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Management of Unicameral Bone Cyst of Proximal Femur: Experience of 14 Cases and Review of Literature

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Management of Unicameral Bone Cyst of Proximal Femur: Experience of 14 Cases and Review of Literature 202 KUWAIT MEDICAL JOURNAL September 2008 Original Article Management of Unicameral Bone Cyst of Proximal Femur: Experience of 14 Cases and Review of Literature Magdy M Abdel-Mota’al, Abdul Salam Othman Mohamad, Kenneth Chukwuka Katchy, Amarnath A Mallur, Fawzy Hamido Ahmad, Barakat El-Alfy Kuwait Medical Journal 2008, 40 (3): 202-210 ABSTRACT Objective: To assess the results of surgical treatment Main Outcome Measures: Patients were followed up of unicameral bone cyst (UBC) involving the proximal post-operatively for an average period of 42 months (range femur = 9–120 months). They were observed for recurrence, Design: Retrospective study of 14 cases of UBC of complications and fracture healing. proximal femur Results: Recurrence was observed in one case while other Setting: Al-Razi Orthopedic Hospital, Kuwait cases showed healing of the cyst with consolidation and Subjects and Methods: Fourteen cases of UBC seen and varying degrees of remodeling in one years time. A case treated at Al-Razi hospital were included in the study. developed mal-union and growth arrest with subsequent Their presentation and the method of treatment were shortening. Avascular necrosis and coxa vara was recorded. detected in another case. All the fractures healed in the Intervention: Thirteen cases were treated surgically using usual expected time according to age. intra-lesional excision (ILE). The cavity was filled with Conclusion: UBC of the proximal femur exhibits unique autogenous bone graft in three cases, hydroxyapatite characters and complications. Hydroxyapatite matrix matrix (HA) in eight cases, and combined autogenous is a useful and effective bone substitute. Post-excision graft and hydroxyapatite matrix in two cases. Internal stabilization of the cyst is recommended to avoid mal- fixation was carried out in six cases. External fixator was union and to facilitate post-operative rehabilitation and applied in one case from iliac bone to femur crossing the earlier return to normal activities. hip joint. KEYWORDS: pathologic fracture, proximal femur, UBC INTRODUCTION necrosis (AVN) of proximal femoral epiphysis and Unicameral bone cyst (UBC) is defined as collapse of the articular surface was reported as a an atrophic degenerative osteolytic process complication of UBC involving proximal femur[9-11]. consisting of a cavity filled with fluid and lined Among the wide range of different modalities [1] by a membrane . The membrane is composed of described for treatment of UBC are: radical excision cells staining positively with CD68,SDF-1,STRO- in form of subperiosteal partial diaphysectomy 1,RANKL and express RUNX2.UBC cells show and allograft[12], subtotal resection with[13] and 24.2% of apoptosis significantly higher than 17.2% without bone graft[14], curettage and bone graft[6], [2] of trabecular bone cells . Biochemical analysis multiple drill holes[15,16], intra-cystic prednisolone of the cyst fluid showed bone-resorptive factors, injection[5,7,9] and recently, intra-medullary flexible i.e., prostaglandins, interleukin 1 and proteolytic nails[17,18]. Some authors focused their interest on enzymes[3]. UBC and other benign lesions located at proximal UBC has highest incidence between 5 and 15 femur as this area exhibits unique characters and years[1] and 50% of upper femoral lesion are over complications[8,19-23]. The aim of this study is to 17 and their age as high as 54 years[4]. It usually describe our experience with the results of surgical arises in the metaphysis of long bones immediately treatment of UBC involving proximal femur in beneath the growth plate and the most common location is proximal humerus followed by proximal Kuwait. femur[1,4-7] which accounts for 27% of cases[5]. UBC was the underlying lesion in 40% of pathological SUBJECTS AND METHODS femoral neck fractures in children[8]. Avascular The current study represents a retrospective Address correspondence to: Magdy M. Abdel-Mota’al, MD (Egypt), Senior registrar, Department of Orthopaedic Surgery, Al-Razi Hospital, Kuwait. P.O.Box # 43402, Postal Code 32049, Hawalli, Kuwait. Tel : +965-5324185, E-mail: [email protected] September 2008 KUWAIT MEDICAL JOURNAL 203 Table 1: Summary of the cases, presentation, treatment and their results Age at Follow Case presen- Sex Side presentation Work up Location of the lesion Location of the fracture Displacement Treatment complications up No. tation months Pathological. ILE + local adjuvant + HA + 1 14 F Lt C.T Inter –subtrochanteric Basotrochanteric Displaced 47 fracture DHS + Screw + Spica Nil Pathological. ILE + local adjuvant + HA + 2 14 M Lt Intertrochanteric Inter-trochanteric Undisplaced Nil 24 fracture DHS Pathological. 3 8 M Lt Neck Transcervical Undisplaced ILE + HA +KW’S + spica Nil 36 fracture Pain, limp, wasting CT+ 4 24 M Rt Head & neck - - ILE+ Auto grafts + Ext fixator Nil 24 of quadriceps Bone scan Pain, limp, wasting CT+ ILE + local adjuvant + HA + 5 24 M Rt Intertrochanteric - - Nil 30 of quadriceps Bone scan Auto graft + DHS + Screw 6 30 F Lt Pain C.T Inter –subtrochanteric - - Auto graft + DHS Nil 120 7 18 M Lt Pain C.T Head & neck - - ILE+ Auto grafts + Spica Nil 60 8 5 M Lt Pain - Inter Trochanteric - - ILE + HA +Auto grafts+ spica Recurrence 9 Pathological. 9 7 M Rt - Inter –subtrochanteric Inter-trochanteric Undisplaced ILE + HA + spica Nil 36 fracture Pathological. 10 8 F Rt - Inter –subtrochanteric Inter-trochanteric Undisplaced ILE + HA + spica Nil 24 fracture Pathological. Neck + Inter –sub Shortening+ mal 11 7 F Rt - Inter-trochanteric Undisplaced ILE + local adjuvant + HA +Spica 30 fracture trochanteric union +growth arrest Pain & limitation of 12 10 M Rt - Inter –subtrochanteric - - ILE + local adjuvant + HA +Spica Nil 33 hip movements Pathological. ILE + local adjuvant + HA + 13 10 M Rt C.T Inter –subtrochanteric Inter-trochanteric Undisplaced Nil 30 fracture DHS Pathological. Neck + inter –sub AVN, Coxa 14 7 M Rt - Neck Displaced Conservative 85 fracture trochanteric vara,shortening Rt = Right, Lt = Left, ILE = Intra-lesional excision, HA = Hydroxyapatite, DHS = Dynamic hip screw, AVN = avascular necrosis, KW = Kirschner wire 204 Management of Unicameral Bone Cyst of Proximal Femur: Experience of .... September 2008 analysis of 14 cases of UBC involving proximal three years time in three cases (case # 1, 6 and 13). femur treated at Al-Razi Orthopedic Hospital, Case # 11 developed mal-union and growth arrest Kuwait during the period from 1990 through of greater tuberosity growth plate with subsequent 2003 (Table 1). Analysis was a thorough review of shortening. This required raising the heel and did medical records, including medical history, clinical not need any surgical procedure at the last clinical examination, work-up, operative details and follow- assessment. AVN and coxa vara were detected in up at the clinic. another case (case # 14). She was 14 years old at last Age at presentation ranged from 5 - 30 years follow-up. Clinical evaluation showed fair range of with an average of 13 years. Ten cases were male movement with occasional hip pain. Radiographic and four were female. All cases were symptomatic. examination reported incongruent congruity of the Pathological fractures were the presenting symptoms involved hip joint. She needs long follow-up to detect in five cases. The other cases presented with pain, the onset of disabling degenerative changes which various degrees of limp, limited hip movement and dictate reconstructive procedures. All the fractures quadriceps wasting. The right side was involved healed in the usual expected time according to age. in eight cases. Radiographic examination was the basic imaging technique for all the cases, whereas DISCUSSION CT was done for selected cases (case # 1, 4, 5, 6, 7 The basic surgical technique employed in the and 13) to assess bony destruction and bone scan current study was ILE in the form of curettage for cases with doubtful diagnosis (case # 4 and 5). and cleaning of the wall by power burr. In order In most cases the lesion was located in the inter- to improve the margin and to decrease recurrence trochanteric area with varying degrees of extension rate, local adjuvant therapy was applied earlier toward the neck and subtrochanteric region. The through this study in six cases (case # 1, 2, 5, 11, head and neck were involved in two cases (case # 12, and 13). 40% phenol was applied with a cotton 4 and 7). The neck was affected in one case (case tipped applicator and was removed by lavage with # 3). In one case (case # 14) diagnosis was based alcohol[25]. No recurrence was reported in those [21,24] on typical X-ray appearance and clinical course . cases. Phenol was first applied to UBC by Neer In the other cases histopathological study of the et al in 1966[6]. However, because of lack of recent curetted material confirmed the diagnosis. eviddence supporting the use of phenol in UBC, we Surgical treatment was employed in all cases did not use it in later cases. with exception of one case (case # 14) which was We used autogenic bone graft alone to fill referred from another hospital. The basic surgical resultant cavity in three cases (case # 4, 6, 7). Neer technique in all cases was intra-lesional excision et al reported surgical treatment of 129 cases of UBC (ILE). Local adjuvant therapy was used in six cases by curettage (ILE) and bone graft. They evaluated (case # 1, 2, 5, 11, 12 and 13) which consisted of 24 out of 31 cases located in the proximal femur and painting with phenol 40%, cleaning with alcohol reported recurrence in four cases (17%). The results 90% and irrigation with normal saline. The cavity of allograft were compared to autograft used to was filled with autogenous bone graft in three cases fill the defect after curettage of 93 cysts located in (case # 4, 6, and 7), hydroxyapatite matrix (HA) in proximal femur and humerus. In 35 cases treated eight cases (case # 1, 2, 3, 9, 10, 11, 12, and 13) and with autograft, 21 cases (60%) were excellent, six combined autogenous graft and hydroxyapatite cases (17%) showed residual defect and eight cases matrix in two cases (case # 5 and 8).
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