What are the indications and considerations for periosteal (outer layer of bone) resection?

Indications and Considerations for Periosteal Resection

Periosteal resection is primarily indicated for specific bone tumors, lateral bone augmentation procedures, and certain orthopedic growth modification techniques, with the specific approach determined by the underlying pathology and anatomical location. 1

Oncological Indications

Bone Tumors

• Periosteal osteosarcoma: This intermediate-grade chondroblastic osteosarcoma requires surgical resection with clear margins 1
  • Unlike high-grade conventional osteosarcoma, periosteal osteosarcoma typically does not benefit from chemotherapy based on retrospective analyses 1
  • Surgical approach should focus on obtaining microscopically clear surgical margins 1

Surgical Principles for Oncological Resection

• Ensure wide surgical margins to prevent local recurrence 1
• Mark areas with suspicion of close margins on the surgical specimen 1
• Consider limb salvage when possible, as most patients should be candidates for this approach 1
• Periosteal osteosarcoma has a lower metastatic potential compared to conventional osteosarcoma 2

Dental/Maxillofacial Indications

Lateral Bone Augmentation

• Periosteal releasing incision (PRI) is essential in guided bone regeneration (GBR) procedures to achieve tension-free flap closure 1, 3
• Indications for lateral ridge augmentation with periosteal involvement:
  1. Extraosseous defects requiring significant width augmentation (≥6 mm) 1
  2. Non-contained defects requiring membrane fixation 1

Surgical Protocol for Lateral Bone Augmentation

1. Make crestal incision with minimal releasing incisions
2. Reflect full-thickness flap, avoiding damage to the periosteum
3. Remove periosteal remnants from native bone
4. Create perforations in native bone to improve blood supply
5. Fix membrane and apply bone graft
6. Perform periosteal releasing incision to achieve tension-free closure 1

Orthopedic Indications

Growth Modification

• Circumferential periosteal sleeve resection can be used for mild limb-length discrepancies (around 3.5 cm) 4
  • More effective in tibia (response persists >2 years) than femur (response lasts approximately 1 year)
  • Results are modest and may not be beneficial in certain conditions like achondroplasia 5

Technical Considerations

Surgical Approaches

1. Conventional scalpel technique: Traditional approach but associated with more bleeding, hematoma, and postoperative pain 3
2. Laser-assisted periosteal releasing incision: Using diode laser (940 nm) can minimize bleeding and postoperative complications 3
3. Periosteal flap creation: Useful in scalp and forehead reconstruction when bone is exposed, providing a vascularized bed for skin grafts 6

Anatomical Considerations

• Respect the periosteum's blood supply when creating flaps
• In maxillofacial procedures, consider the proximity to neurovascular structures
• For oncological resections, periosteal involvement may indicate more aggressive disease 1

Potential Complications

• Hematoma formation, particularly with conventional scalpel techniques 3
• Postoperative pain and swelling 3
• Wound dehiscence if tension-free closure is not achieved 1
• Periostitis with symptoms including localized pain, pressure sensation, and mechanical pain that worsens with activity 7

Contraindications

• Situations where periosteal preservation is crucial for bone healing
• Cases where periosteal stripping might compromise blood supply to critical structures
• Conditions where expected benefits are minimal, such as in achondroplastic children 5

When performing periosteal resection, the surgeon must carefully balance the need for adequate exposure or tumor clearance against the potential impact on bone healing and blood supply. The technique should be performed by surgeons with appropriate expertise in the specific indication being addressed.