Locking plate and fibular strut-graft augmentation in the reconstruction of unicameral bone cyst of proximal femur in the paediatric population. Int Orthop. 2018;42:169-174. [PMID: 28963665 DOI: 10.1007/s00264-017-3648-2]

Treatment of Pathological Proximal Femur Fracture in a Child With a Unicameral Bone Cyst: A Case Report

Pathological proximal femur fractures secondary to unicameral bone cysts in the pediatric age group are uncommon. Despite the development of modern surgical treatments and implant choices, it is still debatable what the gold standard of treatment is for a unicameral bone cyst with pathological proximal femur fractures. We report a case of an eight-year-old child with a unicameral bone cyst and pathological fracture of the proximal right femur who was surgically treated with curettage, synthetic bone graft, and a pediatric hip plate as the choice of implant for osteosynthesis and stability.

Surgical outcomes of proximal femoral bone cysts in pediatric patients: a retrospective study of 41 cases

Purpose

The aim of this study was to evaluate the surgical outcomes of proximal femoral bone cysts in pediatric patients.

Methods

We retrospectively analyzed 41 pediatric patients (31 males and 10 females, mean age 7.47 ± 2.67 years, range 2.03-14.67 years) diagnosed with proximal femoral bone cysts treated at a single institute between March 2009 and November 2021. Data included demographics, preoperative details, intraoperative conditions, surgical techniques, postoperative outcomes, recurrence, and complications.

Results

Of the participants, 68% presented with simple bone cysts and 32% with aneurysmal bone cysts. Prior to surgery, 32% exhibited pathological fractures. Surgical methods included lesion curettage, defect filling using allograft bone and Minimally-Invasive Injectable Graft ×3, and varied fixation techniques. Postoperative recurrence (17%) was associated with cyst location between the capital femoral epiphysis and the linea intertrochanterica (P = 0.010). At the final assessment (mean follow-up: 26.51 ± 18.99 months), all showed radiological bony union with 93% rated as "good" and 7% as 'fair' based on Ratliff hip scores. Complications arose in 20% of patients, significantly correlated with prior pathological fractures (P = 0.007) and their association with the linea intertrochanterica (P = 0.004). Those with fractures reported higher intraoperative blood loss (P = 0.015) and longer surgery durations (P = 0.012) compared to those without.

Conclusion

Treating pediatric proximal femoral bone cysts using techniques such as lesion curettage, defect filling, and selective internal fixation yields favorable outcomes. The presence of pathological fractures can prolong surgical time, increase intraoperative blood loss, and elevate postoperative complication risks. Hence, early surgical intervention for these cysts is recommended to prevent fractures.

Surgical management of proximal femoral unicameral bone cyst in children

Aims

The aim of this study is to evaluate the surgical treatment with the best healing rate for patients with proximal femoral unicameral bone cysts (UBCs) after initial surgery, and to determine which procedure has the lowest adverse event burden during follow-up.

Methods

This multicentre retrospective study was conducted in 20 tertiary paediatric hospitals in France, Belgium, and Switzerland, and included patients aged < 16 years admitted for UBC treatment in the proximal femur from January 1995 to December 2017. UBCs were divided into seven groups based on the index treatment, which included elastic stable intramedullary nail (ESIN) insertion with or without percutaneous injection or grafting, percutaneous injection alone, curettage and grafting alone, and insertion of other orthopaedic hardware with or without curettage.

Results

A total of 201 patients were included in the study. The mean age at diagnosis was 8.7 years (SD 3.9); 77% (n = 156) were male. The mean follow-up was 9.4 years (SD 3.9). ESIN insertion without complementary procedure had a 67% UBC healing rate after the first operation (vs 30% with percutaneous injection alone (p = 0.027), 43% with curettage and grafting (p = 0.064), and 21% with insertion of other hardware combined with curettage (p < 0.001) or 36% alone (p = 0.014)). ESIN insertion with percutaneous injection presented a 79% healing rate, higher than percutaneous injection alone (p = 0.017), curettage and grafting (p = 0.028), and insertion of other hardware combined with curettage (p < 0.001) or alone (p = 0.014). Patients who underwent ESIN insertion with curettage had a 53% healing rate, higher than insertion of other hardware combined with curettage (p = 0.009). The overall rate of postoperative complications was 25% and did not differ between groups (p = 0.228). A total of 32 limb length discrepancies were identified.

Conclusion

ESIN insertion, either alone or combined with percutaneous injection or curettage and grafting, may offer higher healing rates than other operative procedures. Limb length discrepancy remains a major concern, and might be partly explained by the cyst's location and the consequence of surgery. Therefore, providing information about this risk is crucial.

Pathological fracture increases the risk of unsatisfactory functional results and avascular necrosis in children with proximal femur simple bone cysts

INTRODUCTION

Proximal femur simple bone cysts (SBCs) are rare in children, but with a risk of pathological fractures and the associated poor outcomes. This study aimed to evaluate the functional and radiographic outcomes of children with proximal femur SBCs.

PATIENTS AND METHODS

38 children with proximal femur SBCs treated surgically at our department, West China hospital, were enrolled in the study. Patients were divided into two groups according to whether pathological fractures presented before treatment. The non-fracture group received treatment of open curettage, cavity electrocauterization, bone grafting, and fixation (proximal femoral plate, intramedullary nail or Kirschner wire). The pathological fracture group received the same procedures of curettage, electrocauterization, grafting, and fixation. Autogenous iliac bone grafting was done in all cases, and the artificial bone was used as a supplementary based on the size of the cavity. Postoperatively, all patients underwent hip spica or similar orthosis immobilization for six weeks and received the same rehabilitation program after the removal of hip spica. Patients were evaluated by two independent observers, including the functional results based on the Ratliff's criteria, avascular necrosis, healing rate based on the Neer scoring system, coxa vara, and premature physeal arrest. We described the good outcome in Ratliff's criteria as "Satisfactory results", and fair and poor outcomes as "Unsatisfactory results." Grade 1 and grade 2 Neer results were termed as failures in treatment, and grades 3 and 4 were considered successes and healing.

RESULTS

38 patients with 38 hips (18 on the left side and 20 on the right side) were evaluated, including 9 females and 29 males, with a mean age of 9.0±2.6 years old (range, 5 to 14 years). There was no significant difference between these two groups in the baseline data of gender, age, side, grafting, staging, and fixation methods. The rate of unsatisfactory functional results in the pathological fractures group was 56.3% (9/16), significantly higher than that in patients without fracture (22.7%, 5/22. p= 0.047). There was also a significant difference in avascular necrosis of the femoral head between the pathological fractures group (7/16) and the group without fracture (2/22, p=0.021). Thirty cases presented with healing, including 13 in the fractures group and 17 in the non-fracture group (p=1.000), and eight cases were graded as failures (2 cases of grade 1 and 6 cases of grade 2). There were also no significant differences between these two groups in premature physeal arrest (2 in fracture group and 1 in non-fracture group, P=0.562), and Coxa vara (3 in the fracture group and 0 in non-fracture group, P=0.066).

CONCLUSIONS

Pathological fracture significantly increases the risk of unsatisfactory functional results and avascular necrosis of the femoral head in patients with femoral neck SBCs. Prophylactic treatment and fixation of SBCs in weight bearing proximal femur region is better to manage without complications than managing with pathological fractures.

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.

Optimal bone biopsy route to the proximal femur evaluated by computed tomography-based finite element modeling

INTRODUCTION

The proximal femur (PF) is one of the most common locations of benign cystic lesions. A fracture after bone biopsy is a rare but severe complication. However, the risk of fracture after biopsy of this lesion has not been well-studied. Computed tomography (CT)-based finite element (FE) modeling estimates the elastic modulus and compressive strength enables fracture prediction. This study investigated strength of PF after biopsy by CT-FE modeling and determined the optimum biopsy level and size.

MATERIALS AND METHODS

Six male bone tumor patients' (15-38 years) total femur CT data (slice thickness, 0.8-1.0 mm) of the healthy side were obtained. Three different cylindrical bone defect (BD) diameters (10, 15, and 20 mm) were set on the lateral surface of PF at the following levels: level 1, insertion of the gluteus minimums; level 2, lower end of the greater trochanter (GT); level 3, origin of the vastus lateralis; level 4, center of the lesser trochanter (LT); and level 5, lower end of LT using Mechanical Finder software (version 8.0). Virtual loads were applied with incremental increases of 100 N until fracture occurred and the fracture load (FL) was evaluated.

RESULTS

For BD with a diameter of 15 and 20 mm, there was a significant difference in the decrease of the mean FL, with an average of 22% at level 4 and 5, and 33%-44% at levels 3 to 5, respectively. At level 1 and 2, no significant decrease in the mean FL was observed regardless of the diameter of BD.

CONCLUSION

Biopsies at level 1 and 2 showed no significant decrease in bone strength. However, biopsy at level 1 may contaminate the GT bursas. Therefore, biopsy at level 2 (lower end of GT) can avoid contamination and minimize the effect on bone strength.

Are Fibular Allograft Struts Useful for Unicameral Bone Cysts of the Proximal Humerus in Skeletally Mature Patients?

BACKGROUND

Although most unicameral bone cysts (UBCs) are either successfully treated or have healed by the time of skeletal maturity, a small proportion of patients will have persistent UBCs beyond the age of skeletal maturity. More reliable methods are needed to treat persistent UBCs in the humerus because these cysts are associated with a high risk of fracture due to thinning of the humeral cortex. In this study, we evaluated whether inserting a fibular strut allograft into the humerus would be associated with healing of the cyst and union of associated pathologic fractures in skeletally mature patients with a UBC of the proximal humerus.

QUESTIONS/PURPOSES

(1) How effective is inserting a fibular strut allograft in the healing of proximal humerus UBCs in skeletally mature patients with bone cysts and associated fractures? (2) What are the functional results of this procedure? (3) What complications are associated with this procedure?

METHODS

Between 2005 and 2018, we surgically treated 23 skeletally mature patients with persistent humeral UBCs and any of the following indications: a progressive cyst that was not responsive to aspiration and 2 to 3 steroid injections, a cyst with a pathologic fracture, and a cyst at high risk of fracture. Of those, patients with a cyst located in the proximal humerus and a defect length more than 6 cm (n = 18) were considered eligible to be treated with insertion of a fibular strut allograft through a hole created in the greater tuberosity. A further two patients were excluded because they were treated by other surgical methods. From the remaining 16 patients, two patients were lost to follow-up before 2 years and could not be analyzed in this study. Another two patients had incomplete datasets, leaving 12 for analyses in this retrospective study. Three patients presented with a pathologic fracture. Complete filling of the cysts with bone within 24 months was regarded as healing, and after 24 months it was classified as delayed healing. Cyst consolidation with small residual areas of osteolysis was considered healed with residual radiographic appearance. Fracture union was determined by the clear observation of at least three of four cortical views bridged by bone in the radiographic follow-up 3 months after the operation. Fractures in which the cortices were not bridged by bone after 3 months were regarded as a delayed union. The functional outcome of the patients was assessed by the Musculoskeletal Tumor Society (MSTS) scoring system, with a total score ranging from 0 to 30. A higher score was indicative of less pain and better function. MSTS scores were obtained through a chart review by an orthopaedist who was not involved in the care administered.

RESULTS

At a median (range) follow-up of 57 months (33 to 87), the cyst was completely healed in nine patients and healed with residual cyst in the remaining three. Union was observed within 3 months in all patients who presented with a pathologic fracture. The median MSTS score of the patients was 30 (28 to 30). No postoperative complications such as persistent pain or re-fracture were observed.

CONCLUSION

The primary goal of treating a UBC of the proximal humerus is to prevent fracture of the affected bone; insertion of a fibular strut graft in this study met this goal. Therefore, we believe a fibular strut allograft insertion is worth consideration when treating proximal humeral UBCs in skeletally mature patients. Further studies will be needed to determine whether this approach has benefits compared with other treatment options.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Fibular strut allograft or bone cement for reconstruction after curettage of a giant cell tumour of the proximal femur : a retrospective cohort study

AIMS

Giant cell tumours (GCTs) of the proximal femur are rare, and there is no consensus about the best method of filling the defect left by curettage. In this study, we compared the outcome of using a fibular strut allograft and bone cement to reconstruct the bone defect after extended curettage of a GCT of the proximal femur.

METHODS

In a retrospective study, we reviewed 26 patients with a GCT of the proximal femur in whom the bone defect had been filled with either a fibular strut allograft (n = 12) or bone cement (n = 14). Their demographic details and oncological and nononcological complications were retrieved from their medical records. Limb function was assessed using the Musculoskeletal Tumor Society (MSTS) score.

RESULTS

Mean follow-up was 116 months (SD 59.2; 48 to 240) for the fibular strut allograft group and 113 months (SD 43.7; 60 to 192) for the bone cement group (p = 0.391). The rate of recurrence was not significantly different between the two groups (25% vs 21.4%). The rate of nononcological complications was 16.7% in the strut allograft group and 42.8% in the bone cement group. Degenerative joint disease was the most frequent nononcological complication in the cement group. The mean MSTS score of the patients was 92.4% (SD 11.5%; 73.3% to 100.0%) in the fibular strut allograft group and 74.2% (SD 10.5%; 66.7% to 96.7%) in the bone cement group (p < 0.001).

CONCLUSION

Given the similar rate of recurrence and a lower rate of nononcological complications, fibular strut grafting could be recommended as a method of reconstructing the bone defect left by curettage of a GCT of the proximal femur. Cite this article: Bone Joint J 2022;104-B(2):297-301.

Fracture risk assessment in children with benign bone lesions of long bones

BACKGROUND

Fracture risk assessment in children with benign bone lesions of long bones remains poorly investigated.

AIM

To investigate the risk factors for pathological fracture in children with benign bone lesions and to propose a modified scoring system for quantitative analysis of the pathologic fracture risk.

METHODS

We retrospectively reviewed 96 pediatric patients with benign bone lesions. We compared radiographic and clinical features between 40 patients who had fractures through a benign bone lesion and 56 who had no fracture. Information including histological diagnosis, anatomical site, radiographic appearance, severity of pain, and lesion size was recorded for the patients. A modified scoring system was proposed to predict the risk of fracture.

RESULTS

The univariate comparisons showed a significant difference between the fracture and non-fracture groups in terms of lesion type, pain, lesion-to-bone width, and axial cortical involvement of the patients (P < 0.05). Lesion type, pain, lesion-to-bone width, and axial cortical involvement were independently correlated with an increased risk of fracture. The mean score of the fracture group was 7.89, whereas the mean score of the non-fracture group was 6.01. The optimum cut-off value of the score to predict pathological fracture was 7. The scoring system had a sensitivity of 70% and a specificity of 80% for detecting patients with fractures. The Youden index was 0.5, which was the maximum value. The area under the receiver operator characteristic was 0.814.

CONCLUSION

Lesion type, pain, lesion-to-bone width, and axial cortical involvement are risk factors for pathological fracture. The modified scoring system can provide evidence for clinical decision-making in children with benign bone lesions. A bone lesion with a total score > 7 indicates a high risk of a pathologic fracture and is an indication for prophylactic internal fixation.

Surgical treatment of benign osteolytic lesions in the femoral head and neck: a systematic review

Background and objectives

Treatment of benign osteolytic lesions in the femoral head and neck can be extremely challenging, particularly in children with open physis or for aggressive tumors with pathological fracture. There remains the difficult management decision as to whether to perform complete excision of the involved area or only curettage. Moreover, there is no agreed consensus on the optimal approach to lesion access when performing curettage, which included the transcervical, open and direct approach. The current systematic review aims to provide guidance for selection of surgical methods in clinical practice by comparing the advantages and drawbacks of different procedures.

Methods

A comprehensive literature search of PubMed, Embase and Web of Science databases were executed for human studies restricted to the English language. The search was filtered to include studies published from January 1980 to January 2020.

Results

A total of 33 articles including 274 patients were enrolled in the final analysis. The most common diagnosis was chondroblastoma (CBT) (104, 38.0%), followed by giant cell tumor (GCT) (56, 20.4%). There were 57 (20.8%) patients with pathological fracture. Intralesional curettage was performed in 257 (93.8%) patients with the local recurrence of 12.5% at the mean follow-up of 51.5 months. The patients who were presented with open physis or curetted via transcervical approach developed higher local recurrence in patients with CBT (P < 0.001). The local recurrence rate of GCT is 33.3% after curettage, while 8 of 9 (88.9%) patients with fracture were treated successfully with joint preservation. Two of 45 (4.4%) patients developed avascular necrosis (AVN) of femoral head after surgical hip dislocation. The reported Musculoskeletal Tumor Society (MSTS) Score was comparable among patients with different approaches to curettage.

Conclusion

The majority of benign osteolytic lesions in the femoral head and neck can be treated with intralesional curettage with acceptable local tumor control and satisfactory function. The incidence of local recurrence might be decreased dramatically for lesion access under direct visualization. The native joint maintenance could be achieved even in patients with aggressive lesions presenting pathological fracture.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04442-y.

Type lll internal hemipelvectomy for primary bone tumours with and without allograft reconstruction : a comparison of outcomes

AIM

There is insufficient evidence to support bony reconstruction of the pubis after a type III internal hemipelvectomy (resection of all or part of the pubis). In this study, we compared surgical complications, postoperative pain, and functional outcome in a series of patients who had undergone a type III internal hemipelvectomy with or without bony reconstruction.

METHODS

In a retrospective cohort study, 32 patients who had undergone a type III hemipelvectomy with or without allograft reconstruction (n = 15 and n = 17, respectively) were reviewed. The mean follow-up was 6.7 years (SD 3.8) for patients in the reconstruction group and 6.1 years (SD 4.0) for patients in the non-reconstruction group. Functional outcome was evaluated using the Musculoskeletal Tumor Society (MSTS) scoring system and the level of postoperative pain with a visual analogue scale (VAS).

RESULTS

The mean MSTS score of the patients was significantly better in patients after reconstruction (26 (SD 1.7) vs 22.7 (SD 2.0); p < 0.001). The mean visual analogue scale score for pain was significantly less in the reconstruction group (2.1 (SD 2) vs 4.2 (SD 2.2); p = 0.016). One infection occurred in each group. Bladder herniation occurred in three patients (17.6%) in the non-reconstruction group but none in the reconstruction group. Five patients (29.4%) in the non-reconstruction group and one (7%) in the reconstruction group had a limp. Graft displacement occurred in two patients in the reconstruction group.

CONCLUSION

We recommend reconstruction of the bony defect after a type III hemipelvectomy: it gives a better functional result, less postoperative pain, and fewer late surgical complications. Cite this article: Bone Joint J 2021;103-B(6):1155-1159.

Early Diagnosis of Giant Solitary Synovial Chondromatosis of the Hip Using Ultrasound-guided Synovial Biopsy: A Case Report

The diagnosis of synovial chondromatosis (SCM) is usually delayed, as the arthroscopic-guided synovial biopsy is postponed owing to its invasive nature. We report the timely diagnosis of a giant solitary synovial chondromatosis of the hip in a 32-year-old woman using ultrasound-guided synovial biopsy. This technique revealed to be safe and successful in the diagnosis of SCM, when the imaging studies were obscure. Moreover, it avoided the potential arthroscopy-associated complications. We recommend ultrasound-guided synovium biopsy as a less invasive and less complicated technique for the early diagnosis of SCM in future workouts.

Elastic intramedullary nailing combined with methylprednisolone acetate injection for treatment of unicameral bone cysts in children: a retrospective study

PURPOSE

The aetiology of unicameral bone cysts (UBCs) is unclear. This study aims to evaluate the feasibility of elastic intramedullary nailing (EIN) combined with injections of methylprednisolone acetate (MPA) for the treatment of UBCs in children.

METHODS

We retrospectively analyzed 53 children with UBCs in our hospital between January 2010 and April 2016. A total of 24 patients (Group A) were treated by EIN and MPA, whilst 29 patients (Group B) were treated by curettage, bone grafts and EIN fixation. The radiographs of the UBCs were evaluated following the Capanna criteria. All patients were followed-up on the third, sixth, 12th, 24th and 36th months. Fixation time, hospitalization time and complications were evaluated.

RESULTS

In Group A, the mean number of MPA injections was 1.8 (1 to 3). Based on radiographic evaluation, eight patients were healed (Capanna grade I), 14 were healed with residual cysts (Capanna grade II), one showed recurrence (Capanna grade III) and one showed no response to the treatment (Capanna grade IV). In Group B, 11 patients were evaluated as Capanna grade I, 12 as Capanna grade II, three as Capanna grade III and three as Capanna grade IV. There was significant difference in the early postoperative function activity (p < 0.001), hospitalization time (p = 0.028), blood loss during surgery (p < 0.001) and surgery time (p < 0.001).

CONCLUSION

The combination of EIN and MPA for the treatment of UBCs in children is feasible, has little operative trauma, short surgery time, short hospitalization time, less blood loss and a low risk of incision infection.

LEVEL OF EVIDENCE

III.

Onlay fibula autografting technique and its comparison with cortical allograft for the reconstruction of periprosthetic bone defects around the femur

BACKGROUND

Bone defect around the femur related to revisions or periprosthetic fractures (PFF) is an issue. We present a bone defect reconstruction technique in femoral revisions and/or PFF using fibula autograft and compared our radiological and clinical results to that of allograft.

METHODS

A total of 53 patients who underwent revision hip arthroplasty and/or PFF fixation with the use of cortical fibula autograft (FG group) or cortical allograft (CG group) were evaluated. After exclusions, 20 patients who had minimum two years of follow-up were investigated for each group, for their radiological and clinical outcomes.

RESULTS

In FG and CG groups, the median ages were 69.5(44-90) and 62(38-88) years, follow-ups were 59(28-72) and 120(48-216) months, defect lengths were seven (1-10) and ten (1-17) cm, and grafts lengths were 16.5(10-30) and 20(12-37) cm, respectively. The rate of graft incorporation was 90% in each group and median time to incorporations were seven (4-12) and 12(6-24) months (p < 0.001), and graft resorption (moderate and severe) rates were 10% and 25% (p = 0.41), respectively. Median Harris Hip (77.6 vs 78.0), WOMAC (23.2 vs 22), SF-12 physical (50.0 vs 46.1), and SF-12 mental (53.8 vs 52.5) scores were similar between the groups, respectively. Kaplan-Meier survivorship analyses revealed an estimated mean survival of 100% at six years in FG group and 90% at 14 years in CG group.

CONCLUSION

In the reconstruction of periprosthetic bone defects after femoral revision or PPF, onlay cortical fibula autografts provide comparable clinical and radiological outcomes to allografts. Its incorporation is faster, it is cost-effective and easy to obtain without apparent morbidity.

Surgical Excision as the First Therapeutic Choice in Single-muscle Hemangiomas: a Case Series

Background

Conservative management is generally the primary treatment for intramuscular hemangimas. However, many patients will require surgery later in their life, after suffering a long period of pain. We aimed to evaluate the oncologic and functional outcomes of surgery as the initial treatment of single-muscle hemangiomas.

Methods

Medical profiles of 17 patients with hemangiomas of vastus medialis for whom surgery was selected as the initial treatment were reviewed. The indication for surgery was a bothersome pain. Postoperative muscle strength was assessed with manual muscle testing (range 0-5). The postoperative pain was measured by a visual analog scale (VAS) for pain (range 0-10). Lyshölm-Tegner knee scoring scale was used for the evaluation of knee function.

Results

The mean age of the patients was 25.9±8.6 years. Surgery was performed as wide resection in 13 cases and as marginal resection in 4 cases. At a mean follow-up of 55.76±30 months, two local recurrences (11.8%) were observed. At the last evaluation session, muscle strength grade was 5/5 in 13 patients and 4/5 in four patients. Postoperative pain was noticed in four patients (VAS=1). Knee function was excellent in 13 patients and good in four patients. Both of the local recurrences occurred in marginally resected lesions. Three out of four cases with reduced muscle strength, postoperative pain, and reduced function were also treated with marginal resection.

Conclusion

If a wide surgical margin is achievable without compromising the limb function, surgical resection could be considered as the primary choice of treatment for single-muscle hemangiomas.

Percutaneous cyst aspiration with injection of two different bioresorbable bone cements in treatment of simple bone cyst

INTRODUCTION

Simple bone cysts (SBCs) are common in children and adolescents. The risk of refracture and the probability of spontaneous healing in SBCs are mainly dependent on the activity of the cyst and can be quantified with the Cyst-Index. Avoiding pathological fractures is the primary goal. Our study presents a comparison of two different bioresorbable bone graft substitutes (BGSs) in the minimally-invasive treatment of SBC in the active stage by percutaneous cyst aspiration and injection.

METHODS

Between 2006 and 2017, 38 patients (aged two to 37 years; mean age 12.4 (sd 5.6)) were treated with percutaneous cyst aspiration and refilled with bioresorbable BGSs in three hospitals. The cysts of 21 patients (11 humerus, five femur, four calcaneus, one fibula) were refilled with porous beta-tricalcium phosphate (PB-TP group) (ChronOS Inject) and of 17 patients (nine humerus, six femur, one calcaneus, one fibula) with hydroxyapatite/calcium sulphate (H/CS group) (CERAMENT|BONE VOID FILLER). There were 13 (62%) preceding fractures in the PB-TP group and eight (47%) in the H/CS group. The follow-up of all patients was at least two years. During follow-up, radiological healing (modified Neer classification), activity level, refracture rates, recurrence rates, resorption period and complications were analyzed.

RESULTS

In all, 21 patients treated with PB-TP group experienced 27 operations (one refracture, three recurrences and one persistent cyst). A total of 17 patients treated with H/CS experienced 20 operations (one refracture and one recurrence). After six weeks, 95% in the PB-TP group returned to unrestricted activity with one refracture in the femur due to insufficient biomechanical stability and all returned to unrestricted activity in the H/CS group. Partial or complete radiological response was observed in 81% after 13 months (sd 3.4). Three recurrences (14%) occurred in the PB-TP group and one recurrence (6%) occurred in the H/CS group. The refracture rates were similar in both groups; one (5%) in the PB-TP group and one (6%) in the H/CS group. All H/CS treated cysts showed completed resorption after two years, whilst in PB-TP treated cysts no resorption occurred in five cases (25%) (p = 0.031). Two (10%) wound infections occurred in the PB-TP group and no infections occurred in the H/CS group.

CONCLUSION

Both PB-TP and H/CS can provide stability and prevent refracture in patients with single bone cysts at the upper extremity or the foot. For the proximal femur, additional stabilization is necessary, due to the weight-bearing and associated high refracture rate. The H/CS bone graft substitute has a better resorption rate than the PB-TP graft.

LEVEL OF EVIDENCE

III.

Non-vascularised Fibular Autograft for Reconstruction of Paediatric Bone Defects: An Analysis of 10 Cases

Aim and objective

Fibular autograft is a known technique for the reconstruction of traumatic and non-traumatic bone defects in both adult and paediatric populations. We aim to describe our outcomes using various stabilisation methods for non-vascularised fibular autograft to reconstruct both benign and malignant tumours in a paediatric population in a National Paediatric Centre over the past 14 years.

Materials and methods

This was a retrospective review of 10 paediatric cases with non-traumatic primary bone defects in a National Paediatric Centre. Criteria for inclusion were all non-traumatic primary bone defects requiring reconstruction with a non-vascularised fibular autograft in the diaphyseal or metaphyseal regions of the bone. The primary outcome measures were union and time to union (weeks). Time to union was illustrated using Kaplan–Meier curves. Secondary outcome measures included postoperative fracture, infection (deep and superficial), time to full weight-bearing and all-cause revision surgery.

Results

The mean length of follow-up was 63 months for the entire cohort (9–168, SD = 48.6). There was no loss to follow-up. Six lesions were located in the tibia, two in the femur and the remaining two were located in the ulna and third metacarpal. Union was ultimately achieved in 8 of the 10 patients using this donor autograft. The mean time to union was 28 weeks (10–99, SD = 29.8). There were four complications of autograft fracture. The mean time to fracture was 17 weeks (9–32, SD = 10.71). In all four of these cases, the patient achieved union at final follow-up. There were two superficial and two deep infections recorded. Three resolved with the use of antimicrobial therapy and one deep infection ultimately required insertion of an intercalary prosthesis to treat the infected non-union of the fibular graft site.

Conclusion

The use of non-vascularised fibular autograft for the reconstruction of tumours is an effective surgical technique in a paediatric cohort. We report the largest known series of malignant paediatric tumours treated with this technique to date.

Clinical significance

Non-vascularised fibular autograft is successful in the reconstruction of large bone defects secondary to malignant paediatric bone tumours.

How to cite this article

Sheridan GA, Cassidy JT, Donnelly A, et al. Non-vascularised Fibular Autograft for Reconstruction of Paediatric Bone Defects: An Analysis of 10 Cases. Strategies Trauma Limb Reconstr 2020;15(2):84–90.

Active unicameral bone cysts: control firstly, cure secondly

PURPOSE

This retrospective study evaluated the efficacy of minimally invasive surgery to control cyst progression for active unicameral bone cysts (AUBC) by intracystic methylprednisolone injection, percutaneous curettage, and autogenous bone marrow grafting.

METHODS

From May 2010 to May 2017, patients diagnosed with AUBC who underwent percutaneous double-needle intracystic methylprednisolone injection, percutaneous curettage, and autogenous bone marrow grafting were retrospectively reviewed. Recurrence was defined by modified Neer scale score. Patients were followed up regularly, and previous imaging findings were compared to evaluate treatment efficacy.

RESULTS

The 26 patients (17 boys, 9 girls, mean age, 9.4 ± 3.1 years) were followed up for a mean 45.1 months (range, 24-82 months). Follow-up consisted of clinical evaluation and radiographic review. Twenty patients (77%) achieved latent disease stage after the first treatment, while six (23%) achieved it after the second treatment. Postoperative pathological fracture imaging scores were score I in 18 (70%), score II in five (19%), score III in two (8%), and score IV in one patient (4%). All 26 patients returned to their full activities and were asymptomatic at the most recent follow-up. The success rate (scores I and II) independent of the number of treatments was 89%. Treatment time was correlated with cyst size and length. Sex, age, cyst location and size, pathological fracture, and other clinical factors or radiological data did not influence the curative effect. No other complications occurred.

CONCLUSIONS

For AUBC, minimally invasive treatment is feasible to control cyst progression and then cure it without sequelae. Intracystic methylprednisolone injection, percutaneous curettage, and autogenous bone marrow grafting are an excellent choice.

Comparison of curettage and bone grafting combined with elastic intramedullary nailing vs curettage and bone grafting in the treatment of long bone cysts in children

To compare the efficacy of curettage and bone grafting combined with elastic intramedullary nailing (EIN) vs curettage and bone grafting in the treatment of long bone cysts in children and to clarify the necessity of using EIN in the treatment of bone cysts.Sixty-two patients were involved in this study from Jan. 2009 to Sept. 2017 (43 males, 19 females; 27 humeri, 35 femurs); the patients were assigned to an EIN group, comprising 30 patients who underwent curettage and bone grafting combined with EIN, or to a non-elastic intramedullary nailing (NEIN) group, comprising 32 patients who underwent curettage and bone grafting alone. The prognosis of the 2 groups was assessed with reference to the standard of Capanna.No statistically significant differences in sex, age, location, activity, pathological fracture, cyst volume, operative time and intraoperative blood loss were found between the 2 groups (P > .05). The effective rate was 90.0% in the EIN group and 68.8% in the NEIN group, and the difference was statistically significant (P < .05).Compared to simple curettage and bone grafting, curettage and bone grafting combined with EIN treatment can significantly improve the prognosis of children with bone cysts. It is recommended that EIN be added to bone cyst curettage and bone grafting.