eMedicine Specialties > Orthopedic Surgery > Neoplasms
Unicameral Bone Cyst: Treatment
Updated: Apr 8, 2008
Treatment
Medical Therapy
Nonoperative treatment of UBCs usually amounts to closed fracture care following pathologic fracture through the lesion. It has been suggested that in as many as approximately 25% of cases, spontaneous healing of the cyst may occur following such pathologic fractures.27 Not all authors have reported such a high percentage of spontaneous healing. Thus, watchful waiting and routine fracture care only are not a universally accepted treatment option.7,8,20,38,39,40,41,42,43,44,45
Surgical Therapy
Surgical therapy of a UBC may be divided into open and percutaneous procedures. Success of such procedures has been quite varied, and the very definition of success has also varied from author to author.7,8,38,39,40,41,44,45,46A study by Spence et al of 144 UBCs that were treated by curettage and packing with freeze-dried, crushed, cortical-bone allograft demonstrated a higher recurrence rate in patients younger than 10 years, female patients, those with active cysts, and those with incompletely packed cysts.47 Notably, of the cysts that were completely packed, 88% healed. The authors suggested these data showed freeze-dried allogeneic crushed cortical bone was superior relative to similarly processed cancellous bone but comparable to the results achieved with fresh autogenous cancellous bone.47 Other studies have also demonstrated multiloculated cysts and fracture immobilization as a primary treatment as associated with cyst recurrence and/or persistence.
Neer and his coauthors stressed that reported recurrence rates in UBC surgery could be quite misleading if complete cyst obliteration was the criterion for success.48 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.48 The key aspects of the Neer rating system for the purposes of evaluating treatment response are as follows39 :
- 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.49 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).49 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.50 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 3 patients who suffered humeral growth disturbances and 7 patients whose bones fractured during the procedure (although 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, 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 treatment techniques
Interest in percutaneous treatment techniques for a UBC has been rather strong for the last few decades.
In 1974, Scaglietti introduced his procedure by which steroids were percutaneously instilled within UBCs (as well as other types of bone lesions).51 A minimum of 40 mg of methylprednisolone acetate was used for smaller cysts in young patients, and up to 200 mg was used for larger cysts in older patients. The described technique included, on average, 3 or 4 injections in a period of 12-20 months, but as many as 9 injections over 4 years were used.51
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.51 Twenty-four percent of their patients required only 1 injection, whereas 76% required multiple steroid injections. Image 3 shows the typical appearance of the fluid aspirated from UBCs.
Simple mechanical disruption of the cyst wall has also been investigated as a treatment option for UBCs. Komiya and his colleagues called this trepanation, and they reported good results in 91% (10/11) of their patients.52 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.
Many other authors have reported their results and suggested refinements of the percutaneous steroid technique.41,42,45,53,54,55,56 Rosenberg et al emphasized the importance of eliminating fibrous or osseous septa within UBCs to facilitate bathing the entire lesion with the injected steroids.57 Capanna et al also pointed out that contrast examination allows the surgeon to identify noncontiguous septated areas of UBCs.58 Image 4 illustrates intraoperative contrast evaluation of a UBC. This is important if optimizing the treatment response is desired.58 Injectable materials other than steroids, such as alcohol-based fibrosing agents, have also been suggested as treatment options for benign bone cysts.59,60
Killian and his coauthors also reported the use of demineralized bone matrix via a similar percutaneous technique.61 No steroids were used. Eight-two percent (9/11) of their patients demonstrated completely healed cysts at 2-year follow-up.
In the past decade or so, several authors have investigated the effectiveness of autologous bone marrow injection as a treatment for UBCs.7,62 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.63 Highlights of their technique include the following64 :
- 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 cc)
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.62,64 Yandow noted that 83% (10/12) of her patients with UBCs responded satisfactorily to the procedure,62 and Delloye et al had good results in approximately 88% (7/8) of their patients.64 Kose and his fellow Turkish researchers evaluated the outcome of the autologous bone marrow procedure in 12 of their patients.65 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.65
Few comparative studies have been conducted regarding the various treatment alternatives for individuals with UBCs. Farber and Stanton performed a retrospective study of 36 patients with UBCs who were surgically treated over a period of 45 years at the Alfred I. DuPont Institute.27 Curettage and bone grafting (with some patients receiving allograft and others receiving autograft) was associated with a 53% (10/19) healing rate, whereas aspiration and injection with steroid yielded a 70% (12/17) success rate. Twenty-five percent (3/12) of the patients required only one injection.27 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. 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.27
Oppenheim and Galleno evaluated 37 patients treated via open surgical techniques (35 curettage and bone grafting and 2 subperiosteal total or subtotal resection) versus 20 patients treated via steroid injection.40 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.40 Although not calculated by the authors, this difference in recurrence rates is statistically significant (P <0.02 via the Fisher exact test). These same authors used reconstitution of cortical thickness as their endpoint of healing rather than cyst obliteration.
Glaser and his colleagues published a comparative study focused on calcaneal UBCs.11 The calcaneus is a somewhat uncommon site (the third to sixth most common site for a UBC) for UBC.10,11,15,66 Glaser et al's multicenter study suggested that percutaneous steroid injection procedures were less effective in the calcaneal lesions, and the authors believed that curettage and bone grafting may be a more predictable and successful procedure for simple bone cysts in this location.11
Although not a new concept by any means, good results have been reported with flexible intramedullary nailing of UBCs in long bones.67,68 Roposch and his coworkers reported a 94% (30/32) good response rate to flexible nailing of UBCs of the long bones.68 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.68,69,70 However, 28% of patients in Roposch et al's study required at least one further operation due to inadequate nail length in the face of continued bone growth.68
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 MRI.71 Growth arrest has also been reported following treatment either by local injection of steroid or curettage and bone grating.4 Growth disturbance leading to angular deformity or disturbed longitudinal growth has been estimated to possibly 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.72
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Further Reading
Keywords
UBC, simple bone cyst, solitary bone cyst, bone cyst, solitary unicameral bone cyst, benign bone cyst, essential bone cyst, aneurysmal bone cyst
