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Different Surgical margins for bone tumors

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  1. Surgical system for musculoskeletal sarcomas
    Similar system that incorporates histological grade of tumor (most significant prognostic factor)


Low grade well differentiated tumor with few mitoses & moderate cytoplasia

Low (<25%) risk of metastases


High grade poorly differentiated tumor with high mitotic rate & high cell to matrix

>25% risk of metastases


Metastases present at lymph node, lung or other site

Bone biopsy

  1. All imagine investigation (X-ray, CT, MRI) should be done prior to biopsy.
  2. Should be done at the same place by the same surgeon plan to do definitely surgery.
  3. Should be done through muscle without contaminating other compartment / Joints
  4. Meticulous hemostasis (Avoid drain)
  5. Longitudinal oval window made to avoid stress riser (Fracture)
  6. All biopsy specimens should be sent for culture and pathological analysis (and vice versa)

Limb salvage

Preservation of limb should be attempted in most cases.


Indication for limb salvage is roughly guided by “Three strike rules”

  1. Bone
  2. Nerves
  3. Vessel
  4. Soft tissue coverage

If three or more structure is involved, limb salvage is not recommended.


Extra Edge: Bone tumors

  • Metastatic bone tumor (95%)
  • Primary bone tumor (5% Both benign and malignant combined)
  • Most common bone tumor metastasis
  • Most common primary bone tumor osteochondroma.
  • Most common primary true benign tumor osteoid osteoma
  • Most common primary malignant tumor  myeloma
  • Most common primary bone sarcoma Osteosarcoma
  • Most common bone tumor of hand enchondroma
  • Most common soft tissue tumor (Child) hemangioma
  • Most common soft tissue tumor (adult) lipoma
  • Expandable prosthesis used in children (growing skeleton)
  • Megaprosthesis: used to replace joint after resection of bone tumor

Simple/ Solitary/ Unicameral-Bone Cyst

  1. Occur during first two decades of life (most often 4-10 years of age). Males > Females (M: F= 2.: 1).
  2. Arise in juxtaphyseal metaphysis and sometimes extends upto diaphysis but never cross physis to involve ephysis and joint. Most common site proximal humerus (50%) and femur (25%)Q.
  3. Activity of the UBC can be judged on the x-ray by measuring the distance between the cyst and the physis.
    1. Active - Distance between the cyst and the physis <0.5cm.
    2. Latent - Distance between the cyst and physis >0.5cm
  4. Mostly asymptomatic, as because of only mild expansion of bone, the pain and swelling are usually very mild condition is usually discovered after pathological fracture from a trivial trauma, or as an incidental finding on x - ray.




A. Simple Bone Cyst (with out fracture)

B. Simple Bone Cyst (with fracture Fallen leaf (fragment) sign)


it is a true cyst (lined by epithelium)


Fluid contains high level of PG-E2


Most common location: metaphysis, proximal humerus


X Ray: Cyst is central, smaller than the physis, minimal or no periosteal reaction and most important is Fallen leaf (fallen fragment) sign which is pathognomic x-ray finding.


Treatment: aspiration and injection steroid, bone marrow or sclerosants are used. Curretage and bone grafting is also treatment option (contraindicated in active lesion).


Radiotherapy is contraindicated.

Aneurysmal Bone Cyst

It is of two types:

  1. Primary – 65%
  2. Secondary (A V malformation)– 35%, secondary to destructive effect of an underlying primary tumor.
  1. Occur between 5 and 20 years of age. There is no sex predilection. (M=F)
  2. 2. Pathology: Not a true tumor/cyst. Cystic spaces of variable sizes & number which are filled with blood but not lined with vascular endothelium. The wall of vascular space is lined with fibro blast cells with collagen, giant cells, hemosiderin & osteoid (secondary to micro fractures)
  3. 3. 50% of cases in long bones of extremities. The most common sites are femur and tibia > humerus.
  4. 4. Vertebral involvement is common (- 20%) and posterior element is more commonly involved than body (giant cell tumor is more common in body). It is differentiated from osteoblastoma (which is also more common in posterior element i.e. spinous process, transverse process, & pedicle) by it classical appearance i.e. expansile purely radio lucent lesion; while the osteoblastoma is non expansile and partly or extensively calcified or ossified.

   Description: a509797a2f04b9_Osteoblastoma-ABC-vertebra

  1. Radiologically it is eccentric, extensively & asymmetrically expansile (finger in ballon or pencil in cup appearance) radiolucent metaphyseal lesion. Periosteal blowout or ballooned out lesion outlined by thin cell of sub periosteal new born formation. It is usually located eccentrically in metaphyseal region of a long bone. CODMAN’S triangle (Periosteal ossification at the corner of expanded cyst) are also found in ABC which is usual feature of osteosarcoma but not a diagnostic feature.
  2. CT scan shows characteristic fluid level 65% of aneurysmal bone cysts are primary whereas 35% are secondary ie arise from preexisting lesion of bone such as:
    Chondroblastoma, chondromyxoid fibroma, Nonossifying fibroma fibrous dysplasia, Osteoclastoma (most common) Osteoblastoma, Osteosarcoma, Hemangioendothelima, Metastatic tumor.
  3. Treatment: Spontaneous healing is uncommon. Various treatment modalities available are:
    1. Curettage + bone grafting
    2. Extended curettage with cryotherapy, cementation or phenol injection.
    3. Radiotherapy in unaccessible areas.

Extra Edge:

  1. Lytic Lesion In Posterior Element of Vertebrae
    (i.e. spinous process, transverse process, & pedicle)
    1. Expansile & Purely lytic Aneurysmal Bone Cyst
    2. Non expansile and partly or extensively ossified Osteoblastoma
  2. Radiolucent Bone Lesion
    1. With Well Defined Borders-Eccentric, Expansile
      1. Aneurysmal bone cyst
      2. Giant cell tumor
      3. Non ossifying fibroma
      4. Fibrous cortical defect
      5. Chondromyxoid fibroma
    2. Centric Nonexpansile (or minimally expansile) with Marginal Sclerosis
      1. Simple bony cyst
      2. Eosinophiiic granuloma
      3. Enchondroma
      4. Chondroblastoma
      5. Brodie’s abscess

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