Continuous decompression with intramedullary nailing for the treatment of unicameral bone cysts

Purpose  To evaluate the efficacy of decompression of unicameral bone cysts (UBCs) of the long bones with intramedullary nailing and to compare responses to treatment according to location. Materials and methods  We evaluated 48 consecutive patients treated between January 1988 and June 2000. Mean age was 10.3 years. Mean follow-up was 9.8 years. Evaluation was performed according to the radiographic criteria of Capanna. Results  UBCs were located in the proximal humerus (n = 24), humeral shaft (n = 2), proximal femur (n = 19), distal tibia (n = 2) and fibula (n = 1). A total of 62.5% presented a pathological fracture. Successful results were observed in 89.5% (26 total healing, 17 healing with residual radiolucent areas), and there were four recurrences and, in one case, no response to treatment. There was more healing in the humerus than in the femur (92.3% versus 84.2%), and more tendency to restitution ad integrum, although the difference was not statistically significant (P = 0.1499). Conclusions  Intramedullary nailing is a minimally invasive method, which permits early stability and decompresses the cyst allowing healing. Significant differences were not observed among results from different locations.     

Unusually large solitary unicameral bone cyst: case report

A 15-year-old boy presented with complaints of pain and swelling of the right leg. Radiography revealed a large lytic lesion involving the proximal half of the tibia. The patient was taken to surgery, where the cavity was curetted and packed with allogeneic bone graft. Tissue was sent for histopathological evaluation. The patient was kept in an above-knee cast for 4 months, after which partial weight-bearing was allowed. The histopathological diagnosis was a unicameral bone cyst. A radiograph at 1 year showed incorporation of the graft, but a small part of the cavity was still visible and there was a persistent discharge. The patient was again subjected to allogeneic bone grafting in the remaining cavity. At 3.5 years of follow-up now, the patient is walking unsupported, there is no pain, and the radiograph shows complete obliteration of the cavity. Unicameral bone cysts are usually a few centimeters in size. To the best of our knowledge, a unicameral bone cyst of such a large size has never been reported in the literature.     

Flexible but stable intramedullary nailing for unicameral bone cysts of the humerus in juveniles

Objective  Prevention of fracture and healing of bone cysts in juveniles as well as stabilization and healing of pathologic fractures maintaining anatomic alignment. Preservation or restoration of function of upper limb. Indications  Unicameral bone cysts of the humerus in adolescents with or without pathologic fracture. Contraindications  Other bone tumors. Uncertain imaging results not allowing an unambiguous diagnosis of a bone cyst. Surgical Technique  Percutaneous biopsy and frozen section. Intramedullary introduction of Ender nails under fluoroscopy from distal to proximal taking care not to violate the growth plate. Postoperative Care  Clinical and radiographic follow-up examination every 6–12 months. Results  21 patients operated between 1989 and 1997 were followed up for an average of 58.5 (25–105) months. A healing was observed in 20 patients (95%) after 3–96 (average 32) months. No refracture occurred during the postoperative period. One child suffered a recurrence of the bone cyst.     

Flexible intramedullary nailing for unicameral cysts in children’s long bones

Purpose  The purpose of this study was to evaluate the outcome of flexible intramedullary nailing for unicameral bone cysts in terms of function and osseous consolidation. Methods  Twenty-two unicameral bone cysts in children’s long bones were treated by flexible intramedullary nailing. In 13 cases the bone cyst was diagnosed in a traumatic event leading to a pathologic fracture. Fifteen patients were referred to our clinic after failed conservative treatment. In 16 patients the cyst was located in the humerus, and in 6 patients in the femur. Mean duration of follow-up after surgery was 24 months. Results  According to Capanna’s criteria healing was obtained in 20 cases with a mean time of 16 months. Sixteen cysts healed completely. Four lesions were classified as grade 2, meaning that residual radiolucencies were radiographically visible at the latest follow-up. Two recurrences of humeral cysts were seen at 16 and 18 months postoperatively. The complication rate was minimal. Conclusion  Due to the immediate stabilization of the lesion aftercare becomes facile. This method allows prompt mobilization and early weight bearing without the necessity of a plaster cast. Further it prevents effectively the most common complication, a re-fracture or a pathologic fracture. Therefore we propose this surgical procedure as the treatment of choice for unicameral bone cysts in children’s long bones. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study. M. C. Glanzmann is AO Intl. Fellow     

Distance from the growth plate and Its relation to the outcome of unicameral bone cyst treatment

Background  

Interventions to treat unicameral bone cysts vary. Nonetheless, regardless of the intervention modality, the outcome is not certain. The purpose of this study was to determine if the distance between the growth plate and the cyst can be used to predict the outcome of the treatment.     

The role of lysosomes in the pathogenesis of unicameral bone cysts.

Unicameral bone cyst fluid possesses N-acetyl-beta-D-glucosaminidase, beta-glucuronidase, PZ-peptidase, cathepsin D, acid phosphatase, N-acetyl-beta-D galactosaminidase, and beta-galactosidase activities. The activities of lysosomal enzymes in the cyst fluid are, as a rule, higher than in the serum, whereas the total protein content is lower. The content of collagen degradation products in the cyst fluid is higher compared to the serum. In bone cavity wall tissues, the collagen content is decreased. Adenosine 3':5'-cyclic phosphate and cyclic guanosine 3,5'-monophosphate accumulate in the cyst cavity. However, in some cases, there is no correlation among the activities of lysosomal enzymes in the cyst fluid, blood serum, and cyst wall tissues. The ratios of lysosomal enzyme activities in the cyst fluid differ from those in the cyst wall tissues, cultured skin fibroblasts, and blood polymorphonuclear leucocytes. The lack of coincidence of enzymatic spectra of the cyst fluid, wall tissues, and serum is suggestive of the diversity of ways of lysosomal enzyme enter the cyst cavity, i.e., blood, cyst fluid cells, and cyst cavity walls. The cysts with different locations (i.e., active and latent cysts) have similar lysosomal lytic potentials. The presence in the cyst cavity of extracellular lysosomal enzymes and collagen degradation products testifies to the permanent corrosion of the cyst cavity walls from the inside as well as to the increase in the osmotic pressure of the cyst fluid. Lysosome destruction should be regarded as an important pathogenetic factor that requires surgical or pharmacologic correction or both in the course of bone cyst management.     

Endoscopic curettage and allografting of simple bone cysts of the calcaneus in young soccer players: Report of three cases

Open curettage with bone graft has been the traditionally suggested surgical treatment for the symptomatic simple (or unicameral as they used to be called) calcaneal bone cyst. Less invasive endoscopically assisted treatment with curettage and bone grafting with allograft have recently provided less postoperative morbidity. The aim of the present study is to present our experience with this method in young soccer athletes. Between April 2014 and May 2016 three consecutive young soccer players with symptomatic calcaneal bone cysts underwent endoscopic curettage, and percutaneous injection of demineralized bone matrix allograft. The mean age was 17.3 (16, 17 and 19 years old), and the mean follow-up was 32.1 (range 24–47) months. Both radiographic and functional follow-up, using the AOFAS score, showed good to excellent results. All lesions were radiographically healed. Preoperative AOFAS score (max. 100 pts) was 78.6 ± 4.7, improving to 98.0 ± 4.1. The patients returned to their initial level of sports activities within 18.3 (range 17–19) weeks after surgery. Evidence suggests an earlier return to sports using bone substitutes. However, the present study showed that endoscopic curettage and percutaneous injection of bone allograft is also an excellent treatment option for young athletes with a symptomatic calcaneal bone cyst.Level of clinical evidence4.     

吻合血管的腓骨移植治疗股骨近端骨囊肿二次病理骨折

[目的]探索用吻合血管的腓骨移植治疗股骨近端骨囊肿二次病理骨折的疗效.[方法]用吻合血管的腓骨移植治疗14例股骨近端骨囊肿二次骨折.手术方法:将病理骨折复位后用90°或95°角钢板内固定,折叠带血管蒂的腓骨嵌入骨囊肿囊腔内,腓血管与旋股外侧血管分支吻合.在术后X线片上评价腓骨的愈合及形态的变化和骨囊肿愈合的情况.[结果]平均4.2个月移植腓骨愈合,平均10.5个月骨囊肿愈合,患肢完全负重行走.移植腓骨增粗率平均67%,术后无再骨折发生.[结论]吻合血管的腓骨移植治疗股骨近端骨囊肿并病理骨折是较理想的治疗方法.     

兔骨髓基质细胞体外成骨分化鉴定及与煅烧骨复合培养的实验研究

目的研究兔骨髓基质细胞体外向成骨细胞分化的生物学特性及其与牛煅烧骨体外复合培养的生物相容性.方法将体外培养1周的兔骨髓基质细胞向成骨细胞诱导分化,于1、2、4周时提取RNA,采用RT-PCR技术检测ALP和I型胶原mRNA表达,并对培养2周的细胞行VonKossa染色观察钙结节形成;另制备细胞-煅烧骨复合物,继续培养1、7、14 d后取出,扫描电镜观察及X射线衍射仪检测.结果体外诱导培养2、4周后,兔骨髓基质细胞成功表达ALT和I型胶原,VonKossa染色可见钙结节形成.扫描电镜及X射线衍射分析证实细胞在煅烧骨表面大量贴附成活,14 d后细胞铺满支架表面,合成并分泌胶原纤维及钙盐.结论兔骨髓基质细胞体外可成功向成骨细胞诱导分化,成骨特性表达佳;与牛煅烧骨体外复合培养显示良好的生物相容性.     

Aneurysmal bone cysts of the spine

Summary Aneurysmal bone cysts of the spine are uncommon. In the English language literature, there have been less than one hundred reported cases. We present five examples, all of which arose in a vertebral body. One case is the first reported arising from the coccyx; one presented at the sixth thoracic vertebral body with complete paraplegia and two with extremely large abdominal masses and catastrophic bleeding during attempted open biopsy. All were resected by a one-stage anterior or combined anterior-posterior approach. Two cases were treated with preoperative irradiation because of profuse, life-threatening bleeding during biopsy, and 4 weeks later complete anterior excision was carried out without difficulty.

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Résumé Les kystes anévrysmaux du rachis ne sont pas fréquents. Il y en a moins de cent rapportés dans la littérature de langue anglaise. Nous en présentons ici 5 cas, tous localisés au niveau d'une vertèbre. L'un d'entre eux est le premier cas publié atteignant le coccyx, un autre était situé sur la sixième vertèbre dorsale entraînant une paraplégie complète et deux déterminaient une volumineuse tuméfaction abdominale qui entraîna, lors de la biopsie, une très abondante hémorragie. Tous furent réséqués en un temps par voie antérieure ou par voie combinée, antérieure et postérieure. Une irradiation pré-opératoire fut effectuée dans deux cas en raison du saignement profus, mettant la vie en danger, survenu durant la biopsie. Quatre semaines plus tard une excision complète par voie antérieure put être réalisée sans difficulté.

     

Aneurysmal bone cysts of the occipital bone

Two cases of aneurysmal bone cysts are reported. Each patient presented with a palpable mass in the occipital region and signs of compression of structures in the posterior fossa. One of the cases is unique, in that the aneurysmal bone cyst was associated with an epidural hematoma in the posterior fossa. The pertinent literature is reviewed.     

Aneurysmal bone cysts of the spine

Purpose

Aneurysmal bone cyst is a benign, relatively uncommon lesion, representing 1.4 % of primary bone tumors. The vertebral column is involved in 3–30 % of cases. This report describes clinical characteristics and treatment results of 18 patients with aneurysmal bone cyst of the spine.

Methods

Between 1991 and 2008, 18 patients with aneurysmal bone cyst of the spine were surgically treated in our department. The clinical records, radiographs, histologic sections, and operative reports were analyzed.

Results

There were 11 male and 7 female patients; mean age was 22.1 years (range 7–46 years). Localizations were cervical (3), cervicothoracic (2), thoracic (3), lumbar (4), and sacrum (6). Tumor was localized on the left side in 11 cases, on the right side in 2 and at midline in 5 patients. The two most common clinical features were axial pain (14 patients) and radicular pain (8 patients). Neurological signs were paraparesis in 3, monoparesis in 6. Mean duration of symptoms was 9 months (range 3 months–3 years). All patients underwent surgery: total removal was performed in 13 patients and subtotal resection in 5. Posterior (11), anterolateral (1), or combined anterior-posterior (6) approaches were used. Mean follow-up duration was 112.3 months (range 4–21 years). We detected four recurrences in subtotal excision group (4/5), and one recurrence in total excision group (1/13).

Conclusion

Treatment options for aneurysmal bone cysts are simple curettage with or without bone grafting, complete excision, embolization, radiation therapy, or a combination of these modalities. Radical surgical excision should be the goal of surgery to decrease the recurrence rate. Recurrence rate is significantly lower in case of total excision.     

A quantitative histomorphometric comparison of 40 micron thick Paragon® sections with 5 micron thick goldner sections in the study of undecalcified bone

Summary The value of quantitative histomorphometric analysis of undecalcified stained sections of bone is widely recognized. Five micron thick sections have been regarded as essential to carry out this analysis, but their production requires expensive equipment. Our laboratory was equipped initially only for the production of Paragon?-stained 40μm thick sections. These thicker sections have been used traditionally to guide the planimetric analysis of microradiographs. However, we found that they could be used for the simpler eyepiece graticule histomorphometric analysis in the same way that 5μm sections have been examined. Sequential sections from iliac bone biopsy of 12 different patients with renal osteodystrophy were examined using each method. For 7 histologic features, the analysis of the thick sections compared very well with that of the Goldner-stained thin sections. The correlation coefficients varied from 0.88 for osteoid volume to 0.99 for osteoid surface. Other features compared included active and inactive osteoclastic surface activity. Further evidence of the usefulness of these thicker sections come from three other analyses. The expected close coupling of osteoblastic and osteoclastic activity was demonstrated (N=56,r=0.87,P<0.001). For 19 additional patients, two forms of histologic evidence of the degree of hyperparathyroidism correlated very well with the measured immunoreactive PTH (r=0.93 and 0.93). Finally, normal values obtained with our method compare favorably with published normal values. Throughout this report Paragon?, a trade name, is used where we mean the toluidine blue—basic fuscin stain sold under that name by Paragon C & C Co. (Bronx, N.Y.). This stain can be made from readily available materials and is no longer available from this company.     

Nicotine modulates bone metabolism-associated gene expression in osteoblast cells

Smoking has a broad range of physiological effects, such as being a risk factor in osteoporosis, bone fracture incidence, and increased nonunion rates. Recent studies showed that nicotine has effects at the cellular level in human osteoblast cells. To identify possible mechanisms underlying nicotine-induced changes in osteogenic metabolism, we defined changes in proliferation and osteocalcin, type I collagen, and alkaline phosphatase gene expression after treating human osteosarcoma cells (MG63), with various concentration of nicotine. Nicotine affects cell proliferation in a biphasic manner, including toxic and antiproliferative effects at high levels of nicotine and stimulatory effects at low levels. Moreover, low levels of nicotine upregulated osteocalcin, type I collagen, and alkaline phosphatase gene expression. The increased cell proliferation and gene upregulation induced by nicotine were inhibited by addition of the nicotinic receptor antagonist d-tubocurarine. High nicotine concentrations downregulated the investigated genes. Our results demonstrate, for the first time, that the addition of nicotine concentrations analogous to those acquired by a light to moderate smoker yields increased osteoblast proliferation and bone metabolism, whereas the addition of nicotine concentrations analogous to heavy smokers leads to the opposite effect. The inhibition of these effects by d-tubocurarine suggests that nicotine acts via the nicotinic acetylcholine receptor (nAChR).     

Characterization of human bone cells in culture

Summary Cultures of human bone cells were established, maintained, and characterized with respect to several metabolic parameters. These studies were undertaken with a view to using the bone culture system as a means of studying mechanisms of bone metabolism. The donor patients' ages ranged from 1 to 90 years and their disease states included congenital limb anomalies, exostosis, and osteo- and rheumatoid arthritis. Cultures were maintained up to 5 months. The osteoblast-like character of these cells was confirmed with the use of measurements applied to bone cells from other systems. Analyses showed that (a) the cells' appearance resembled that of cultured osteoblasts from other animal sources, b) intracellular cAMP was stimulated by human parathyroid hormone, c) osteocalcin was detected in the medium of all tested bone cell cultures and its production was found to be stimulated by 1,25-dihydroxycholecalciferol, and d) newly synthesized collagen was almost exclusively type I. In contrast, cultures of human fibrolasts, established in one instance from tissue specimens of the same donor patient, grew faster, reached a higher limiting density, and produced a greater proportion of type III collagen than the corresponding bone cells. Furthermore, fibroblasts did not accumulate osteocalcin in their culture medium. The conditions described in this report to maintain human bone cells in culture should provide a suitable test system to study the regulation of human bone metabolism.     

Selective arterial embolisation in aneurysmal bone cysts

Summary The treatment of three cases of aneurysmal bone cyst by selective arterial embolism is described. Two cases had involvement of the pelvis and one of the knee. The 2-year follow up has been promising. Radiologically the lesion has been arrested with increased density of the cyst wall and intra-cystic trabecular new bone formation. Pain relief has been complete and up to now no surgical treatment has been required.

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Résumé Présentation de l'évolution clinique et radiologique de trois cas de kyste osseux anévrysmal, deux localisés au bassin et le troisième au genou, traités par embolisation artérielle sélective. Les résultats, avec 2 ans de recul, sont encourageants. Radiologiquement la lésion paraît stabilisée avec densification des parois et apparition de travées d'os nouveau à l'intérieur du kyste. Les douleurs ont complétement disparu et jusqu'à présent aucun geste chirurgical n'a été nécessaire.

     

Active aneurysmal bone cysts in children: possible evolution after biopsy

Purpose

The active or aggressive character in certain localisations of aneurysmal bone cysts in children requires either curettage with a considerable recurrence rate or a radical segmental excision, raising complex reconstructive challenges. Cyst maturation with subsequent ossification may be observed either spontaneously or after incisional biopsy.

Patients

Five new cases of active aneurysmal bone cysts (ABCs) with healing of the cyst after biopsy alone are reported. All patients had no treatment of the cyst after the biopsy.

Results

In two cases, the lesion initially increases in size immediately after the biopsy, and it is only secondarily that the lesion decreases in size. Four out of five cases of the spontaneous healing occurred in pelvic bone. The cysts healed after, respectively, 36, 24, 12, 32 and 12 months.

Conclusions

The emergence of these new cases of spontaneous healing encourages promoting clinical and radiological supervision after biopsy in selected cases. Unfortunately, it is impossible to predict a possible aggressive behaviour in ABCs. Then, if the lesion is quickly aggressive with clinically and radiologically increasing size after biopsy, it would be illogical and dangerous to let this ABC evolve. It would be necessary to treat it without delay. On the other hand, if the lesion moderately increased after the biopsy, it is possible to wait and observe the patient during a period of 5 months for a possible healing, if the ABC localisation is not dangerous. Of course, if the lesion does not increase in size after biopsy, there is no delay to treat it.     

神经肽Y对骨代谢调节的研究进展

在神经系统与骨代谢关系的研究中,神经肽起着重要作用,尤其是神经肽Y（Neuropeptide Y,NPY）。 NPY可通过结合其特异性Y受体,尤其是Y1受体和Y2受体,来调节成骨细胞和破骨细胞的活性,在骨的生理与病理过程中起重要作用。通过简要介绍NPY及其受体的分布特点与作用,从骨形成、骨吸收及骨愈合方面分析了NPY对骨代谢的调节作用,以期进一步加深NPY对骨代谢调节的认识。