Flexible intramedullary nailing in simple bone cysts of the proximal humerus: prospective study for high-risk cases of pathologic fracture

Percutaneous calcium sulfate injection versus localized scrape bone grafting: clinical effect comparison in titanium elastic nail treatment of pathological fracture of proximal humerus caused by unicameral bone cysts in children

Objective

A retrospective study was conducted to compare the mid-term clinical efficacy between percutaneous calcium sulfate injection (PCSI) and localized scrape bone grafting (LSBG) in using titanium elastic nails treat humerus pathologic fractures caused by unicameral bone cysts in children.

Methods

Humerus pathologic fracture patients with unicameral bone cysts in our pediatric orthopedic department from January 2015 to January 2020 were retrospectively analyzed. Patients were divided into two groups, namely the PCSI group and the LSBG group, based on the type of bone grafting material they received. Preoperative assessments were made in both groups using the Cyst Index and Cyst activity. During the perioperative phase, assessments were made regarding operative time, bleeding, postoperative VAS scores, and the frequency of reoperation within 2 years. Clinical outcomes were evaluated using the Capanna scale at the last follow-up, and the occurrence of re-fractures during the follow-up period.

Results

A total of 22 patients were included, with a mean follow-up duration of 33.5 ± 5.8 months. No significant differences were found between the two groups in terms of Cyst Index and Cyst activity before the operation. The operative time, bleeding, and postoperative VAS scores in the PCSI group were found to be lower than those in the LSBG group (P < 0.05). The PCSI group also showed a higher frequency of reoperation within 2 years compared to the LSBG group (P < 0.05). However, no significant differences were observed between the two groups in terms of Capanna scale scores at the last follow-up and the incidence of re-fractures during follow-up.

Conclusions

Both titanium elastic nails (TEN) combined with PCSI or LSBG were found to be safe and effective treatments for humerus pathologic fractures caused by unicameral bone cysts in children. PCSI is considered as a less invasive option with shorter operative times, less bleeding, and reduced postoperative pain, although it comes with the risk of multiple injections. On the other hand, LSBG is considered as a more invasive option for the treatment of active bone cysts but is associated with a lower recurrence rate.

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.

Risk factors for pathological fractures of simple bone cysts of the humerus in children: a retrospective cohort study

BACKGROUND

Simple bone cysts (SBCs) are common osteolytic lesions in children, which often lead to pathological fractures of the non-weight-bearing bone (humerus) in patients. Cyst index is a classic index to evaluate the risk of pathological fracture, but the reliability of this index is reduced due to the deviation of cyst area in the frontal and lateral position and the subjectivity of the determination of cyst area. MRI can clearly show the cyst boundary, the appointment cycle is long, and children need to be examined under sedation, which cannot be judged by clinicians in time. Therefore, it is necessary to find a basic and simple imaging evaluation index in clinic. The purpose of this study is to retrospectively analyze the risk factors of pathological fracture of simple bone cyst of humerus in children.

METHODS

The medical records and plain films of patients with SBCs from January 2014 to December 2021 were retrospectively analyzed. Patients were divided into a fracture group (35 cases) and a non-fracture group (10 cases). The relationship between pathological fractures and the children's age, gender, and cyst index was analyzed. The presence of the pectoralis major and the link to the tendon insertion site of ectopectoralis and anconeus lateralis (TEAL) of the lesion were also examined. Perform binary logistic regression analysis.

RESULTS

Binary logistic regression analysis was performed on the age, gender, and cyst index, and whether the lesion was located in the TEAL. The results demonstrated that the TEAL was an independent risk factor for fractures [odds ratio (OR) =21.423, 95% confidence interval (CI): 2.409-190.539; P=0.006].

CONCLUSIONS

SBCs of humerus in children is often accompanied by pathological fracture. The lesion is located at TEAL, so we should be alert to the risk of pathological fracture.

The role of fractures on pathologic bone in healing of proximal humerus unicameral bone cysts

PURPOSE

To evaluate the role of fractures on pathologic bone in healing of proximal humerus unicameral bone cysts (UBCs) and investigate the clinical factors that affect healing of UBCs after fractures on pathologic bone.

METHODS

This prospective study was carried out between 2002 and 2014. We evaluated 56 patients with a UBC accompanying fractures on pathologic bone in the proximal humerus. Clinical data were collected from the patients' medical records. Age, gender, degree of fracture displacement, location of cyst, and cyst size were investigated, and we assessed how these factors affected cyst healing.

RESULTS

The overall healing rate of UBCs 1 year after fracture was 66% (37 of 56 cases). The healing rate was significantly lower in pubescent patients (10-14 years old; 45%) than in those who were 9 years old (76%) or 15 years old (80%). The rate of healing of fractures in the metaphysis (53%) was lower than that of breaks in the diaphysis (85%). The mean cyst ratio was 1.31 in the 37 patients who experienced cyst healing within 1 year and 1.79 in the 19 patients who needed surgical treatment within 1 year.

CONCLUSION

In latent lesions and in patients who are older (after puberty), UBCs of the humerus after fracture have better clinical results than do active lesions and those in younger patients (before puberty). Fractures on pathologic bone in proximal humerus UBCs often dramatically decrease cyst size, and patients with such fractures have excellent clinical results in terms of healing rate.

Inter-rater reliability of the radiographic assessment of simple bone cysts

PURPOSE

To develop and evaluate the reliability of an explicit set of parameters and criteria for simple bone cysts (SBCs) and evaluate the reliability of single versus serial chronological reading methods.

METHODS

Radiographic criteria were developed based on the literature and expert consensus. A single anteroposterior/lateral radiograph from 32 subjects with SBC were evaluated by three radiologists. A second reading was then conducted using revised criteria including a visual schematic. In the third reading the same images were assessed but radiologists had access to images from two additional time points. Inter-rater reliability was assessed after each reading using kappa (κ) and percentage agreement for categorical and binary parameters and intra-class correlation coefficient (ICC) for continuous parameters.

RESULTS

Parameters that were revised with more explicit definitions including the visual schematic demonstrated consistent or improved inter-rater reliability with the exception of continuous cortical rim present and cyst location in the metaphysis and mid-diaphysis. Cortical rim displayed only slight reliability throughout (κ= -0.008 to 0.16). All other categorical parameters had a percentage agreement above 0.8 or a moderate (κ= 0.41 to 0.60), substantial (κ = 0.61 to 0.80) or almost perfect inter-rater reliability (κ = 0.81 to 1.0) in at least one reading. All continuous parameters demonstrated excellent inter-rater reliability (ICC > 0.75) in at least one reading with the exception of scalloping (ICC = 0.37 to 0.70). Inter-rater reliability values did not indicate an obviously superior method of assessment between single and serial chronological readings.

CONCLUSION

Explicit criteria for SBC parameters used in their assessment demonstrated improved and substantial inter-rater reliability. Inter-rater reliability did not differ between single and serial chronological readings.

LEVEL OF EVIDENCE

Not Applicable.

A comparative study for the treatment of simple bone cysts of the humerus: open curettage and bone grafting either without instrumentation or with intramedullary nailing

Functional and radiographic outcomes, in addition to complication and reoperation rates of open curettage and grafting without instrumentation or with intramedullary nailing, in the treatment of simple bone cysts (SBCs) of the humerus were compared. Thirty-seven children [25 males, 12 females; median age=9.5 years (range, 3-17 years)] with humeral SBC were treated with curettage and grafting without instrumentation (group 1, 21 patients) or with intramedullary nailing (group 2, 16 patients). The pathological fracture rate was 85.7% in group 1 and 87.5 in group 2. The follow-up duration ranged from 26 to 85 months. The average last follow-up Musculoskeletal Tumor Society functional scores for groups 1 and 2 were 28.9 and 29.5 (P>0.05). Higher, but statistically insignificant (P>0.05), complete or significant partial radiographic healing rates were achieved in group 2 (100%) compared with group 1 (76.2%). The overall complication rate of the entire study population was 21.6% (19%; 4/21 in group 1; 25%; 4/16 in group 2). The reoperation rates for groups 1 and 2 were 9.5% (2/21; one for partial cyst healing, one for recurrence) and 56.25% (9/16; one for surgical complication, eight for implant removal). Surgical intervention is indicated for selected patients with SBCs. Even though perfect functional results were possible with open curettage and grafting, continuous intramedullary decompression with elastic nails led to a higher radiographic healing rate in the treatment of humeral SBCs. Open curettage and grafting with or without intramedullary nailing was associated with a high number of complications, but the rate of reoperation for complications was very low.

Comparison of titanium elastic intramedullary nailing versus injection of bone marrow in treatment of simple bone cysts in children: a retrospective study

BACKGROUND

Simple bone cysts are common benign lytic bone lesions in children. The main goals of treatment for bone cysts are to prevent pathological fractures, support the healing process, and prevent recurrence. This retrospective study compared fixation with titanium elastic intramedullary nailing (TEN) versus aspiration and injection of autogenous bone marrow (ABM) for the treatment of simple bone cysts in children.

METHODS

Forty-six patients (mean follow-up, 62 months; range, 34-71 months) who presented with bone cysts (30 in the humerus, 16 in the femur) from January 2006 to December 2012 were retrospectively evaluated. Patients were treated with either TEN or ABM injection. Radiographs were evaluated according to previously established criteria. Clinical evaluations of pain, infection, additional fractures, and range of motion were performed.

RESULTS

After treatment, all patients were pain-free and had normal range of motion in adjacent joints. In the ABM group, 14 (60.9 %) bone cysts completely healed, six (26.1 %) healed with small residuals after two injections, and three (13.0 %) recurred. In the TEN group, 16 (69.6 %) bone cysts completely healed, four (17.4 %) healed with small residuals, and three (13.0 %) recurred. There were no significant differences in radiographic outcomes between groups at the final follow-up (P > 0.05). Three patients developed skin irritation as a result of the nail ends. Additional fractures occurred in four patients who underwent ABM injection and in two patients who underwent TEN. No significant associations were found between pathological fractures and cyst activity, location, or treatment outcomes in the patients studied.

CONCLUSIONS

Both TEN and ABM injection are safe and effective treatment for bone cysts. ABM injection promotes osteogenic differentiation of bone marrow stromal cells; multiple injections can reduce the likelihood of recurrence. TEN stabilizes the affected bone and thus allows early limb mobilization. It also reduces pressure in the capsule wall by continuous decompression to promote cyst healing. ABM injections can be used to treat cyst recurrence after previous TEN, with favorable results.

A treatment strategy for proximal femoral benign bone lesions in children and recommended surgical procedures: retrospective analysis of 62 patients

PURPOSE

We aimed to develop a surgical treatment strategy for benign bone lesions of the proximal femur based upon retrospective review of our data in 62 children.

METHODS

Sixty-two children [38 male, 24 female; median age 9 years (range 5-18 years)] with proximal femoral benign bone lesions were surgically treated between 2005 and 2013. Histopathological diagnoses were simple (31) or aneurysmal (27) bone cysts, and nonossifying fibromas (4). The pathological fracture rate was 77.4 %. Surgical treatment was determined due to four criteria, including patient's skeletal maturity, localization and initial diagnosis of lesion, and amount of bone loss in the femoral neck and lateral proximal femur. Surgical procedure consisted of biopsy, curettage, bone grafting, and internal fixation when required. The median follow-up was 45 months (range 25-89 months).

RESULTS

Complete clinical recovery was achieved in 56 (90.3 %) patients between 4 and 8 months postoperatively; full weight-bearing and mobilization, without pain and limping, was possible. The median preoperative and postoperative last follow-up Musculoskeletal Tumor Society (MSTS) scores were 13.3 % (range 10-23.3 %) and 96.6 % (range 90-100 %), respectively (p < 0.0001). The pathological fractures were healed in 10 weeks on average (range 8-12 weeks). Fifty-seven (92 %) patients demonstrated complete or significant partial radiographic healing between 5 and 7 months that maintained throughout follow-up. Local recurrence was not observed, and only 1 (1.6 %) patient required reoperation for partial cyst healing. There were 5 (8 %) complications, 1 (1.6 %) of which required reoperation.

CONCLUSIONS

This treatment strategy can provide good local control and excellent functional and radiological results in the management of benign bone lesions of the proximal femur in children.

Flexible Intramedullary Nailing of Pediatric Humeral Fractures: Indications, Techniques, and Tips

Most proximal and diaphyseal pediatric humeral fractures can be treated successfully by closed means; however, certain patient factors or fracture characteristics may make surgical stabilization with flexible intramedullary nails (FIN) a better choice. Common indications for FIN of pediatric humeral fractures include unstable proximal-third fractures in children nearing skeletal maturity, unstable distal metaphyseal-diaphyseal junction fractures, shaft fractures in polytraumatized patients or patients with ipsilateral both-bone forearm fractures (floating elbow), and prophylactic stabilization of benign diaphyseal bone cysts or surgical stabilization of pathologic fractures. FIN can be safely inserted in an antegrade or retrograde manner depending on the fracture location and configuration. Careful dissection at the location of rod insertion can prevent iatrogenic nerve injuries. Rapid fracture union and return to full function can be expected in most cases. Implant prominence is the most common complication.

Does fracture affect the healing time or frequency of recurrence in a simple bone cyst of the proximal femur?

BACKGROUND

Studies have focused on intramedullary nailing of femoral simple bone cysts but have not clarified the recurrence frequency or management of recurrent cysts. In particular, the affect of pathologic fractures on cyst healing, recurrence, and complications of treatment have not been reported.

QUESTIONS/PURPOSES

We performed a retrospective comparative study to examine whether there were differences between simple bone cysts in the proximal femur nailed after pathologic fracture and those without pathologic fracture in terms of (1) healing time, (2) frequency and timing of recurrence, and (3) complications.

METHODS

From 1995 to 2005, 54 patients diagnosed with femoral simple bone cysts were treated and followed for a minimum of 8 years. Flexible nails were inserted in a retrograde fashion in 25 patients with fractures and 29 patients without fractures. The healing period, degree of radiographic consolidation based on the criteria of Capanna et al., recurrence frequency, and final bony abnormalities were analyzed. The mean followups were 107 months (range, 96-124 months) and 103 months (range, 96-140 months) in the groups with and without fractures, respectively. With the numbers available, a post hoc calculation showed that this study had 80% power to detect a difference of 7 months of healing time as significant with a probability less than 0.05.

RESULTS

With the numbers available, the mean healing period was not different between groups (25 versus 30 months in the groups with and without fractures, respectively; p = 0.16). Complete healing was observed at 19 versus 18 months, incomplete healing at 5 versus 8 months, and recurrence was observed in one and three patients in the groups with and without fractures, respectively. No differences were found in the distribution of healing grade based on the criteria of Capanna et al. A second surgery was performed using intramedullary nails in two patients with an open physis and compression hip screw fixation was performed in two patients with a closed physis. Finally, the recurrent cysts were classified as completely healed in three patients and incompletely healed in one.

CONCLUSIONS

Whether a pathologic fracture had occurred before surgical treatment, intramedullary nailing of femoral simple bone cysts resulted in reliable healing, and the frequency of recurrence did not differ. Because this was a retrospective study, the optimal treatment for recurred cysts after intramedullary nailing should be further investigated through a comparative or prospective study.