Vascularized the Greater Trochanter Grafting Treatment Cysts of the Femoral Neck ⇑ Hui Xie, Dewei Zhao

Medical Hypotheses xxx (2012) xxx–xxx

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Medical Hypotheses

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Vascularized the greater trochanter grafting treatment cysts of the femoral neck ⇑ Hui Xie, Dewei Zhao

Department of Orthopedics, Afﬁliated Zhongshan Hospital of Dalian University, Dalian, Liaoning 116001, China article info abstract

Article history: Bone cyst is a common benign bone tumor lesion, it is characterized by a clear boundary appearing round Received 7 December 2011 or oval osteolytic area, cortical bone thinning, and sometimes it can be visible sclerotic margin. Limb long Accepted 22 March 2012 bone cysts occur more common shares, the current jaw bone cysts are also relatively common, and most Available online xxxx patients are asymptomatic. Femoral neck bone cyst can lead to pain and pathologic fractures, which is one of the main reasons why patients are in treatment. Due to the lesion site and patients age speciﬁcity of femoral proximal bone cysts especially femoral neck bone cysts in young adults, treatment is necessary to completely remove the lesion to prevent cyst recurrence, but also as far as possible to restore function in patients with hip joint. Crown Copyright Ó 2012 Published by Elsevier Ltd. All rights reserved.

Bone cyst is a common benign bone tumor lesion, it is charac- vascular pedicle and implant into the windowing. This can provide terized by a clear boundary appearing round or oval osteolytic good blood supply for femoral head, prevent the recurrence of area, cortical bone thinning, and sometimes it can be visible scle- bone cyst and stop for lack of the femoral head blood to the avas- rotic margin. Limb long bone cysts occur more common shares, cular necrosis and pathologic fracture. the current jaw bone cysts are also relatively common, and most patients are asymptomatic [1]. Femoral neck bone cyst can lead to pain and pathologic fractures, which is one of the main reasons Introduction why patients are in treatment. Due to the lesion site and patients age specificity of femoral proximal bone cysts especially femoral The cause of bone cysts is still a mystery, and there are many neck bone cysts in young adults, treatment is necessary to com- hypotheses about it. By 1960 Cohen et al. analyzed the SBC cyst pletely remove the lesion to prevent cyst recurrence, but also as fluid of 6 cases for chemical composition and found that the com- far as possible to restore function in patients with hip joint. If position is similar to that of serum, and proposed ‘block theory’. not handled properly it often leads to femoral neck fractures, hip They believe that the formation of SBC is because of metaphyseal varus deformity and avascular necrosis, resulting in lower limb rapid absorption during shaped bone and sinusoidal blood vessel shortening, causing lameness, seriously affecting the health of blockage [4]. Mirra et al. think its formation is because of SBC syno- young patients and quality of life, this also caused great confusion vial blurred during the embryonic development of the department to the clinician [2,3]. Thus, to avoid the recurrence of bone cysts from bone, and still has a secretory function, secretion of fluid and completely cure a variety of treatment methods have been accumulation retention. In 1973, Neer proposed sinusoids closure studied and applied by researchers. Many methods have been tried led to the formation of tissue fluid exudation and SBC doctrine, for treatment, including conservative treatment, hormone injec- he found in cyst fluid that alkaline phosphatase (AKP) is the con- tions, injection of autologous red bone marrow, lesion curettage tent of 10–20 of venous blood, may display the repair of osteo- and bone graft surgery and so on, they have some healing effects, blasts, and as the ratio of AKP and acid phosphatase in cyst fluid but there are many advantages and disadvantages which cannot ‘‘active’’ indicator [5]. Gerasimov (1991), think that due to the exis- be ignored. In this paper we use vascularized greater trochanter tence of many enzymes to promote the degradation of macromo- grafting transplantation for femoral neck bone cyst, which is differ- lecular substances SAC increased hydrostatic pressure within the ent from other current surgical approaches. We adopt fenestration cavity and fluid retention which caused cysts forming [6].In in the head and neck border line of the caput femor, thoroughly 1979, Sanerkin and so on are often found aging calcification of fi- clear away cyst organization, slice greater trochanter grafting with brin clots in the SBC, they provide support for formation of new bone, similar to the process of cartilage within bone, which clot from trauma caused by plasma coagulation factors after the cyst fluid plasma composition-like entity in part, this phenomenon in ⇑ Corresponding author. Address: Department of Orthopedics, Affiliated Zhong- shan Hospital of Dalian University, No. 6 Jiefang St. Dalian, Liaoning 116001, China. other bone tumor or tumor-like variable does not exist. This in turn Tel.: +86 411 6289 3015; fax: +86 411 8210 8116. makes the doctrine of trauma, or other factors lead to agglutination E-mail address: [email protected] (D. Zhao). of Medullary cavity or subcortical hemorrhage fibrosis bone

Please cite this article in press as: Xie H, Zhao D. Vascularized the greater trochanter grafting treatment cysts of the femoral neck. Med Hypotheses (2012), http://dx.doi.org/10.1016/j.mehy.2012.03.019 2 H. Xie, D. Zhao / Medical Hypotheses xxx (2012) xxx–xxx absorption and formation of SBC [7]. Shindell et al. (1989) with tively complete femoral head by exploration. Then operate a win- radioimmunoassay method for determination of activity of prosta- dow about 1.5 Â 1.5 Â 2.0 cm in the femoral head and neck. Scrape glandin E of SBC cyst fluid: (PGE:) and found it significantly ele- away cystic changes material by using spoon, drill the cyst until vated, that PGE: might be partial synthesis of an active new blood exudation. Implant great trochanter bone flap and make substance, is the osteoclast activator, precipitate bone absorption, it ramming. Detect if the bone disc is fixed stably or hip activities acceleration cyst formation [8]. In 1970, Cohen in a state of low are unlimited. In turn suture broadly fascia, shallow fascia, subcu- pressure to the injection in contrast, distal cyst found no contrast taneous and skin. It is reported that with vascular pedicle bone agents and contrast agents out there intracapsular after injection graft relative to traditional bone graft repair bone defect has more of 24 h, proposed the ‘‘Cava’’ theory [9]. In 2000, Komiya discov- advantages [11,12]. We applied with the blood of the bone flap ered through observations that within the cyst fluid, such as nitrate transplant or transfer, introduced auto-bone graft with reliable reductase, nitrite content significantly higher serum, cyst fluid of blood supply after bone cyst is cleared, which not only can restore interleukin-6 and interleukin-1b level is significantly elevated. the femoral head blood supply, but also can play support and bone Cyst fluid and immunostaining of cells within the cyst wall are induction role of the graft bone, and simultaneously simplify the clearly displayed with nitrogen oxide synthesis. Through cell cul- operation and overcome many questions that may occur after vas- ture of the cyst capsule found cytokinin joined caused elevated ni- cular anastomosis. Zhao Dewei et al. [16] achieved good results by trate reductase, nitrite, synthesis of these findings suggest that SBC using the method such as with vascular pedicle big rotor bone flap beneficial nitrogen oxides [10]. So, how to thoroughly eliminate transfer treatment. Eisenschenk [13] applied with deep iliac cir- the femoral head cysts within organizations to prevent recurrence cumflex iliac flap in the treatment of vascular necrosis of the fem- and restore blood circulation in the prevention of osteonecrosis of oral head has achieved excellent results, the clinical good rate was the femoral head, provide mechanical support to prevent patholog- 92.5%. Mont et al. [14] and McGrory et al. [15] give full of certain ical fractures of the femoral head, is the key in the treatment of for the method of belt vascular pedicle flap transfer bone treating avascular necrosis of bone cyst. avascular necrosis, after the study of different treatment methods So, the key of the treatment of femoral neck bone cyst is how to to femoral head avascular necrosis of 10 years follow-up research completely remove the femoral neck cyst, relapse prevention, re- results. It is proved that with vascular pedicle flap transfer bone cover femoral head blood supply, preventing femoral head necro- is effective clearly and is one of recommended therapeutic sis, and providing mechanical support to prevent pathologic methods. fracture of femoral head.

Consequences of the hypothesis Hypothesis Currently, there are many ways for the treatment of femoral We use vascularized greater trochanter grafting transplantation neck bone cysts, such as simple cyst injection of hormone and sim- for the treatment of femoral neck bone cyst. We adopt fenestration ple injection of anhydrous alcohol. Injection of autologous red bone in the head and neck border line of the caput femoris, thoroughly marrow transplantation for the treatment, the lesion curettage and clear away cyst organization, slice greater trochanter bone flap bone graft surgery, drilling drainage, etc., and they have also with vascular pedicle and implant into the windowing, the bone achieved good results, but these methods of treatment are not a flap survival after implantation may become a part of the femoral complete change in the sclerotin of the femoral head and neck head. This can provide good blood supply for femoral head, prevent bone, blood circulation and mechanical support issues. If this the recurrence of bone cyst and stop for lack of the femoral head hypothesis is correct, we adopt a large rotor with vascularized blood to the avascular necrosis and pathologic fracture. bone graft to the femoral neck bone cyst location, not only increased the sclerotin of the femoral head and femoral head blood Evaluation of the hypothesis supply, but also provided mechanical support and removed the bone cyst to prevent cyst recurrence and femoral head necrosis. There are still strong surgical indications for adult big bone cyst However, to show that this hypothesis is correct, ultimately it re- in femoral head and neck, reasons are as follows: (1) adult bone quires a large number of clinical validation, evaluation and further cyst bursa wall is sclerous, growth still, and is not sensitive for ste- well-designed. roid drugs. So it is impossible for conservative treatment or healing by itself. (2) The older the patient higher the risk of femoral neck fracture. (3) It is easily complicated by coax vara or shortening of Conflicts of interest statement the lower limbs, even avascular necrosis of femoral head after the femoral neck pathologic fracture. (4) It is deep in the femoral None declared. head and neck, where there are many important nerves and vessels nearby, so it is difficult to puncture. (5) It needs surgery to excision References biopsy itself for that cannot be diagnosed by imaging examination.

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