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.

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Indications

  • Benign bone tumors (Curative)
  • 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 visualised.

  • 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.

Examples are

  1. Hydrogen peroxide
  2. Absolute alcohol, phenol (85%)
  3. Liquid nitrogen.
  4. Argon Plasma Cautery (APC)
  • The walls of curetted host bone are then burnt or Cauterized with Monopolar cautery or APC.
  • Reconstruction of Bone Defect or Cavity is baked 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
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