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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 52  |  Issue : 1  |  Page : 62-65

Treatment of benign cystic lesions of bone with a composite of bone substitute and bone marrow


Department of Orthopedic Surgery, Faculty of Medicine, Zagazig University, Zagazig, Egypt

Date of Submission04-Jun-2016
Date of Acceptance18-Dec-2016
Date of Web Publication6-Nov-2017

Correspondence Address:
Elsayed E Saoudy
Met Ghamr, Elgish Street, Elsafa Tour Zip 44519
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/eoj.eoj_18_17

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  Abstract 

Background There are many methods for the treatment of unicameral bone cysts, which are benign cystic lesions seen in the metaphseal–diaphyseal region of long bones in growing children.
Patients and methods Totally 20 patients, eight boys and four girls with a mean age of 10 years (range: 8–14 years), who had unicameral bone cysts were treated by curettage and a CaSO4–CaPO4 bone substitute mixed with bone marrow aspiration. The lesion size ranged from 2×4 to 3×7 cm.
Results New bone formation was noted in all cases with residual defects in five cases ranging from 15 to 25%. No pathological fracture occurred in this study. Recurrence of the lesion occurred in one case and was treated by reoperation with another dose of CaSO4–CaPO4. Complications within this series included superficial infection with serous drainage 3 weeks postoperatively in two cases treated conservatively.
Conclusion Early results of this study using the CaSO4–CaPO4 incorporated with bone marrow aspirate are promising in treating benign bone cysts with bone formation, which can stand for normal bone strength and low rate of complications.

Keywords: benign, bone cyst, bone marrow, substitute


How to cite this article:
Saoudy EE. Treatment of benign cystic lesions of bone with a composite of bone substitute and bone marrow. Egypt Orthop J 2017;52:62-5

How to cite this URL:
Saoudy EE. Treatment of benign cystic lesions of bone with a composite of bone substitute and bone marrow. Egypt Orthop J [serial online] 2017 [cited 2017 Nov 18];52:62-5. Available from: http://www.eoj.eg.net/text.asp?2017/52/1/62/217672


  Introduction Top


Unicameral bone cysts or simple bone cysts are benign cystic lesions seen in the metaphseal–diaphyseal region of long bones in growing children. Virchow R. described the lesion for the first time in 1876. Pathological fracture usually is the first presentation of patients [1],[2].

A number of treatment methods have been suggested for addressing these lesions like intralesional injections of steroids and autologous bone marrow. The most frequent technique used for treatment of bone cysts and benign tumors is curettage with bone grafting [3],[4]. The large resultant defects from curettage are often filled with autologous bone graft, allograft material, or synthetic bone substitutes. Although autologous bone graft has traditionally been considered the gold standard, bone graft substitutes are often attractive options because of the size of the defect, location of the defect, autograft harvesting morbidity, and overall patient health [5]. A minimally invasive (the bone substitute acts as a scaffold so if normal bone did not form fracture can occur if it is united in x-ray) surgical technique described here preserves the periosteum, muscles, and blood supply and provides access to cyst curettage, decompression, and use of filling material − in this case autologous bone grafts − which gives easy and effective approach and successful outcome [6]. Several reports recommended the use calcium sulfate (CaSO4)-based bone graft substitutes both with and without demineralized bone matrix in benign bone tumors [7],[8],[9].


  Patients and methods Top


Between June 2008 and January 2011, 12 patients with benign bone cysts were treated by curettage and with a CaSO4–CaPO4 bone substitute mixed with bone marrow aspiration. This prospective study was conducted at Zagazig University Hospitals, after approval of our ethical committee for research in accordance with the ethical standards laid down in the 1964 declaration of Helsinki and its later amendments. There were eight boys and four girls, and the mean age of the patients was 10 years (range: 8–14 years). The pathologic diagnoses of patients were simple bone cyst in six patients, nonossifying fibromas in four, and intraosseous lipomas in two patients. The lesion size ranged from 2×4 to 3×7 cm. Lesion size was determined through preoperative radiographic or MRI measurements. The amount of CaSO4–CaPO4 graft used ranged from two to four packages of 5 ml granules. The site of the lesion in the bone was distal femur in four cases ([Figure 1]), distal tibia in five cases ([Figure 2]), and talus in three cases ([Figure 3]).
Figure 1 Male patient, 16 years old, with osteolytic lesion of the lower femur. (a and b) Preoperative radiography; (c and d) mixing of bone substitute with bone marrow aspiration from iliac crest; (e and f) 1 month postoperative radiography with plate and screw fixation; (g) 1 year postoperative radiography

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Figure 2 Female patient, 11 years old, with osteolytic lesion in lower tibial metaphysis. (a and b) Preoperative radiography; (c and d) postoperative radiography with leg in cast; (e) 3 months postoperative radiography; (f) radiography 1.5 years postoperatively

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Figure 3 Nine-year-old girl. (a and b) Preoperative radiography with osteolytic lesion of the talus; (c and d) MRI of foot and ankle showing size and boundaries of the lesion; (e) 6 months postoperatively; (f) 1 year postoperative radiography

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Surgical technique in all cases was curettage and filling of the defect by CaSO4–CaPO4. A cortical window was made over the lesion using a drill bit followed by curetting the lesion and taking the contents as biopsy. In all cases the resultant cavity was filled with the CaSO4–CaPO4 injectable composite. Complete filling of the cavity was confirmed using fluoroscopy. The method of fixation in the case of pathological fracture was internal fixation with plate and screws used in distal femur, and plaster cast was used in the remaining cases.


  Results Top


The average time of follow-up was 15 months (range: 12–19 months). Clinically, all patients have returned to normal activity without restrictions. Pain was resolved in 10 of 12 patients. Two patients had pain at the site of internal fixation in the distal femur. Radiographically, seven patients had complete bone incorporation, and new bone formation was first noted at an average of 8 weeks (range: 4–10 weeks).

Residual defects in five cases ranged from 15 to 25%. No pathological fracture occurred in this study. Recurrence of the lesion occurred in one case and was treated by reoperation with another amount of CaSO4–CaPO4.

Complications within this series included superficial infection with serous drainage 3 weeks postoperatively in two cases treated by parenteral cephalosporin antibiotics and repeated dressings.


  Discussion Top


Traditional bone graft substitutes can offer osteoconductive and/or osteoinductive properties. These materials have been shown to be replaced by bone through creeping substitution. As the material resorbs, bone subsequently forms in place of the material. The resultant histological pattern is typically marked by concentric lamellar rings corresponding to the original shape of the material [10],[11]. If faster resorbing CaSO4 materials are placed in conditions subjected to soft tissue interaction or increased aqueous flow like those found in uncontained defects, the speed of dissolution could occur at a rate higher than bone formation [12]. The resulting mismatch in the rate of graft removal and rate of bone growth can produce an inadequately filled defect [13],[14],[15].

The early clinical data for the use of this CaSO4–CaPO4 composite has been encouraging. In this series, all patients had bone incorporation without pathological fracture, one recurrence, and pain at the site of internal fixation in distal femur persisted for 6 months in two patients. Residual defects in five cases ranged from 15 to 250%. Superficial infection with serous drainage was observed in two cases treated conservatively. Kelly et al. [8] reported four cases of serous wound drainage using CaSO4 in tibia sites. Matsumine et al. [12] reported two cases of serous wound drainage in large defects treated with an injectable CaPO4.


  Conclusion Top


The early results of this study indicate that the CaSO4–CaPO4 incorporated with bone marrow aspirate can give good results in treating benign bone cysts with bone formation, which can stand for normal bone strength and low rate of complications (stand here for the duration needed for normal bone creebing and consolidation and not absorbed before). Residual defects were less effective and did not compromise bone integrity. The limitation of this study was the small number of cases and short follow-up period.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Hsien YH, Karl W, Chen TW, Shun MC, Wei HL, Rong SY. Treatment of unicameral bone cyst: a comparative study of selected techniques. J Bone Joint Surg Am 2010; 92:855–862.  Back to cited text no. 1
    
2.
Cottalorda J, Bourelle S. Current treatments of primary aneurysmal bone cysts. J Pediatr Orthop B 2006; 15:155–167.  Back to cited text no. 2
    
3.
Oppenheim WL, Galleno H. Operative treatment versus steroid injection in the management of unicameral bone cysts. J Pediatr Orthop 1984; 4:1–7.  Back to cited text no. 3
    
4.
Rougraff BT, Kling TJ. Treatment of active unicameral bone cysts with percutaneous injection of demineralized bone matrix and autogenous bone marrow. J Bone Joint Surg Am. 2002; 84:921–929.  Back to cited text no. 4
    
5.
Sung AD, Anderson ME, Zurakowski D, Hornicek FJ. Unicameral bone cyst: a retrospective study of three surgical treatments. Clin Orthop Relat Res 2008; 466:2519–2526.  Back to cited text no. 5
    
6.
Radulescu A, Boia ES, Iacob RE, Adam O. Minimally invasive treatment of a femur bone cyst with percutaneous autogenous bone marrow injection case report. J Pediatrului 2005; viii:31–32.  Back to cited text no. 6
    
7.
Gitelis S, Urban RM, Turner TM, Hall DJ, Neel M. Early radiological results with a bio-engineered degradable bone graft substitute for bone tumors. In: Musculoskeletal Tumor Society Annual Meeting. December 6–9, 2007. St. Louis, MO; 2007.  Back to cited text no. 7
    
8.
Kelly CM, Wilkins RM, Gitelis S, Hartjen C, Watson JT, Kim PT. The use of a surgical grade calcium sulfate as a bone graft substitute: results of a multicenter trial. Clin Orthop Relat Res 2001; 382:42–50.  Back to cited text no. 8
    
9.
Gitelis S, Piasecki P, Turner T, Haggard W, Charters J, Urban R. Use of a calcium sulfate-based bone graft substitute for benign bone lesions. Orthopedics 2001; 24:162–166.  Back to cited text no. 9
    
10.
Mirzayan R, Panossian V, Avedian R, Forrester DM, Menendez LR. The use of calcium sulfate in the treatment of benign bone lesions. A preliminary report. J Bone Joint Surg Am 2001; 83-A:355–358.  Back to cited text no. 10
    
11.
Turner TM, Urban RM, Gitelis S, Haggard WO, Richelsoph K. Resorption evaluation of a large bolus of calcium sulfate in a cannine medullary defect. Orthopedics 2003; 26(5 Suppl):577–579.  Back to cited text no. 11
    
12.
Matsumine A, Kusuzaki K, Matsubara T, Okamura A, Okuyama N, Miyazaki S et al. Calcium phosphate cement in musculoskeletal tumor surgery. J Surg Oncol 2006; 93:212–220.  Back to cited text no. 12
    
13.
Urban RM, Turner TM, Hall DJ, Inoue N, Gitelis S. Increased bone formation using calcium sulfate-calcium phosphate composite graft. Clin Orthop Relat Res 2007; 459:110–117.  Back to cited text no. 13
    
14.
Wilkins RM. Unicameral bone cysts. J Am Acad Orthop Surg 2000; 8:217–224.  Back to cited text no. 14
    
15.
Wilkins RM, Kelly CM, Giusti DE. Bioassayed demineralized bone matrix and calcium sulfate: use in bone-grafting procedures. Ann Chir Gynaecol 1999; 88:180–185.  Back to cited text no. 15
    


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  [Figure 1], [Figure 2], [Figure 3]



 

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Introduction
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