32 Surgical management of bone tumors 2024.pdf

Surgical Management of Bone Tumors College of podiatric Medicine and Surgery Des Moines University John D. Bennett DPM. FACFAS. objectives Recognize and identify Common characteristics of benign and malignant bone tumors. Recognize Pathological findings on diagnostic studies to evaluate the extent o...

Surgical Management of Bone Tumors College of podiatric Medicine and Surgery Des Moines University John D. Bennett DPM. FACFAS. objectives Recognize and identify Common characteristics of benign and malignant bone tumors. Recognize Pathological findings on diagnostic studies to evaluate the extent of the tumor. Recognize and understand the Conservative and surgical treatment for the management of bone tumors. Initial evaluation Thorough and meticulous H&P -age -occupation -lifestyle Need to have a high suspicion for a tumor Radiographs, any add’n imaging (bone scan, CT, MRI) labs Biopsy of lesion if indicated -incisional -excisional Referral to Oncologist if warranted if pathology is suggestive of malignancy: Evaluation for mets. (CT scan of lungs and bone scan) Geographic Motheaten permeative Margins Narrow: 0.1-1.0 mm tumor and surrounding normal bone are touching, and you see a very small distance between them Wide: 2-10 mm there is an area representing tumor, and you can see where there is normal bone, but in between the two areas there is an indistinct presentation of bone that looks like it might be partially damaged Poorly defined: may be several centimeters or it may be impossible to measure the margin. One can tell there is a tumor in the bone, and there are areas that are distinctly abnormal, but you can’t tell how big the lesion is or where it begins or ends Periosteal Reaction Are an indicator of biologic activity of the bone lesion. Lamellar Multilamellar Spiculated Buttress Codman’s triangle If growth is very rapid, two patterns may develop: 1. “sun-burst” or “hair-on-end” appearance-periosteum has no time to lay down bone, but Sharpey’s fibers become stretched out perpendicular to the bone, and then ossify 2. Codman’s “triangle”-only the edges of the raised periosteum will ossify-this little bit of ossification forms a small angle with the surface of the bone, but not a complete triangle lamellar Treatment based on staging of the lesion Benign Lesions Stage 1: lesions that are static or tend to heal spontaneously. Stage 2: lesions that present with a more aggressive radiographic presentation, and evidence of continued growth. Stage 3: locally aggressive lesions, and show progressive growth not limited by barriers. Stage 2 and 3 are histologically immature Adjunct t(x) Cryotherapy Phenol polymethacrylate Benign stage 1 & 2: -intra lesional currettage -reconstructed with cancellous bone grafting methyl methacrylate augmentation Benign stage 2 & 3: -over treat with marginal excision that removes the intra articular surface with associated fusion Clinics in sports medicine October 1994 pg. 909-938 Treatment based on staging of the lesion Malignant Lesions Stage 1: low grade lesions Stage 2 : high grade lesions Stage 3: presence of metastasis Malignant stage 1 lesions: require a wide marginal excision, may require a partial or complete amputation at the appropriate level. Malignant stage 1B and 2 lesions: result in reconstruction by Malignant stage 1B and 2 lesions: result in reconstruction, amputation Clinics in sports medicine October 1994 pg. 909-938 Analysis of surgical treatment of 33 foot and ankle tumors 33 patients treated for tumors of the foot ankle at one institution and followed for 14 yrs. Age range from 1 to 64 (avg. 22.6yrs.) Most common bone tumors.(chondrosarcoma, and aneurysmal bone cyst.) Treatment: wide resection, local resection, curettage and cryosurgery, BKA Follow up: 1 to 13 yrs.(avg. of 7.2 yrs.) There were no local recurrences Functional results: good to excellent in 82% (27/33) 55%(18/33) were full weightbearingwith unlimited activity Foot & Ankle International/Vol. 15, No. 4/April 1994 Foot & Ankle International/Vol. 15, No. 4/April 1994 Treatment of Bone Tumors Biopsy Fine needle biopsy Core needle biopsy Excisional biopsy Principles of biopsy Incision placement and orientation -longitudinal and based on the anticipated area of resection -performed without the formation of tissue planes -hemostasis Dissection should be carried out sharply to the level of bone and remain within one fascial compartment Soft tissue mass sent if present Cortical window created Closed in layers Cases of Foot and Ankle Bone Tumors Case 1 12 year old male presents with a chief complaint of right heel pain 2 weeks duration. Initial presentation secondary to increase in level of activity PMH: unremarkable Med: none NKDA Initial treatment: ibuprofen 600mg. Bid, modify level of activity. What are some differentials that would be appropriate for a 12 year old male? Radiographs Computer tomography treatment Creation of a cortical window Curretage of tumor and adjacent bone Packing of the defect (tri-cortical graft) illiac crest Below knee cast and nonweight bearing Case 2 37 year old male presents with pain to the right hallux of 4 months duration. Pain associated with ambulation and weight bearing activities. Radiographs were unremarkable. Treatment: excision of the lesion with bone currettage. Packing with allogenic bone graft. Biopsy consistent w/ chondroma. Case 3 14 year old male presents with a history of heel pain, unresponsive to conservative treatment. Defect packed with allogenic bone graft matrix Pathology: findings consistent with an aneurysmal bone cyst Case 4 27 year old female presents with a chief complaint of stiffness and periodic pain in the ankle joint. PMH: unremarkable Neuro/vasc intact Musc: limited ROM of the ankle joint Intra-osseous ganglion Case 5 35 year old female presents with a mass present to the lateral right foot centered over the 5th mpj. Path: chondroma Case # 6 57 year old female presents with a recent onset of severe pain to the hallux. PMH: Niddm w/ neuropathy, Htn Objectivefindings: -dp and pt +1/4 -epicritic sensation intact -atrophic, scaley, xerotic skin -+5/5 extrinic muscles -pain on palpation to the hallux Osteoid osteoma Case #7 A 11 year old male presents with a chief complaint of a left painful 2nd. Digit. No history of trauma PMH: unremarkable Meds: none Surgical history: none Vasc: dp and pt +2/4, cft