(range 18-27 months). The most common histological diagnosis was that of giant cell tumor (32%, n=8) followed by aneurysmal bone cyst (28%, n=7), chondroblastoma (12%, n=3), enchondroma (8%, n=2), and fibrous dysplasia, simple bone cyst, chondromyxoid fibroma, and eosinophilic granuloma (4% each, n=1). [Table 1].

Table 1: Tumor profile - Histological diagnosis (n=25). 

Out of 25 tumors, 5 (20%) were radiographic grade-1 lesions, 20 (80%) were grade-2 as per Campanacci grading. The tibia was the most commonly involved bone at (n=8, 32%) followed by the femur (n=5, 20%) and humerus (n=4, 16%). The pelvis, metacarpals and calcaneum were involved in two cases (8%) each while in one case (4%) the lesion was present in the talus. Based on the location of the tumor is within the bone, a majority (n=11, 44%) of the tumors occurred in the metaphyseal region of the respective bones followed by epiphyseal (n=3, 12%), diaphyseal (n=3, 12%), cancellous bones (n=3, 12%), flat bones (n=3, 12%) and short tubular bones (n=2, 8%).

Although several patients reported a vague sense of discomfort on being asked a leading question, only 3 patients (12%) recorded pain as their complaint. There were superficial infections in 2 patients (8%) patients that were easily controlled with the change of oral antibiotics. There was no neurovascular deficit in any of the 25 patients who participated in this study. There was no reported fracture during surgery or the follow-up period. No recurrence was recorded clinically or radiologically during the follow-up period. (P<0.05) (Table 4).

In 20 patients (80%) the MSTS scores (max=30points) were between 26-30 points, while in 4 patients (16%) the scores were between 21-25 points. Only one patient (4%) had a score below 20 points. Twenty-three patients (92%) had excellent

is the most commonly applied mode of the treatment in benign lytic lesions of bone, being a simple modality with minimal morbidity for the patient, it does have a fairly high rate of recurrence as compared to marginal or wide excision, especially in lesions like giant cell tumor that have a propensity for recurrence. The majority of the benign bone lesions (44%) in our study are present in the epiphysio-metaphysial area of the bone, and the area around the knee joint is the most commonly involved. These findings are consistent with international literature. [7,10,11]. This tendency of benign bone tumors for the involvement of periarticular regions and more involvement in lower limbs makes it more likely to cause increased morbidity in case radical surgical modalities are used for the treatment. In this context, curettage offers an option of limiting post-surgical morbidity.

Extended curettage provides a bridge that increases the cure rate when used judiciously in the selected profile of cases, while at the same time avoiding the complications or morbidity associated with radical excisional surgery or amputation. Multiple authors have reported greatly reduced recurrence rates of aggressive tumours with the use of adjuvants [12,13]. Although each adjuvant treatment has its proponents, no study has proved that anyone is superior, with each having advantages and disadvantages.

A high-speed burr helps in the removal of hard bony ridges and spurs that prevent the effective removal of tumor tissue lodged between them. This clears the way for curette and other adjuvants to act unhindered on the tumor margins and hence is commonly used alone or in combination with other adjuvants while performing extended curettage. Cryosurgery with liquid nitrogen is effective at extending the tumor kill. It is superior to phenol and methacrylate at creating a rim of necrotic bone. It is usually applied by direct pour technique and associated with greater complications, such as pathological fracture and nerve injury. High rates of such complications have been reported at 30% by Schreuder et al and 79% by Marcove et al including 20% fracture incidence in one study[ 14,15].  Khalil et al have reported a 17% recurrence rate in lesions managed by extended curettage with cryosurgery and bone cement [16]. With the use of cryoprobe instead of direct pour technique, the complication rate has been reported to be

and complications of 10%-25% concerning neurovascular deficit and articular degeneration. & McDonald et al reported a 34% recurrence rate and a 4% incidence of neurovascular complications [11,18]. Stewart et al reported 36% recurrence [19]. (Table 7) Polymethylmethacrylate (PMMA) bone cement may act as an adjuvant through the heat of polymerization or direct toxicity of the monomer [2,20,21]. It is easily applied and can be used as a filling agent in conjunction with other adjuvants. Once applied, it is difficult to control the tissue damage due to the heat produced and may result in unintended damage to nearby tissue and/or articular surface [22,23]. Dreinhofer et al reported 20% recurrence using H2O2 with PMMS while Khalil et al reported 28% recurrence with PMMA alone [16,24].

Adjuvant treatment also may be accomplished through an argon beam coagulator which is electric cautery through a beam of argon gas that improves the conductivity of electricity. It is associated with a low rate of local recurrence and is also a reasonable adjuvant treatment option. But its use is limited by the availability of equipment in the treating centre and its cost [5]. Electrosurgical cautery cuts tissue with electric sparks that focus on intense heat at the surgical site. This produces the greatest amount of heat over a very short period, which results in the vaporization of tissue. The current density at the tip of the surgical electrode is very high leading to heat generation in the immediately adjacent tissue. Tissue destruction using electrosurgical cautery is easy to control and is widely available, and therefore makes it a suitable option for use as an adjuvant [3,4].

Hydrogen peroxide is a commonly available product with wide usage. It has an oxidative and thermal impact on the tumour cells as well as the effervescence helps in the cleansing of the cavity from difficult to reach areas with minimal damage to surrounding soft tissue and bone cells [6]. It is a cheap and universally available adjuvant that is easy to handle with minimal risk to surrounding healthy tissue. Studies by Lim & Tan, and Dreinhofer et al have used hydrogen peroxide in combination with Cryotherapy & PMMA respectively and reported 20% & 28% recurrence rates respectively [24,25]. Deventer et al have reported a recurrence rate of 12% in a retrospective study of chondroblastomas when using hydrogen peroxide after extensive curettage and burring compared to

Figure 1: Simple tools used as adjuvants for extended curettage.

Figure 2: Xrays showing a) ABC of talus b) post-op showing osteotomised fibula for talus exposure c) at 6months d) at 2years complete healing including osteotomised fibula.

Figure 3: Xrays showing a) GCT of upper end tibia juxta-articular b) after curettage and bone grafting c) at 6months d) at 2years complete graft integration and maintenance of articular surface integrity.

A review of serial radiographs revealed that while smaller cysts filled up completely, the larger ones healed by initial thickening of the cortex followed by the development of septae within the defect. The earliest radiological evidence of bone formation was observed at 3months. The cavity wall became increasingly thick, sclerosed, and radio-opaque, even if complete bone filling of all cavities was not achieved. The healing of the bone progressed uneventfully and on expected lines resulting in fully functional limbs in all our patients. There was no disturbance in activities of daily living and the quality of life in our series. (Figure 4 & 5) While our study using simple protocol has significantly superior results (p<0.05) when compared to historical literature, there are certain limitations of this study that the series size was modest and therefore all histological types of benign bone tumors were not adequately represented to offer a robust inference of the treatment protocol used. Different types of benign bone tumors that have different biological behavior were treated by the same protocol.