Extended Curettage

Extended Curettage

What is Extended Curettage ?

• Curettage is the process of entering a tumour and clearing its contents.
• Extended curettage is the process of extending the clearance using a high speed burr (beyond the borders of tumour to clear microscopic debris)
• Reconstruction of the defect is then carried out by various methods.

What are indications for Extended curettage?

• Benign bone tumors (Curative)
  • Chondromyxoid fibroma
  • Giant cell tumour https://bonecancer.in/2020/05/01/giant-cell-tumor/
  • Bone cysts https://bonecancer.in/2020/05/01/aneurysmal-bone-cyst/ 
  • Fibrous dysplasia https://bonecancer.in/2020/05/01/fibrous-dysplasia/
  • Chondroblastoma
  • Enchondroma
  • Osteoblastoma
• Bone Metastases (For Palliation)
• Very Rarely in malignant bone tumors ( For Palliation)

 How is extended curettage performed?

• Incision depends on location of tumour and biopsy scar or previous surgery.
• Biopsy scars are excised during the incision.
• A tourniquet is almost always used in case of extremities or limbs.
• This enables the surgeon to operate in a near bloodless field.
• Also the risk of bleeding is negligible during surgery.
• The tourniquet is then removed post procedure.
• A “Window” of sufficient size is created on the affected site of bone.
• A “Curette” is used to clear macroscopic tumor tissues from the host bone.
• Periodic regular saline wash and hydrogen peroxide wash is given to flush out tumour debris.
• Small pockets of tumor are cleared with help of “High speed Burr”, which can clear microscopic tumor tissues.
• The recommended clearance is 2-3 mm or until healthy normal bone is visualized.
• The periosteum layer of bone is cleared of any tumor tissues.
• Adjuvants are often used to help clear the tumor and kills the tumour cells.
  • Hydrogen peroxide
  • Absolute alcohol, phenol (85%)
  • Liquid nitrogen.
  • Argon Plasma Cautery (APC)

• The walls of curetted host bone are then burnt or Cauterized with Monopolar cautery or APC.

How is Reconstruction performed ?

Depends on the following factors

• • Type of Bone Involved
  • Location (Epiphysis, Metaphysis or Diaphysis)
  • Age
  • Size and Shape of Defect
  • Expectant functional return of patient following counselling
  • How close the tumour is to the joint cartilage

• Different Reconstruction Options are as follows
  • Cement (PMMA or polymethylmethacrylate)
    • Ideal filler after curettage of benign bone tumors with high risk of local recurrence.
    • Also acts as tumoricidal (kills tumor cells) due to thermogenic (production of heat) effect.
    • Ideally suited for cavities which have good host bone stock available.
    • An advantage of using cement over bone graft is that recurrence is easily identifiable.

• • Bone graft
    • Bone grafts are used for reconstructing a defect when the bone stock is less or the host bone needs structural support.
    • Different types of bone grafts can be utilized to reconstruct the cavity/ defect, such as autograft, allograft in the form of cancellous bone chips or strut grafts.
    • The advantage with utilizing bone graft is that remodeling occurs leaving host bone residue.
    • Autograft (Harvested from Patients own body).
      • Autogenous bone is preferred if a rapid and extensive bone growth is required, but has the disadvantage of another procedure to harvest.
    • Allograft (Harvested from Healthy donor & Processed).
      • Allogeneic bone grafts are utilized more commonly as struts or block fillers providing structural integrity.
    • Combination of Autograft & Allograft
    • Bone graft substitutes

• • Osteosynthesis (Use of Plate or Screws or Nail or combination)

• A suction drain is inserted into the cavity to drain and clear any post- operative fluid collection.
• Postoperative rehabilitation depends on the bone involved, size and reconstruction of defects.
• Average duration of stay in hospital will be 3-4 days.