A study of 23 unicameral bone cysts of the calcaneus: open chip allogeneic bone graft versus percutaneous injection of bone powder with autogenous bone marrow

BACKGROUND: The treatment of unicameral bone cyst varies from percutaneous needle biopsy, aspiration and local injection of steroid, autologous bone marrow, or demineralized bone matrix to curettage and open bone-grafting. The purpose of this study was to compare the results of open chip allogeneic bone graft versus percutaneous injection of demineralized bone powder with autogenous bone marrow in management of calcaneal cysts. MATERIALS AND METHODS: Twenty-three calcaneal unicameral cysts in 20 patients were treated. Lyophilized irradiated chip allogeneic bone (CAB) and autogenous bone marrow were used for treatment of 13 cysts in 11 patients, and 10 cysts in 9 patients were treated with percutaneous injection of irradiated allogeneic demineralized bone powder (DBP) and autogenous bone marrow. There were 11 males and 9 female patients with mean age of 17 years. RESULTS: The patients were followed for an average of 49.4 months. Complete healing was achieved in 9 cysts treated with chip allogeneic bone and in 5 cysts treated with powdered bone. Four cysts treated with CAB and 3 cysts treated with DBP healed with a defect. Two cysts treated with powdered bone and autogenous bone marrow were classified as persistent. No infections or pathological fractures were observed during the followup period. CONCLUSION: Percutaneous injection of a mixture of allogeneic bone powder with autogenous bone marrow is a minimal invasive method and could be an effective alternative in the treatment of unicameral calcaneal bone cysts. The postoperative morbidity was low, the hospital stay was brief, and patient's comfort for unrestricted activity was enhanced.     

Percutaneous reaming of simple bone cysts in children followed by injection of demineralized bone matrix and autologous bone marrow

The authors report the successful treatment of 19 patients (mean age 10 years) with active unicameral bone cysts using a combination of percutaneous reaming and injection of a mixture of demineralized bone matrix and autologous bone marrow. Follow-up ranged from 12 to 42 months (mean 28 months). All patients were asymptomatic at the latest follow-up. Two required a second intervention to accomplish complete cyst healing. Radiographic outcome was improved in all patients according to the Neer classification at the latest follow-up. There were no significant complications related to the procedure, nor did any fracture occur after initiation of the above regimen.     

Minimal invasive surgery for unicameral bone cyst using demineralized bone matrix: a case series

ABSTRACT: BACKGROUND: Various treatments for unicameral bone cyst have been proposed. Recent concern focuses on the effectiveness of closed methods. This study evaluated the effectiveness of demineralized bone matrix as a graft material after intramedullary decompression for the treatment of unicameral bone cysts. METHODS: Between October 2008 and June 2010, twenty-five patients with a unicameral bone cyst were treated with intramedullary decompression followed by grafting of demineralized bone matrix. There were 21 males and 4 female patients with mean age of 11.1 years (range, 3-19 years). The proximal metaphysis of the humerus was affected in 12 patients, the proximal femur in five, the calcaneum in three, the distal femur in two, the tibia in two, and the radius in one. There were 17 active cysts and 8 latent cysts. Radiologic change was evaluated according to a modified Neer classification. Time to healing was defined as the period required achieving cortical thickening on the anteroposterior and lateral plain radiographs, as well as consolidation of the cyst. The patients were followed up for mean period of 23.9 months (range, 15-36 months). RESULTS: Nineteen of 25 cysts had completely consolidated after a single procedure. The mean time to healing was 6.6 months (range, 3-12 months). Four had incomplete healing radiographically but had no clinical symptom with enough cortical thickness to prevent fracture. None of these four cysts needed a second intervention until the last follow-up. Two of 25 patients required a second intervention because of cyst.     

Unicameral bone cysts treated by injection of bone marrow or methylprednisolone

In 79 consecutive patients with unicameral bone cysts we compared the results of aspiration and injection of bone marrow with those of aspiration and injection of steroid. All were treated by the same protocol. The only difference was the substance injected into the cysts. The mean radiological follow-up to detect activity in the cyst was 44 months (12 to 108). Of the 79 patients, 14 received a total of 27 injections of bone marrow and 65 a total of 99 injections of steroid. Repeated injections were required in 57% of patients after bone marrow had been used and in 49% after steroid. No complications were noted in either group. In this series no advantage could be shown for the use of autogenous injection of bone marrow compared with injection of steroid in the management of unicameral bone cysts.     

经皮囊内注射移植自体骨髓治疗单房性骨囊肿的初步报告

目的报道经皮囊内注射移植自体骨髓治疗８例单房性骨囊肿的疗效。方法保守治疗８例单房性骨囊肿,男５例,女３例,平均年龄１０岁５个月（７～１８岁）。５例位于肱骨近端,２例位于股骨颈,１例位于股骨干。抽去囊液后注入从髂骨吸取的骨髓。结果平均用骨髓３５ｍｌ（３０～６５ｍｌ）。５ｍｌ组每个穿刺点骨髓有核细胞为（５８５±２９９）×１０９／Ｌ。计算机测量平均囊腔面积为１０９００４ｍｍ２。未见手术并发症发生。下肢治疗６周后去石膏逐渐负重。治疗后６个月内Ｘ线片示所有囊腔骨化,随访６～１７个月,平均１１个月,骨愈合满意,未见并发症发生。结论经皮囊腔内注射移植自体骨髓治疗单房性骨囊肿有效。     

Surgical management of calcaneal unicameral bone cysts

Unicameral bone cysts are not seen commonly in the calcaneus. Little is known about the etiology and natural history of these lesions. Calcaneal cysts often are symptomatic, although some of these lesions are detected as incidental findings. Treatment has been advocated based on the fear of pathologic fracture and collapse. Several published series have been divided in their favor for either open treatment or injection management. These series are small, and the optimal treatment is still in question. The current study compared the efficacy of methylprednisolone acetate injection treatment with curettage and bone grafting in the treatment of unicameral bone cysts of the calcaneus. All patients treated for unicameral bone cysts of the calcaneus during the past 7 years at two institutions were reviewed. Eleven patients met inclusion criteria. All diagnoses were confirmed radiographically or histologically. Demographic information, presenting complaints, diagnostic imaging, treatment modalities, and outcome were analyzed. Long term radiographic and subjective followup was obtained. Eighteen surgical procedures were performed on 11 patients with 12 cysts. Nine injections performed on six patients failed to show healing of the cyst. Nine cysts treated with curettage and bone grafting showed cyst healing. At mean followup of 28 months (range, 12-77 months), all 11 patients had no symptoms; there were no recurrences of the cyst in the nine patients who underwent bone grafting and persistence of the cyst in the two patients who underwent injection therapy. This review reports one of the largest series of cysts in this location. The results indicate that steroid injection treatment, although useful in other locations, may not be the best option for the management of unicameral bone cysts in the calcaneus. Curettage and bone grafting yielded uniformly good results.     

Demineralized bone implants for nonunion fractures, bone cysts, and fibrous lesions.

Demineralized bone implants were used to treat eight patients with fracture nonunion, five patients with bone cysts, and eight patients with fibrous lesions. Five of the eight patients with nonunions had had previous unsuccessful attempts at reconstruction. After fixation and implantation with either human or bovine demineralized bone, all eight fractures healed. For those patients with nonunion fractures, mean followup time was 8 years, 5 months, and longest followup was 15 years, 3 months. The cystic lesions in five patients included three typical aneurysmal bone cysts and two recurrent unicameral bone cysts. The aneurysmal bone cysts had excellent healing and bone remodeling. The two unicameral bone cysts were repacked more densely after 1 year and healed. For these patients with bone cysts, the mean followup time was 12 years, 5 months, and longest followup was 15 years, 1 month. The various fibrous lesions in seven of the eight patients were healed within 6 months, with only one requiring repacking. For these patients with fibrous bone lesions, the mean followup time was 9 years, 8 months, and longest followup was 14 years. A biopsy of the lesions in five patients was performed and in two cases showed osteoblasts and new bone around small particles of the implants. These results with long term followup show that allogeneic or xenogeneic demineralized bone implants offer a reasonable alternative for the treatment of typical nonunion fractures, bone cysts, and fibrous lesions of bone.     

Diagnosing aneurysmal and unicameral bone cysts with magnetic resonance imaging

The differential between aneurysmal bone cysts and unicameral bone cysts usually is clear clinically and radiographically. Occasionally there are cases in which the diagnosis is not clear. Because natural history and treatment are different, the ability to distinguish between these two entities before surgery is important. The authors reviewed, in a blinded fashion, the preoperative magnetic resonance images to investigate criteria that could be used to differentiate between the two lesions. All patients had operative or pathologic confirmation of an aneurysmal bone cyst or unicameral bone cyst. The authors analyzed the preoperative magnetic resonance images of 14 patients with diagnostically difficult bone cysts (eight children with unicameral bone cysts and six children with aneurysmal bone cysts) and correlated these findings with diagnosis after biopsy or cyst aspiration and contrast injection. The presence of a double density fluid level within the lesion strongly indicated that the lesion was an aneurysmal bone cyst, rather than a unicameral bone cyst. Other criteria that suggested the lesion was an aneurysmal bone cyst were the presence of septations within the lesion and signal characteristics of low intensity on T1 images and high intensity on T2 images. The authors identified a way of helping to differentiate between aneurysmal bone cysts and unicameral bone cysts on magnetic resonance images. Double density fluid level, septation, and low signal on T1 images and high signal on T2 images strongly suggest the bone cyst in question is an aneurysmal bone cyst, rather than a unicameral bone cyst. This may be helpful before surgery for the child who has a cystic lesion for which radiographic features do not allow a clear differentiation of unicameral bone cyst from aneurysmal bone cyst.     

Efficacy of aspiration and autogenous bone marrow injection in the treatment of simple bone cysts

Twenty eight patients with simple bone cyst that were treated by aspiration and percutaneous autogenous bone marrow injection were reviewed to evaluate the treatment outcome. There were 18 boys and ten girls. Their mean age was 10.9 ± 2.75 years. Single injection was performed for 16 patients; the rest had double or triple injections. There were no operative complications. The mean follow-up was 34.7 ± 6.87 months. The procedure succeeded in obtaining healing in 23 cysts (82%). Cysts with index of more than five and cortical thickness of less than 1 mm were significantly prone to pathological fractures and had significant poor results after treatment. Our results suggested that autogenous bone marrow injection is a safe and effective treatment method for simple bone cysts, but sometimes repeated injections are necessary. Cyst index and cortical thickness are good indicators for cyst aggressiveness and good predictors for treatment outcome.     

Flexible intramedullary nailing for the treatment of unicameral bone cysts in long bones

BACKGROUND: Unicameral bone cyst is characterized by its tenacity and risk of recurrence. Pathological fracture is common and is often the presenting symptom. The objective of the present study was to evaluate the results of flexible intramedullary nailing for the treatment of a unicameral bone cyst with or without a pathological fracture. METHODS: Flexible intramedullary nailing for the treatment of a unicameral bone cyst was performed in thirty-two patients. Thirty of these patients presented with a pathological fracture; twenty-four were managed immediately with intramedullary nailing, and the other six had been managed conservatively at other clinics before they were referred to our department. The remaining two cysts were detected incidentally. The cyst was located in the humerus in twenty-one patients, in the femur in nine, and in the radius in two. The mean age of the patients at the time of surgery was 9.8 years, and the mean duration of follow-up was 53.7 months. Radiographic evaluation was performed according to the criteria of Capanna et al., and the cyst was classified as completely healed, healed with residual radiolucency (osteolysis), recurred, or having no response. RESULTS: The healing period ranged from three to 105 months. Fourteen cysts healed completely, and sixteen healed with residual radiolucent areas visible on radiographs. There was recurrence of two cysts that had healed with residual radiolucency. All of the cysts in the present study responded to treatment. A change of nails was necessary in nine patients, as the nails had become too short after bone growth. No major complications were observed. CONCLUSIONS: Flexible intramedullary nailing provides early stability, which allows early mobilization and thus obviates the need for a plaster cast and decreases the prevalence of the most common complication: a pathological fracture. This method of treatment also allows for an early return to normal activity.     

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.     

Percutaneous autologous bone marrow grafting for simple bone cysts.

Twelve patients with simple bone cysts treated by percutaneous autologous bone marrow grafting were studied prospectively to evaluate the radiographic healing of the cysts, complications, and clinical outcome. The procedure included percutaneous aspiration of the cyst's fluid and the injection of the autologous bone marrow into the cyst cavity, which was aspirated from the posterior iliac crest. The mean volume of the lesions was 51.2 cubic centimeters (27 to 74 cc). The mean follow-up time was 23 months (range: 18 to 38 months). Complete healing occurred in two of the patients. Three cysts had residual cystic defect in which two required curettage and bone chip grafts. Six cases recurred. One patient failed to show any signs healing. We concluded that factors such as the size, multi-loculation, and completeness of the filling of the cyst with bone marrow grafting might influence the postoperative results of the treatment of simple bone cysts with bone marrow injection. We found more favorable result with unilobular, small cysts. Therefore, we believe that this method of treatment should be applied to carefully selected patients.     

Autologous bone marrow injection in the management of simple bone cysts in children

The majority of simple bone cysts (SBC's) is not symptomatic and remains undiagnosed or is discovered fortuitously. A number of simple bone cysts are only diagnosed after a pathological fracture which occurs as a presenting symptom. Fractures are managed either conservatively or surgically, based on criteria such as the age of the child and the type and localisation of the fracture. The risk for fracture can be evaluated radiographically. In the absence of a fracture risk, plain radiographic follow-up is sufficient. In case of a high fracture risk, percutaneous aspiration and injection of bone marrow may be performed. The result of this treatment in 21 simple bone cysts with a high risk for fracture is reported. Slow regression of the cyst and progressive healing were obtained in 15 cases (71.4%) whereas no response was noted in 3 cases (14.3%) and recurrence in another 3 (14.3%), after a mean follow-up of 37.1 months. Guidelines are proposed for the follow-up and management of SBC.     

经皮自体骨髓注射治疗单纯性骨囊肿疗效评价

目的评价经皮自体骨髓注射治疗单纯性骨囊肿的疗效，探讨影响疗效的相关因素。方法2000年3月～2005年6月收治单纯性骨囊肿患儿并获随访31例，男18例，女13例。年龄5岁7个月～15岁，平均9岁6个月。肱骨近端18例，股骨近端7例，肱骨干2例，腓骨近端、股骨远端、胫骨远端及跟骨各1例。活动期13例，静止期18例。其中植骨术后复发2例，类固醇注射5次未愈合1例。合并病理性骨折19例。患儿均先抽去囊液后，注入从髂后上棘吸取的骨髓，平均注入骨髓40ml（30～70m1）。结果术中及术后无并发症发生。31例获随访1～5年，平均2．2年。经1次注射后囊腔完全愈合9例，占29．0％；基本愈合7例，占22．6％；部分愈合5例，占16．1％；未愈合8例，占25．8％；无效2例，占6．5％。骨囊肿静止期与活动期疗效差异有统计学意义（P〈0．05）；5～8岁年龄段与9～15岁年龄段、骨髓增生活跃组与增生明显活跃组、肱骨近端病灶与股骨近端疗效比较，差异均无统计学意义（P〉0．05）。结论经皮注射自体骨髓治疗单纯性骨囊肿安全、有效，但1次注射疗效有限，部分需多次注射；静止期疗效优于活动期。     

Bone regeneration after enucleation of mandibular cysts: comparing autogenous grafts from tissue-engineered bone and iliac bone.

OBJECTIVE: The aim of this study was to compare bone regeneration after grafting enucleated mandibular cyst cavities using either autogenous osteoblasts cultured on a biomaterial or autogenous spongiose iliac bone. STUDY DESIGN: Twenty patients with 22 mandibular cysts were assessed. Eleven cysts were filled in with tissue-engineered bone (autogenous osteblasts cultured on demineralized bone matrix Osteovit) and 11 with spongiose iliac bone as controls. Panoramic radiographs were taken preoperatively, immediately postoperatively, and 3, 6, and 12 months after surgery. Radiolucency was computer analyzed using gray-level histograms. RESULTS: In both groups bone regeneration took place in a similar fashion. After 3 and 6 months there were few differences in bone density between the groups. However, in radiographic controls after 12 months ossification was considerably stronger in cysts grafted with tissue-engineered bone. CONCLUSION: These results advocate for the clinical application of tissue-engineered bone as an alternative viable filling material for cysts.     

BMP复合牛骨胶原液经皮囊内注射治疗孤立性骨囊肿的初步报告

目的：观察经皮囊内注射BMP复合牛骨胶原液移植治疗孤立性骨囊肿的治疗结果。方法：在X线机电视屏引导下，用骨穿针刺入骨囊腔内，抽去囊液后，平均注入复合胶原液量34ml(20-40ml)。临床治疗8例孤立性骨囊肿，5例位于肱骨近端，2例位于股骨近端，1例位于髌骨。结果 7例骨囊腔平均愈合时间5－6个月（3－8个月），无并发症发生。结论 ：BMP复合牛骨胶原液囊内注射移植治疗孤立性骨囊肿是一种简单、有效、安全性高的方法。     

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.     

Injectable form of calcium sulphate as treatment of aneurysmal bone cysts

Background: Aneurysmal bone cysts (ABC) are a rare condition in adolescents and teenagers but may result in pain, fracture and growth abnormalities. The gold standard of open curettage carries the risk of surgical complications and still a local recurrence rate of 20–30%. Percutaneous treatment of ABC have rarely been reported and a poor response the usual outcome. This study investigated a new technique of percutaneous aspiration and injection of ABC using an aqueous solution of calcium sulphate. Methods: A radiological diagnosis of a bone cyst was made in 15 consecutive patients and pathologically confirmed as ABC. Most had already sustained a fracture and/or had been previously unsuccessfully treated by minimally invasive techniques including embolization or methylprednisolone injection. The procedure of aspiration and injection with calcium sulphate was undertaken, and the patients were reviewed regularly both clinically and radiologically for a minimum of 2 years. Results: The calcium sulphate cement was reabsorbed completely within 8 weeks. The first osseous response was periosteal new bone formation circumferentially followed by gradual opacification of the cystic cavity. All except one patient that described pain before the procedure reported complete relief of symptoms by 4 weeks. Two patients developed a local recurrence of the cyst, and one subsequently developed a pathological fracture. Two patients sustained pathological fractures through healed cysts, 12 and 22 months after the procedure, respectively. Conclusions: This new technique has shown good early clinical and radiological responses and a low complication rate in a consecutive group of patients with ABC.     

Unicameral bone cysts: a comparison of injection of steroid and grafting with autologous bone marrow

Open surgery is rarely justified for the initial treatment of a unicameral bone cyst, but there is some debate concerning the relative effectiveness of closed methods. This study compared the results of steroid injection with those of autologous bone marrow grafting for the treatment of unicameral bone cysts. Between 1990 and 2001, 30 patients were treated by steroid injection and 28 by grafting with autologous bone marrow. The overall success rates were 86.7% and 92.0%, respectively (p>0.05). The success rate after the initial procedure was 23.3% in the steroid group and 52.0% in those receiving autologous bone marrow (p<0.05), and the respective cumulative success rates after second injections were 63.3% and 80.0% (p>0.05). The mean number of procedures required was 2.19 (1 to 5) and 1.57 (1 to 3) (p<0.05), the mean interval to healing was 12.5 months (4 to 32) and 14.3 months (7 to 36) (p>0.05), and the rate of recurrence after the initial procedure was 41.7% and 13.3% in the steroid and in the autologous bone marrow groups, respectively (p<0.05). Although the overall rates of success of both methods were similar, the steroid group had higher recurrence after a single procedure and required more injections to achieve healing.     

弹性髓内针与自体骨髓血注射治疗儿童骨囊肿的疗效对比研究

目的:对比自体骨髓血注射与弹性髓内针支撑引流治疗儿童骨囊肿的临床疗效。方法:自2012年1月至2016年12月将收治的单纯性骨囊肿患儿56例分为2组,自体骨髓血注射组和弹性髓内针组。其中自体骨髓血注射组28例,男16例,女12例;年龄(7.7±1.9)岁;肱骨近端10例,股骨近端8例,胫骨近端6例,股骨干4例;采用多次自体骨髓血注射治疗。弹性髓内针组28例,男18例,女10例;年龄(7.5±2.2)岁;肱骨近端11例,股骨近端7例,胫骨近端5例,股骨干4例,股骨远端1例;采用弹性髓内针支撑引流治疗。术后采用Capanna骨囊肿评价标准评价治疗效果。结果:56例患儿均获得随访,其中弹性髓内针组随访时间17～35 (25.6±4.2)个月,自体骨髓血注射组19～35(27.4±4.8)个月。按照Capanna的骨囊肿评价标准,弹性髓内针组27例治疗有效(25例治愈,2例愈合但残留部分病灶),1例复发,0例治疗无反应;自体骨髓血注射组中18例治疗有效(13例治愈,5例愈合但残留部分病灶),8例复发,2例治疗无反应;两组比较差异有统计学意义(P0.01)。通过对两组患儿中完全治愈病例,弹性髓内针组(25例)和自体骨髓血注射组(13例)随访计算整体治愈时间,弹性髓内针组患儿治愈时间(20.2±3.5)个月,自体骨髓血注射组治愈时间(27.7±4.9)个月,差异有统计学意义(P0.05)。结论:对于儿童骨囊肿的治疗,弹性髓内针治疗疗效优于自体骨髓血注射,并且治愈时间更短。