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Unicameral Bone Cyst Treatment & Management

  • Author: Charles T Mehlman, DO, MPH; Chief Editor: Harris Gellman, MD  more...
 
Updated: Apr 21, 2015
 

Medical Therapy

Nonoperative treatment of a unicameral bone cyst (UBC) usually amounts to closed fracture care following pathologic fracture through the lesion. It has been suggested that in as many as 25% of cases, spontaneous healing of the cyst may occur after such pathologic fractures.[28] However, not all authors have reported such a high frequency of spontaneous healing. Thus, watchful waiting and routine fracture care only are not a universally accepted treatment option.[7, 8, 20, 39, 40, 41, 42, 43, 44, 45, 46]

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Surgical Therapy

Surgical therapy for a UBC may be divided into open and percutaneous procedures. The success rates of such procedures have varied considerably, and the very definition of success has also varied from author to author.[7, 8, 39, 40, 41, 42, 45, 46, 47]

Open procedures

In a study of 144 UBCs treated by curettage and packing with freeze-dried, crushed, cortical-bone allograft, Spence et al demonstrated higher recurrence rates in patients younger than 10 years, female patients, those with active cysts, and those with incompletely packed cysts.[48] Of the completely packed cysts, 88% healed. The authors suggested that freeze-dried allogeneic crushed cortical bone yielded results superior to those of similarly processed cancellous bone but comparable to those of fresh autogenous cancellous bone.

Other studies have also demonstrated multiloculated cysts and fracture immobilization as a primary treatment as associated with cyst recurrence and/or persistence.

Neer et al stressed that reported recurrence rates in UBC surgery could be quite misleading if complete cyst obliteration was the criterion for success.[49] They believed that true recurrences were characterized by the cyst cavity reappearing and enlarging, causing expansion and thinning of the cortex and the threat of fracture.

The key aspects of the Neer rating system for the purposes of evaluating treatment response are as follows[40] :

  • Excellent – Complete obliteration of the cyst
  • Residual defect – One or more static cystlike areas with good reestablishment of bone strength
  • Reoperation – Subsequent operation required due to recurrence

Open techniques that have been reported include subtotal resection with and without bone grafting. Different bone-grafting materials that have been used include autograft, allograft, demineralized bone matrix, high-porosity hydroxyapatite bone grafting material, and plaster-of-paris pellets.

Subtotal resection with and without grafting

In 1962, Fahey and O'Brien introduced a technique for UBC treatment that they referred to as subtotal resection and grafting.[50] The described technique involved subperiosteal exposure of the cyst and a portion of the adjacent normal bone, followed by removal of two thirds to four fifths of the cyst. Cortical struts of bone graft harvested from the patient's iliac crest or tibia were then used to fill the defect. Freeze-dried allograft was also used at times.

At an average of almost 4 years' follow-up, Fahey and O'Brien reported a 95% (19/20) success rate with their technique (using absence of cyst as their criterion).[50] They considered the operation to be the procedure of choice for individuals with latent primary cysts and for persons with cysts that have recurred following conventional operation. One patient required repeat grafting to achieve healing, and no other specific complications were reported with the technique.

Fifteen years later, McKay and Nason reported on a similar subtotal resection approach to UBCs but without bone grafting.[51] Their technique yielded a 90% (19/21) success rate (also defined as complete cyst obliteration). No infectious or neurocirculatory complications were reported, but the authors did identify three patients who suffered humeral growth disturbances and seven patients whose bones fractured during the procedure (though this did not substantively affect their later outcome).

Subtotal resection and bone grafting thus remains an option for UBC treatment. The procedure certainly carries with it a higher level of surgical morbidity than other procedures do, and the surgeon's enthusiasm for the procedure may be directly proportional to the cyst's distance from the growth plate.

Curettage and bone grafting procedures have been used extensively in the treatment of a UBC.

Percutaneous procedures

In 1974, Scaglietti introduced a procedure by which steroids were percutaneously instilled within UBCs (as well as other types of bone lesions).[52] A minimum of 40 mg of methylprednisolone acetate was used for smaller cysts in young patients, and as much as 200 mg was used for larger cysts in older patients. The described technique included, on average, three or four injections in a period of 12-20 months, but as many as nine injections over 4 years were used.

Scaglietti et al reported complete healing of the bone cysts in 55% of his cases and 45% with some improvement, such as cortical thickening within the area of the cyst or areas of new bone formation within the cyst.[52] Whereas 24% of their patients required only one steroid injection, 76% required multiple injections. The image below shows the typical appearance of the fluid aspirated from UBCs.

Typical appearance of cyst fluid is depicted. Init Typical appearance of cyst fluid is depicted. Initial aspiration often yields thin, clear, yellow fluid that rapidly becomes blood-tinged.

Simple mechanical disruption of the cyst wall has also been investigated as a treatment option. Komiya et al called this trepanation, and they reported good results in 91% (10/11) of their patients.[53] The technique consisted of aspiration of the cyst until venous hemorrhage became visible, perfusion of the cyst with saline, and cyst wall as well as proximal and distal medullary bone drilling with a Kirschner wire (K-wire).

Chigira et al reported similar success with multiple drilling in 86% (6/7) of their patients.[17] Their technique included leaving the 2.0-mm K-wires in place in some instances to allow drainage of the fluid through the cyst wall.

Various other authors have reported their results and suggested refinements of the percutaneous steroid technique.[42, 43, 46, 54, 55, 56, 57, 58, 59] Rosenberg et al emphasized the importance of eliminating fibrous or osseous septa within UBCs to facilitate bathing the entire lesion with the injected steroids.[60]

Capanna et al also pointed out that contrast examination allows the surgeon to identify noncontiguous septated areas of UBCs (see the image below).[61] This is important if optimizing the treatment response is desired.[61]

Double-cannula technique demonstrates intraoperati Double-cannula technique demonstrates intraoperative use of contrast material for evaluation of cyst's interior. In this case, large partial septum remains along inferior portion of cyst.

Injectable materials other than steroids, such as alcohol-based fibrosing agents, have also been suggested as treatment options for benign bone cysts.[62, 63]

Killian et al also reported the use of demineralized bone matrix via a similar percutaneous technique.[64] No steroids were used. At 2-year follow-up, 82% (9/11) of their patients demonstrated completely healed cysts.

Several authors have investigated the effectiveness of autologous bone marrow injection as a treatment for UBCs.[7, 65] Spurred on by their earlier published work, a group of Israeli researchers reported marked improvement in cortical thickness and cyst remodeling in 10 of their patients following a single bone marrow injection.[66] Highlights of their technique include the following[67] :

  • A single puncture into the cyst with a thin trocar or needle
  • Aspiration of cyst fluid, which is sent for pathologic analysis
  • Disruption of the lining and septations within the cyst using the trocar or needle
  • Contrast media examination (may be used)
  • Injection of autologous bone marrow aspirated from the iliac crest (average volume, 25 mL)

All cysts healed completely with one procedure within 6-12 months.[7]

Other authors have demonstrated similar results with the percutaneous bone marrow injection procedure.[65, 67] Yandow noted that 83% (10/12) of patients with UBCs responded satisfactorily to the procedure,[65] and Delloye et al had good results in approximately 88% (7/8) of their patients.[67]

Kose et al evaluated the outcome of the autologous bone marrow procedure in 12 patients.[68] Only 42% (5/12) cases responded to the treatment, whereas 50% (6/12) recurred and 8% (1/12) exhibited no response at all. These authors concluded that the technique may be less effective in large cysts and in multiloculated cysts, and they recommended that the procedure be applied to selected patients only.

A Cochrane review published in September 2014 concluded that the available evidence was not sufficient to allow a determination of the relative merits of bone marrow injections and steroid injections for treatment of UBCs in the long bones of children.[69]

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Complications

Injury to the growth plate (physis) may occur secondary to direct cyst expansion, pathologic fracture, or unintended mechanical disturbance during surgical intervention.

Direct cyst expansion across the growth plate and into the epiphysis of the proximal humerus has been well documented by Gupta and Crawford via magnetic resonance imaging (MRI).[70] Growth arrest has also been reported following treatment either with local steroid injection or with curettage and bone grafting.[4] Growth disturbance leading to angular deformity or disturbed longitudinal growth has been estimated to occur in approximately 14% of cases.[7, 8]

Steroid injection has been a successful treatment, even in the setting of cyst extension into the epiphysis.[71]

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Outcome and Prognosis

The overall outcome and prognosis of a UBC is good. The lesion is believed to resolve spontaneously in most cases if given enough time.

Cases that present to the orthopedic surgeon are typically patients who demonstrate a combination of a cyst that has caused cortical thinning and the right stressful event (eg, being tackled while playing football). In general, treatment may be summarized as doing nothing more than trying to promote natural healing. The flexible intramedullary nail studies mentioned earlier may do nothing more than mechanically support the bone while the natural healing process occurs.

Few comparative studies have been conducted regarding the various treatment alternatives for individuals with UBCs.[28, 72, 73, 74] Some of the more important ones are summarized below.

In a retrospective study of 36 patients with UBCs who were surgically treated over a period of 45 years,[28] Farber and Stanton found that curettage and bone grafting (with some patients receiving allograft and others receiving autograft) yielded a 53% (10/19) healing rate, whereas aspiration and injection with steroid yielded a 70% (12/17) success rate. In 25% (3/12) of the patients, only one injection was required. Although this difference in overall healing rates might appear clinically significant, it was not statistically significant.

Farber and Stanton also did not explicitly define their criteria for success.[28] Because of the similar healing rates and the lower morbidity of the steroid injection, the authors concluded that they favored the percutaneous approach over traditional open curettage and bone grafting.

In a retrospective review, Canavese et al compared the outcomes of percutaneous curettage, intralesional injection of methlyprednisolone, and intralesional injection of bone marrow.[75] The three treatment groups included 46 patients with radiologically confirmed unicameral bone cysts and at least 2 years of follow-up. Results showed that the rate of satisfactory healing was 70% in the percutaneous curettage group, 21% in the bone marrow injection group, and 41% in the methylprednisolone group.

Oppenheim and Galleno evaluated 37 patients treated via open surgical techniques (35 with curettage and bone grafting and two with subperiosteal total or subtotal resection) against 20 patients treated via steroid injection.[41] They found a 40% recurrence rate and a 15% major complication rate in their open group, whereas the steroid injection group had only a 5% recurrence rate and a 5% major complication rate.

Although not calculated by the authors, this difference in recurrence rates was statistically significant (P < 0.02 via the Fisher exact test).[41] These same authors used reconstitution of cortical thickness as their endpoint of healing rather than cyst obliteration.

Glaser et al published a comparative multicenter study focused on calcaneal UBCs.[11] The calcaneus is a somewhat uncommon (ie, the third to sixth most common) site for UBC.[10, 11, 15, 76] The study by Glaser et al suggested that percutaneous steroid injection procedures were less effective in the calcaneal lesions and that curettage and bone grafting may be a more predictable and successful procedure for simple bone cysts in this location.[11]

Flexible intramedullary nailing of UBCs in long bones, though not a new concept by any means, has been reported to yield good results.[77, 78] Roposch et al documented a 94% (30/32) good response rate to flexible nailing of UBCs of the long bones.[78] Complete cyst healing or healing with minor residual lucent areas occurred at an average of 36 months. Thus, this technique appears to support the compromised bone while the UBC follows its natural history and spontaneously resolves.

Some authors have stated that they believe such flexible nails allow continuous decompression of the UBC, with a resulting decrease in intralesional pressure.[78, 79, 80] However, 28% of patients in a study by Roposch et al required at least one further operation because of inadequate nail length in the face of continued bone growth.[78]

In a systematic review and meta-analysis by Kadhim et al that included 62 studies and 3211 patients with 3217 UBCs, active treatment of these lesions (eg, curettage, grafting, injection of steroid or bone marrow, flexible intramedullary nailing, and continuous decompression with cannulated screws) was associated with variable healing rates, and the outcomes were favorable in comparison with conservative treatment.[81]

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Future and Controversies

Despite the extensive literature available on this common benign bone tumor, much remains to be learned about UBCs. As Bensahel stated, "The solitary bone cyst has not revealed all its secrets."[82] Among the questions that remain to be answered are the following:

  • What is the root cause of the UBC lesion?
  • Does a genetic basis to the problem exist?
  • Should pathologic fractures of the long bones (secondary to a UBC) be treated via immediate flexible intramedullary nailing?

Answering these and similar questions will require a far more coordinated research effort than has been made to date. A multicenter study (a combined effort of the Shriner's Hospital System and the Pediatric Orthopaedic Society of North America) holds some promise of refining the treatment approach to a UBC.

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Contributor Information and Disclosures
Author

Charles T Mehlman, DO, MPH Professor of Pediatrics and Pediatric Orthopedic Surgery, Division of Pediatric Orthopedic Surgery, Director, Musculoskeletal Outcomes Research, Cincinnati Children's Hospital Medical Center

Charles T Mehlman, DO, MPH is a member of the following medical societies: American Academy of Pediatrics, American Fracture Association, Scoliosis Research Society, Pediatric Orthopaedic Society of North America, American Medical Association, American Orthopaedic Foot and Ankle Society, American Osteopathic Association, Arthroscopy Association of North America, North American Spine Society, Ohio State Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Sean P Scully, MD 

Sean P Scully, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, International Society on Thrombosis and Haemostasis, Society of Surgical Oncology

Disclosure: Nothing to disclose.

Chief Editor

Harris Gellman, MD Consulting Surgeon, Broward Hand Center; Voluntary Clinical Professor of Orthopedic Surgery and Plastic Surgery, Departments of Orthopedic Surgery and Surgery, University of Miami, Leonard M Miller School of Medicine, Clinical Professor, Surgery, Nova Southeastern School of Medicine

Harris Gellman, MD is a member of the following medical societies: American Academy of Medical Acupuncture, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Society for Surgery of the Hand, Arkansas Medical Society

Disclosure: Nothing to disclose.

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Large proximal humeral unicameral bone cyst demonstrates early cortical healing following pathologic fracture.
Large unicameral bone cyst of pelvis. Pathologic fracture is depicted. Note extension of cyst into region of proximal femoral physis.
Typical appearance of cyst fluid is depicted. Initial aspiration often yields thin, clear, yellow fluid that rapidly becomes blood-tinged.
Double-cannula technique demonstrates intraoperative use of contrast material for evaluation of cyst's interior. In this case, large partial septum remains along inferior portion of cyst.
 
 
 
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