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

Outcomes and complications of surgical treatment modalities for simple bone cysts of the humerus in children and adolescents

PURPOSE

The aim of this study was to evaluate and compare different surgical treatment modalities for simple bone cysts (SBC) of the humerus regarding their effectiveness and recurrence rate.

METHODS

In this retrospective study, patients who received surgical treatment for previously untreated primary SBCs of the humerus were analyzed. Demographic data, cyst-specific as well as treatment-specific parameters, complications, treatment failures, and recurrence rates were collected and correlated with different treatment modalities. Observed procedures were categorized as open procedure (n=20) or osteosynthesis alone (n=3). For the open procedure group, four subgroups could be defined.

RESULTS

Twenty-three patients were included. The mean age at diagnosis was 11.6 ± 2.5 years, and the mean postoperative follow-up was 3.9 ± 2.6 years (range 1.0-10.3). After surgical intervention, a total of five (21.7%) patients showed at least one recurrence. Fracture occurred in three (13.0%) cases. The incidence of treatment failure was significantly higher in the curettage, allograft, adjuvants group, with five (83.3%) of six cases showing recurrence, than in the other subgroups (≤ 25.0%) including the osteosynthesis alone group (p=.024). For the open procedure group, the failure-free survival rates were 80.0% after two years and 50.4% after five years. For the three cases treated by osteosynthesis alone, no failures were observed.

CONCLUSION

Open procedures showed similar failure rates except for the subgroup using curettage, allograft, and adjuvants which showed significantly higher treatment failure. Promising results were observed in the group which received solely osteosynthesis without cyst excision or filling, as no treatment failure was observed here.

Treatment of Unicameral Bone Cysts Utilizing the Sclerograft™ Technique

PURPOSE

To evaluate the Sclerograft™ procedure, which is an image-guided, minimally invasive approach of chemical sclerotherapy followed by bone grafting of unicameral bone cysts (UBC).

MATERIALS AND METHODS

A retrospective evaluation from August 2018 through August 2023 was performed at a single institution on patients that underwent the Sclerograft™ procedure for UBCs. Radiographic healing was evaluated utilizing the Modified Neer Classification. Two different regenerative grafts, CaSO4-CaPO4 and HA-CaSO4 were utilized. A total of 50 patients were evaluated with 41 patients grafted with CaSO4-CaPO4 and 9 patients grafted with HA-CaSO4.

RESULTS

The average age of the patient was 12.1 years with an average radiographic follow-up of 14.5 months. Average cyst size was 5.5 cm in the largest dimension and average cyst volume was 20.2 cc. 42 out of 50 (84%) showed healed cysts (Modified Neer Class 1) on the most recent radiograph or MRI. Recurrences occurred on average at 7.2 months. Activity restrictions were lifted at 3-4.5 months post-procedure. Cyst stratification by size did not show a difference in recurrence rates (p = 0.707). There was no significant difference in recurrence rate between lesions abutting the physis compared to those that were not abutting the physis (p = 0.643). There were no major complications.

CONCLUSIONS

The Sclerograft™ procedure is an image-guided approach to treating unicameral bone cysts, utilizing chemical sclerosis and regenerative bone grafting. The radiographic healing of cysts compares favorably to open curettage and grafting as determined utilizing previously published trials.

Trigger thumb treatment approach: Results of a survey of EPOS members

Purpose

The aim of this study is to analyze the clinical reality of pediatric trigger thumb among members of the European Paediatric Orthopaedic Society.

Methods

A 35-question survey was sent to all European Paediatric Orthopaedic Society members, focusing on surgeon's profile and experience, trigger thumb diagnostic and trigger thumb treatment approach. Descriptive statistics were performed.

Results

A total of 99 responses were analyzed. Most important factor considered in the therapeutic approach was the presence of a locked interphalangeal joint (52%). Regarding treatment, 41.4% opt for conservative approach as the first line of treatment, while 30.3% consider surgery and 28.3% just observe. Nevertheless, 76% mention to treat conservatively their patients and 99% to consider surgery at some stage. Regarding surgical technique, 96% do it open and 56% consider 2 years as the minimum age for procedure. Most surgeons perform this procedure in out-patient care (87%), don't administer prophylactic antibiotherapy (80%), use a tourniquet (75%), don't use any postoperative immobilization (64%), and report complications related to surgery (64%), mainly recurrence/incomplete division (59%) and superficial wound infection (30%).

Conclusion

Our study shows a significant variability in the initial management of pediatric trigger thumb with a predominance of conservative management, followed by surgery and observation without treatment. The disparity in treatment options and timing, or waiting times before moving on to different therapeutic options, shows us that this is a controversial issue and that the development of prospective randomized controlled studies is needed to analyze the different treatment methods and determine which ones give the best outcomes.

Pathological Fractures in Benign Bone Lesions - Diagnosis and Therapy

INTRODUCTION

Most tumour-related pathological fractures occur in patients with bone metastases. However, in mostly younger patients, a pathological fracture can be due to both a benign or a malignant bone tumour. Making the correct diagnosis from among these two differential diagnoses is enormously important. If the tumour is malignant, treating the fracture inevitably leads to tumour cell contamination and can significantly worsen the oncological situation. The aim of this review article is firstly to provide the reader with diagnostic assistance in the case of suspected pathological fractures, and secondly to focus on the treatment of pathological fractures occurring with benign bone tumours.

METHODS

This is a non-systematic review of the diagnosis and treatment of pathological fractures in benign bone tumours or tumour-like lesions, based on an electronic PubMed database search. We also present our own procedures, in particular for ruling out a malignant bone tumour.

RESULTS AND DISCUSSION

Whenever a fracture occurs in the absence of sufficient traumatic force, the possibility of a pathological fracture should always be considered. As well as taking a general history for a possible primary tumour, it is particularly important to ask the patient whether they had any pain before the fracture occurred. If the findings from clinical examination or conventional radiological imaging give rise to suspicion of a pathological fracture, an MRI of the affected skeletal section with contrast medium should be carried out before commencing any fracture treatment. A CT scan is also helpful for accurately assessing bone destruction. If a malignant or locally aggressive benign bone tumour such as giant cell tumour (GCT) or aneurysmal bone cyst (ABC) cannot be definitively ruled out through imaging, a biopsy is essential. The bone biopsy must always be carried out on the assumption that the histological work-up will reveal a malignant bone tumour; it must therefore be performed according to strict oncological criteria. If the radiological diagnosis is unambiguous, e. g., a juvenile bone cyst (JBC) or a non-ossifying fibroma (NOF), conservative treatment of the fracture can be considered, depending on the location. In the presence of a locally aggressive benign bone tumour such as a GCT or ABC, curettage of the tumour must be carried out as well as treating the fracture. With GCT in particular, neoadjuvant therapy with denosumab prior to curettage and osteosynthesis or en bloc resection of the tumour should be considered, depending on the extent of the tumour.

CONCLUSION

Pathological fractures, especially in younger patients, should not be overlooked. Only after a malignant or benign locally aggressive bone tumour has been definitively ruled out should fracture treatment be performed. In the presence of a locally aggressive bone tumour, as well as treating the fracture, it is usually necessary to perform curettage of the tumour - also en bloc resection, where applicable, in the case of a GCT. Depending on the location, benign, non-aggressive tumours can be treated conservatively if necessary.

Open surgical treatment of unicameral bone cysts : A retrospective data analysis

BACKGROUND

A variety of treatment options for unicameral bone cysts (UBC) exist. The controversy of open management of UBC is discussed. The aim of this study was to analyze a single institution's experience in the open surgical treatment of UBC.

PATIENTS AND METHODS

By retrospective analysis of the Vienna Bone and Soft Tissue Tumor Registry, 119 patients with open surgery and histologically verified UBC with a mean follow up of 4.8 years (range 1-30 years) were included. Lesion treatment failure was defined as surgically addressed UBC undergoing revision surgery due to persistence or recurrence.

RESULTS

Local revision-free survival for lesion treatment failure was 93% after 1 year, 80% after 2 years, 60% after 5 years and 57% after 10 years. Of the patients 34 (29%) had at least 1 revision surgery due to lesion treatment failure. We found that patients with lesion treatment failure were younger (p = 0.03), had UBC with less minimal distance to the growth plate (p = 0.02) and more septation chambers in radiologic imaging (p = 0.02). Patients with open revision surgery were less likely to require a second revision due to lesion treatment failure than patients with percutaneous revision surgery (p = 0.03).

CONCLUSION

Open surgery for UBC can only be recommended as reserve treatment in younger children with actively growing lesions. Open UBC surgery carries a relatively high risk of almost 30% of lesion treatment failure and therefore the indications should be limited to extensive osteolysis with high risk of pathological fractures, lesions with displaced pathological fractures, and lesions with an ambiguous radiological presentation that require tissue collection.

Management of juvenile and aneurysmal bone cysts: a systematic literature review with meta-analysis

PURPOSE

Numerous approaches to the management of juvenile and aneurysmal bone cysts (ABC) are described in the specialist literature together with discussion of the associated healing and recurrence rates. Since there is currently no evidence-based treatment standard for these conditions, the aim of this systematic literature review with meta-analysis was to examine the different management approaches, evaluate the corresponding clinical outcomes and, as appropriate, to formulate a valid treatment recommendation.

METHODS

A systematic search on OVID Medline^® based on a pre-existing search strategy returned 1333 publications. Having defined inclusion and exclusion criteria and analysis of the relevant full texts, 167 publications were included in the descriptive analysis and 163 in the meta-analysis. For this purpose, different subgroups were created, based on the type of cyst and the therapeutic procedure. Those subgroups were then analysed in relation to their healing rates, the number of recurrences and complication rates.

RESULTS

For aneurysmal bone cysts, both surgical removal and Doxycycline injection lead to excellent outcomes (98% healing) and low recurrence rates (6% and 11% resp.). Curettage (91% healing), including its combination with autologous cancellous bone graft (96% healing), showed very good healing rates but higher recurrence rates (22% and 15%, resp.), which were however improved by preoperative selective arterial embolization. A critical view must be taken of radiotherapy (90% healing) and the injection of alcohol (92% healing) because of their high complication rates (0.43/cyst and 0.42/cyst, resp.). In the management of juvenile bone cysts, surgical interventions like curettage and cancellous bone graft (87% healing) are far superior to non-surgical approaches (51% healing), furthermore, the application of autologous cancellous bone graft reduced the recurrence rate (3% recurrence) compared to curettage alone (20% recurrence). In subgroup analysis, treatment by ESIN was found to produce excellent outcomes (100% healing), though the patient collectives were small.

CONCLUSION

Surgical procedures to treat aneurysmal bone cysts appear to be the method of choice whereby Doxycycline injection may be an alternative. A surgical approach should be preferred in the treatment of juvenile bone cysts.

Outcomes in Unicameral Bone Cyst Management Utilizing a Decision Tree Algorithm Approach

OBJECTIVE

To determine if utilization of a decision tree algorithm could improve the healing rate of unicameral bone cysts (UBCs).

METHODS

Creation of the decision tree algorithm was based on previous literature and assessment of our clinical practice. Demographic, treatment, and radiographic data were collected retrospectively. Radiographic healing was determined using the Neer classification. Healing rate, as well as clinical/radiographic characteristics, were compared based on adherence to the treatment algorithm.

RESULTS

Forty-seven subjects were included. Mean age at initial surgery was 10.0 ± 3.3 years in children following the algorithm and 9.1 ± 3.2 years in those deviating from the algorithm (p = 0.393). Follow-up was found to be similar among those following the algorithm (37.5 ± 15.8 months) and those deviating from the algorithm (45.2 ± 24.6 months), p = 0.38. Children who followed the algorithm healed at a rate of 75%, while children who deviated from the algorithm healed at a rate 67% (p = 0.552).

CONCLUSIONS

Although we reject our hypothesis that a decision tree algorithm for the management of UBCs in the pediatric population could improve the healing rate, we believe that we uncovered some utility in applying an algorithm to this pathology. Our algorithm was designed to minimize risk to the child and maximize healing with the least number of surgical events. Treating surgeons should consider this proposed pathway to determine the best treatment and to help families understand that these lesions rarely heal with a single-event surgery.

Current trends in the treatment of supracondylar fractures of the humerus in children: Results of a survey of the members of European Paediatric Orthopaedic Society

PURPOSE

The purpose of this study was to evaluate the current trends in the treatment of supracondylar humerus fractures as well as the preferred post-operative follow-up protocol among members of the European Paediatric Orthopaedic Society.

METHODS

The survey was composed by four main domains and 26 items: (1) surgeon information (3 items); (2) treatment (8 items); (3) post-operative treatment (3 items); and (4) factors influencing the outcome (12 items). All active members of European Paediatric Orthopaedic Society were invited by email to answer an electronic questionnaire.

RESULTS

The survey was submitted to 397 European Paediatric Orthopaedic Society active members; 184 members answered (46.3%) the questionnaire. Among respondents, 64.1% declared >10 years of experience and 55.4% declared to treat >20 supracondylar humerus fractures per year. Closed reduction, percutaneous pinning, and supine position were the preferred treatment option for Gartland type II and III supracondylar humerus fractures by 79.9%, 95.5%, and 84.8% of respondents, respectively. Supracondylar humerus fractures are treated within 24 h from trauma by 33.2% of respondents. Pins are removed 4 weeks from index procedure by 58.2% of respondents. Fracture type (72.3%), surgeon experience, and (71.2%) are of "crucial importance" for expected outcome of supracondylar humerus fractures treatment.

CONCLUSION

Surgeon experience, type of fracture, treatment modality, and pins configuration were considered the main factors potentially influencing the outcome of supracondylar humerus fractures. European Paediatric Orthopaedic Society members agreed on the treatment modality of Gartland type II and III supracondylar humerus fractures, patient positioning, and timing of hardware removal. Other important issues such as timing of surgery, pins configuration, surgical approach, and post-operative protocol are still debated.

LEVEL OF EVIDENCE

level II.

Unicameral Bone Cysts: Review of Etiopathogenesis and Current Concepts in Diagnosis and Management

Objective

This article aims to review the epidemiology, etio-pathogenesis and updates in clinical diagnostics and management of unicameral bone cysts (UBC).

Methods

A computerized literature search using Cochrane database of systematic reviews, EMBASE and PubMed was performed. MeSH (Medical Subject Headings) terms used in searches included the following sub-headings: "unicameral bone cyst", "epidemiology", "etiology", "pathogenesis", "diagnosis", "management" and "surgery". Studies were analyzed based on clinical relevance for the practicing orthopedic surgeon.

Results

UBC accounts for 3% of all bone tumors and is asymptomatic in most cases. Nearly 85% of cases occur in children and adolescents, with more than 90% involving the proximal humerus and proximal femur. Despite multiple theories proposed, the exact etiology is still unclear. Diagnosis is straightforward, with radiographs and MRI aiding in it. While non-surgical treatment is recommended in most cases, in those warranting surgery, combined minimal-invasive techniques involving decompression of cyst and stabilization have gained importance in recent times.

Conclusion

There is variation in the diagnosis and treatment of UBCs among surgeons. Due to the vast heterogeneity of reported studies, no one method is the ideal standard of care. As most UBCs tend to resolve by skeletal maturity, clinicians need to balance the likelihood of successful treatment with morbidity associated with procedures and the risks of developing a pathological fracture.

Study Design

Review Article.

Proximal Humerus Fractures in the Pediatric Population

PURPOSE OF REVIEW

The purpose of this review is to review recent literature focusing on proximal humerus anatomy, epidemiology of these fractures, diagnosis and treatment options, and clinical outcomes.

RECENT FINDINGS

Non- or minimally displaced proximal humerus fractures treated nonoperatively do not lead to short- or long-term complication and do not cross over to operative treatment. There is a higher rate of operative management with older age, increased injury severity score, treatment at an adult hospital, and private insurance. Operative management is preferred with closed or open reduction and percutaneous pinning, but elastic nailing and plate fixation are other options with good postoperative outcomes. Pediatric proximal humerus fractures occur after fall onto the affected shoulder or arm. Diagnosis is usually made with radiographs. Understanding the proximal humerus anatomy is critical to the proper management of these injuries to aid reduction and predict remodeling potential. There is considerable debate around the management of proximal humerus fractures in the pediatric population. Treatment is based on patient age, fracture displacement, and remodeling capacity. Nonoperative management is successful in younger patients or less displaced fractures, and operative management is usually considered in older patients with more displaced fractures.

Minimally Invasive Treatment for Unicameral Bone Cysts with Chemical Sclerosis and Bone Graft Substitute: A Preliminary Report

PURPOSE

Unicameral bone cysts (UBCs) are benign lesions that primarily occur in childhood and can present with pain, pathologic fracture and growth disturbances. Existing treatment approaches for the management of UBCs are highly variable and recurrence is not uncommon. This study seeks to evaluate near-term outcomes of an image-guided, minimally invasive combination of chemical sclerotherapy and synthetic grafting as a novel outpatient management treatment option for UBCs.

MATERIALS AND METHODS

Retrospective evaluation from August 2018 to July 2020 of fourteen pediatric patients, ages 5-14 years, undergoing treatment for a UBC, at a single institution. All UBCs were treated in a single, minimally invasive, image-guided procedure using percutaneous needle access into the UBC followed by chemical sclerotherapy and injection of regenerative synthetic graft. Patients were followed clinically and with serial radiographs to evaluate for healing and complications, with an average follow-up of 13.7 months. Descriptive statistics were performed.

RESULTS

Twelve of 14 (85.7%) patients showed Modified Neer classification class 1 or 2 healed cysts at their most recent follow-up. There were two recurrences. All patients were pain-free and returned to normal physical activity on average within 2.0 months, and all patients with healed cysts remained asymptomatic at the most recent follow-up. There were no complications related to the procedures.

CONCLUSIONS

Image-guided chemical sclerosis and bone grafting is a minimally invasive treatment option for unicameral bone cysts and compares favorably to other existing treatment options. The preliminary findings of this technique are promising as an alternative management option for UBCs.

Diagnosis and treatment of flexible flatfoot: results of 2019 flexible flatfoot survey from the European Paediatric Orthopedic Society

The aim of the study was to evaluate flexible flatfoot (FFF) diagnostic and current therapeutic modalities, as well as treatment expectations, among members of the European Paediatric Orthopaedic Society (EPOS). A 59-questions survey on FFF diagnosis and treatment preferences was distributed to EPOS members. The survey consisted of six sections (1) general clinical parameters; (2) foot aspects; (3) X-ray angles (or lines); (4) expectations; (5) standard clinical assessment; and (6) management options. Descriptive statistics were performed. A total of 93 responses were analysed. In general, clinical parameters, age (91.4% of cases), laxity (81.7%), diffuse pain (84.9%), and pain at the ankle joint (81.7%) were rated as 'average' and 'crucial importance' by the vast majority of respondents. Meary's angle (47.3% of cases), talonavicular coverage (35.5%), and lateral talocalcaneal angle (35.5%) were assessed as main radiological tools in the FFF evaluation. Among respondents, 61.3% rated 'improved ability to walk longer without symptoms' as of 'crucial importance'. Eighty-two percent of the respondents felt less than 10% of patients with FFF are candidates for corrective surgery. Arthroereisis (29.3%) was the most common surgical procedure (16.4% for subtalar and 12.9% for extra-articular arthroereisis, respectively), followed by lateral column lengthening (17.9%) and medializing calcaneal osteotomy (12.3%). There is great variation among respondents in diagnostic and treatment preferences in the management of children with FFF. The results of the EPOS 2019 FFF survey clearly show that large-scale, multicentric, international studies are necessary to elucidate which diagnostic and treatment practices lead to the best outcomes.

Impact of the COVID-19 pandemic on patients suffering from musculoskeletal tumours

BACKGROUND

The aim of the current study was to evaluate the impact of the coronavirus disease (COVID-19) pandemic on musculoskeletal tumor service by conducting an online survey of physicians.

METHODS

The survey was conducted among the members of the ISOLS (International Society of Limb Salvage) and the EMSOS (European Musculo-Skeletal Oncology Society). The survey consisted of 20 questions (single, multiple-response, ranked): origin and surgical experience of the participant (four questions), potential disruption of healthcare (12 questions), and influence of the COVID-19 pandemic on the particular physician (four questions). A matrix with four different response options was created for the particular surgical procedures).

RESULTS

One hundred forty-nine physicians from five continents completed the survey. Of the respondents, 20.1% and 20.7% stated that surgery for life-threatening sarcomas were stopped or delayed, respectively. Even when the malignancy was expected to involve infiltration of a neurovascular bundle or fracture of a bone, still 13.8% and 14.7% of the respondents, respectively, stated that surgery was not performed. In cases of pending fractures of bone tumors, 37.5 to 46.2% of operations were canceled.

CONCLUSION

The SARS-CoV-2 pandemic caused a significant reduction in healthcare (surgery, radiotherapy, chemotherapy) for malignancies of the musculoskeletal system. Delaying or stopping these treatments is life-threatening or can cause severe morbidity, pain, and loss of function. Although the coronavirus disease causes severe medical complications, serious collateral damage including death due to delayed or untreated sarcomas should be avoided.