Clinical Orthopaedics and Related Research®

, Volume 468, Issue 11, pp 3047–3055 | Cite as

Injection of Demineralized Bone Matrix With Bone Marrow Concentrate Improves Healing in Unicameral Bone Cyst

  • Claudia Di Bella
  • Barbara Dozza
  • Tommaso Frisoni
  • Luca Cevolani
  • Davide Donati
Symposium: Highlights of the ISOLS/MSTS 2009 Meeting

Abstract

Background

Unicameral bone cysts are benign lesions that usually spontaneously regress with skeletal maturity; however, the high risk of pathologic fractures often justifies treatment that could reinforce a weakened bone cortex. Various treatments have been proposed but there is no consensus regarding the best procedure.

Questions/purposes

We compared the healing rates and failures of two methods of cure based on multiple injections of corticosteroid or a single injection of demineralized bone matrix (DBM) in association with bone marrow concentrate (BMC).

Methods

We retrospectively reviewed 184 patients who had one of the two treatments for unicameral bone cysts with cortical erosion. Clinical records were reviewed for treatment failures and radiographs for healing in all patients. The minimum followup was 12 months for the Steroids Group (mean, 48 months; range, 12–120 months) and 12 months for the DBM + BMC Group (mean, 20 months; range, 12–28 months).

Results

After one treatment we observed a lower healing rate of cysts treated with multiple injections of steroids compared with the healing after the first injection of DBM + BMC (21% versus 58%, respectively). At last followup, 38% healed with steroids and 71% with DBM + BMC. The rate of failure after one steroid injection was higher than after a single injection of BDM + BMC (63% versus 24%, respectively). We observed no difference in fracture rates after treatment between the two groups.

Conclusions

A single injection of DBM added with autologous bone marrow concentrate appears to provide a higher healing rate with a lower number of failures compared with a single injection of steroids.

Level of Evidence

Level III, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Notes

Acknowledgments

We thank Elettra Pignotti for contributions regarding statistical analysis and Enrico Lucarelli for manuscript review.

References

  1. 1.
    Ahn JI, Park JS. Pathological fractures secondary to unicameral bone cysts. Int Orthop. 1994;18:20–22.PubMedGoogle Scholar
  2. 2.
    Brecelj J, Suhodolcan L. Continuous decompression of unicameral bone cyst with cannulated screws: a comparative study. J Pediatr Orthop B. 2007;16:367–372.PubMedGoogle Scholar
  3. 3.
    Campanacci M, Capanna R, Picci P. Unicameral and aneurysmal bone cysts. Clin Orthop Relat Res. 1986;204:25–36.PubMedGoogle Scholar
  4. 4.
    Capanna R, Dal Monte A, Gitelis S, Campanacci M. The natural history of unicameral bone cyst after steroid injection. Clin Orthop Relat Res. 1982;166:204–211.PubMedGoogle Scholar
  5. 5.
    Chang CH, Stanton RP, Glutting J. Unicameral bone cysts treated by injection of bone marrow or methylprednisolone. J Bone Joint Surg Br. 2002;84:407–412.PubMedGoogle Scholar
  6. 6.
    Cho HS, Oh JH, Kim HS, Kang HG, Lee SH. Unicameral bone cysts. A comparison of injection of steroid and grafting with autologous bone marrow. J Bone Joint Surg Br. 2007;89:222–226.PubMedGoogle Scholar
  7. 7.
    Cohen J. Etiology of simple bone cysts. J Bone Joint Surg Am. 1970;52:1493–1497.PubMedGoogle Scholar
  8. 8.
    Cohen J. Unicameral bone cysts: current synthesis of reported cases. Orthop Clin North Am. 1977;8:715–736.PubMedGoogle Scholar
  9. 9.
    Delloye C, Docquier PL, Cornu O, Poilvache P, Peters M, Woitrin B, Rombouts JJ, De Nayer P. Simple bone cysts treated with aspiration and single bone marrow injection. Int Orthop. 1998;22:134–138.PubMedGoogle Scholar
  10. 10.
    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.PubMedGoogle Scholar
  11. 11.
    Farber JM, Stanton RP. Treatment options in unicameral bone cysts. Orthopedics. 1990;13:25–32.PubMedGoogle Scholar
  12. 12.
    Garceau GJ, Gregory CF. Solitary unicameral bone cysts. J Bone Joint Surg Am. 1954;36:267–280.PubMedGoogle Scholar
  13. 13.
    Hashemi-Nejad A, Cole WG. Incomplete healing of simple bone cysts after steroid injections. J Bone Joint Surg Br. 1997;79:727–730.PubMedGoogle Scholar
  14. 14.
    Hernigou P, Poignard A, Beaujean F, Rouard H. Percutaneous autologous bone-marrow grafting for nonunions. Influence of the number and concentration of progenitor cells. J Bone Joint Surg Am. 2005;87:1430–1437.PubMedGoogle Scholar
  15. 15.
    Hosmer DW, Lemeshow S, May S. Applied Survival Analysis: Regression Modeling of Time to Event Data. 2nd Ed. New York, NY: Wiley; 2008.Google Scholar
  16. 16.
    Kaelin AJ, MacEwen GD. Unicameral bone cysts: natural history and risk of fracture. Int Orthop. 1989;13:275–282.PubMedGoogle Scholar
  17. 17.
    Kanellopoulos AD, Mavrogenis AF, Papagelopoulos PJ, Soucacos PN. Elastic intramedullary nailing and DBM-bone marrow injection for the treatment of simple bone cysts. World J Surg Oncol. 2007;5:111–118.PubMedGoogle Scholar
  18. 18.
    Kanellopoulos AD, Yiannakopoulos CK, Soucacos PN. Percutaneous reaming of simple bone cysts in children followed by injection of demineralized bone matrix and autologous bone marrow. J Pediatr Orthop. 2005;25:671–675.PubMedGoogle Scholar
  19. 19.
    Killian JT, Wilkinson L, White S, Brassard M. Treatment of unicameral bone cyst with demineralized bone matrix. J Pediatr Orthop. 1998;18:621–624.PubMedGoogle Scholar
  20. 20.
    Komiya S, Minamitani K, Sasaguri Y, Hashimoto S, Morimatsu M, Inoue A. Simple bone cyst: treatment by trepanation and studies on bone resorptive factors in cyst fluid with a theory of its pathogenesis. Clin Orthop Relat Res. 1993;287:204–211.PubMedGoogle Scholar
  21. 21.
    Lokiec F, Ezra E, Khermosh O, Weintroub S. Simple bone cysts treated by percutaneous autologous bone marrow grafting. J Bone Joint Surg Br. 1996;78:934–937.PubMedGoogle Scholar
  22. 22.
    Makley JT, Joyce MJ. Unicameral bone cyst (simple bone cyst). Orthop Clin North Am. 1989;20:407–415.PubMedGoogle Scholar
  23. 23.
    McKay DW, Nason SS. Treatment of unicameral bone cysts by subtotal resection without grafts. J Bone Joint Surg Am. 1977;59:515–519.PubMedGoogle Scholar
  24. 24.
    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;467:2949–2954.PubMedGoogle Scholar
  25. 25.
    Milbrandt T, Hopkins J. Unicameral bone cysts: etiology and treatment. Curr Opin Orthop. 2007;18:555–560.Google Scholar
  26. 26.
    Neer CS, Francis KC, Johnston AD, Kiernan HA. Current concepts on the treatment of solitary unicameral bone cyst. Clin Orthop Relat Res. 1973;97:40–51.PubMedGoogle Scholar
  27. 27.
    Neer C, Francis KC, Marcove RC, Terz J, Carbonara P. Treatment of unicameral bone cyst. A follow-up study of one hundred seventy-five cases. J Bone Joint Surg Am. 1966;48:731–745.PubMedGoogle Scholar
  28. 28.
    Roposch A, Saraph V, Linhart WE. Flexible intramedullary nailing for the treatment of unicameral bone cysts in long bones. J Bone Joint Surg Am. 2000;82:1447–1453.PubMedGoogle Scholar
  29. 29.
    Rosenthal RK, Folkman J, Glowacki J. Demineralized bone implants for nonunion fractures, bone cysts, and fibrous lesions. Clin Orthop Relat Res. 1999;364:61–69.PubMedGoogle Scholar
  30. 30.
    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.PubMedGoogle Scholar
  31. 31.
    Santori F, Ghera S, Castelli V. Treatment of solitary bone cysts with intramedullary nailing. Orthopedics. 1988;11:873–878.PubMedGoogle Scholar
  32. 32.
    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;61:200–204.PubMedGoogle Scholar
  33. 33.
    Scaglietti O, Marchetti PG, Bartolozzi P. Final results obtained in the treatment of bone cysts with methylprednisolone acetate (Depo-Medro) and a discussion of results achieved in other bone lesions. Clin Orthop Relat Res. 1982;165:33–42.PubMedGoogle Scholar
  34. 34.
    Spence KF Jr, Bright RW, Fitzgerald SP, Sell KW. Solitary unicameral bone cyst: treatment with freeze-dried crushed cortical-bone allograft: a review of one hundred and forty-four cases. J Bone Joint Surg Am. 1976;58:636–641.PubMedGoogle Scholar
  35. 35.
    Sung AD, Anderson ME, Zurakowski D, Hornicek FJ, Gebhardt MC. Unicameral bone cyst. A retrospective study of three surgeries. Clin Orthop Relat Res. 2008;466:2519–2526.PubMedGoogle Scholar
  36. 36.
    Thawrani D, Thai CC, Welch RD, Copley L, Johnston CE. Successful treatment of unicameral bone cyst by single percutaneous injection of α-BSM. J Pediatr Orthop. 2009;29:511–517.PubMedGoogle Scholar
  37. 37.
    Trombi L, Mattii L, Pacini S, D’Alessandro D, Battolla B, Orciuolo E, Buda G, Fazzi R, Galimberti S, Petrini M. Human autologous plasma-derived clot as a biological scaffold for mesenchymal stem cells in treatment of orthopedic healing. J Orthop Res. 2008;26:176–183.PubMedGoogle Scholar
  38. 38.
    Vasconcellos DA, Yandow SM, Grace AM, Moritz BM, Marley LD, Fillman RR. Cyst Index. A non predictor of simple bone cyst fracture. J Pediatr Orthop. 2007;27:307–310.PubMedGoogle Scholar
  39. 39.
    Virchow R. On the formation of bony cysts. In: Uber die Bilding von Knochencysten. Berlin, Germany: SB Akad Wiss; 1876:369–381.Google Scholar
  40. 40.
    Wilkins R. Unicameral bone cysts. J Am Acad Orthop Surg. 2000;8:217–224.PubMedGoogle Scholar
  41. 41.
    Wright JG, Yandow S, Donaldson S, Marley L. A randomized clinical trial comparing intralesional bone marrow and steroid injection for simple bone cyst. J Bone Joint Surg Am. 2008;90:722–730.PubMedGoogle Scholar
  42. 42.
    Yandow SM, Lundeen G, Scott SM, Coffin C. Autogenic bone marrow injections as a treatment for simple bone cyst. J Pediatr Orthop. 1998;18:616–620.PubMedGoogle Scholar
  43. 43.
    Zamzam MM, Abak AA, Bakarma KA, Aj-Jassir FF, Khoshhal KI, Zamzami MM. Efficacy of aspiration and autogenous bone marrow injection in the treatment of simple bone cysts. Int Orthop. 2009;33:1353–1358.PubMedGoogle Scholar

Copyright information

© The Association of Bone and Joint Surgeons® 2010

Authors and Affiliations

  • Claudia Di Bella
    • 1
    • 2
  • Barbara Dozza
    • 2
  • Tommaso Frisoni
    • 1
    • 2
  • Luca Cevolani
    • 1
    • 2
  • Davide Donati
    • 1
    • 2
  1. 1.Department of Oncology OrthopaedicRizzoli Orthopaedic InstituteBolognaItaly
  2. 2.Bone Regeneration Laboratory, Codivilla-Putty Research InstituteRizzoli Orthopaedic InstituteBolognaItaly

Personalised recommendations