Archives of Orthopaedic and Traumatic Surgery
Arch Orthop Traumat Surg 93, 231-239 (1979)
© J F Bergmann Verlag 1979
Total Subperiosteal Resection Treatment of Solitary Bone Cysts of the Humerus H Stiirz, H Zenker, and H Bucki Orhopaedic Clinic and Polyclinic of the University of Munich (Director: Prof Dr A N Witt), Harlachinger Str 51, D-8000 Munich 90, Federal Republic of Germany
Summary The solitary bone cyst is most frequently located in the upper arm and the average age of the affected patients is between 7 and 9 years, thus perceptibly lower than in cases where solitary bone cyst occurs elsewhere, where the average age is 15 The tendency towards recurrence before 10 years of age is twice as great as the tendency after that age Investigation of the results obtained from the treatment of 26 patients suffering from solitary bone cyst of the humerus showed a recurrence rate of 55% after curettage and filling-in of the defect with cancellous bone grafts, whereas after total subperiosteal resection and bridging the defect with an autologous tibia graft the corresponding recurrence frequency was 7 % The average duration of the plaster cast fixing period after resection treatment was 18 days longer than after curettage, but the low rate of recurrence in the first-mentioned case makes up for this disadvantage It is absolutely essential to retain the periosteum in cases of cyst resections The defect is bridged over by an autologous tibia graft, but fibula grafts are also suitable for bridging the defect Osteosyntheses are not necessary with latent cysts In the case of active cysts screws, wire loops, Kirschner wires, and thin Kiintscher nails can be used as temporary stabilisation means. Plate osteosyntheses constitute an exception. Complete removal of the cyst by resection is the most certain prophylactic method against recurrence, and hence the most reliable form of treatment of the solitary bone cyst of the humerus. Zusammenfassung Der Oberarm ist die hufigste Lokalisation der juvenilen Knochenzyste, und das Durchschnittsalter dieser Patienten liegt mit 7 bis 9 Jahren deutlich unter dem aller sonstigen Manifestationsorte der juvenilen Knochenzyste von 15 Jahren Die Rezi-
divneigung ist vor dem 10 Lebensjahr doppelt so gro B wie danach Die Uberpruifung der Behandlungsresultate an 26 Patienten mit juveniler Knochenzyste des Humerus zeigte nach Kiirettage und Spongiosaauffiillung des Defektes eine Rezidivrate von 55 %, nach Resektion und Defektiiberbruickung mit einem corticospongi 6sen Tibiaspan eine Rezidivhaufigkeit von 7 %. Die durchschnittliche Gipsfixationsdauer nach Resektionsbehandlung betrug 18 Tage mehr als nach Kirettage, jedoch rechtfertigt die geringe Rezidivquote diesen Nachteil Das Periost soIl bei der Zystenresektion unbedingt erhalten werden Die Defektuiberbriickung erfolgt mit einem autologen Tibiaspan, auch Fibularesektate sind zur Defektiiberbriickung geeignet Osteosynthesen sind bei latenten Zysten nicht erforderlich, bei aktiven Zysten knnen Schrauben, Cerclagen, Kirschnerdrihte und diinne Kiintschernagel zur voribergehenden Stabilisierung beniitzt werden. Plattenosteosynthesen stellen eine Ausnahme dar. Die vollstindige Zystenentfernung durch Resektion ist die sicherste Rezidivprophylaxe und damit die beste Behandlung der juvenilen Knochenzyste am Oberarm.
One of the cystic skeletal lesions most frequently occurring among children is the solitary bone cyst In the majority of cases the patients in whom its presence is diagnosed are between 9 and 14 years of age, and before the age of 4 and after the age of 20 the disease is increasingly rare (Hellner, 1950 ; Gliser, 1974) The proximal humerus is accordingly stated to be the most frequent location, the frequency fluctuating between 38 % (Garceau and Gregory, 1954) and 57 % (Spence et al., 1969) Table 1.
0344-8444/79/0093/0231/$ 1 80
232
H Stiirz et al : Solitary Bone Cysts of the Humerus
Second in order of location is the femur Joint data on the frequency of this location fluctuate between 54 % (Dominok and Knoch, 1977) and 75 % (Lodwick, 1958). The source of the first recorded description of a solitary bone cyst of the humerus was Virchow in 1876 In 1942 a clear distinction was made between the "solitary unicameral bone cyst" and other cystic and fibro-cystic bone diseases by Jaff& and Lichtenstein who were also responsible for making the important differentiation between the active and latent cyst, the former being in direct contact with the epiphyseal cartilage plate, and the latter being more or less remote from the growth plate and capable of emerging from the active stage. In the majority of cases, the cystic bone lesion is manifested by a fracture with inadequate trauma and it is less often diagnosed from pain or swelling The necessity for therapeutic treatment is dictated by the loss of stability of the affected limb, which is naturally noted in the arms at a later stage than in the statically streamed lower extremities Spontaneous healing after fractures which Garceau and Gregory (1954) assess at 15 % is not an advantageous form of therapy Other more reliable possibilities of treatment have therefore to be sought The purpose of every treatment must be to eradicate the cyst as promptly and as permanently as possible and to reimpart to the limb the necessary stability which is a prerequisite condition for an unimpaired function free from the persistence or occurrence of harmful deformations. Since the solitary bone cyst shows after operative treatment, depending upon the age of the patient as well as on the size and location of the cyst, a particular
standard scale of measurement of the efficiency of the treatment procedure adopted in each specific case. Such fears as were formerly expressed regarding the danger of a malignant degeneration of the solitary bone cyst following one or two recurrences (Hellner, 1950; Witt et al , 1972) are certainly only slightly, if indeed at all, justified (Dahlin, 1973 ; Fuchs and Koch, 1974) Recurrence does, however, imply a renewed threat to the function and proper growth of the affected limb and involves the risks of a further operation The resection treatment of recurring solitary bone cyst was recommended by Witt et al (1972). The value of resection also as a primary treatment for a solitary bone cyst on the upper arm is demonstrated below using the results of post treatment examination.
Cases Treated and Treatment Results Between 1958 and 1978, 26 patients underwent operative treatment for a solitary bone cyst of the humerus With 20 male and 6 female patients, the former predominated 3:1 The youngest patient was 4 years old and the oldest 19, and the average age was 9 6 years. At the time of the initial operation, 19 out of the 26 patients concerned were 10 years old or less, only 7 patients being 11 or over The size of the cyst, measured as the gross diameter, varied between 3 cm and 16 cm, and in the case of 13 patients varied between 5 and 9 cm; the average for the total number of patients was 7 5 cm Five active cysts revealed direct contact with the epiphyseal cartilage plate, 21 occurred in the metaphysis or in the diaphysis, being in the latent stage. In 17 cases, the primary operative treatment consisted of curettage of the cysts and filling-in of the defect with autologous bone grafts from the iliac bone or tibia, in five cases with additional homologous material from the bone bank or with an heterologous graft On 9 occasions in the primary treatment total subperiosteal resection of the cyst was effected, where the
tendency to recur, the rate of recurrences serves as a l
.
Size of cyst at first operation
-g
Arch Orthop Traumat Surg 93, 231-239 (1979)
© J F Bergmann Verlag 1979
Total Subperiosteal Resection Treatment of Solitary Bone Cysts of the Humerus H Stiirz, H Zenker, and H Bucki Orhopaedic Clinic and Polyclinic of the University of Munich (Director: Prof Dr A N Witt), Harlachinger Str 51, D-8000 Munich 90, Federal Republic of Germany
Summary The solitary bone cyst is most frequently located in the upper arm and the average age of the affected patients is between 7 and 9 years, thus perceptibly lower than in cases where solitary bone cyst occurs elsewhere, where the average age is 15 The tendency towards recurrence before 10 years of age is twice as great as the tendency after that age Investigation of the results obtained from the treatment of 26 patients suffering from solitary bone cyst of the humerus showed a recurrence rate of 55% after curettage and filling-in of the defect with cancellous bone grafts, whereas after total subperiosteal resection and bridging the defect with an autologous tibia graft the corresponding recurrence frequency was 7 % The average duration of the plaster cast fixing period after resection treatment was 18 days longer than after curettage, but the low rate of recurrence in the first-mentioned case makes up for this disadvantage It is absolutely essential to retain the periosteum in cases of cyst resections The defect is bridged over by an autologous tibia graft, but fibula grafts are also suitable for bridging the defect Osteosyntheses are not necessary with latent cysts In the case of active cysts screws, wire loops, Kirschner wires, and thin Kiintscher nails can be used as temporary stabilisation means. Plate osteosyntheses constitute an exception. Complete removal of the cyst by resection is the most certain prophylactic method against recurrence, and hence the most reliable form of treatment of the solitary bone cyst of the humerus. Zusammenfassung Der Oberarm ist die hufigste Lokalisation der juvenilen Knochenzyste, und das Durchschnittsalter dieser Patienten liegt mit 7 bis 9 Jahren deutlich unter dem aller sonstigen Manifestationsorte der juvenilen Knochenzyste von 15 Jahren Die Rezi-
divneigung ist vor dem 10 Lebensjahr doppelt so gro B wie danach Die Uberpruifung der Behandlungsresultate an 26 Patienten mit juveniler Knochenzyste des Humerus zeigte nach Kiirettage und Spongiosaauffiillung des Defektes eine Rezidivrate von 55 %, nach Resektion und Defektiiberbruickung mit einem corticospongi 6sen Tibiaspan eine Rezidivhaufigkeit von 7 %. Die durchschnittliche Gipsfixationsdauer nach Resektionsbehandlung betrug 18 Tage mehr als nach Kirettage, jedoch rechtfertigt die geringe Rezidivquote diesen Nachteil Das Periost soIl bei der Zystenresektion unbedingt erhalten werden Die Defektuiberbriickung erfolgt mit einem autologen Tibiaspan, auch Fibularesektate sind zur Defektiiberbriickung geeignet Osteosynthesen sind bei latenten Zysten nicht erforderlich, bei aktiven Zysten knnen Schrauben, Cerclagen, Kirschnerdrihte und diinne Kiintschernagel zur voribergehenden Stabilisierung beniitzt werden. Plattenosteosynthesen stellen eine Ausnahme dar. Die vollstindige Zystenentfernung durch Resektion ist die sicherste Rezidivprophylaxe und damit die beste Behandlung der juvenilen Knochenzyste am Oberarm.
One of the cystic skeletal lesions most frequently occurring among children is the solitary bone cyst In the majority of cases the patients in whom its presence is diagnosed are between 9 and 14 years of age, and before the age of 4 and after the age of 20 the disease is increasingly rare (Hellner, 1950 ; Gliser, 1974) The proximal humerus is accordingly stated to be the most frequent location, the frequency fluctuating between 38 % (Garceau and Gregory, 1954) and 57 % (Spence et al., 1969) Table 1.
0344-8444/79/0093/0231/$ 1 80
232
H Stiirz et al : Solitary Bone Cysts of the Humerus
Second in order of location is the femur Joint data on the frequency of this location fluctuate between 54 % (Dominok and Knoch, 1977) and 75 % (Lodwick, 1958). The source of the first recorded description of a solitary bone cyst of the humerus was Virchow in 1876 In 1942 a clear distinction was made between the "solitary unicameral bone cyst" and other cystic and fibro-cystic bone diseases by Jaff& and Lichtenstein who were also responsible for making the important differentiation between the active and latent cyst, the former being in direct contact with the epiphyseal cartilage plate, and the latter being more or less remote from the growth plate and capable of emerging from the active stage. In the majority of cases, the cystic bone lesion is manifested by a fracture with inadequate trauma and it is less often diagnosed from pain or swelling The necessity for therapeutic treatment is dictated by the loss of stability of the affected limb, which is naturally noted in the arms at a later stage than in the statically streamed lower extremities Spontaneous healing after fractures which Garceau and Gregory (1954) assess at 15 % is not an advantageous form of therapy Other more reliable possibilities of treatment have therefore to be sought The purpose of every treatment must be to eradicate the cyst as promptly and as permanently as possible and to reimpart to the limb the necessary stability which is a prerequisite condition for an unimpaired function free from the persistence or occurrence of harmful deformations. Since the solitary bone cyst shows after operative treatment, depending upon the age of the patient as well as on the size and location of the cyst, a particular
standard scale of measurement of the efficiency of the treatment procedure adopted in each specific case. Such fears as were formerly expressed regarding the danger of a malignant degeneration of the solitary bone cyst following one or two recurrences (Hellner, 1950; Witt et al , 1972) are certainly only slightly, if indeed at all, justified (Dahlin, 1973 ; Fuchs and Koch, 1974) Recurrence does, however, imply a renewed threat to the function and proper growth of the affected limb and involves the risks of a further operation The resection treatment of recurring solitary bone cyst was recommended by Witt et al (1972). The value of resection also as a primary treatment for a solitary bone cyst on the upper arm is demonstrated below using the results of post treatment examination.
Cases Treated and Treatment Results Between 1958 and 1978, 26 patients underwent operative treatment for a solitary bone cyst of the humerus With 20 male and 6 female patients, the former predominated 3:1 The youngest patient was 4 years old and the oldest 19, and the average age was 9 6 years. At the time of the initial operation, 19 out of the 26 patients concerned were 10 years old or less, only 7 patients being 11 or over The size of the cyst, measured as the gross diameter, varied between 3 cm and 16 cm, and in the case of 13 patients varied between 5 and 9 cm; the average for the total number of patients was 7 5 cm Five active cysts revealed direct contact with the epiphyseal cartilage plate, 21 occurred in the metaphysis or in the diaphysis, being in the latent stage. In 17 cases, the primary operative treatment consisted of curettage of the cysts and filling-in of the defect with autologous bone grafts from the iliac bone or tibia, in five cases with additional homologous material from the bone bank or with an heterologous graft On 9 occasions in the primary treatment total subperiosteal resection of the cyst was effected, where the
tendency to recur, the rate of recurrences serves as a l
.
Size of cyst at first operation
-g
