Unicameral Bone Cysts are fluid-filled bone lesions most common in children under 20. They form due to venous occlusion in the bone marrow and contain substances that cause bone resorption. Clinically, they present as swelling and pain after trauma in the femur or humerus. Radiographs show expanded thin bone with fractures. Treatment involves injections or surgery to curette the cyst membrane and fill the cavity to prevent fractures and recurrence.
2. Introduction
Initially described by Jaffe and Lichtenstein in 1942
Common in first two decades of the life, the rarity of the
lesion in the adults suggests that spontaneous healing occurs.
3. Pathogenesis
Hypothesized that the cyst forms as a response to venous
occlusion in the intramedullary space
Considered them to be intraosseous synovial cysts
Dysplastic areas, which they believed developed in response
to trauma
4. Pathology
An area of fusiform expansion
Periosteum lifts away easily and underlying bone is egg-shell
thin, semitranslucent,bluish and easily penetrated.
6. The fluid within the cyst has been
analyzed and shown to contain high
levels of oxygen-free-radical
scavengers, prostaglandins
(prostaglandin E2), interleukin-1, and
proteolytic enzymes
7. These substances, which cause bone resorption, may play a role
in the formation and growth of cysts.
The cyst fluid has a lower total protein content than serum but
higher levels of protein-bound hydroxyproline, lactate, and
alkaline phosphatase.
8. Vascular occlusion theory
The pressures within a cyst are elevated above venous
pressures
if radiopaque dye is injected into the cyst with enough
pressure, the dye can be extruded into the venous system of
the limb. Reestablishing these outflow channels may assist in
the involution of the cyst
9. simply lowering the interstitial pressure by multiple
perforations may cause cyst involution
10. Clinical Features
Age- younger patients
Sex- M:F 2:1
Most common site-the proximal femur, followed by the proximal
humerus
Many cysts are immediately adjacent to, and appear to involve,
the epiphyseal growth plate
11. The area is slightly warm and swollen
The symptoms of unicameral bone cysts are most often
brought on by trauma
When fractures do become evident, they rarely involve the
growth plate itself
12. Cysts progress from active to quiescent to an involutional
stage in the course of their natural history
The difficulty for the clinician is to assess the current stage of
the cyst at the time of diagnosis
18. Treatment
Difficult to decide whether the cyst is in the active, latent, or
involutional Stage
Unless there is a tremendous amount of cortical thinning,
there may not be a comparable decrease in strength as a cyst
expands the cortical margins
19. It may be reasonable to choose close observation rather than
a surgical procedure
If the cyst is active and obviously enlarging during
observation (3 to 6 months), treatment may be appropriate
23. Injection Techniques
Injecting methylprednisolone into the cyst under fluoroscopic
control while using radiopaque dye to confirm entry into the cyst
Aspiration of the cyst is done prior to injection
The level of PGE2 in cyst fluid is reduced after injection of
methylprednisolone
24. Advantageous by decreasing the morbidity due to a major
surgical procedure
Recurrence rates of 15% to 88% after an average of three
injections
25. Surgical Techniques
Resection or curettage plus bone grafting has been employed
as the definitive treatment for unicameral bone cysts
26. Technique
A cortical window is made, which allows access to the entire
contents of the cavity
The clear fluid should be removed, and the fibrous membrane
curetted from the cyst wall
27. Autologous bone marrow, allograft, demineralized bone matrix
(DBM), and other bone substitute materials have been used
successfully
Thus sparing the patient the morbidity of an autograft harvesting
site
Allograft bone chips have proved effective in the treatment of
cysts
28. Calcium sulfate in the form of plaster of paris has been used
with a good success rate and a low recurrence rate
31. Recurrence
Recurrence is more when the patient is younger than 10
years,
When the lesion is in the upper humerus and closely adjacent
to the growth plate