Bulent EROL, Tolga ONAY, Emrah CALİSKAN, Ahmet AYDEMİR, Osman TOPKAR

Basit kemik kistlerine bağlı patolojik kırıklarınküretaj-grefonaj ve intramedüllerdekompresyon ile tedavisi

Amaç: Basit kemik kistine bağlı patolojik kırıkların tedavisinde küretaj-grefonaj ve intramedüller dekompresyonun etkinliği ve morbiditesi değerlendirildi.Çalışma planı: 2005–2012 yılları arasında basit kemik kisti tanısıyla genişletilmiş küretaj-grefonaj ve intramedüller dekompresyon uygulanan 34 çocuk retrospektif değerlendirildi. Hastaların (23 erkek/11 kadın) cerrahi sırasındaki ortalama yaşları 11.7 yıldı (aralık, 6–21). Humerus (19), femur (12), tibia (2) ve ulna (1) yerleşimli lezyonlara, 31 hastada patolojik kırık eşlik etti. Cerrahi işlem, koterizasyon ve burrlama ile genişletilmiş küretaj, grefonaj ve elastik çivilerle intramedüller dekompresyonu içerdi. Altı hastaya önceden konservatif veya cerrahi tedavi uygulanmıştı. Radyolojik ve fonksiyonel sonuçlar sırasıyla Capanna kriterleri ve MSTS skorlaması ile değerlendirildi. Erken ve geç dönem komplikasyonlar ve bunlara yönelik ilave cerrahi girişim ihtiyacı araştırıldı.Bulgular: Hastalar ortalama 37 ay (aralık, 18–89) takip edildi. Patolojik kırıkların tümü ortalama sekiz haftada (aralık, 6–12 hafta) sorunsuz kaynadı. Yirmi sekiz (%82) hastada Grad 1, altı (%18) hastada Grad 2 radyolojik iyileşme sağlandı. Son takip ortalama MSTS skoru 28.5 (aralık, 17–30) hesaplandı; 32 (%94) hastada mükemmel, iki (%6) hastada iyi sonuç elde edildi. Hiçbir hastada erken veya geç enfeksiyon, refraktür veya implant yetmezliği görülmedi. İki humerus ve iki femur olgusunda tedavi sonrası malunion gelişti, sadece biri hafif klinik bulgu verdi. Uzun takipli iki çocukta çivilerin çıkartılması dışında hiçbir hastada ilave cerrahi girişim yapılmadı.Çıkarımlar: Küretaj-grefonaj ve elastik çivilerle intramedüller dekompresyon genellikle tam kist iyileşmesi ve iyi fonksiyonel sonuçlarla seyreder. Patolojik kırık varlığında kemik bütünlüğünü sağlayarak erken harekete izin veren bu yöntem, uzun vadede re-fraktür ve deformite gelişimini engeller. DOI: 10.3944/AOTT.2015.14.0108Bu özet, makalenin henüz redaksiyonu tamamlanmamış haline aittir ve bilgi verme amaçlıdır. Yayın aşamasında değişiklik gösterebilir.

Anahtar Kelimeler:

Basit kemik kisti; intrameduller çivileme; küretaj ve grefonaj.

Treatment of pathological fractures due to simple bone cysts by extended curettage grafting and intramedullary decompression

Objective: Effectiveness and morbidity of curettage grafting and intramedullary decompression in the treatment of pathological fractures due to simple bone cysts (SBCs) were evaluated.Methods: Between 2005 and 2012, 34 children with SBCs were treated with extended curettage grafting and intramedullary decompression. Average age of the patients (23 male, 11 female) at surgery was 11.7 years (range: 6–21 years). The lesions were localized in the humerus (19), femur (12), tibia (2), and ulna (1). Pathological micro- or displaced fractures occurred in 31 patients. Surgical procedure included extended curettage by using cauterization and high-speed burring, bone grafting, and intramedullary decompression with elastic nails. Six patients had been treated conservatively or surgically in other institutions previously. Radiographic and functional results were evaluated by Capanna criteria and MSTS scores respectively. Early and late complications and additional surgical procedures were recorded.Results: The average follow-up was 37 months (range: 18–89 months). The average time to heal for pathological fractures was 8 weeks (range: 6–12 weeks). Radiographic evaluation revealed Grade 1 healing in 28 patients (82%) and Grade 2 healing in 6 patients (18%). The average MSTS score based on final follow-up was 28.5 (range: 17–30); excellent (32 patients; 94%) and good (2 patients; 6%) functional results were obtained. There was no early or late infection, refracture or implant failure. Malunion developed following treatment of 2 humeral and 2 femoral lesions. With the exception of 2 implant removals, no patients required additional surgical intervention.Conclusion: Complete cyst healing and satisfactory functional results can be obtained by curettage grafting and intramedullary decompression. This technique restores bone integrity by allowing early motion and prevents refracture and subsequent deformity in the majority of patients.

Keywords:

Curettage and grafting, intramedullary decompression, intramedullary nailing simple bone cyst,

PDF

___

Virchow R. Uber die Bildung von Knochencysten. Monatsberichte der Koniglich Preussischen Akademie der Wissenschafen 1876; Suppl:369–81.
Greenspan A, Jundt G, Remagen W. Miscellaneous tumors and tumor-like lesions. In: Greenspan A, Jundt G, Rema- gen W, editors. Differential diagnosis of orthopaedic oncol- ogy. 2nd ed. Chapter 7. Philadelphia: Lippincott, Williams & Wilkins; 2007.
Kelly CM. Benign tumors of bone. In: Tornetta P, Einhorn TA, Damron TA, editors. Orthopedic surgery essentials: oncology and basic science. 7th ed. Chapter 5, Philadel- phia: Lippincott Williams & Wilkins 2008. p. 54–9.
Jaffe H, Lichtenstein L. Solitary unicameral bone cyst, with emphasis on the roentgen picture, pathologic appearance and pathogenesis. Arch Surg 1942;44:1001–25.
Cohen J. Etiology of simple bone cyst. J Bone Joint Surg Am 1970;52:1493–7.
Chigira M, Maehara S, Arita S, Udagawa E. The aetiology and treatment of simple bone cysts. J Bone Joint Surg Br 1983;65:633–7.
Watanabe H, Arita S, Chigira M. Aetiology of a simple bone cyst. A case report. Int Orthop 1994;18:16–9.
Donaldson S, Chundamala J, Yandow S, Wright JG. Treat- ment for unicameral bone cysts in long bones: an evidence based review. Orthop Rev (Pavia) 2010;2:13.
Garceau Gj, Gregory Cf. Solitary unicameral bone cyst. J Bone Joint Surg Am 1954;36:267–80.
Neer CS 2nd, Francis KC, Marcove RC, Terz J, Carbonara PN. Treatment of unicameral bone cyst. A follow-up study of one hundred seventy-five cases. J Bone Joint Surg Am 1966;48:731–45.
Campanacci M, Capanna R, Picci P. Unicameral and aneu- rysmal bone cysts. Clin Orthop Relat Res 1986;204:25– 36.
McKay DW, Nason SS. Treatment of unicameral bone cysts by subtotal resection without grafts. J Bone Joint Surg Am 1977;59:515–9.
Fahey JJ, O’Brien ET. Subtotal resection and grafting in selected cases of solitary unicameral bone cyst. J Bone Joint Surg Am 1973;55:59–68.
MacKenzie DB. Treatment of solitary bone cysts by diaph- ysectomy and bone grafting. S Afr Med J 1980;58:154–8.
Scaglietti O, Marchetti PG, Bartolozzi P. The effects of methylprednisolone acetate in the treatment of bone cysts. Results of three years follow-up. J Bone Joint Surg Br 1979;61:200–4.
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;84:921–9.
Killian JT, Wilkinson L, White S, Brassard M. Treatment of unicameral bone cyst with demineralized bone matrix. J Pediatr Orthop 1998;18:621–4.
Chang CH, Stanton RP, Glutting J. Unicameral bone cysts treated by injection of bone marrow or methylpredniso- lone. J Bone Joint Surg Br 2002;84:407–12.
Canavese F, Wright JG, Cole WG, Hopyan S. Unicameral bone cysts: comparison of percutaneous curettage, steroid, and autologous bone marrow injections. J Pediatr Orthop 2011;31:50–5.
Dormans JP, Sankar WN, Moroz L, Erol B. Percutane- ous intramedullary decompression, curettage, and grafting with medical-grade calcium sulfate pellets for unicameral bone cysts in children: a new minimally invasive technique. J Pediatr Orthop 2005;25:804–11.
Tang XY, Liu LJ, Peng MX, Xiang B. Simple bone cysts in children treated with intracystic fibrin sealant injection. Chin Med J (Engl) 2006;119:523–5.
Kokavec M, Fristakova M, Polan P, Bialik GM. Surgical options for the treatment of simple bone cyst in children and adolescents. Isr Med Assoc J 2010;12:87–90.
Wright JG, Yandow S, Donaldson S, Marley L; Simple Bone Cyst Trial Group. A randomized clinical trial com- paring intralesional bone marrow and steroid injections for simple bone cysts. J Bone Joint Surg Am 2008;90:722–30.
Hou HY, Wu K, Wang CT, Chang SM, Lin WH, Yang RS. Treatment of unicameral bone cyst: a comparative study of selected techniques. J Bone Joint Surg Am 2010;92:855– 62.
Cho HS, Oh JH, Kim HS, Kang HG, Lee SH. Unicam- eral bone cysts: a comparison of injection of steroid and grafting with autologous bone marrow. J Bone Joint Surg Br 2007;89:222–6.
Mik G, Arkader A, Manteghi A, Dormans JP. Results of a minimally invasive technique for treatment of unicameral bone cysts. Clin Orthop Relat Res 2009;467:294954.
Hunt KJ, Bergeson A, Coffin CM, Randall RL. Percutane- ous curettage and bone grafting for humeral simple bone cysts. Orthopedics 2009;32:89.
Schreuder HW, Conrad EU 3rd, Bruckner JD, Howlett AT, Sorensen LS. Treatment of simple bone cysts in chil- dren with curettage and cryosurgery. J Pediatr Orthop 1997;17:814–20.
Bumci I, Vlahović T. Significance of opening the medullar canal in surgical treatment of simple bone cyst. J Pediatr Orthop 2002;22:125–9.
Givon U, Sher-Lurie N, Schindler A, Ganel A. Titanium elastic nail-a useful instrument for the treatment of simple bone cyst. J Pediatr Orthop 2004;24:317–8.
Santori F, Ghera S, Castelli V. Treatment of solitary bone cysts with intramedullary nailing. Orthopedics 1988;11:873–8.
Catier P, Bracq H, Canciani JP, Allouis M, Babut JM. The treatment of upper femoral unicameral bone cysts in chil- dren by Ender’s nailing technique. [Article in French] Rev Chir Orthop Reparatrice Appar Mot 1981;67:147–9. [Abstract]
Roposch A, Saraph V, Linhart WE. Flexible intramedul- lary nailing for the treatment of unicameral bone cysts in long bones. J Bone Joint Surg Am 2000;82:1447–53.
de Sanctis N, Andreacchio A. Elastic stable intramedullary nailing is the best treatment of unicameral bone cysts of the long bones in children?: Prospective long-term follow- up study. J Pediatr Orthop 2006;26:520–5.
Glanzmann MC, Campos L. Flexible intramedullary nail- ing for unicameral cysts in children’s long bones : Level of evidence: lV, case series. J Child Orthop 2007;1:97–100.
Masquijo JJ, Baroni E, Miscione H. Continuous decom- pression with intramedullary nailing for the treatment of unicameral bone cysts. J Child Orthop 2008;2:279–83.
Pogorelić Z, Furlan D, Biocić M, Mestrović J, Jurić I, Todorić D. Titanium intramedullary nailing for treatment of simple bone cysts of the long bones in children. Scott Med J 2010;55:35–8.
Cha SM, Shin HD, Kim KC, Kang DH. Flexible intra- medullary nailing in simple bone cysts of the proximal hu- merus: prospective study for high-risk cases of pathologic fracture. J Pediatr Orthop B 2013;22:475–80.
Capanna R, Dal Monte A, Gitelis S, Campanacci M. The natural history of unicameral bone cyst after steroid injec- tion. Clin Orthop Relat Res 1982;166:204–11.
Enneking WF, Dunham W, Gebhardt MC, Malawar M, Pritchard DJ. A system for the functional evaluation of re- constructive procedures after surgical treatment of tumors of the musculoskeletal system. Clin Orthop Relat Res 1993;286:241–6.
Shindell R, Huurman WW, Lippiello L, Connolly JF. Pros- taglandin levels in unicameral bone cysts treated by intral- esional steroid injection. J Pediatr Orthop 1989;9:516–9.
Sakamoto A, Matsuda S, Yoshida T, Iwamoto Y. Clinical outcome following surgical intervention for a solitary bone cyst: emphasis on treatment by curettage and steroid injec- tion. J Orthop Sci 2010;15:553–9.
Oppenheim WL, Galleno H. Operative treatment versus steroid injection in the management of unicameral bone cysts. J Pediatr Orthop 1984;4:1–7.
Brecelj J, Suhodolcan L. Continuous decompression of unicameral bone cyst with cannulated screws: a compara- tive study. J Pediatr Orthop B 2007;16:367–72.
Roposch A, Saraph V, Linhart WE. Treatment of femo- ral neck and trochanteric simple bone cysts. Arch Orthop Trauma Surg 2004;124:437–42.
De Mattos CB, Binitie O, Dormans JP. Pathological frac- tures in children. Bone Joint Res 2012;1:272–80.
Ortiz EJ, Isler MH, Navia JE, Canosa R. Pathologic frac- tures in children. Clin Orthop Relat Res 2005;432:116–26.