Treatment of benign lesions of humerus with resection and non-vascularised, autologous fibular graft

Pathological Fractures in Aneurysmal Bone Cysts: A Systematic Review

Background: Aneurysmal bone cysts (ABCs) are osteolytic, non-malignant, vascular lesions of the bone. Pathological fractures can be a manifestation of the ABCs, which occur in about 8% of ABCs. Different treatments have been described in the literature, but, nowadays, an optimal management of the pathological fractures in patients with ABCs is still a matter of debate and there are no standard guidelines for treatment nor any shared indication about the best surgical intervention. The aim of our study is to review the current literature available on this matter exploring and confronting different surgical treatments for pathological fractures in ABC in order to clarify the surgical approach to these patients. Methods: A systematic review of the literature indexed in PubMed, MEDLINE, and Cochrane Library databases was carried out. The Preferred Reporting Items for Systematically Reviews and Meta-Analyses (PRISMA) were followed. Results: A total of 37 articles were relevant and were finally included in the study. In total, we reached a population of 140 patients. Of the 140 patients included in the review, 124 patients (88.6%) underwent curettage surgery, 15 patients (10.7%) underwent en bloc resection surgery. A total of 47% of patients (70) underwent synthesis surgery with a plate, screw, nail, or external fixator. Adjuvant treatments were used in 8.6% of patients (12). Complications involved 20.7% of the patients (29). Conclusions: In conclusion, the treatment of pathological fractures in aneurysmal bone cysts requires careful patient assessment, considering factors such as age, the presence of open growth plates, the location of the lesion, and the surgeon's expertise.

Treatment and Outcomes of 4,973 Unicameral Bone Cysts: A Systematic Review and Meta-Analysis

» Unicameral bone cysts (UBCs) can increase the risk of pathologic fractures of both long and short bones. Although multiple treatments exist, data are conflicting regarding optimal management.

» We sought to analyze treatment strategies for UBCs and their rates of successful treatment.

» Success rates were analyzed according to treatment modality, with emphasis on filling techniques and/or decompression associated with curettage, and injection compounds.

» Curettage with bone substitute and cyst decompression was identified as a highly successful technique for UBC treatment.

» Decompressing the cyst wall after injection, regardless of the specific compound used, had a greater potential to enhance healing rates.

» The management decision should be individually guided within the patient's context.

A Case Report of Giant Aneurysmal Bone Cyst of Distal Tibia with a Non-healing Fungating Mass and its Management in a 30-year-old Male

Introduction

Aneurysmal bone cyst (ABC) is a benign, expansible, non-neoplastic tumor of usually long bones and is identified by blood vessels and spaces that are most often differentiated by fibrous septae. It is challenging to treat these rare, giant ABCs as they have a damaging effect on the bones and compress the nearby structures, especially in load-bearing bones of the body.

Case Report

We report a case of a giant ABC in the distal tibia one-third with soft tissue component of a 30-year-old male. The patient presented to our outpatient department with complaints of pain and swelling over left ankle for 1 year. The size of the swelling was 15 cm × 10 cm × 10 cm over medial aspect of ankle with 3 discharging sinuses which present over swelling. His blood parameters were suggestive of low hemoglobin count. X-rays showed cystic lesions over medial aspect of left ankle. Computed tomography scan and magnetic resonance imaging reports were suggestive of ABC.

Conclusion

Our case report is unique as it reminds us that when presented with a case of ABC, excision of fungating soft tissue with curettage followed by cementing can be a preferable and better treatment option. ABC was extensively curetted out, the formed cavity was packed with bone cement, and fixation with 3 cortico cancellous screws was carried out. At 4-month follow-up, the lesion had receded, and the patient was walking without pain and any deformity. We suggest that this method of treatment is beneficial for ABC at this site and at this age.

MR angiography facilitates the differentiation of aneurysmal from unicameral bone cysts

OBJECTIVES

The objective of this work was to evaluate the incremental value of MR angiography over plain radiographs and MRI for the differentiation of aneurysmal bone cysts (ABCs) from unicameral bone cysts (UBCs).

METHODS

Thirty-six juvenile patients with histologically secured primary ABCs or UBCs were included in this retrospective study. Two radiologists assessed all obtained images in a blinded fashion using a catalog of previously suggested imaging findings. A second readout with supplementary MR angiography images was performed after 8 weeks to prevent observer recall bias. Diagnostic accuracy parameters were calculated for individual imaging findings, and overall diagnostic accuracy and diagnostic confidence were assessed for all readouts. Receiver operating characteristic (ROC) curve comparison was used to determine the incremental value of MR angiography.

RESULTS

Of 16 imaging features, only abnormal vascularization in MR angiography provided sufficient diagnostic accuracy for the identification of ABCs. Other imaging features such as fluid-fluid levels and internal septations were insufficient for the differentiation of UBCs from ABCs. Availability of MR angiography images significantly increased diagnostic accuracy (94.4 vs 75.0% and 83.3 vs 69.4%, respectively, p < 0.05) and diagnostic confidence (4.5 vs 3.7, p < 0.05) of reading radiologists.

CONCLUSION

The presence of arterial feeders in MR angiography can accurately discriminate primary ABCs from UBCs and increases the diagnostic accuracy and diagnostic confidence of reporting radiologists.

ADVANCES IN KNOWLEDGE

Radiographic differentiation of cystic bone lesions such as ABCs and UBCs remains challenging. We demonstrate that MR angiography provides incremental value and suggest inclusion in standard examination protocols.

Periosteal preservation: a new technique in resection of bone high-grade malignant tumors in children-about eleven cases

Objective

The purpose of this study was to describe a surgical technique of bone resection with periosteal preservation and reconstruction in patients with high-grade bone malignant tumors and to determine its effect on local recurrences, and time and quality of bone union in bone autografting reconstruction.

Patients and methods

We retrospectively reviewed 11 cases of high-grade malignant bone tumors in children aged 4 to 16 years, who were treated with chemotherapy and tumor resection while preserving partially the adjacent periosteum. Tumors were located in the lower limb in eight cases; three tumors were in the humerus. The mean length of the bone defect after resection was 15.8 cm (range, 6–34.5 cm). Reconstruction was provided by non-vascularized autograft in eight cases (lower limb) and polymethyl methacrylate spacer in three cases (upper limb). Patients were followed up for a mean of 71 months.

Results

At the last follow-up, no patients had local recurrence. Three patients were dead because of metastasis. Bone union was good in time and quality in all children who had bone autografting. In cases of PMMA reconstruction, there was periosteal bone formation around the spacer. According to the MSTS functional score, patients with lower limb localizations had a mean score of 27.75 points and patients with upper limb localizations had a score of 24/30.

Conclusion

Preservation of the periosteum in bone resection for malignant tumors could be a good adjuvant alternative for bone reconstruction, without increasing the risk of local recurrence. However, patients must be carefully selected.

The West China Hospital radiographic classification for fibrous dysplasia in femur and adjacent bones: A retrospective analysis of 205 patients

Objective

This study aims to investigate the reliability and clinical outcome of a newly developed classification system for patients with fibrous dysplasia (FD) of the femur and adjacent bones, optimizing its evaluation and management.

Methods

A total of 205 patients (121 female and 84 male) with FD in the femur and adjacent bones were included in this retrospective study. All affected femurs were measured and treated based on this classification at our institution between 2009 and 2019. Based on previous studies and extensive clinical follow‐up, we cautiously proposed the West China Hospital radiographic classification for FD in femur and adjacent bones following corresponding treatment options. There are five types with five radiographic features, including proximal femur bone loss, coxa vara, femoral shaft deformity, genu valgum, and hip arthritis. The intraobserver and interobserver reproducibility of this classification was assessed by four observers using the Cohen kappa statistic. The clinical outcome was evaluated using the criteria of Guille.

Results

At a median follow‐up of 60 months (range 6–120), 205 patients (median 34.8 years old, range 18–73 years old) were categorized into the following five types: Type I 31.7%, Type II 30.2%, Type III 20.5%, Type IV 10.2%, and Type V 7.3%. The mean interobserver and intraobserver kappa scores were 0.85 (range 0.77–0.89) and 0.85 (range 0.79–0.92), respectively. For clinical outcomes, there was no significant difference in the postoperative Guille score for Type I patients (mean 9.01 ± 1.22). There was a significant increase in the postoperative Guille score in Type II, III, IV, and V, compared to the preoperative values (P < 0.01). For complications, two Type III patients reported pain, and one Type III patient had mild‐to‐moderate Trendelenburg gait. One Type IV patient had a mild Trendelenburg gait. And two Type V patients still had mild limping.

Conclusion

This classification is reproducible and serves as a tool for evaluating and treating FD in the femur and adjacent bones. Therefore, we recommend this classification for the diagnosis and treatment of FD‐related deformities in the femur and adjacent bones.

A Case Report of Aneurysmal Bone Cyst with Pathologic Fracture of Proximal Femur Managed with EnblocExcision and Autologous Non-vascularized Fibular Graft

INTRODUCTION

Aneurysmal bone cyst (ABC) is typically a benign, expansile, and cystic lesion of the bone that can be locally aggressive characterized by vascular gaps separated by fibrous septae. Treatment modalities available are sclerosing agents, arterial embolization, surgical excision, curettage with or without bone grafting, and adjuvant radiotherapy.

CASE REPORT

We report a rare case of ABC with pathologic fracture in the proximal femur in a 15-year-old female patient, treated with en blocexcision, bone grafting with non-vascularized fibular strut graft and stabilized with a 95°dynamiccondylar screw plate system. Follow-up at 24 months showed incorporation of the fibular graft and full union.

CONCLUSION

Structural support and autologous bone grafting in giant ABC in young individuals would yield adequate results.

An Uncommon Presentation of an Uncommon Bone Tumor: A Case Study of a Pathologic Fracture of an Intertrochanteric Aneurysmal Bone Cyst

Aneurysmal bone cyst (ABC) is a benign, destructive lesion characterized by a expansile fluid-filled cystic structure primarily affecting children and young adults. Common treatment modalities include arterial embolization, curette, intralesional injections and en bloc resection with instrumentation placement. We present the case of a 22-year-old patient presenting to the emergency department with an ABC in the intertrochanteric region of the right femur and a minimally displaced pathologic femoral neck fracture. Open biopsy with curettage, bone grafting and cephalomedullary nailing were performed with fracture stabilization and favorable recovery. Reports of these lesions presenting with pathologic fracture are scarce. We discuss treatment modalities and guidelines for ABCs and pathological fractures. Future studies are needed to assess clinical guidelines for the management of ABCs and pathological fractures.

Treatment of diaphyseal pathological fractures in children with monostotic fibrous dysplasia using cortical strut allografts and internal plating: A retrospective clinical study

Children with fibrous dysplasia (FD) chronically suffer from pain, pathological fractures, and limb deformities. The most effective methods for managing the associated pathological fractures remain controversial. The purpose of this study was to evaluate the clinical results of the treatment of diaphyseal pathological fractures in children with monostotic fibrous dysplasia (MFD) using cortical strut allografts and internal plating.We retrospectively analyzed outcomes in nine children (5 boys, 4 girls) with diaphyseal pathological fractures due to MFD, who were treated with cortical strut allografts and internal plating (6 femoral fractures and 3 humeral fractures) between July 2007 and November 2012. The median age of patients in our study was 10 years (range 6-14 years). The fracture healing time, pain, extremity function, refracture, graft resorption, and complications were recorded to evaluate treatment effects.The median time of follow-up was 69 months (range 60-75 months). All patients had good postoperative fracture healing with a median healing time of 14 weeks (range 12-16 weeks). None experienced refracture, graft resorption, nerve injury, or limitation of extremity function or other complications. The fixation remained stable in all patients, with no evidence of loosening screws after surgery.In pediatric patients, the described surgical approach is an effective and reliable treatment method for diaphyseal pathological fractures caused by MFD. Cortical strut allografts, which act as biological bone plates, can provide good mechanical support while increasing the rate of fracture union.

A Case Report of Aneurysmal Bone Cyst with Pathologic Fracture of Proximal Femur Managed with EnblocExcision and Autologous Non-vascularized Fibular Graft

INTRODUCTION

Aneurysmal bone cyst (ABC) is typically a benign, expansile, and cystic lesion of the bone that can be locally aggressive characterized by vascular gaps separated by fibrous septae. Treatment modalities available are sclerosing agents, arterial embolization, surgical excision, curettage with or without bone grafting, and adjuvant radiotherapy.

CASE REPORT

We report a rare case of ABC with pathologic fracture in the proximal femur in a 15-year-old female patient, treated with en blocexcision, bone grafting with non-vascularized fibular strut graft and stabilized with a 95°dynamiccondylar screw plate system. Follow-up at 24 months showed incorporation of the fibular graft and full union.

CONCLUSION

Structural support and autologous bone grafting in giant ABC in young individuals would yield adequate results.

Denosumab in patients with aneurysmal bone cysts: A case series with preliminary results

Purpose:

Aneurysmal bone cyst (ABC) is a rare skeletal tumor usually treated with surgery/embolization. We hypothesized that owing to similarities with giant cell tumor of bone (GCTB), denosumab was active also in ABC.

Methods:

In this observational study, a retrospective analysis of ABC patients treated with denosumab was performed. Patients underwent radiologic disease assessment every 3 months. Symptoms and adverse events were noted.

Results:

Nine patients were identified (6 male, 3 female), with a median age of 17 years (range 14–42 years). Primary sites were 6 spine–pelvis, 1 ulna, 1 tibia, and 1 humerus. Patients were followed for a median time of 23 months (range 3–55 months). Patients received a median of 8 denosumab administrations (range 3–61). All symptomatic patients had pain relief and 1 had paresthesia improvement. Signs of denosumab activity were observed after 3 to 6 months of administration: bone formation by computed tomography scan was demonstrated in all patients and magnetic resonance imaging gadolinium contrast media decrease was observed in 7/9 patients. Adverse events were negligible. At last follow-up, all patients were progression-free: 5 still on denosumab treatment, 2 off denosumab were disease-free 11 and 17 months after surgery, and the last 2 patients reported no progression 12 and 24 months after denosumab interruption and no surgery.

Conclusions:

Denosumab has substantial activity in ABCs, with favorable toxicity profile. We strongly support the use of surgery and/or embolization for the treatment of ABC, but denosumab could have a role as a therapeutic option in patients with uncontrollable, locally destructive, or recurrent disease.

The role of the periosteal sleeve in the reconstruction of bone defects using a non-vascularised fibula graft in the pediatric population

BACKGROUND

Following resection of large benign bone tumors surgeons are confronted with bone defects severely affecting the stability of a limb. To restore the mechanical continuity of the bone different treatment methods using bone grafts have been described. In pediatric patients the thick periosteal sleeve is thought to contribute to bone formation.

HYPOTHESIS

An intact periosteal sleeve is crucial in bone remodelling around a non-vascularised fibular graft used to bridge large bone defects.

METHODS

We present a treatment technique applied in 6 cases comprising of subperiosteal tumor resection at the diaphyseal or metaphyseal level of long bones followed by defect bridging with a non-vascularised fibula graft inserted into the periosteal sleeve of the resection zone. Elastic intramedullary nails or plates were used for stabilisation.

RESULTS

Due to the intact periosteum at the resection site bone integration occurred quickly and full remodelling was seen in all but one case. Tumor location in this case was at the metaphyseal level resulting in tumor resection at the growth plate. Although bone healing at the distal resection site was seen after a few weeks proximal consolidation was only partial. Full reconstitution of the fibula in the remaining periosteal sleeve was seen in 5 cases, partial reconstitution in 1 case.

DISCUSSION

In the pediatric patient, the described technique is an effective and reliable treatment method for large benign bone tumors requiring resection. However, great diameter discrepancy of the donor and recipient site and a thin periosteum can be a limiting factor for its application.

LEVEL OF EVIDENCE

Level IV clinical study.

Non-vascularised fibula grafts for reconstruction of segmental and hemicortical bone defects following meta- /diaphyseal tumour resection at the extremities

Background

The reconstruction of meta−/diaphyseal bone defects following bone tumour resection is challenging, and biological treatment options should be applied whenever possible, especially in benign lesions and early stage sarcomas. We aimed to evaluate the results of segmental (SR) and hemicortical reconstructions (HR) at the extremities using non-vascularised fibula grafts.

Methods

We retrospectively enrolled 36 patients who were treated with non-vascularised fibula reconstructions (15 SR, 21 HR) after bone tumour resection (15 malignant, 21 benign). All cases were evaluated regarding consolidation, hypertrophy at the graft-host junctions, and complications; moreover, the functional and oncological results were assessed. The mean follow-up was 8.3 years (2.1–26.6 years).

Results

Primary union was achieved in 94% (SR 87%, HR 100%) of patients, and 85% (SR 81%, HR 88%) showed hypertrophy at the graft-host junction. The overall complication rate was 36% with 4 patients (11%) developing local recurrence. There was a significant correlation between the development of mechanical complications (fracture, delayed-/non-union) and a defect size of ≥12 cm (p = 0.013), segmental defects (p = 0.013) and additional required treatment (p = 0.008). The functional outcome was highly satisfactory (mean MSTS score 86%).

Conclusions

Due to encouraging results and advantages (such as their remodelling capacity at the donor site), non-vascularised fibula reconstructions should be considered a valuable alternative treatment option for patients with hemicortical defects or segmental reconstructions of less than 12 cm in which no additional neo-/adjuvant treatment is necessary.

Lower Limb Reconstruction with Tibia Allograft after Resection of Giant Aneurysmal Bone Cyst

Aneurysmal bone cysts (ABCs) are benign, expansible, nonneoplastic lesions of the bone, characterized by channels of blood and spaces separated by fibrous septa, which occur in young patients and, occasionally, with aggressive behavior. Giant ABC is an uncommon pathological lesion and can be challenging because of the destructive effect of the cyst on the bones and the pressure on the nearby structures, especially on weight-bearing bones. In this scenario, en bloc resection is the mainstay treatment and often demands complex reconstructions. This paper reports a difficult case of an unusual giant aneurysmal bone cyst, which required extensive resection and a knee fusion like reconstruction with tibia allograft.

Current Strategies for the Treatment of Aneurysmal Bone Cysts

Aneurysmal bone cysts are benign bone tumors that usually present in childhood and early adulthood. They usually manifest as expansile osteolytic lesions with a varying potential to be locally aggressive. Since their first description in 1942, a variety of treatment methods has been proposed. Traditionally, these tumors were treated with open surgery. Either intralesional surgical procedures or en bloc excisions have been described. Furthermore, a variety of chemical or physical adjuvants has been utilized in order to reduce the risk for local recurrence after excision. Currently, there is a shift to more minimally invasive procedures in order to avoid the complications of open surgical excision. Good results have been reported during percutaneous surgery, or the use of embolization. Recently, sclerotherapy has emerged as a promising treatment, showing effective consolidation of the lesions and functional results that appear to be superior to the ones of open surgery. Lastly, non-invasive treatment, such as pharmaceutical intervention with denosumab or bisphosphonates has been reported to be effective in the management of the disease. Radiotherapy has also been shown to confer good local control, either alone or in conjunction to other treatment modalities, but is associated with serious adverse effects. Here, we review the current literature on the methods of treatment of aneurysmal bone cysts. The indication for each type of treatment along reported outcome of the intervention, as well as potential complications are systematically presented. Our review aims to increase awareness of the different treatment modalities and facilitate decision-making regarding each individual patient.

Fibular strut graft for humeral aneurysmal bone cyst with varus deformity

PURPOSE

Proximal humerus is a common site for ABC and frequently associated with varus deformity that limits shoulder abduction. A prospective study was conducted to evaluate the use of intramedullary non-vascularised autogenous fibular strut graft for reconstruction without internal fixation.

METHODS

A total of 20 patients (12 girls, 8 boys) were managed for proximal humeral ABC with varus deformity by extended curettage, osteotomy, intramedullary fibular graft and composite bone substitute. Their ages ranged from 10 to 17 years (average, 13.3 years). The lesion was juxtaphyseal in 16 patients and metaphyseal in 4. All cysts were active and centrally located type 2. The modified Enneking scoring system was used for final functional evaluation. Radiological assessment was done for the extent of defect healing, incorporation of the fibula and correction of the deformity.

RESULTS

After a mean follow-up of 41.2 months (range, 24-74) most of patients were satisfied and resumed daily activities without pain and with good range of shoulder movement. One patient complained of shoulder pain 10 months after surgery and was attributed to local recurrence. Limitation of recreational activity was experienced by one patient. There were no cases of deep infection, nerve deficit or pathological fracture. No cases of failed healing or incorporation of the fibula was detected. The improved shoulder abduction was closely related to the mean correction of the neck shaft angle.

CONCLUSIONS

The technique is proved to be effective in controlling disease, correcting deformity and improving function.

Subperiosteal resection of fibular aneurysmal bone cyst

Aneurysmal bone cyst (ABC) of the fibula poses a challenge as to the most appropriate treatment particularly in children and adolescents. A prospective study was conducted to evaluate the results of subperiosteal resection of fibular ABCs. Eleven patients (six boys and five girls) with an average age of 12.4 years (6-18 years) were treated by subperiosteal resection of ABC of the fibula. The lesion was juxtaphyseal in three patients (two distal and one proximal), metaphyseal in seven and diaphyseal in one. All cysts were active and centrally located type 2. The modified Enneking scoring system was used for final functional evaluation while a scale proposed by the author was used for final radiological assessment. At the final follow-up, there was no difference in the range of movement, alignment or stability of the ankle or the knee when compared with the opposite side. Three patients complained of mild discomfort on heavy activity. One patient had failure of healing that was related to the use of suction drain. After a mean follow-up of 41.6 months (24-64 months), the mean functional score was 98.8% (93-100%). According to the proposed radiological scale, six patients were rated excellent, three good, one fair and one poor. In conclusion, subperiosteal resection is effective in eradicating fibular ABCs, regenerates a new bone and avoids the morbidity of other techniques.

An aggressive aneurysmal bone cyst of the proximal humerus and related complications in a pediatric patient

Clinical behavior of aneurysmal bone cyst (ABC) in younger patients can be more aggressive than that in older children and adults. Angular deformity and shortening can occur due to growth plate destruction or tumor resection. A 11-year-old boy who had been operated twice in another center for an ABC located in the left proximal humerus presented to the author's institution with complaints of pain, deformity and shortening of the left arm. Plain radiographs revealed left proximal humerus nonunion with a large defect. Reconstruction with nonvascularized fibular autograft was applied and left upper extremity was immobilized in a velpou bandage. At the third-month follow-up, graft incorporation was observed in the distal part; however, proximal part did not show adequate healing on radiographs. Additional immobilization in a sling for 3 months was advised to the patient and his family. However, they were lost to follow-up and readmitted to the author's institution at the 12th month postoperatively. Radiographs showed failure of the fibular graft fixation and nonunion of the humerus. Autogenic bone grafts, either vascularized or nonvascularized are the best treatment method for the large defects after tumor curettage or resection. Nonvascularized grafts are technically much easier to use than vascularized grafts and provide excellent structural bone support at the recipient side. However, they may take several months to be fully incorporated. In addition, good therapeutic outcomes require patience and collaboration with the patient and parents. Most importantly, the patient should be monitored closely.