Outcomes in Unicameral Bone Cyst Management Utilizing a Decision Tree Algorithm Approach

Abstract

Objective To determine if utilization of a decision tree algorithm could improve the healing rate of unicameral bone cysts (UBCs).

Methods Creation of the decision tree algorithm was based on previous literature and assessment of our clinical practice. Demographic, treatment, and radiographic data were collected retrospectively. Radiographic healing was determined using the Neer classification. Healing rate, as well as clinical/radiographic characteristics, were compared based on adherence to the treatment algorithm.

Results Forty-seven subjects were included. Mean age at initial surgery was 10.0 ± 3.3 years in children following the algorithm and 9.1 ± 3.2 years in those deviating from the algorithm (p = 0.393). Follow-up was found to be similar among those following the algorithm (37.5 ± 15.8 months) and those deviating from the algorithm (45.2 ± 24.6 months), p = 0.38. Children who followed the algorithm healed at a rate of 75%, while children who deviated from the algorithm healed at a rate 67% (p = 0.552).

Conclusions Although we reject our hypothesis that a decision tree algorithm for the management of UBCs in the pediatric population could improve the healing rate, we believe that we uncovered some utility in applying an algorithm to this pathology. Our algorithm was designed to minimize risk to the child and maximize healing with the least number of surgical events. Treating surgeons should consider this proposed pathway to determine the best treatment and to help families understand that these lesions rarely heal with a single-event surgery.

Zusammenfassung

Zielsetzung Auf der Grundlage früherer Literatur und unserer eigenen Erfahrung untersuchten wir, ob ein Entscheidungsbaum-Algorithmus einen guten Ansatz darstellt, um das Risiko bei Kindern mit Knochenzysten zu minimieren und die Heilung bei der geringsten Anzahl von chirurgischen Eingriffen zu gewährleisten.

Patienten und Methoden Die Studie schloss 47 Patienten ein, die entweder mit oder ohne Algorithmus behandelt wurden – mit einem anfänglichen Durchschnittsalter von 10,0 ± 3,3 bzw. 9,1 ± 3,2 Jahren (p = 0,393). Die Nachbeobachtungszeiten betrugen 37,5 ± 15,8 bzw. 45,2 ± 24,6 Monate (p = 0,38).

Ergebnisse Die Heilungsraten waren 75% mit Algorithmus und 67% ohne Algorithmus (p = 0,552; keine Signifikanz).

Schlussfolgerung Die Anwendung des Algorithmus hat zu keiner Verbesserung der Heilungsrate geführt, ist aber trotzdem von Nutzen bei pathologischen Überlegungen und bei Besprechungen mit den Familien der jungen Patienten.

Key words

unicameral bone cyst - decision tree - UBC

Schlüsselwörter

Entscheidungsbaum - Einkammerknochenzyste - UBC

Publication History

Article published online:
18 February 2021

• References

• 1 Bovill DF, Skinner HB. Unicameral bone cysts. A comparison of treatment options. Orthop Rev 1989; 18: 420-427
• 2 Boseker EH, Bickel WH, Dahlin DC. A clinicopathologic study of simple unicameral bone cysts. Surg Gynecol Obstet 1968; 127: 550-560
• 3 Ahn JI, Park JS. Pathological fractures secondary to unicameral bone cysts. Int Orthop 1994; 18: 20-22 doi:10.1007/bf00180173
• 4 Neer CS, Francis KC, Marcove RC. et al. Treatment of unicameral bone cyst. A follow-up study of one hundred seventy-five cases. J Bone Joint Surg Am 1966; 48: 731-745
• 5 Noordin S, Allana S, Umer M. et al. Unicameral bone cysts: Current concepts. Ann Med Surg 2018; 34: 43-49 doi:10.1016/j.amsu.2018.06.005
• 6 Pretell-Mazzini J, Murphy RF, Kushare I. et al. Unicameral bone cysts: general characteristics and management controversies. J Am Acad Orthop Surg 2014; 22: 295-303 doi:10.5435/JAAOS-22-05-295
• 7 Scaglietti O, Marchetti PG, Bartolozzi P. Final results obtained in the treatment of bone cysts with methylprednisolone acetate (depo-medrol) and a discussion of results achieved in other bone lesions. Clin Orthop Relat Res 1982; (165): 33 – 42. Clin Orthop Relat Res 1982; (165) 33-42
• 8 Capanna R, Dal Monte A, Gitelis S. et al. The natural history of unicameral bone cyst after steroid injection. Clin Orthop Relat Res 1982; (166) 204-211
• 9 Wright JG, Yandow S, Donaldson S. et al. Simple Bone Cyst Trial Group. A randomized clinical trial comparing intralesional bone marrow and steroid injections for simple bone cysts. J Bone Joint Surg Am 2008; 90: 722-730 doi:10.2106/JBJS.G.00620
• 10 Yandow SM, Lundeen GA, Scott SM. et al. Autogenic bone marrow injections as a treatment for simple bone cyst. J Pediatr Orthop 1998; 18: 616-620 doi:10.1097/00004694-199809000-00012
• 11 Lokiec F, Wientroub S. Simple bone cyst: etiology, classification, pathology, and treatment modalities. J Pediatr Orthop B 1998; 7: 262-273
• 12 Docquier PL, Delloye C. Treatment of simple bone cysts with aspiration and a single bone marrow injection. J Pediatr Orthop 2003; 23: 766-773 doi:10.1097/00004694-200311000-00015
• 13 Killian JT, Wilkinson L, White S. et al. Treatment of unicameral bone cyst with demineralized bone matrix. J Pediatr Orthop 1998; 18: 621-624 doi:10.1097/00004694-199809000-00013
• 14 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 doi:10.2106/00004623-200206000-00005
• 15 Inoue O, Ibaraki K, Shimabukuro H. et al. Packing with high-porosity hydroxyapatite cubes alone for the treatment of simple bone cyst. Clin Orthop Relat Res 1993; (293) 287-292
• 16 Thawrani D, Thai CC, Welch RD. et al. Successful treatment of unicameral bone cyst by single percutaneous injection of alpha-BSM. J Pediatr Orthop 2009; 29: 511-517 doi:10.1097/BPO.0b013e3181aad704
• 17 Hou HY, Wu K, Wang CT. et al. Treatment of unicameral bone cyst: a comparative study of selected techniques. J Bone Joint Surg Am 2010; 92: 855-862 doi:10.2106/JBJS.I.00607
• 18 Mik G, Arkader A, Manteghi A. et al. Results of a minimally invasive technique for treatment of unicameral bone cysts. Clin Orthop 2009; 467: 2949-2954 doi:10.1007/s11999-009-1008-2
• 19 Gentile JV, Weinert CR, Schlechter JA. Treatment of unicameral bone cysts in pediatric patients with an injectable regenerative graft: a preliminary report. J Pediatr Orthop 2013; 33: 254-261 doi:10.1097/BPO.0b013e318285c56c
• 20 Chigira M, Maehara S, Arita S. et al. The aetiology and treatment of simple bone cysts. J Bone Joint Surg Br 1983; 65: 633-637
• 21 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 doi:10.2106/00004623-200010000-00011
• 22 Santori F, Ghera S, Castelli V. Treatment of solitary bone cysts with intramedullary nailing. Orthopedics 1988; 11: 873-878
• 23 Farr S, Balacó IMS, Martínez-Alvarez S. et al. Current Trends and Variations in the Treatment of Unicameral Bone Cysts of the Humerus: A Survey of EPOS and POSNA Members. J Pediatr Orthop 2020; 40: e68-e76 doi:10.1097/BPO.0000000000001376
• 24 Kadhim M, Sethi S, Thacker MM. Unicameral Bone Cysts in the Humerus: Treatment Outcomes. J Pediatr Orthop 2016; 36: 392-399 doi:10.1097/BPO.0000000000000462
• 25 Zhao JG, Wang J, Huang WJ. et al. Interventions for treating simple bone cysts in the long bones of children. Cochrane Database Syst Rev 2017; (02) CD010847
• 26 Ramirez A, Abril JC, Touza A. Unicameral bone cyst: radiographic assessment of venous outflow by cystography as a prognostic index. J Pediatr Orthop B 2012; 21: 489-494 doi:10.1097/BPB.0b013e328355e5ba
• 27 Abril JC, Queiruga JA, Casas J. et al. Unusual finding after contrast injection of a solitary bone cyst. A case report. Acta Orthop Belg 1999; 65: 235-238
• 28 Yandow SM, Marley LD, Fillman RR. et al. Precordial Doppler evaluation of simple bone cyst injection. J Pediatr Orthop 2009; 29: 196-200 doi:10.1097/BPO.0b013e31819827a8
• 29 Colville MR, Aronson DD, Prcevski P. et al. The systemic and local effects of an intramedullary injection of methylprednisolone acetate in growing rabbits. J Pediatr Orthop 1987; 7: 412-414 doi:10.1097/01241398-198707000-00006
• 30 Rosenborg M, Karlsson A, Hirsch G. et al. Contrast medium injected into juvenile bone cysts to analyze interior morphology and guide intracavity corticosteroid treatment. Acta Radiol 1992; 33: 221-224
• 31 Oppenheim WL, Galleno H. Operative treatment versus steroid injection in the management of unicameral bone cysts. J Pediatr Orthop 1984; 4: 1-7 doi:10.1097/01241398-198401000-00001
• 32 Broder HM. Possible precursor of unicameral bone cysts. J Bone Joint Surg Am 1968; 50: 503-507 doi:10.2106/00004623-196850030-00008
• 33 Gebhart M, Blaimont P. Contribution to the vascular origin of the unicameral bone cyst. Acta Orthop Belg 1996; 62: 137-143
• 34 Nystrom L, Raw R, Buckwalter J. et al. Acute intraoperative reactions during the injection of calcium sulfate bone cement for the treatment of unicameral bone cysts: a review of four cases. Iowa Orthop J 2008; 28: 81-84
• 35 Adamsbaum C, Kalifa G, Seringe R. et al. Direct Ethibloc injection in benign bone cysts: preliminary report on four patients. Skeletal Radiol 1993; 22: 317-320 doi:10.1007/bf00198389
• 36 Shisha T, Marton-Szucs G, Dunay M. et al. The dangers of intraosseous fibrosing agent injection in the treatment of bone cysts. The origin of major complications shown in a rabbit model. Int Orthop 2007; 31: 359-362 doi:10.1007/s00264-006-0177-9
• 37 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-B: 200-204
• 38 Cho HS, Oh JH, Kim HS. et al. Unicameral bone cysts: a comparison of injection of steroid and grafting with autologous bone marrow. J Bone Joint Surg Br 2007; 89: 222-226 doi:10.1302/0301-620X.89B2.18116
• 39 Kadhim M, Thacker M, Kadhim A. et al. Treatment of unicameral bone cyst: systematic review and meta analysis. J Child Orthop 2014; 8: 171-191 doi:10.1007/s11832-014-0566-3
• 40 Mascard E, Gomez-Brouchet A, Lambot K. Bone cysts: unicameral and aneurysmal bone cyst. Orthop Traumatol Surg Res 2015; 101 (1 Suppl.): S119-S127 doi:10.1016/j.otsr.2014.06.031
• 41 Hashemi-Nejad A, Cole WG. Incomplete healing of simple bone cysts after steroid injections. J Bone Joint Surg Br 1997; 79: 727-730
• 42 Garceau GJ, Gregory CF. Solitary unicameral bone cyst. J Bone Joint Surg Am 1954; 36: 267-280
• 43 Glowacki M, Ignys-OʼByrne A, Ignys I. et al. Limb shortening in the course of solitary bone cyst treatment–a comparative study. Skeletal Radiol 2011; 40: 173-179 doi:10.1007/s00256-010-0964-7
• 44 Stanton RP, Abdel-Motaʼal MM. Growth arrest resulting from unicameral bone cyst. J Pediatr Orthop 1998; 18: 198-201
• 45 Dormans JP, Pill SG. Fractures through bone cysts: unicameral bone cysts, aneurysmal bone cysts, fibrous cortical defects, and nonossifying fibromas. Instr Course Lect 2002; 51: 457-467
• 46 Chuo CY, Fu YC, Chien SH. et al. Management strategy for unicameral bone cyst. Kaohsiung J Med Sci 2003; 19: 289-295 doi:10.1016/S1607-551X(09)70475-9