Comparison of three surgical treatment options for unicameral bone cysts in humerus

Results of Allografts and Synthetic Grafts in Humeral Simple Bone Cysts

PURPOSE OF THE STUDY

Simple bone cysts (SBCs) are the most common benign bone lesions in childhood. There are many different methods in the treatment of SBCs. There is no consensus on which method to use in the treatment. In this study, we compared the results of allogeneic bone graft or synthetic bone graft in addition to fl exible intramedullary nail (FIN) for SBC located in the humerus.

MATERIAL AND METHODS

This retrospective study comparing the data of 19 (group 1: 8 curettage, allograft and FIN; group 2: 11 curettage, synthetic graft and FIN) patients with a mean age of 11.4 (6 to 26; seven female, twelve male) who were surgically treated in our hospital for humeral SBC between April 2014 and January 2020. Patient data included age, sex, anatomical side, stage of the cyst, pathological fracture, previous treatments and complications.

RESULTS

The mean follow-up period was 33.7 months (12 to 61). The average last follow-up Musculoskeletal Tumor Society functional scores for groups 1 and 2 were 27.8 (20 to 30) and 28.6 (21 to 30) (P > 0.05). Complete or signifi cant partial radiographic healing rates were achieved in group 1 (75%) compared with group 2 (81.9%). The reoperation rates for groups 1 and 2 were 62.5% (5/8; three for nails removed, two for recurrence) and 36.3% (4/11; two for nails removed, two for recurrence). One patient in group 2 had a 15° varus deformity due to recurrence. No other complications were observed.

CONCLUSIONS

The combination of curettage-grafonage FIN is a common treatment method in recent years, as it provides early cyst healing and limb mobilization in SBCs located in the upper extremity. For defects after curettage of the bone cysts, allogeneic or synthetic grafts (granule b-tricalcium phospate) which have similar results in terms of healing can be used as an alternative to each other.

KEY WORDS

allografts, bone cysts, bone nails, synthetic grafts, humerus.

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.

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.

What's New in Pediatric Orthopaedic Tumor Surgery

BACKGROUND

Pediatric Orthopaedic Oncology is a developing subspecialty within the field of Pediatric Orthopaedics. Traditionally, the field of Orthopaedic Oncology has been focused on the skeletally mature individual, and the research tends to be all encompassing rather than truly evaluating isolated populations. The purpose of this review is to summarize the most clinically relevant literature in the field of Pediatric Orthopaedic Oncology over the last 6 years.

METHODS

We evaluated the PubMed database utilizing keywords for pediatric orthopaedic oncology: sarcoma, osteosarcoma, Ewing sarcoma, bone cyst. In additionally, we further broadened our search by searching for relevant articles in the contents sections of major orthopaedic surgery journals that routinely publish both pediatric and orthopaedic oncology literature. In keeping with "What's New," we selected the most clinically relevant articles published in the last 6 years from January 1, 2014 through February 2020. Basic science and systemic therapies literature was widely reviewed and the research and clinical trials most relevant to pediatric sarcoma and neoplastic processes found in the pediatric population were included.

RESULTS

Our search yielded 60 articles that met general criteria, from which 14 were determined to be most relevant to the goals of this paper. Of the papers presented in this review, there were papers related to management of benign tumors/tumor-like conditions, bone cysts, limb salvage procedures, and amputation procedures. Ultimately included in the review were 5 studies related to limb salvage, 4 related to bone cysts, 1 related to multiple hereditary exostoses, 2 related to osteofibrous dysplasia, 1 related to chondroblastoma, and 1 discussing cementation in skeletally immature patients. They were level III, IV, and V studies. Basic science and systemic therapies literature was widely reviewed and the research and clinical trials most relevant to pediatric sarcoma and neoplastic processes found in the pediatric population were included. Our search of the basic science and systemic therapies literature yielded 19 sources were found to be pertinent to our aims and 18 of those sources were published between 2015 and 2020.

CONCLUSIONS

There are many, varied, and creative procedures in the realm of limb salvage, though there remains a lack of high-level evidence to support some of the more novel procedures. In regards to benign bone tumors, despite a more solid base of literature, there still does not seem to be consensus as to the best treatment. In particular, there continue to be many schools of thought on the treatment of benign bone cysts. Research in the basic science arena and systemic therapies are advancing in exciting ways in regards to pediatric sarcoma. Orthopaedic oncologic research specific to the pediatric population overall continues to be impeded by low sample sizes and inadequate levels of evidence, which limits the ability of surgeons to draw definitive conclusions from the literature.

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.

Comparison of three treatment methods for simple bone cyst in children

BACKGROUND

The unicameral bone cyst (UBC) is a kind of benign tumor whose clinical treatments and efficacy are controversial. The purpose of this study was to evaluate the efficacy of the elastic stable intramedullary nail (ESIN), the injection of autologous bone marrow (ABM), and the combination of ESIN and ABM in the treatment of bone cyst in children.

METHODS

Eighty-three cases with simple bone cyst were analyzed retrospectively. Twenty-eight cases were treated with ABM. Twenty-eight cases were treated with ESIN. Twenty-seven cases were treated with ABM and ESIN. All cases were diagnosed through X-ray, CT, or MRI scans. For the suspicious ones, the pathological biopsy was performed for an accurate diagnosis. X-ray examinations were carried out for the postoperative follow-up. Capanna criteria for bone cyst was used for postoperative evaluation of three methods.

RESULTS

All cases accomplished the follow-up. The effective rate of the ABM + ESIN group was significantly higher than that of the ABM group (P < 0.05), and the cure rates of the ESIN group and the ABM + ESIN group were higher than that of the ABM group (P < 0.05, respectively). The cure time in the ESIN group was lower than that of the other two groups (P < 0.05, respectively). The times for admission were 2.0 ± 0.0 in the ESIN group, 5.7 ± 1.9 in the ABM group, and 4.7 ± 2.4 in the ABM + ESIN group (P < 0.05 when compared with each other).

CONCLUSIONS

The method of ABM combined with ESIN for children's bone cyst has the highest effective rate and curative rate. For the individual method, ESIN has a higher effective rate and curative rate than that of ABM. Meanwhile, it has the fewest time of hospitalization.

Evaluation of immediate and delayed surgery for pathological fracture due to unicameral bone cysts in children

PURPOSE

Unicameral bone cysts (UBCs) are most often found when accompanied by a pathological fracture. In these cases, the doctor must determine the optimal timing for the surgery. The purpose of this study was to evaluate the outcome of immediate surgery as compared with delayed surgery in paediatric pathological fractures due to UBCs.

METHODS

This retrospective study assessed the medical records of 65 patients between January 2012 and September 2016. Group A included 34 patients who underwent immediate surgery, including curettage, demineralized bone matrix and fixation with elastic stable intramedullary nailing. Group B included 31 patients who underwent the same surgery several months later. The outcome evaluations included the radiological changes, brace fixation time, cyst healing time, at the first-, third- and sixth month, and final visit.

RESULTS

The mean brace fixation time was 26.3 days (sd 5.7) for group A and 53.8 days (sd .1) for group B (p = 0.012). According to radiological evaluations, 3/34 patients in group A and 5/31 in group B had recurrence after the first surgery. A second surgery was performed in all cases of recurrence, and all fractures were healed at the last visit. There was no significant difference in the recurrence rate between the two groups (p = 0.4631), and healing times were also similar (p = 0.6033).

CONCLUSION

Both the immediate and delayed surgery were safe for the treatment of UBCs with fractures. We suggest immediate surgery for shorter fixation time and early activity.

LEVEL OF EVIDENCE

IV.

Current Trends and Variations in the Treatment of Unicameral Bone Cysts of the Humerus: A Survey of EPOS and POSNA Members

BACKGROUND

A variety of treatment methods have so far been described for unicameral bone cysts (UBC). However, to the best of our knowledge, no particular consensus has yet been reached on when to operatively treat a patient with a humeral UBC. Therefore, members of the European Pediatric Orthopedic Society (EPOS) and Pediatric Orthopedic Society of North America (POSNA) were surveyed to characterize current treatment preferences.

METHODS

An online electronic questionnaire was sent out to all registered EPOS and POSNA members. The survey comprised 45 questions related to the diagnosis, treatment, and follow-up characteristics of patients with UBCs of the humerus. Particular questions related to the nonoperative or surgical treatment of pathologic proximal humerus and humeral shaft fractures were also included.

RESULTS

In total, 444 participants (132 EPOS and 292 POSNA members) responded, of whom 400 were actively involved in UBC treatment. The preferred diagnostic modalities to confirm the diagnosis of a UBC in the humerus were radiographs (88%), MRI in cases of questionable diagnosis (58%) or CT scan (8%). For painless UBCs 67% prefer no treatment at all except when the fracture risk is deemed high (then 53% recommend surgery); 71% of respondents would treat painful UBCs with surgery. Most common surgical techniques comprise curettage (45%), artificial bone substitutes (37%), corticosteroid injection (29%), or intramedullary stabilization (eg, rodding; 24%).Fractured, nondisplaced and mildly displaced proximal humerus UBCs and mildly displaced pathologic humerus shaft fractures are all preferably treated nonoperatively (94%, 91%, 83%, respectively). Severely displaced pathologic proximal humerus fractures are treated less often conservatively (36%) than surgically (40%), and severely displaced humerus shaft fractures are preferably treated surgically (63%) by intramedullary stabilization (60%).

CONCLUSIONS

There is great variation among EPOS and POSNA members with regards to the diagnosis and treatment of UBCs in the humerus. Although some consensus on general treatment principles is seen, specific surgical treatment indications vary.Prospective randomized-controlled studies are needed to evaluate the outcomes of the different surgical approaches compared with nonoperative strategies.

LEVEL OF EVIDENCE

Level V-expert opinion.

Curettage as first surgery for bone giant cell tumor : adequate surgery is more important than oncology training or surgical management by high volume specialized teams

We reviewed the files of 203 patients with extremities GCTB treated with curettage as first surgery from 1990 to 2013. Median follow-up was 84.2 months. We evaluated whether the years of practice and training in orthopaedic oncology are associated with local recurrences, function and complications after curettage as first surgery for giant cell tumour of bone (GCTB). Local recurrences were not significantly different between orthopaedic oncology trained and non-trained orthopaedic surgeons and between orthopaedic surgeons with < 10 years and ≥ 10 years of practice. Function was not significantly different between orthopaedic oncology trained and non-trained surgeons and between orthopaedic surgeons with < 10 years and ≥ 10 years of practice. The only important univariate and multivariate predictor for local recurrence was PMMA adjuvant. Complications were not significantly different between orthopaedic oncology trained and non-trained orthopaedic surgeons and between orthopaedic surgeons with < 10 years and ≥ 10 years of practice. Curettage may be effectively performed as first surgery for GCTB by early-career (< 10 years of practice) non-trained orthopaedic oncology orthopaedic surgeons. PMMA adjuvant is recommended after appropriate curettage.

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.