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Treatment of Simple Bone Cysts of the Humerus by Intramedullary Nailing

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Treatment of Simple Bone Cysts of the Humerus by Intramedullary Nailing Zhang et al. BMC Musculoskeletal Disorders (2020) 21:70 https://doi.org/10.1186/s12891-020-3054-6 RESEARCH ARTICLE Open Access Treatment of simple bone cysts of the humerus by intramedullary nailing and steroid injection Peng Zhang1†, Naiqiang Zhu1†, Lilong Du2, Jihui Zheng3, Sibin Hu3 and Baoshan Xu2* Abstract Background: Simple bone cysts (SBCs) are common benign lytic bone lesions in children. This study focused on exploring a clinical treatment method, minimally invasive intramedullary decompression and drainage with elastic stable intramedullary nailing (ESIN) combined with intralesional injections of steroids, and evaluated its effectiveness, complications and morbidity through functional and radiographic outcomes. Methods: The postoperative recovery of 18 children who suffered from SBCs of humerus was evaluated (mean follow- up, 40 months) from January 2009 to December 2016. These patients (11 males, 7 females; 8 in the left, 10 in the right; mean age, 10.9 years old) were treated with minimally invasive intramedullary decompression and drainage with ESIN combined with intralesional injections of steroids. The diagnosis was based on not only pre-operative typical medical images (X-rays/CT/MRI) but also surgical findings and pathological diagnosis. Radiological and functional outcomes were evaluated according to Capanna and Musculoskeletal Tumor Society (MSTS) score. The interclass differences were analyzed by t-test. Results: According to Capanna and MSTS criteria, after treatment, 14 patients made full recoveries which was presented by all the cysts filled with bone tissue, and 4 patients made partially recoveries, which were presented by cystic spaces partially filled with low density bone. All the cysts responded to treatment method, and there was no cyst recurrence. All except 2 patients had good functional results. One of the two patients had irritation of the end of the nail and one patient had a valgus deformity. Conclusions: Treatment for SBCs of humerus by minimally invasive intramedullary decompression and drainage with ESIN combined with intralesional injections of steroids is safe, effective and convenient. The clinical effect is satisfactory and worth popularizing. Keywords: Simple bone cyst of humerus, Children, ESIN, Steroids, Combination therapy Background to female patients with SBCs is approximately 2:1, indi- According to Virchow, simple bone cysts (SBCs), also cating the incidence of this disease may be related to called unicameral bone cysts (UBCs), are benign fluid- gender [7]. In addition, many studies have raised other filled bone tumors, which commonly and typically locate relevant hypotheses on its pathogenesis, including ven- in metaphysis of long bones in children [1]. SBCs are ous obstruction, and destructive factors like interleukin usually discovered in the presence of pathological frac- (IL)-1 and Prostaglandin (PG) [8, 9]. There is no specific tures [2–4], and they are more common in long bones, and standard therapeutic schedule in terms of the treat- especially in humerus and femur, and less common in ment of SBCs. The surgical methods commonly used in tibia, fibula, radius, and ulna [5, 6]. The sex ratio of male clinical practice are total resection with bone grafting to remove all the cyst and associate bone tissue, and sub- * Correspondence: [email protected]; [email protected] total resection with or without bone grafting [10, 11]. †Peng Zhang and Naiqiang Zhu contributed equally to this work. 2Department of Orthopedics, Tianjin Hospital, Jiefang South Road 406, Hexi Those aggressive operations are extensive and complex, district, Tianjin 300211, People’s Republic of China often with high complications [12]. In recent decades, Full list of author information is available at the end of the article © The Author(s). 2020 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Zhang et al. BMC Musculoskeletal Disorders (2020) 21:70 Page 2 of 11 new treatments have been developed, such as intrale- The surgery-indications of these patients included large sional injections of steroids [13, 14], intralesional injec- and painful SBCs with or without pathological fracture. tions of bone marrow [15], bone grafting with Diagnosis information was obtained from orthopedic files, homologous cancellous bone chips [16], bone grafting including preoperative/postoperative X-rays, computed with freeze-dried crushed cortical bone [17], and decom- tomography (CT) and magnetic resonance imaging (MRI). pression with screws or pins with holes [18]. Even Clinical data included gender, age, symptoms, presence or though these new surgical treatments present promising absence of pathological fracture, surgical procedures, and short-term outcomes, most of them are likely to end up functional or radiological outcomes. with partial recoveries [19], and the recrudesce and ten- As well known, X-ray images of SBCs show that the acity are still the biggest challenges [3]. medullary cavity is a central elliptical bright shadow with Recently, with the rapid development of minimally in- no gravel-like densification point inside, which some- vasive surgical techniques, great changes have taken times is segregated by bone ridges, and cortical bone will place in the treatment of SBCs by percutaneous intrame- expand and becomes thinner, but there is no periosteal dullary decompression. Santori et al. was the first to re- reaction (except pathological bones). Magnetic Reson- port elastic nails in 1986 [20]. Then, elastic nails were ance Imaging (MRI) always presents a low or intermedi- used in the treatment of unicameral bone cyst in long ate signal on T1-weighted images and a homogeneous bones by Roposch’s group [21]. When the elastic intra- high signal on T2 weighting. The cystic fluids extracted medullary nails were inserted between the medullary by surgeon are tested for pathological examination, canal and the cyst cavity, continuous drainage and intra- which can confirm the diagnosis of SBCs. In this study, cystic pressure decompression were carried out. Further- considering the diagnosis of simple bone cysts was clear more, elastic intramedullary nails could play a stable and based on related images, especially in X-rays and MRI, supporting role, enabling early postoperative motion, no preoperative biopsy was performed. Moreover, the preventing adjacent joint stiffness and promoting heal- clinical and radiologic features were used for differential ing, particularly in the treatment of pathological frac- diagnosis of SBC from another cystic lesions based on a tures [22, 23]. However, it was reported that residual previous report [3], including aneurysmal bone cyst, fi- lesions were found in the patients with SBCs after brous dysplasia, enchondroma, eosinophlic granuloma treated of only by elastic stable intramedullary nailing and intraosseous ganglia. Briefly, aneurysmal bone cyst (ESIN) [24, 25]. on roentgenograms appear as a lytic, eccentric, intrame- Various methods in the treatment of SBCs ended up dullary bone lesion, with a transverse diameter that is with partial healing or residual lesions, thus there is a wider than the epiphyseal plate, and the MRI images of debate on whether to take conservative treatment or ag- these lesions show double-density fluid levels and septa- gressive surgical treatment. However, as SBCs are typic- tions. Fibrous dysplasia cases can be distinguished by ally located in metaphysis of long bones in juvenile ground glass appearance of the matrix. Enchondromas children, who are eager to return to sports and activities, are distinct radiolucent intramedullary lesions with thin- the minimally invasive and reliable fixed method seemed ning and expansion of the cortices, which are usually to be the optimal choice. To explore a better treatment, happened in short tubular bones of the hands and feet. with a retrospective of SBCs’ etiology, we found both Eosinphilic granuloma frequently involves axial skeleton venous outflow obstruction and PG E2/IL-1β enzymes than appendicular skeleton, while intraosseous ganglia within the cyst fluid, which would cause bone destruc- are small radiolucent lesions that mainly observed in the tion [26]. Considering the validity of minimally invasive epiphysis and subchondral region. intramedullary decompression, drainage with ESIN, and The demographic data of this study group are summa- steroids intralesional injection to these pathogenic fac- rized in Table 1. Eleven males and 7 females with an tors, and there were no related reports about a com- average age of 10.94 years (range, 7 to 15 years) were in- bined method before, we conducted the current research cluded in this study, and the mean follow-up period was to assess the safety and effectiveness of this combination 40 months (range, 19–65 months). Most of the cysts therapy in the clinical practice. were located in the metaphyseal, isolated diaphyseal or metaphyseal-diaphyseal regions of the humerus. Accord- Methods ing to the standard proposed by Neer et al. [27], the
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