Chondroblastoma of the femoral head: Curettage without dislocation

Chondroblastoma of the femoral head: Curettage without dislocation | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Chondroblastoma of the femoral head: Curettage without dislocation Di Yang, Haiping Ouyang, Ziyu Zhou, Zhongliang Wang This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4425706/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 18 Nov, 2024 Read the published version in BMC Surgery → Version 1 posted 4 You are reading this latest preprint version Abstract Background: Chondroblastoma (CBL)of femoral head is a rare disease, and its treatment is still controversial. The purpose of this research is to share our experience in curettage without dislocation for femoral head chondroblastoma. Methods: A total of 7 children diagnosed with chondroblastoma of the femoral head underwent a surgical procedure involving curettage, the application of anhydrous alcohol as an adjuvant therapy, and subsequent bone grafting. The epiphyseal plate status of the femoral head was categorized as open, closing, or closed. To assess the children's postoperative functional outcome, the Musculoskeletal Tumour Society (MSTS) scoring system was employed. Additionally, the Lodwick classification served to evaluate the extent of bone destruction. Furthermore, the kappa coefficient was utilized to quantify the level of agreement among observers in assessing the status of the epiphyseal plate. Results: The epiphyseal plate status was closing in two patients and closed in five patients. According to the Lodwick classification, three patients were classified as IA, one as IB, and three as IC. The mean MSTS score was 27.86. Notably, one patient sustained a femoral neck fracture three months post-curettage. Conclusions: Curettage without surgical dislocation, combined with the use of anhydrous alcohol as an adjuvant therapy, followed by bone grafting, constitutes an effective treatment technique for femoral head chondroblastoma (CBL). Chondroblastoma femoral head curettage Figures Figure 1 Figure 2 Background Chondroblastoma (CBL) is a rare nonmalignant tumor characterized by local invasion. Nonetheless, it exhibits metastatic and recurrent tendencies akin to those observed in malignant tumors. This tumor commonly occurs in the long bone epiphysis of adolescents and can penetrate the epiphyseal plate to invade the metaphysis. The ratio of male to female is 3:2 [ 1 ] . In children, the most prevalent locations for Chondroblastoma (CBL) are the distal femur, proximal tibia, and proximal humerus, with curettage being the primary treatment modality. However, the femoral head is not a typical site for CBL, with its incidence comprising only 3.8% -16.7% of all CBL cases [ 2 – 8 ] . Nonetheless, chondroblastomas affecting the epiphysis of the femoral head pose a therapeutic dilemma in determining the best surgical approach, primarily because the femoral head epiphysis is located entirely within the joint capsule. Accessing the lesion necessitates breaching either the growth plate or the articular cartilage. Seven pediatric patients with chondroblastoma (CBL) of the femoral head, treated at the Children's Hospital affiliated to Chongqing Medical University, were included. All patients underwent curettage without surgical dislocation, anhydrous alcohol flushing, and subsequent bone grafting. The aim of this study is to present our experience in the management of CBL affecting the femoral head. Methods From 2017 to 2023, we included 7 children with chondroblastoma of femoral head who underwent surgical treatment in Children's Hospital affiliated to Chongqing Medical University. There were 3 males and 4 females. Inclusion criteria: (1) Pathological diagnosis suggested chondroblastoma; (2) The lesion was located at the femoral head; (3) Detailed hospitalization records; (4) Regular postoperative follow-up records. Exclusion criteria: (1) Children who lost follow-up; (2) Children with lesions in other sites; (3) Children with irregular follow-up; (4) Children with incomplete hospitalization records. The following data were documented: age at diagnosis, gender, tumor location, tumor size, status of the femoral head epiphyseal plate, presence of epiphyseal plate invasion by the lesion, coexistence of aneurysmal bone cyst (ABC), surgical method, disease progression, presenting symptoms, recurrence, timing of complication onset, and treatment administered for the complication (Table 1). The status of the femoral head epiphyseal plate were defined as open, closing and closed. Open meant the epiphyseal plate was wide and transparent in X-ray; closing meant the epiphyseal plate was thin and irregular; closed meant the epiphyseal scar was present. The kappa coefficient was used to analyze the differences in the assessment of epiphyseal plate status among observers. Preoperative CT imaging was utilized to ascertain the dimensions of the lesion and assess whether the epiphyseal plate was involved. The Lodwick classification system was applied to evaluate the degree of bone destruction. The observed appearance was described as follows: Type I represented a geographic pattern; IA signified absent or partial cortical penetration with the presence of a sclerotic rim and an expanded shell measuring less than 1cm; IB denoted absent or partial cortical penetration lacking a sclerotic rim or featuring an expanded shell exceeding 1cm; and IC indicated complete cortical penetration [ 9 ] . The Musculoskeletal Tumour Society scoring system (MSTS) [ 10 ] was used to evaluate the postoperative functional outcome of pediatric patients based on several criteria, including pain, function, emotional acceptance, supports, walking ability, gait. This study has been approved by the Ethics Committee of Children's Hospital affiliated to Chongqing Medical University (ID: 2024研190 ), and obtained the written consent of the legal guardian of the child. Surgical technique: The patient was given general anesthesia and local nerve block anesthesia. A cushion placed underneath the buttock on the affected limb to make the body form a 30-degree angle with the operating table. An incision was made from anterior superior iliac spine to the front of the greater trochanter. The skin, hypodermis, and deep fascia of the buttocks were incised, allowing access to the space situated between the gluteus medius and tensor fascia lata, thereby exposing the capsule. Subsequently, a 'Z'-shaped incision was made on the capsule to reveal the femoral head and neck. If the preoperative CT scan indicated that the lesion was located on the medial side of the femoral head, the affected lower extremity should be maximally externally rotated. Once the edge of the femoral head lesion was localized using a C-arm X-ray machine, an articular window was opened at the lesion closest to the articular cartilage. One edge of the articular window was extended by 5mm to facilitate fixation with absorbable cartilaginous pins when the cartilage lid was replanted. (Fig. 1). After curettage of the tumor though the window with a spatula, the cavity was then irrigated with anhydrous alcohol for 5min and washed out. After the tumor was curetted through the window using a spatula, the cavity was irrigated with anhydrous alcohol for 5 minutes, taking precautions to avoid spillage that could potentially cause damage to surrounding tissues, and then washed out. Subsequently, the cavity wall was scraped once more, followed by irrigation with normal saline and thorough washing. After this process, the cavity was refilled with anhydrous alcohol. This step was repeated for a total alcohol contact time of 10 min. Subsequent to copious irrigation with normal saline solution, autogenous bone or allogenous bone grafts were utilized to fill the bone defects. Following this, the tumor on the lesion surface of the cartilage lid was removed and the lid was replanted, ensuring a smooth and flat articular surface. To stabilize the lid, two absorbable cartilage pins were utilized for fixation, and the affected side was immobilized with a brace. Patient activity was encouraged, with early rehabilitation training and continuous passive. Movement starting on the second postoperative day, with partial weight-bearing on the six weeks postoperatively and full weight-bearing on the three months postoperatively. Figure 1. A 'Z'-shaped incision was made in the capsule, and an articular window was opened to expose the tumor. After the operation, patients underwent X-ray imaging every three months for the first two years, every six months for the subsequent three years, and annually thereafter. Recurrence was suspected if there was any new zone of bone destruction or enlargement of a low-density area in the primary lesion observed on X-rays when compared to the postoperative baseline film. Patients with suspected recurrence underwent CT and MRI scans of the lesion site, accompanied by a chest CT. Results Among our 7 cases of chondroblastoma of the femoral head, there were 3 males and 4 females. Five and 2 cases were located on the left and right, respectively. The average age at diagnosis was 13 (11–15) years old. The mean follow-up time was 22 months (3 to 70). Based on preoperative radiographic findings, the epiphyseal plates of all patients were invaded by the tumor. Among them, the epiphyseal plates of 2 patients were in the process of closing, while 5 patients had closed epiphyseal plates. According to the Lodwick classification system, three patients were classified as IA, one as IB, and three as IC. All children underwent curettage and bone grafting procedures. Specifically, five children opted for artificial bone implantation, one child chose autologous bone, and another child combined both artificial and autologous bone grafts. Postoperative biopsies confirmed that all cases were diagnosed as chondroblastoma without any evidence of aneurysmal bone cyst. During the follow-up, one child developed a pathological fracture of the femoral neck. At the last follow-up, the gait of the other children was normal, and a review of X-ray results showed normal joint spaces in bilateral hip joints, smooth surfaces of bilateral femoral heads without obvious depression, and no signs of recurrence. The postoperative MSTS score was 27.86. The preoperative and postoperative imaging results of one patient are displayed (Fig. 2). The inter-rater reliability of epiphyseal plate status was assessed using Kappa, which showed a remarkable agreement between the two raters, with a kappa coefficient of 1 (p = 0.008). Figure 2. Chondroblastoma of the hip in a 13-year-old male. (A) A frontal radiograph of the left hip demonstrates a round and lobulated osteolytic lesion of the femoral head, extending up to the subchondral area. (B) A sagittal CT scan demonstrates to better advantage the lytic lesion with the thick sclerotic zone. (C)A sagittal T1 MR image demonstrates the moderate-signal intensity lesion extending to the subchondral area and surrounded by the low-signal intensity border. (D)A f rontal radiograph of the left hip at the 1-month follow-up shows that the cavity has been filled with autogenous bone. Femoral bone traction was performed on the patient who had experienced a fracture of the affected femoral neck three months after curettage. There were no other complications upon follow-up. Discussion Chondroblastoma is a rare, nonmalignant but invasive tumor. The effects of various surgical methods are also controversial. This the object of this article is to share the treatment experience of femoral head chondroblastoma without surgical dislocation in our medical center from 2017 to 2023. Currently, the most prevalent locations of chondroblastoma in children are the distal femur, proximal tibia, and proximal humerus, although there is debate regarding which of these sites has the highest incidence rate [ 4 , 5 , 7 , 11 ] . Nonetheless, chondroblastoma affecting the femoral head is uncommon. The majority of pediatric patients primarily complain of pain, sometimes accompanied by lameness. Due to its distinct anatomical position, the surgical approach is more intricate than that for chondroblastoma in more common sites. Strong has proposed three surgical approaches to removing the lesions in the femoral head. The first route involved accessing the lesion through a bone tunnel from the outside of the proximal femur along the long axis of the femoral neck to the femoral head (known as curettage via the femoral neck, or CVFN). The second route involved a direct approach through the head-neck junction below the growth plate or the femoral neck. The third route was traditional trapdoor procedure [ 12 ] . Two out of the five children who underwent the CVFN approach experienced local recurrences. When this surgical approach was employed, the lesion located in the femoral head could not be directly visualized, and the precise delineation between the lesion and healthy tissue remained elusive. The extensive pathway through the femoral neck to access the lesion posed challenges, as the curette or other surgical instruments could not easily reach all areas of the tumor, thereby hindering its complete removal. Additionally, the CBL tissue was soft and left in the path which may increase the risk of recurrence [ 4 , 12 ] . Furthermore, the study has shown that this surgical approach could potentially harm the epiphyseal plate of the femoral head in children. In fact, an 11-year-old patient who underwent CVFN surgery experienced a minor shortening (< 1cm) of the affected lower limb a year after the operation [ 12 ] . Hence, CVFN was not considered the most effective method. Although Strong did not report any occurrences of femoral head necrosis, the second surgical approach undoubtedly damaged the blood vessels supplying the femoral head, thus increasing the risk of necrosis. Furthermore, this approach also caused harm to the growth plate. Although this technique undeniably enhanced the surgeon's field of vision, achieving comprehensive tumor curettage through this method remained challenging during the actual surgical procedure. The traditional trapdoor procedure required extreme caution during the operation to dislocate the hip joint. However, even with such precautions taken, there was still a risk of damaging the articular surface of the femoral head, which could increase the chance of femoral head necrosis [ 13 , 14 ] . In recent years, Liu et al. have put forward the modified trapdoor procedure. The difference between this surgery and the traditional trapdoor procedure was that ligamentum teres was used to close the window on the cartilage surface. Of the 13 children, one child developed necrosis of the femoral head four months postoperatively, another exhibited heterotopic ossification, while the remaining children had a favorable prognosis during the follow-up period [ 15 ] . We believe that the modified trapdoor procedure exhibits a favorable therapeutic outcome; however, it is not suitable for the lesions on the edge of the femoral head surface. Additionally, surgical excision of the ligamentum teres of the femoral head can compromised the blood supply to the femoral head, thereby elevating the risk of femoral head necrosis. Ganz et al. have previously demonstrated that the blood supply to the femoral head primarily originates from the deep branch of the medial femoral circumflex artery (MFCA) [ 13 ] . However, numerous authors have reported the existence of ligamental arteries and their significant contribution to the blood supply of the femoral head [ 16 , 17 ] . The role of the ligamentum teres remains controversial. We tend to preserve the ligamentum teres, which we believe will result in a more favorable prognosis for children. The smooth texture of the ligamentum teres does not match the articular cartilage found on the femoral head surface. Furthermore, the potential for developing secondary osteoarthritis among children who were treated with the modified trapdoor procedure remained uncertain when compared to other surgical options, especially in long-term follow-up studies. Articular cartilage primarily receives its nutritional supply from synovial fluid, and numerous successful instances of osteochondral transplantation have unambiguously established the viability of articular cartilage replantation [ 18 – 20 ] . Therefore, in our treatment, we recommend autologous articular cartilage replantation to ensure the smoothness of the femoral head surface. In the surgery of curettage without hip dislocation for femoral head CBL, only a few articles have described the surgical process in detail. In 2022, Hirohisa Katagiri reported on two patients who underwent focal curettage of the femoral head without hip dislocation. These two patients did not experience any complications during the 6 and 12-year follow-ups, respectively. Unlike in our surgical approach, Katagiri chose a non-weight-bearing area for fenestration [ 21 ] . Currently, there are no clear reports regarding the impact of fenestration in weight-bearing versus non-weight-bearing areas on prognosis. In the curettage of CBL in the femoral head, it has always been a concern to avoid the injuring the epiphyseal plate of the femoral head. The epiphyseal plate of femoral head promotes the elongation of femoral neck [ 22 ] . It has been proved that simple curettage leads to higher possibility of local recurrence. Tomic et al. observed that the recurrence rate of surgical treatment with simple curettage was high (as high as 30%), which they deemed unacceptable, especially for invasive lesions [ 23 ] . Extended curettage can significantly reduce the risk of local recurrence in chondroblastoma of the femoral head. However, it may exacerbate the damage to the epiphyseal plate [ 11 ] . Suneja et al. have stated that the damage to the epiphyseal plate can be repaired through appropriate post-operative nursing care. In their study, all patients underwent aggressive intralesional curettage as the sole treatment, which proved curative in most cases. However, the authors did not provide comprehensive data on the status of the epiphyseal plate for all patients [ 3 ] . Liu Qing et al. postulated that the epiphyseal plate near the knee joint possesses resilience and has the potential to regenerate following extensive curettage. This assertion was based on two primary reasons: Firstly, only a minor portion of the epiphyseal plate is associated with the tumor. Secondly, the blood supply to the epiphyseal plate originates from the soft tissue connected to the epiphysis, which remains largely unaffected during the surgical procedure [ 24 ] . Another study found that out of 20 children treated with extended curettage, only 2 experienced relapse, with no cases of leg length discrepancy (LLD) reported. It's worth noting that most of the patients had epiphyseal plates that were either closing or already closed, with only one child having an open epiphyseal plate [ 5 ] . It is widely believed that the risk of LLD is lower when the epiphyseal plate is in a closed state compared to an open state. Mashhour and Abdel Rahman recommended extended curettage during the initial surgery to reduce the chances of recurrence [ 25 ] . However, whether extended curettage can effectively treat CBL in the femoral head needs further investigation. In our study, we prioritized protecting the epiphyseal plate as much as possible, while ensuring complete removal of the lesion. During our surgical procedure, we applied anhydrous alcohol to deactivate any remaining tumor cells within the cavity. Among the locally available adjuvants, such as burring, liquid nitrogen, phenol, and cement, high-speed burring is predominantly used. It is widely acknowledged as the most effective adjuvant for preventing local tumor recurrence [ 2 , 7 , 26 ] . However, Cong Huang et al. expressed concern that the epiphyseal plate could potentially be harmed by the heat generated by the burr [ 11 ] . Additionally, cement was also regarded as detrimental to the epiphyseal plate due to the heat it emitted during the solidification process [ 7 ] . Furthermore, studies have indicated that adjuvants like phenol or liquid nitrogen may induce necrosis [ 15 ] . Currently, there is a scarcity of published data examining the use of anhydrous alcohol as an adjuvant in the treatment of CBL. Anhydrous alcohol has the potential to induce protein denaturation in tumor cells, cytoplasmic degeneration, and embolism of the small vessels supplying the tumors. Furthermore, it has been established that anhydrous alcohol exerts minimal adverse effects on surrounding tissues [ 27 ] . Karem advocated for the use of phenol and anhydrous alcohol as adjuvants in curettage [ 5 ] . However, our findings revealed that anhydrous alcohol alone can achieve satisfactory surgical outcomes. Secondary osteoarthritis is a prevalent complication associated with CBL of the femoral head [ 17 ] . Studies have indicated that CBL located specifically in the hip joint, particularly the femoral head, is often linked to extended curettage of lesions and the utilization of adjuvants like phenol and liquid nitrogen, factors that may contribute to the development of secondary osteoarthritis. Farfalli previously noted that while extended curettage can decrease the likelihood of recurrence in pediatric patients, it also elevates the risk of secondary osteoarthritis [ 14 ] . The unique and delicate circulatory system of the hip joint may contribute to degenerative changes observed in this condition [ 28 ] . In the management of comparable tumors, such as giant cell tumors, phenolic compounds demonstrated a reduced risk of osteoarthritis compared to liquid nitrogen [ 29 , 30 ] . Farfalli et al. demonstrated that the incidence of secondary osteoarthritis increased after first 5 years of follow-up [ 14 ] , which was a limitation that we cannot explore due to insufficient follow-up time. When addressing CBL of the femoral head, the chosen surgical approach varied based on the lesion's location and extent. If the lesion was wholly contained within the femoral head and had minimal or no impact on the epiphyseal plate, we opted to create a window through the articular cartilage of the femoral head. However, if the epiphyseal plate lesion was significant and the CBL extended considerably into the femoral neck, we contemplated opening a window through the femoral neck to extract the tumor. This method helped to reduce harm to the articular cartilage, thereby maintaining joint integrity and functionality. Our research encountered several limitations. Firstly, there were few cases of femoral head involvement, which limited our ability to obtain more precise risk factors through our research. Secondly, our follow-up period was insufficient to adequately assess long-term complications. Conclusions Curettage, performed without surgical hip dislocation, in conjunction with bone grafting and the utilization of anhydrous alcohol as an adjuvant, demonstrates significant efficacy. This treatment approach serves to safeguard the epiphyseal plate and minimize the recurrence of CBL of the femoral head. Abbreviations CBL Chondroblastoma MTST Musculoskeletal Tumour Society scoring system LLD Leg Length Discrepancy CNFV Curettage via the femoral neck MFCA Medial Femoral Circumflex Artery Declarations Ethics approval and consent to participate The research had been approved by the Ethics Committee of Children's Hospital affiliated to Chongqing Medical University. Consent for publication Not applicable Availability of data and materials Data is provided within the manuscript. Competing interests The authors declare that they have no competing interests. Funding Not applicable Authers’ Contributions DY and ZLW designed the study; DY, ZYZ collected the data; ZLW and DY analyzed the data; DY drafted the initial manuscript; DY and ZLW revised the article critically; HO repeated measurement data; DY, ZLW and HO reviewed and edited the article; All authors read and approved the final manuscript. Acknowledgements Not applicable Statement for use of human tissue samples Informed consent was obtained from all of their legal guardians. References Chen W, DiFrancesco LM. Chondroblastoma: An Update. Arch Pathol Lab Med. 2017;141:867-871. Hsu CC, Wang JW, Chen CE, Lin JW. Results of curettage and high-speed burring for chondroblastoma of the bone. Chang Gung Med J. 2003;26:761-7. Suneja R, Grimer RJ, Belthur M, Jeys L, Carter SR, Tillman RM, et al. Chondroblastoma of bone: long-term results and functional outcome after intralesional curettage. J Bone Joint Surg Br. 2005;87:974-8. 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The surgical anatomy of the blood supply to the femoral head: description of the anastomosis between the medial femoral circumflex and inferior gluteal arteries at the hip. J Bone Joint Surg Br. 2008;90:1298-303. Knochentumoren A, Becker WT, Dohle J, Bernd L, Braun A, Cserhati M, et al. Local recurrence of giant cell tumor of bone after intralesional treatment with and without adjuvant therapy. J Bone Joint Surg Am. 2008;90:1060-7. van der Heijden L, van der Geest IC, Schreuder HW, van de Sande MA, Dijkstra PD. Liquid nitrogen or phenolization for giant cell tumor of bone?: a comparative cohort study of various standard treatments at two tertiary referral centers. J Bone Joint Surg Am. 2014;96:e35. Table 1 Table 1 is available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files Table1.xlsx Cite Share Download PDF Status: Published Journal Publication published 18 Nov, 2024 Read the published version in BMC Surgery → Version 1 posted Editorial decision: Revision requested 30 May, 2024 Editor assigned by journal 25 May, 2024 Submission checks completed at journal 25 May, 2024 First submitted to journal 15 May, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4425706","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":308762312,"identity":"66801699-1021-49c0-bb56-492b0968ec41","order_by":0,"name":"Di Yang","email":"","orcid":"","institution":"Children's Hospital of Chongqing Medical University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Di","middleName":"","lastName":"Yang","suffix":""},{"id":308762314,"identity":"0afc81fd-8630-4927-ad03-5c685c2dc6ee","order_by":1,"name":"Haiping Ouyang","email":"","orcid":"","institution":"Children's Hospital of Chongqing Medical University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Haiping","middleName":"","lastName":"Ouyang","suffix":""},{"id":308762315,"identity":"d74f21d8-ca4e-48fe-b5f1-53670f86aa06","order_by":2,"name":"Ziyu Zhou","email":"","orcid":"","institution":"Children's Hospital of Chongqing Medical University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Ziyu","middleName":"","lastName":"Zhou","suffix":""},{"id":308762316,"identity":"e854ba7d-99bd-4858-8c37-58fe0ac31f03","order_by":3,"name":"Zhongliang Wang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAx0lEQVRIiWNgGAWjYBACxvbmgw8+/vknx8befoA4Lcw9x5INZzYcMObjOZNAnBb2GTlm0rwNBxLnSTgYEKeFt+eAmeTMHXfS2yQYEhh+VGwjrEWyvSHZ4uOZZ7lt0o0HGHvO3CasxbDnwMGbM9iYc9tkDiQwM7YRocX+RmKDNA8bczqbRIIBcVoYZyQzSfO2HU4gQUvPMWbDGWfSDNuAgXyQKL8wtvd/fPChwkZevr394IMfFURoQQEHSFQ/CkbBKBgFowAXAACYzUQ+4jRTVQAAAABJRU5ErkJggg==","orcid":"","institution":"Children's Hospital of Chongqing Medical University","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Zhongliang","middleName":"","lastName":"Wang","suffix":""}],"badges":[],"createdAt":"2024-05-15 14:08:34","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4425706/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4425706/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12893-024-02660-4","type":"published","date":"2024-11-18T15:58:14+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":58086155,"identity":"8bb0ede0-a164-4eea-9547-64c741d8ab41","added_by":"auto","created_at":"2024-06-11 02:47:12","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":402030,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eA 'Z'-shaped incision was made in the capsule, and an articular window was opened to expose the tumor.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4425706/v1/ade9e3d2a8b9129854132a81.jpeg"},{"id":58086156,"identity":"1ef79c5d-60b0-4de8-ba41-ce60ffd8f6d3","added_by":"auto","created_at":"2024-06-11 02:47:12","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":577948,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eChondroblastoma of the hip in a 13-year-old male. (A) A frontal radiograph of the left hip demonstrates a round and lobulated osteolytic lesion of the femoral head, extending up to the subchondral area. (B) A sagittal CT scan demonstrates to better advantage the lytic lesion with the thick sclerotic zone. (C)A sagittal T1 MR image demonstrates the moderate-signal intensity lesion extending to the subchondral area and surrounded by the low-signal intensity border. (D)A f rontal radiograph of the left hip at the 1-month follow-up shows that the cavity has been filled with autogenous bone.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4425706/v1/fb01fcdf2b10e57392ca9d68.jpeg"},{"id":69835101,"identity":"f282d8c1-b1d7-4700-8e26-a0b5e8057b3f","added_by":"auto","created_at":"2024-11-25 16:12:00","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1612801,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4425706/v1/a4675d6b-f748-4c62-9d49-cd518fc86c12.pdf"},{"id":58086153,"identity":"7010af78-45f2-41e6-a5e3-e73ae0ddafcb","added_by":"auto","created_at":"2024-06-11 02:47:12","extension":"xlsx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":10556,"visible":true,"origin":"","legend":"","description":"","filename":"Table1.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-4425706/v1/f45bbeb906b27ff8ea0f159b.xlsx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Chondroblastoma of the femoral head: Curettage without dislocation","fulltext":[{"header":"Background","content":"\u003cp\u003eChondroblastoma (CBL) is a rare nonmalignant tumor characterized by local invasion. Nonetheless, it exhibits metastatic and recurrent tendencies akin to those observed in malignant tumors. This tumor commonly occurs in the long bone epiphysis of adolescents and can penetrate the epiphyseal plate to invade the metaphysis. The ratio of male to female is 3:2 \u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eIn children, the most prevalent locations for Chondroblastoma (CBL) are the distal femur, proximal tibia, and proximal humerus, with curettage being the primary treatment modality. However, the femoral head is not a typical site for CBL, with its incidence comprising only 3.8% -16.7% of all CBL cases \u003csup\u003e[\u003cspan additionalcitationids=\"CR3 CR4 CR5 CR6 CR7\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e. Nonetheless, chondroblastomas affecting the epiphysis of the femoral head pose a therapeutic dilemma in determining the best surgical approach, primarily because the femoral head epiphysis is located entirely within the joint capsule. Accessing the lesion necessitates breaching either the growth plate or the articular cartilage.\u003c/p\u003e \u003cp\u003eSeven pediatric patients with chondroblastoma (CBL) of the femoral head, treated at the Children's Hospital affiliated to Chongqing Medical University, were included. All patients underwent curettage without surgical dislocation, anhydrous alcohol flushing, and subsequent bone grafting. The aim of this study is to present our experience in the management of CBL affecting the femoral head.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eFrom 2017 to 2023, we included 7 children with chondroblastoma of femoral head who underwent surgical treatment in Children's Hospital affiliated to Chongqing Medical University. There were 3 males and 4 females. Inclusion criteria: (1) Pathological diagnosis suggested chondroblastoma; (2) The lesion was located at the femoral head; (3) Detailed hospitalization records; (4) Regular postoperative follow-up records. Exclusion criteria: (1) Children who lost follow-up; (2) Children with lesions in other sites; (3) Children with irregular follow-up; (4) Children with incomplete hospitalization records.\u003c/p\u003e \u003cp\u003eThe following data were documented: age at diagnosis, gender, tumor location, tumor size, status of the femoral head epiphyseal plate, presence of epiphyseal plate invasion by the lesion, coexistence of aneurysmal bone cyst (ABC), surgical method, disease progression, presenting symptoms, recurrence, timing of complication onset, and treatment administered for the complication (Table\u0026nbsp;1). The status of the femoral head epiphyseal plate were defined as open, closing and closed. Open meant the epiphyseal plate was wide and transparent in X-ray; closing meant the epiphyseal plate was thin and irregular; closed meant the epiphyseal scar was present. The kappa coefficient was used to analyze the differences in the assessment of epiphyseal plate status among observers. Preoperative CT imaging was utilized to ascertain the dimensions of the lesion and assess whether the epiphyseal plate was involved. The Lodwick classification system was applied to evaluate the degree of bone destruction. The observed appearance was described as follows: Type I represented a geographic pattern; IA signified absent or partial cortical penetration with the presence of a sclerotic rim and an expanded shell measuring less than 1cm; IB denoted absent or partial cortical penetration lacking a sclerotic rim or featuring an expanded shell exceeding 1cm; and IC indicated complete cortical penetration \u003csup\u003e[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/sup\u003e. The Musculoskeletal Tumour Society scoring system (MSTS) \u003csup\u003e[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/sup\u003e was used to evaluate the postoperative functional outcome of pediatric patients based on several criteria, including pain, function, emotional acceptance, supports, walking ability, gait.\u003c/p\u003e \u003cp\u003e This study has been approved by the Ethics Committee of Children's Hospital affiliated to Chongqing Medical University (ID: 2024研190 ), and obtained the written consent of the legal guardian of the child.\u003c/p\u003e \u003cp\u003eSurgical technique: The patient was given general anesthesia and local nerve block anesthesia. A cushion placed underneath the buttock on the affected limb to make the body form a 30-degree angle with the operating table. An incision was made from anterior superior iliac spine to the front of the greater trochanter. The skin, hypodermis, and deep fascia of the buttocks were incised, allowing access to the space situated between the gluteus medius and tensor fascia lata, thereby exposing the capsule. Subsequently, a 'Z'-shaped incision was made on the capsule to reveal the femoral head and neck. If the preoperative CT scan indicated that the lesion was located on the medial side of the femoral head, the affected lower extremity should be maximally externally rotated. Once the edge of the femoral head lesion was localized using a C-arm X-ray machine, an articular window was opened at the lesion closest to the articular cartilage. One edge of the articular window was extended by 5mm to facilitate fixation with absorbable cartilaginous pins when the cartilage lid was replanted. (Fig.\u0026nbsp;1). After curettage of the tumor though the window with a spatula, the cavity was then irrigated with anhydrous alcohol for 5min and washed out. After the tumor was curetted through the window using a spatula, the cavity was irrigated with anhydrous alcohol for 5 minutes, taking precautions to avoid spillage that could potentially cause damage to surrounding tissues, and then washed out. Subsequently, the cavity wall was scraped once more, followed by irrigation with normal saline and thorough washing. After this process, the cavity was refilled with anhydrous alcohol. This step was repeated for a total alcohol contact time of 10 min. Subsequent to copious irrigation with normal saline solution, autogenous bone or allogenous bone grafts were utilized to fill the bone defects. Following this, the tumor on the lesion surface of the cartilage lid was removed and the lid was replanted, ensuring a smooth and flat articular surface. To stabilize the lid, two absorbable cartilage pins were utilized for fixation, and the affected side was immobilized with a brace. Patient activity was encouraged, with early rehabilitation training and continuous passive. Movement starting on the second postoperative day, with partial weight-bearing on the six weeks postoperatively and full weight-bearing on the three months postoperatively.\u003c/p\u003e \u003cp\u003e \u003cb\u003eFigure\u0026nbsp;1. A 'Z'-shaped incision was made in the capsule, and an articular window was opened to expose the tumor.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eAfter the operation, patients underwent X-ray imaging every three months for the first two years, every six months for the subsequent three years, and annually thereafter. Recurrence was suspected if there was any new zone of bone destruction or enlargement of a low-density area in the primary lesion observed on X-rays when compared to the postoperative baseline film. Patients with suspected recurrence underwent CT and MRI scans of the lesion site, accompanied by a chest CT.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eAmong our 7 cases of chondroblastoma of the femoral head, there were 3 males and 4 females. Five and 2 cases were located on the left and right, respectively. The average age at diagnosis was 13 (11\u0026ndash;15) years old. The mean follow-up time was 22 months (3 to 70). Based on preoperative radiographic findings, the epiphyseal plates of all patients were invaded by the tumor. Among them, the epiphyseal plates of 2 patients were in the process of closing, while 5 patients had closed epiphyseal plates. According to the Lodwick classification system, three patients were classified as IA, one as IB, and three as IC. All children underwent curettage and bone grafting procedures. Specifically, five children opted for artificial bone implantation, one child chose autologous bone, and another child combined both artificial and autologous bone grafts. Postoperative biopsies confirmed that all cases were diagnosed as chondroblastoma without any evidence of aneurysmal bone cyst. During the follow-up, one child developed a pathological fracture of the femoral neck. At the last follow-up, the gait of the other children was normal, and a review of X-ray results showed normal joint spaces in bilateral hip joints, smooth surfaces of bilateral femoral heads without obvious depression, and no signs of recurrence. The postoperative MSTS score was 27.86. The preoperative and postoperative imaging results of one patient are displayed (Fig.\u0026nbsp;2). The inter-rater reliability of epiphyseal plate status was assessed using Kappa, which showed a remarkable agreement between the two raters, with a kappa coefficient of 1 (p\u0026thinsp;=\u0026thinsp;0.008).\u003c/p\u003e \u003cp\u003e \u003cb\u003eFigure\u0026nbsp;2. Chondroblastoma of the hip in a 13-year-old male. (A) A frontal radiograph of the left hip demonstrates a round and lobulated osteolytic lesion of the femoral head, extending up to the subchondral area. (B) A sagittal CT scan demonstrates to better advantage the lytic lesion with the thick sclerotic zone. (C)A sagittal T1 MR image demonstrates the moderate-signal intensity lesion extending to the subchondral area and surrounded by the low-signal intensity border. (D)A f rontal radiograph of the left hip at the 1-month follow-up shows that the cavity has been filled with autogenous bone.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eFemoral bone traction was performed on the patient who had experienced a fracture of the affected femoral neck three months after curettage. There were no other complications upon follow-up.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eChondroblastoma is a rare, nonmalignant but invasive tumor. The effects of various surgical methods are also controversial. This the object of this article is to share the treatment experience of femoral head chondroblastoma without surgical dislocation in our medical center from 2017 to 2023.\u003c/p\u003e \u003cp\u003eCurrently, the most prevalent locations of chondroblastoma in children are the distal femur, proximal tibia, and proximal humerus, although there is debate regarding which of these sites has the highest incidence rate \u003csup\u003e[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/sup\u003e. Nonetheless, chondroblastoma affecting the femoral head is uncommon. The majority of pediatric patients primarily complain of pain, sometimes accompanied by lameness. Due to its distinct anatomical position, the surgical approach is more intricate than that for chondroblastoma in more common sites.\u003c/p\u003e \u003cp\u003eStrong has proposed three surgical approaches to removing the lesions in the femoral head. The first route involved accessing the lesion through a bone tunnel from the outside of the proximal femur along the long axis of the femoral neck to the femoral head (known as curettage via the femoral neck, or CVFN). The second route involved a direct approach through the head-neck junction below the growth plate or the femoral neck. The third route was traditional trapdoor procedure \u003csup\u003e[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/sup\u003e. Two out of the five children who underwent the CVFN approach experienced local recurrences. When this surgical approach was employed, the lesion located in the femoral head could not be directly visualized, and the precise delineation between the lesion and healthy tissue remained elusive. The extensive pathway through the femoral neck to access the lesion posed challenges, as the curette or other surgical instruments could not easily reach all areas of the tumor, thereby hindering its complete removal. Additionally, the CBL tissue was soft and left in the path which may increase the risk of recurrence \u003csup\u003e[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/sup\u003e. Furthermore, the study has shown that this surgical approach could potentially harm the epiphyseal plate of the femoral head in children. In fact, an 11-year-old patient who underwent CVFN surgery experienced a minor shortening (\u0026lt;\u0026thinsp;1cm) of the affected lower limb a year after the operation \u003csup\u003e[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/sup\u003e. Hence, CVFN was not considered the most effective method. Although Strong did not report any occurrences of femoral head necrosis, the second surgical approach undoubtedly damaged the blood vessels supplying the femoral head, thus increasing the risk of necrosis. Furthermore, this approach also caused harm to the growth plate. Although this technique undeniably enhanced the surgeon's field of vision, achieving comprehensive tumor curettage through this method remained challenging during the actual surgical procedure. The traditional trapdoor procedure required extreme caution during the operation to dislocate the hip joint. However, even with such precautions taken, there was still a risk of damaging the articular surface of the femoral head, which could increase the chance of femoral head necrosis \u003csup\u003e[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eIn recent years, Liu et al. have put forward the modified trapdoor procedure. The difference between this surgery and the traditional trapdoor procedure was that ligamentum teres was used to close the window on the cartilage surface. Of the 13 children, one child developed necrosis of the femoral head four months postoperatively, another exhibited heterotopic ossification, while the remaining children had a favorable prognosis during the follow-up period \u003csup\u003e[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/sup\u003e. We believe that the modified trapdoor procedure exhibits a favorable therapeutic outcome; however, it is not suitable for the lesions on the edge of the femoral head surface. Additionally, surgical excision of the ligamentum teres of the femoral head can compromised the blood supply to the femoral head, thereby elevating the risk of femoral head necrosis. Ganz et al. have previously demonstrated that the blood supply to the femoral head primarily originates from the deep branch of the medial femoral circumflex artery (MFCA) \u003csup\u003e[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/sup\u003e. However, numerous authors have reported the existence of ligamental arteries and their significant contribution to the blood supply of the femoral head \u003csup\u003e[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/sup\u003e. The role of the ligamentum teres remains controversial. We tend to preserve the ligamentum teres, which we believe will result in a more favorable prognosis for children. The smooth texture of the ligamentum teres does not match the articular cartilage found on the femoral head surface. Furthermore, the potential for developing secondary osteoarthritis among children who were treated with the modified trapdoor procedure remained uncertain when compared to other surgical options, especially in long-term follow-up studies. Articular cartilage primarily receives its nutritional supply from synovial fluid, and numerous successful instances of osteochondral transplantation have unambiguously established the viability of articular cartilage replantation \u003csup\u003e[\u003cspan additionalcitationids=\"CR19\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/sup\u003e. Therefore, in our treatment, we recommend autologous articular cartilage replantation to ensure the smoothness of the femoral head surface.\u003c/p\u003e \u003cp\u003eIn the surgery of curettage without hip dislocation for femoral head CBL, only a few articles have described the surgical process in detail. In 2022, Hirohisa Katagiri reported on two patients who underwent focal curettage of the femoral head without hip dislocation. These two patients did not experience any complications during the 6 and 12-year follow-ups, respectively. Unlike in our surgical approach, Katagiri chose a non-weight-bearing area for fenestration \u003csup\u003e[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/sup\u003e. Currently, there are no clear reports regarding the impact of fenestration in weight-bearing versus non-weight-bearing areas on prognosis.\u003c/p\u003e \u003cp\u003eIn the curettage of CBL in the femoral head, it has always been a concern to avoid the injuring the epiphyseal plate of the femoral head. The epiphyseal plate of femoral head promotes the elongation of femoral neck \u003csup\u003e[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]\u003c/sup\u003e. It has been proved that simple curettage leads to higher possibility of local recurrence. Tomic et al. observed that the recurrence rate of surgical treatment with simple curettage was high (as high as 30%), which they deemed unacceptable, especially for invasive lesions \u003csup\u003e[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/sup\u003e. Extended curettage can significantly reduce the risk of local recurrence in chondroblastoma of the femoral head. However, it may exacerbate the damage to the epiphyseal plate \u003csup\u003e[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/sup\u003e. Suneja et al. have stated that the damage to the epiphyseal plate can be repaired through appropriate post-operative nursing care. In their study, all patients underwent aggressive intralesional curettage as the sole treatment, which proved curative in most cases. However, the authors did not provide comprehensive data on the status of the epiphyseal plate for all patients \u003csup\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e. Liu Qing et al. postulated that the epiphyseal plate near the knee joint possesses resilience and has the potential to regenerate following extensive curettage. This assertion was based on two primary reasons: Firstly, only a minor portion of the epiphyseal plate is associated with the tumor. Secondly, the blood supply to the epiphyseal plate originates from the soft tissue connected to the epiphysis, which remains largely unaffected during the surgical procedure \u003csup\u003e[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]\u003c/sup\u003e. Another study found that out of 20 children treated with extended curettage, only 2 experienced relapse, with no cases of leg length discrepancy (LLD) reported. It's worth noting that most of the patients had epiphyseal plates that were either closing or already closed, with only one child having an open epiphyseal plate\u003csup\u003e[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e. It is widely believed that the risk of LLD is lower when the epiphyseal plate is in a closed state compared to an open state. Mashhour and Abdel Rahman recommended extended curettage during the initial surgery to reduce the chances of recurrence \u003csup\u003e[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]\u003c/sup\u003e. However, whether extended curettage can effectively treat CBL in the femoral head needs further investigation. In our study, we prioritized protecting the epiphyseal plate as much as possible, while ensuring complete removal of the lesion.\u003c/p\u003e \u003cp\u003eDuring our surgical procedure, we applied anhydrous alcohol to deactivate any remaining tumor cells within the cavity. Among the locally available adjuvants, such as burring, liquid nitrogen, phenol, and cement, high-speed burring is predominantly used. It is widely acknowledged as the most effective adjuvant for preventing local tumor recurrence \u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]\u003c/sup\u003e. However, Cong Huang et al. expressed concern that the epiphyseal plate could potentially be harmed by the heat generated by the burr \u003csup\u003e[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/sup\u003e. Additionally, cement was also regarded as detrimental to the epiphyseal plate due to the heat it emitted during the solidification process \u003csup\u003e[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e. Furthermore, studies have indicated that adjuvants like phenol or liquid nitrogen may induce necrosis \u003csup\u003e[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/sup\u003e. Currently, there is a scarcity of published data examining the use of anhydrous alcohol as an adjuvant in the treatment of CBL. Anhydrous alcohol has the potential to induce protein denaturation in tumor cells, cytoplasmic degeneration, and embolism of the small vessels supplying the tumors. Furthermore, it has been established that anhydrous alcohol exerts minimal adverse effects on surrounding tissues \u003csup\u003e[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]\u003c/sup\u003e. Karem advocated for the use of phenol and anhydrous alcohol as adjuvants in curettage \u003csup\u003e[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e. However, our findings revealed that anhydrous alcohol alone can achieve satisfactory surgical outcomes.\u003c/p\u003e \u003cp\u003eSecondary osteoarthritis is a prevalent complication associated with CBL of the femoral head \u003csup\u003e[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/sup\u003e. Studies have indicated that CBL located specifically in the hip joint, particularly the femoral head, is often linked to extended curettage of lesions and the utilization of adjuvants like phenol and liquid nitrogen, factors that may contribute to the development of secondary osteoarthritis. Farfalli previously noted that while extended curettage can decrease the likelihood of recurrence in pediatric patients, it also elevates the risk of secondary osteoarthritis \u003csup\u003e[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/sup\u003e. The unique and delicate circulatory system of the hip joint may contribute to degenerative changes observed in this condition \u003csup\u003e[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]\u003c/sup\u003e. In the management of comparable tumors, such as giant cell tumors, phenolic compounds demonstrated a reduced risk of osteoarthritis compared to liquid nitrogen \u003csup\u003e[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]\u003c/sup\u003e. Farfalli et al. demonstrated that the incidence of secondary osteoarthritis increased after first 5 years of follow-up \u003csup\u003e[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/sup\u003e, which was a limitation that we cannot explore due to insufficient follow-up time.\u003c/p\u003e \u003cp\u003eWhen addressing CBL of the femoral head, the chosen surgical approach varied based on the lesion's location and extent. If the lesion was wholly contained within the femoral head and had minimal or no impact on the epiphyseal plate, we opted to create a window through the articular cartilage of the femoral head. However, if the epiphyseal plate lesion was significant and the CBL extended considerably into the femoral neck, we contemplated opening a window through the femoral neck to extract the tumor. This method helped to reduce harm to the articular cartilage, thereby maintaining joint integrity and functionality.\u003c/p\u003e \u003cp\u003eOur research encountered several limitations. Firstly, there were few cases of femoral head involvement, which limited our ability to obtain more precise risk factors through our research. Secondly, our follow-up period was insufficient to adequately assess long-term complications.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eCurettage, performed without surgical hip dislocation, in conjunction with bone grafting and the utilization of anhydrous alcohol as an adjuvant, demonstrates significant efficacy. This treatment approach serves to safeguard the epiphyseal plate and minimize the recurrence of CBL of the femoral head.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"693\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"10.38961038961039%\"\u003e\n \u003cp\u003eCBL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"89.6103896103896%\"\u003e\n \u003cp\u003eChondroblastoma\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"10.38961038961039%\"\u003e\n \u003cp\u003eMTST\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"89.6103896103896%\"\u003e\n \u003cp\u003eMusculoskeletal Tumour Society scoring system\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"10.38961038961039%\"\u003e\n \u003cp\u003eLLD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"89.6103896103896%\"\u003e\n \u003cp\u003eLeg Length Discrepancy\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"10.38961038961039%\"\u003e\n \u003cp\u003eCNFV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"89.6103896103896%\"\u003e\n \u003cp\u003eCurettage via the femoral neck\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"10.38961038961039%\"\u003e\n \u003cp\u003eMFCA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"89.6103896103896%\"\u003e\n \u003cp\u003eMedial Femoral Circumflex Artery\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe research had been approved by the Ethics Committee of Children\u0026apos;s Hospital affiliated to Chongqing Medical University.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData is provided within the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthers\u0026rsquo; Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDY and ZLW designed the study; DY, ZYZ collected the data; ZLW and DY analyzed the data; DY drafted the initial manuscript; DY and ZLW revised the article critically; HO repeated measurement data; DY, ZLW and HO reviewed and edited the article; All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatement for use of human tissue samples\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed consent was obtained from all of their legal guardians.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eChen W, DiFrancesco LM. Chondroblastoma: An Update. Arch Pathol Lab Med. 2017;141:867-871.\u003c/li\u003e\n\u003cli\u003eHsu CC, Wang JW, Chen CE, Lin JW. Results of curettage and high-speed burring for chondroblastoma of the bone. Chang Gung Med J. 2003;26:761-7. \u003c/li\u003e\n\u003cli\u003eSuneja R, Grimer RJ, Belthur M, Jeys L, Carter SR, Tillman RM, et al. Chondroblastoma of bone: long-term results and functional outcome after intralesional curettage. J Bone Joint Surg Br. 2005;87:974-8.\u003c/li\u003e\n\u003cli\u003eLaitinen MK, Stevenson JD, Evans S, Abudu A, Sumathi V, Jeys LM, et al. Chondroblastoma in pelvis and extremities- a signle centre study of 177 cases. J Bone Oncol. 2019;17:100248.\u003c/li\u003e\n\u003cli\u003eZekry KM, Yamamoto N, Hayashi K, Takeuchi A, Araki Y, Alkhooly AZA, et al. Surgical treatment of chondroblastoma using extended intralesional curettage with phenol as a local adjuvant. J Orthop Surg (Hong Kong). 2019;27:2309499019861031.\u003c/li\u003e\n\u003cli\u003eRuiz Santiago F, L\u0026aacute;inez Ramos-Bossini AJ, Mart\u0026iacute;nez Mart\u0026iacute;nez A, Garc\u0026iacute;a Espinosa J. Chondroblastoma treatment by radiofrequency thermal ablation: Initial experience and implementation. Eur J Radiol. 2021;144:109950.\u003c/li\u003e\n\u003cli\u003eWang J, Du Z, Yang R, Tang X, Yan T, Guo W. Analysis for clinical feature and outcome of chondroblastoma after surgical treatment: A single center experience of 92 cases. J Orthop Sci. 2022;27:235-241.\u003c/li\u003e\n\u003cli\u003eMuratori F, Scanferla R, Roselli G, Frenos F, Campanacci DA. Long term outcome of surgical treatment of chondroblastoma: analysis of local control and growth plate/articular cartilage related complications. BMC Musculoskelet Disord. 2023;24:139.\u003c/li\u003e\n\u003cli\u003eBenndorf M, Bamberg F, Jungmann PM. The Lodwick classification for grading growth rate of lytic bone tumors: a decision tree approach. Skeletal Radiol. 2022;51:737-745.\u003c/li\u003e\n\u003cli\u003eEnneking WF, Dunham W, Gebhardt MC, Malawar M, Pritchard DJ. A system for the functional evaluation of reconstructive procedures after surgical treatment of tumors of the musculoskeletal system. Clin Orthop Relat Res. 1993;(286):241-6.\u003c/li\u003e\n\u003cli\u003eHuang C, L\u0026uuml; XM, Fu G, Yang Z. Chondroblastoma in the Children Treated with Intralesional Curettage and Bone Grafting: Outcomes and Risk Factors for Local Recurrence. Orthop Surg. 2021;13:2102-2110.\u003c/li\u003e\n\u003cli\u003eStrong DP, Grimer RJ, Carter SR, Tillman RM, Abudu A. Chondroblastoma of the femoral head: management and outcome. Int Orthop. 2010;34:413-7.\u003c/li\u003e\n\u003cli\u003eGanz R , Gill TJ , Gautier E, et al. Surgical dislocation of the adult hip[J].J Bone Joint Surg B, 2001;83:1119-1124.\u003c/li\u003e\n\u003cli\u003eFarfalli GL, Slullitel PA, Muscolo DL, Ayerza MA, Aponte-Tinao LA. What Happens to the Articular Surface After Curettage for Epiphyseal Chondroblastoma? A Report on Functional Results, Arthritis, and Arthroplasty. Clin Orthop Relat Res. 2017;475:760-766.\u003c/li\u003e\n\u003cli\u003eXu H, Niu X, Li Y, Binitie OT, Letson GD, Cheong D. What are the results using the modified trapdoor procedure to treat chondroblastoma of the femoral head? Clin Orthop Relat Res. 2014;472:3462-7.\u003c/li\u003e\n\u003cli\u003eChandler SB, Kreuscher PH. A STUDY OF THE BLOOD SUPPLY OF THE LIGAMENTUM TERES AND ITS RELATION TO THE CIRCULATION OF THE HEAD OF THE FEMUR. international surgery. 1932.\u003c/li\u003e\n\u003cli\u003eMulfinger GL, Trueta J. The blood supply of the talus. J Bone Joint Surg Br. 1970;52(1):160-7.\u003c/li\u003e\n\u003cli\u003eAdams SB, Dekker TJ, Schiff AP, Gross CP, Nunley JA, Easley ME. Prospective Evaluation of Structural Allograft Transplantation for Osteochondral Lesions of the Talar Shoulder. Foot Ankle Int. 2018;39:28-34.\u003c/li\u003e\n\u003cli\u003eJohnson JD, Desy NM, Sierra RJ. Ipsilateral femoral head osteochondral transfers for osteochondral defects of the femoral head. J Hip Preserv Surg. 2017;4:231-239.\u003c/li\u003e\n\u003cli\u003eMaldonado DR, Mu BH, Chen AW, Ortiz-Declet V, Perets I, Yuen LC, et al. Fresh Femoral Head Osteochondral Allograft Transplantation for Treating Osteochondritis Dissecans of the Femoral Head. Arthrosc Tech. 2018;7:e331-e335.\u003c/li\u003e\n\u003cli\u003eKatagiri H, Takahashi M, Murata H, Wasa J, Miyagi M, Honda Y. Direct femoral head approach without surgical dislocation for femoral head chondroblastoma: a report of two cases. BMC Surg. 2022;22(1):327.\u003c/li\u003e\n\u003cli\u003eWang ZL, Qin JQ, Zhang DW, Li M, Liu CK, Liu X, et al. Early radiographic signs of the greater trochanter overgrowth in children with Perthes\u0026rsquo; disease. Chin J Pediatr Surg. 2010;31:338-342.\u003c/li\u003e\n\u003cli\u003eTomić S, Lesić A, Bumbasirević M, Sopta J, Rakocević Z, Atkinson HD. An aggressive chondroblastoma of the knee treated with resection arthrodesis and limb lengthening using the Ilizarov technique. J Orthop Surg Res. 2010;5:47.\u003c/li\u003e\n\u003cli\u003eLiu Q, He H, Yuan Y, Zeng H, Long F, Tian J, et al. Have the difficulties and complications of surgical treatment for chondroblastoma of the adjoining knee joint been overestimated? J Bone Oncol. 2019;17:100240.\u003c/li\u003e\n\u003cli\u003eMashhour MA, Abdel Rahman M. Lower recurrence rate in chondroblastoma using extended curettage and cryosurgery. Int Orthop. 2014;38:1019-24.\u003c/li\u003e\n\u003cli\u003eYurtbay A, Coşkun HS, \u0026Ccedil;inka H, Erdoğan F, B\u0026uuml;y\u0026uuml;kceran İ, Dabak N. The effect of adjuvant cryotherapy added to well-performed high-speed burr curettage on the long-term surgical outcomes of chondroblastoma cases. Jt Dis Relat Surg. 2023;34:338-345.\u003c/li\u003e\n\u003cli\u003eGiacomo GD, Ziranu A, Perisano C, Piccioli A, Maccauro G. Local Adjuvants in Surgical Management of Bone Lesions. Journal of Cancer Therapy. 2015, 06(6):473-481\u003c/li\u003e\n\u003cli\u003eGrose AW, Gardner MJ, Sussmann PS, Helfet DL, Lorich DG. The surgical anatomy of the blood supply to the femoral head: description of the anastomosis between the medial femoral circumflex and inferior gluteal arteries at the hip. J Bone Joint Surg Br. 2008;90:1298-303.\u003c/li\u003e\n\u003cli\u003eKnochentumoren A, Becker WT, Dohle J, Bernd L, Braun A, Cserhati M, et al. Local recurrence of giant cell tumor of bone after intralesional treatment with and without adjuvant therapy. J Bone Joint Surg Am. 2008;90:1060-7.\u003c/li\u003e\n\u003cli\u003evan der Heijden L, van der Geest IC, Schreuder HW, van de Sande MA, Dijkstra PD. Liquid nitrogen or phenolization for giant cell tumor of bone?: a comparative cohort study of various standard treatments at two tertiary referral centers. J Bone Joint Surg Am. 2014;96:e35.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Table 1","content":"\u003cp\u003eTable 1 is available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Chondroblastoma, femoral head, curettage","lastPublishedDoi":"10.21203/rs.3.rs-4425706/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4425706/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground: Chondroblastoma (CBL)of femoral head is a rare disease, and its treatment is still controversial. The purpose of this research is to share our experience in curettage without dislocation for femoral head chondroblastoma.\u003c/p\u003e\n\u003cp\u003eMethods: A total of 7 children diagnosed with chondroblastoma of the femoral head underwent a surgical procedure involving curettage, the application of anhydrous alcohol as an adjuvant therapy, and subsequent bone grafting. The epiphyseal plate status of the femoral head was categorized as open, closing, or closed. To assess the children's postoperative functional outcome, the Musculoskeletal Tumour Society (MSTS) scoring system was employed. Additionally, the Lodwick classification served to evaluate the extent of bone destruction. Furthermore, the kappa coefficient was utilized to quantify the level of agreement among observers in assessing the status of the epiphyseal plate.\u003c/p\u003e\n\u003cp\u003eResults: The epiphyseal plate status was closing in two patients and closed in five patients. According to the Lodwick classification, three patients were classified as IA, one as IB, and three as IC. The mean MSTS score was 27.86. Notably, one patient sustained a femoral neck fracture three months post-curettage.\u003c/p\u003e\n\u003cp\u003eConclusions: Curettage without surgical dislocation, combined with the use of anhydrous alcohol as an adjuvant therapy, followed by bone grafting, constitutes an effective treatment technique for femoral head chondroblastoma (CBL).\u003c/p\u003e","manuscriptTitle":"Chondroblastoma of the femoral head: Curettage without dislocation","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-06-11 02:47:08","doi":"10.21203/rs.3.rs-4425706/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-05-30T16:30:16+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-05-25T11:57:34+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-05-25T11:57:33+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Surgery","date":"2024-05-15T14:07:10+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"9e092659-a43a-4ce0-ad49-5fc53de67bd1","owner":[],"postedDate":"June 11th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-11-25T16:05:09+00:00","versionOfRecord":{"articleIdentity":"rs-4425706","link":"https://doi.org/10.1186/s12893-024-02660-4","journal":{"identity":"bmc-surgery","isVorOnly":false,"title":"BMC Surgery"},"publishedOn":"2024-11-18 15:58:14","publishedOnDateReadable":"November 18th, 2024"},"versionCreatedAt":"2024-06-11 02:47:08","video":"","vorDoi":"10.1186/s12893-024-02660-4","vorDoiUrl":"https://doi.org/10.1186/s12893-024-02660-4","workflowStages":[]},"version":"v1","identity":"rs-4425706","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4425706","identity":"rs-4425706","version":["v1"]},"buildId":"omnImTCwR2MFx8CMYfrG7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}