumors.[1],[2],[3],[4],[5] It is preponderance for appendicular skeleton involving long bones and rarely affects flat bones and axial skeleton.[1],[2],[3],[6],[7],[8] There is a male preponderance of this disease and commonly seen in the second decade of life.[3],[4],[5],[6] The symptoms include pain followed by swelling around the affected region and reduction in joint mobility.[8],[9],[10],[11],[12]

The treatment options are curettage or radiofrequency ablation or rarely require wide resection.[1],[2],[3],[10],[11],[12] Due to epiphyseal location and affection in growing age, treatment may lead to growth arrest, injury to articular cartilage, and arthritis.[1],[2],[3],[4] The local recurrence rate is approximately 5%–30% following curettage surgery.[1],[2],[3],[8],[9],[10],[11],[12]

Extended curettage can be performed using pulse lavage, and use of mechanical and chemical adjuvants, i.e., hydrogen peroxide, liquid nitrogen, phenol, and bone cement to extend destruction of tumor cells. The void created following curettage can be filled with autologus bone graft, allograft, bone graft substitute, and bone cement. The purpose of placing the material to fill the defect is to help in consolidation of cavity and provide bone strength. Autograft is harvested from the iliac crest and fibula with ease of availability and limited associated complications. Bone graft substitutes have been used with a good success rate in filling of defect benign bone tumors. Bone cement is a method for filling defects but has a theoretical risk of damage to the epiphyseal growth plate and cartilage due to thermal necrosis. The hematoma in the cavity created by curettage has a good capacity to form new bone and remodel in bone, providing optimal functions leading to concept of no fillers usage following curettage.[13] Lack of a sufficient number of bone banks makes allograft procurement a limiting factor for its usage. The aim of this retrospective study was to evaluate the outcomes of surgical management of chondroblastoma in appendicular skeleton treated with curettage.


  Materials and Methods Top


The study included retrospective cases of patients who were operated for chondroblastoma with curettage from January 2004 to January 2017. According to the Enneking radiographic grading system, Grade I (latent) tumors involve a well-marginated border of a thin cortical rim of mature bone, Grade II (active) tumors involve relatively well-defined margins but no radio-opaque rim, and Grade III (aggressive) tumors involve indistinct borders or fuzzy border.[14] On plain radiograph the physis was considered open, closing and closed on basis of the clear space between epiphysis and metaphysis.[11] The medical records, plain radiographs, and magnetic resonance imaging (MRI) were carefully studied [Figure 1] and [Figure 2]. Ethical clearance for the study was obtained and informed consent was obtained. In all the cases, a biopsy specimen was obtained prior to definitive surgery using the core biopsy needle. The bone specimen curetted at the time of definitive surgery was also sent for histopathological evaluation. The use of filler was planned according to the age, size of defect, and location of the lesion.
Figure 1: (a) Plain radiograph of 13-year-old girl with chondroblastoma of tibia (white arrow over the lytic lesion). (b) Magnetic resonance imaging of chondroblastoma tibia showing a well-defined lesion in epiphyseal location

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Figure 2: (a) Immediate postoperative radiograph of tibia showing chondroblastoma treated with curettage and defect was filled with bone graft substitute. (b) Follow-up radiograph

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Curettage was performed after appropriate anesthesia with the use of an image intensifier to assess the extent of curettage. A window was made over the lesion with the help of osteotome and burr and the lesion was grossly removed with curette and scoop. Pulsed lavage was used to remove the residual tumour after high speed dental burr use. Hydrogen peroxide was used as a chemical adjuvant and followed by a wash with a pulse lavage system. The endpoint of curettage was assessed with the absence of residual tumor visualized and gritty sensation on curette usage. The defect created following curettage was filled with bone graft, bone graft substitute, or bone cement. We had used bone graft and bone graft substitute in patients with open physis and size of lesion <= 4 cm. Bone cement was used in patients with closing and closed physis and size >= 5 cm.

A plaster was applied until suture removal. This was followed by a splint until the bone union is achieved. Graded exercise programs were guided by the postoperative clinical and radiological status. Serial radiograph was performed monthly to assess consolidation of bone graft or bone graft substitute in the lesion [Figure 3]. The patients were called for follow-up every 2 month for 1st year and subsequently every 6 months. The patients were followed to consolidation of cavity with bone graft or bone graft substitute, and minimum follow-up was 1-year period. The clinical observations were made regarding recurrence of tumor, functional status, and limb length discrepancy [Figure 4] and [Figure 5]. This was a retrospective study, and patients were followed up in a prospective way with regular follow-up clinical examination and plain radiographs were used for assessment of local recurrence, status of bone, the consolidation of bone graft and bone graft substitute with host bone, and deformity. The patient's Musculoskeletal Tumor Society (MSTS) score was calculated at every follow-up.[14]
Figure 3: Clinical picture showing healed surgical scar and knee function

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Figure 4: (a) Radiograph of a 16-year-old boy with chondroblastoma of proximal tibia showing a well-defined lesion in epiphyseal location. (b and c) Magnetic resonance imaging showing a well-defined lesion in epiphyseal location

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Figure 5: (a) Clinical picture showing healed scar on the medial aspect of tibia, (b) immediate postoperative radiograph following curettage and defect filled with bone cement. (c) Follow-up radiograph

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  Results Top


Of the 40 patients of chondroblastoma treated with intralesional curettage, there were 24 males and 16 females. The mean age of presentation was 14 years (13–32 years). The physis was found open (8), closing (12), and closed (20) patients. The Enneking grade of tumour was 1 in 22, II in 14 and III in 4 patients [Table 1]. The patients were followed to bone union and the minimum follow-up was 4 year. The mean follow-up was 11 years (4–17 years). The location of lesion was proximal tibia in 12 patients, distal femur in 14 patients, proximal femur in eight patients, and proximal humerus in six patients. Mean tumor size was 4 (range, 3–5 cm) and the defect following curettage was filled with bone graft (18), bone graft substitute (12), and bone cement (10) patients. The mean union time in bone graft group and bone graft substitute group was 3 months and 4 months, respectively. There was local recurrence in six patients (3 in bone graft group, 2 in bone graft substitute group, and 1 in bone cement group).
Table 1: Inclusion and exclusion criteria in the current study

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The complications were surgical site infection (two cases), recurrence (six cases: 3 cases in bone graft, 2 cases in bone graft substitute, and 1 case in bone cement), and autologus bone graft site morbidity (two cases). One patient of bone graft substitute group developed infection was treated by thorough debridement and appropriate antibiotics and infection subsided in 1 month's time. One patient with bone cement group developed surgical site infection and was treated with debridement and antibiotics. Three patients of bone graft substitute group developed local recurrence and were treated with curettage and bone grafting and showed good recovery. The mean timing of recurrence in bone graft substitute group was seen at mean period of 23 months (20, 28, 20 months). The area of recurrence was proximal tibia in two cases and distal femur in one case. Two patients of bone graft group developed local recurrence and were treated with curettage, and bone grafting with mean timing was seen at a mean period of 20 months (16, 24 months). The area of recurrence was proximal tibia in two cases and distal femur in one case. There was hypertrophic painful scar at the iliac crest bone graft harvest site in two patients. The mean MSTS score was 27. All patients had an excellent range of movement in adjacent joints.

The variables of physis (open, closing, closed), stage of disease (latent, active, aggressive), and method used to fill defect (bone graft, bone cement, bone graft substitute) were used for analysis [Table 2].
Table 2: Demographic data and study characteristics

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  Discussion Top


The term “benign chondroblastoma” was coined by Jaffe and Lichtenstein, and the lesion has a predisposition for the active epiphyseal region of the appendicular skeleton.[1],[2],[3],[4],[5] The clinical features include insidious onset of pain and swelling with limitation of movement around the affected joint.[2],[3],[4],[5] The imaging studies of chondroblastoma include plain radiograph, MRI, and computed tomography (CT) scan and are useful to assess the distance between lesion, growth plate, and articular cartilage.[5],[6],[7],[8],[9],[10] On plain radiography, there is a well-defined lytic lesion at the epiphyseal area with a sclerotic rim.[1],[2],[3],[4] CT images are characterized by well-defined lesions with calcification and endosteal scalloping.[4],[5],[6],[7],[8] The MRI features of chondroblastoma include low-to-high signal intensity images on T1 image and intermediate to high signal intensity on T2 image with lesion surrounded by areas of marrow and tissue edema.[5],[8],[9],[10],[11],[12] Histopathological features include chondroid-rich matrix, chicken wire calcification, and chondroblast cells (round or polygonal cells with an oval or round nucleus and eosinophilic cytoplasm).[10],[11],[12]

Curettage is a treatment modality used in the surgical treatment of chondroblastoma with a filling of void with variety of modalities.[1],[2],[3],[4],[5],[6],[7],[15] The method of filling void is determined by careful consideration of patient age, defect size, lesion location, and bone quality.[15] The different material used for filling the defect has been evaluated in the published literature [Table 3] The local recurrence rate varies from 5% to 30% following curettage surgery.[1],[2],[3],[8],[9],[10],[11],[12] The chances of local recurrence depend on location of lesion and lesions of foot and ankle have higher preponderance for recurrence, as compared to other sites.[9],[15] The results of Ramappa et al. had suggested that rate local recurrence is affected by anatomic location of chondroblastoma.[5] Recurrent lesions are treated with curettage and, if required, with wide resection and reconstruction depending on the location of lesion.
Table 3: The evaluation of local recurrence in different reconstruction groups

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The effect of the open growth plate in young patients with chondroblastoma has been analyzed and considered as a risk factor for local recurrence.[16] Springfield et al. suggested that a higher risk of recurrence due to inadequate curettage is due to fear of damaging physeal region.[17] Bone graft is the most common modality used for filling of defect following curettage. Curettage and bone grafting has shown good outcome when the articular surface is not involved. Suneja et al. in a study of 53 patients showed that the local recurrence rate was13% and one patient had a malignant transformation.[11] All the patients were treated with curettage and patient's own bone was used to fill or partly fill the defect. The local recurrence rate in patients treated with curettage and bone grafting in the current study had a local recurrence rate of 11%. Garin and Wang reported good outcome of intralesional curettage and bone grafting in osteochondroma with or without bone cement at mean followup of 5.5years.[4]

Bone cement may provide a theoretical advantage of thermal effect of polymerization, reducing local recurrence by extending curettage. Lower recurrence rate is found in patients treated by packing the defect with polymethylmethacrylate instead of bone graft.[1],[2],[3],[4],[5],[11] Cho et al. in a study of proximal tibia chondroblastoma treated with curettage and bone graft and cement provide optimal outcomes.[3] There was no local recurrence or pulmonary metastasis at a mean duration of follow-up of 47.2 months with a mean functional score of 29 in both bone grafting and bone cement group.[3] The local recurrence rate in patients treated with bone cement in the current study had a local recurrence rate of 10%.

Bone graft substitutes are used for filling defect following benign bone tumors with optimal functions. Bone graft substitute was used by Wu and Yu in the treatment of proximal tibia chondroblastoma following curettage.[6] They used bone substitute pellets graft following curettage and high-speed burring with good functional outcomes.[6] Kaczmarczyk et al. had analyzed the use of injectable bone graft substitute in treatment of benign bone tumor and showed good outcomes and bone integration.[18] Van Hoff et al. had used bone graft substitute for filling void after curettage in benign bone tumor, and at 6 months of follow-up, half of the bone graft substitute had progressed to trabeculation.[19] The advantage of bone graft substitute is rapid resorption with host bone and reduces the risk of morbidity in harvesting autogenous bone graft.[18],[19],[20] The complications after the use of bone graft include pain, aseptic inflammation, and soft tissue cyst. The local recurrence rate in patients treated with bone graft substitute in the current study had a local recurrence rate of 25% [Table 4].[18],[19],[20]
Table 4: Review of literature and comparison with the current study

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Radiofrequency ablation technique is based on use of heat on killing the tumor and has been used in the treatment of chondroblastoma.[21] Radiofrequency thermo-ablation with CT guidance was also introduced as an alternative primary treatment for chondroblastoma and has proven to be an effective treatment for osteoid osteoma.[21],[22],[23]

Arthroscopic method has been used as a method to monitoring of articular cartilage in the treatment of chondroblastoma around the knee joint.[22] Zoccali et al. had treated chondroblastoma of proximal tibia with arthroscopy and radiofrequency thermoablation.[22] Cohen et al. have treated patients with chondroblastoma around knee with arthroscopy and intra-articular resection.[23] We have used MSTS score which is a system for the functional evaluation of reconstructive procedures after surgical treatment of tumors of the musculoskeletal system.[14]

The limitation of the current study was its retrospective nature of this study. Second, the sample size was small and warranted a multicenter study.


  Conclusion Top


Intralesional curettage provides excellent functional outcomes with preservation of adjacent joint mobility. The methods of reconstruction with bone graft, bone graft substitute, and bone cement provide optimal results, and the outcomes were comparable in all these groups.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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Cho HS, Park YK, Oh JH, Lee JH, Han I, Kim HS. Proximal tibia chondroblastoma treated with curettage and bone graft and cement use. Orthopedics 2016;39:e80-5.  Back to cited text no. 3
    
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Wu CC, Yu CT. Pure reconstruction with bone substitute pellets graft following curettage and high-speed burring for chondroblastoma of the proximal tibia: A case report and review of the literature. Orthop Surg 2011;3:271-5.  Back to cited text no. 6
    
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Van Hoff C, Samora JB, Griesser MJ, Crist MK, Scharschmidt TJ, Mayerson JL. Effectiveness of ultraporous β-tricalcium phosphate (vitoss) as bone graft substitute for cavitary defects in benign and low-grade malignant bone tumors. Am J Orthop (Belle Mead NJ) 2012;41:20-3.  Back to cited text no. 19
    
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Friesenbichler J, Maurer-Ertl W, Bergovec M, Holzer LA, Ogris K, Leitner L, et al. Clinical experience with the artificial bone graft substitute Calcibon used following curettage of benign and low-grade malignant bone tumors. Sci Rep 2017;7:1736.  Back to cited text no. 20
    
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Erickson JK, Rosenthal DI, Zaleske DJ, Gebhardt MC, Cates JM. Primary treatment of chondroblastoma with percutaneous radio-frequency heat ablation: Report of three cases. Radiology 2001;221:463-8.  Back to cited text no. 21
    
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Zoccali C, Teori G, Salducca N, Di Paola B, Adriani E. Arthroscopic guided biopsy and radiofrequency thermoablation of a benign neoplasm of the tibial spines area: A treatment option. BMC Musculoskelet Disord 2012;13:52.  Back to cited text no. 22
    
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Cohen B, Khan TH, Dandy DJ. Arthroscopic resection of chondroblastoma of the knee. Arthroscopy 1992;8:370-2.  Back to cited text no. 23
    


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