Surgical techniques
A longitudinal approach was chosen for extended curettage, depending on the most affected cortex. For type III Campanacci lesions, the soft tissue component over the involved area was removed with a margin of 5 mm. The cortical window was widened to access the entire tumor area and avoid overhanging bone ridges. The tumor was then removed with a curette, and the margin was expanded by high-speed burring about 5 mm into the normal cancellous bone and 1 mm into the normal cortical bone. There was an exception for the articular cartilage aspect when the subchondral bone was exposed. After extended curettage, we used hydrogen peroxidase V10 as a chemical adjuvant therapy and a better cavity visualization. Following the extended curettage, the cavity was filled with cement or bone graft [Figure 1]. Bone graft was not used from 2008 based on the recent literature, which recommended cement augmentation, following the intralesional surgery of giant cell tumor. If the cement was used as the filling agent in cases with less than 10-mm intact subchondral bone, the articular surface was supported by a 10-mm flat fresh frozen cancellous allograft (mostly from the femoral head). A similar layer of bone graft was utilized to promote the healing of pathologic fracture after reduction and cementation without hardware fixation.
En bloc-wide resection was performed to manage cases in which reconstruction was not possible with extended curettage. It included tumors with more than one-half of circumferential cortical loss, tumors with articular loss or defect, pathologic femoral neck fracture, and tumors of expendable bones (the proximal part of the fibula or distal part of the ulna). Prostheses, osteoarticular allografts, or allograft-prosthesis composites were used to reconstruct the bone defects after resection.
Postoperative protocol
The patients’ follow-up was performed every three months for the first two years after the surgery, every six months until the fifth year, and every year afterward. At each follow-up session, plain radiographs of the involved area and a chest X-ray were taken.
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