Is sclerotherapy with polidocanol a better treatment option for aneurysmal bone cyst compared to conventional curettage and bone grafting?

Sclerotherapy with polidocanol as a treatment for aneurysmal bone cyst: A systematic review

Background

Sclerotherapy with polidocanol is a minimally invasive treatment for smaller Aneurysmal bone cysts (ABCs), offering safety and lower recurrence rates compared to surgery. Treatment choice depends on ABC size and location, with denosumab and titanium elastic nails as alternatives. To our knowledge, there are no systematic reviews regarding sclerotherapy with polidocanol as a treatment for ABCs. We aim to elucidate the effects of polidocanol in patients with ABCs.

Methods

This systematic review included studies involving patients with aneurysmal bone cyst treated with sclerotherapy using polidocanol as its agent. Literature search from database such as Pubmed, Cochrane, and Scopus resulted in 14 studies included in this review.

Results

Multiple studies have examined the effectiveness of percutaneous sclerotherapy with polidocanol as a primary treatment for ABCs. Most studies favored this approach without comparisons, while some compared it to extended curettage or other methods. Results varied, with some showing successful healing and pain relief, while others noted minor complications. Sequential polidocanol instillations were found to reduce cyst volume and minimize recurrence. Other interventions, like absolute alcohol gel and Denosumab, showed potential but with varying outcomes.

Conclusion

While percutaneous sclerotherapy with polidocanol has been prominently effective in managing aneurysmal bone cysts, further studies are required to identify the most effective and least invasive treatment strategies to optimize outcomes and minimize complications in clinical practice.

Minimally Invasive Treatment of Aneurysmal Bone Cysts with Gelified Ethanol (DiscoGel®): Evaluation of Feasibility, Safety, and Efficacy

INTRODUCTION

Aneurysmal bone cysts are locally aggressive bone lesions. The aim of this study was to evaluate safety and effectiveness of radio-opaque gelified ethanol sclerotherapy in treating primary aneurysmal bone cyst.

MATERIALS AND METHODS

In this single-center, retrospective study (January 1st, 2012, to June 30th, 2024), 32 patients with primary aneurysmal bone cysts were treated with percutaneous sclerotherapy using radio-opaque gelified ethanol at various skeletal sites. Of these, 27 patients were included in the analysis, 5 patients were excluded due to follow-up of less than 12 months. The primary outcome measure was the safety of the procedures. Secondary outcomes measures included clinical success, defined as the absence of post-sclerotherapy fractures or the need for surgical revision, and radiological success, determined by the conversion of an active or aggressive aneurysmal bone cyst to inactive, according to Campanacci's classification.

RESULTS

No major complications related to the procedure were observed. One minor complication (3.7%) was reported: One local collection resolved with antibiotic therapy. The remaining patients showed favorable clinical and radiological outcomes. No fractures were recorded after sclerotherapy. Surgical revision for progressive recurrence was necessary in 2 cases (7.4%). Aneurysmal bone cyst becoming inactive in 21 of 27 (77.8%) patients after 12 months, 13 of 14 (92.8%) patients after 24 months, and 7 of 7 (100%) and 5 of 5 (100%) patients after more than 36 and 48 months, respectively.

CONCLUSION

Radio-opaque gelified ethanol sclerotherapy offers a safe, effective, and minimally invasive treatment for primary aneurysmal bone cyst. It may be considered a first-line approach, similar to other sclerotherapy methods, potentially avoiding the need for invasive surgery as an initial treatment option.

Clinical efficacy of allograft bone combined with calcium phosphate bone powder in repairing bone defects of benign bone tumors: A retrospective controlled study

OBJECTIVE

To evaluate the clinical efficacy of repairing bone defects caused by benign bone tumors using allograft bone combined with calcium phosphate bone powder.

METHODS

A retrospective analysis was conducted on 55 patients (aged 10-61 years, mean 35 ± 13.2) with benign bone tumors treated at our hospital from June 2020 to December 2022. The bone defects in these cases were created after surgical curettage of the tumor lesions, which included common benign tumors such as osteochondroma, giant cell tumor of bone, and enchondroma. Patients were divided into two groups based on bone graft materials: a simple allograft bone group (n = 30) and a combined group using allograft bone with calcium phosphate bone powder (n = 25). Preoperative data, surgical time, intraoperative blood loss, postoperative complications, imaging findings, limb function, and quality of life (KPS scores) were analyzed.

RESULTS

All 55 patients were followed for 12-30 months (mean 13.45 ± 5.18). All incisions healed by primary intention without complications such as graft nonunion, fractures, or tumor recurrence. The combined group showed a significantly shorter healing time (t = 4.280, P < 0.05) and higher KPS scores at 6 months postoperatively (X2 = 3.646, P < 0.05) compared to the simple group. However, no significant differences were observed between groups in healing rate, residual bone defects, or limb function at 12 months postoperatively (P > 0.05).

CONCLUSION

Allograft bone combined with calcium phosphate bone powder is superior to allograft bone alone for repairing bone defects following curettage of benign bone tumors, promoting faster healing and better postoperative functional recovery.

Successful Treatment of a Rapidly Enlarging Mandibular Aneurysmal Bone Cyst With Sclerotherapy and Intralesional Curettage

An aneurysmal bone cyst (ABC) is a benign bone lesion primarily found in the metaphysis of long bones or spine, with rare occurrences in the head and neck region. We report the case of a 17-year-old female patient with a rapidly enlarging mandibular ABC. Initial imaging and biopsy confirmed the diagnosis of ABC, revealing a blood-filled lesion with multinucleated giant cells and no solid components. Owing to the lesion's size and rapid growth, hemimandibulectomy was initially considered but postponed due to concerns about aesthetic and functional outcomes. The patient underwent percutaneous sclerotherapy with polidocanol, followed by intralesional curettage. Post-treatment evaluations indicated complete lesion resolution and improved facial symmetry with no recurrence at 36 months. This case highlights the potential benefits of combining polidocanol sclerotherapy and intralesional curettage for the treatment of jaw ABCs. Further research is needed to determine the optimal application and follow-up of this approach.

Modern treatment of unicameral and aneurysmatic bone cysts

The best treatment of unicameral bone cyst and aneurismatic bone cyst (ABC) is debated in the literature. For simple bone cysts, multiple treatments were proposed from observation only to open curettage. The historical treatment with intraosseous injection of methylprednisolone acetate into the bone cysts nowadays is reduced due to the morbidity of multiple injections and the risk of multiple pathologic fractures until the healing. Different types of treatments for ABC are reported, including surgery, percutaneous treatments, and medical treatments; however, there is currently no consensus on the best approach. The association of curettage, bone graft, and elastic stable intramedullary nail (ESIN) had a success rate of over 85%. Decompressing the cyst wall is more critical for increasing the healing rate than the type of graft used to fill the cavity. In ABC, sclerotherapy offers the advantages of lower invasiveness and morbidity, associated with better functional scores and faster return to full weight-bearing. Moreover, they can be used in challenging locations. Selective arterial embolization is a complex procedure and often requires association with other treatments. Further studies are needed to confirm the effectiveness of denosumab and its side effects on skeletally immature patients. Curettage with adjuvants and autogenous bone grafting still shows promising results and can be used in larger, aggressive defects or superficial lesions. For simple bone cysts, the combination of curettage, bone graft, and ESIN showed the best results. Sclerotherapy for ABC also shows promising results.

Outcomes of a single dose of injection polidocanol application in aneurysmal bone cyst

Background

Aneurysmal bone cysts are common osteolytic tumours that have ability to expand and produce pathological fractures. Recurrence is a major issue in such tumours posing a treatment dilemma to clinicians. Injection polidocanol has shown promising results, but the number of injections still remains a topic of debate.

Methodology

A prospective interventional study done on 13 patients of biopsy-proven aneurysmal bone cysts. Patient related outcome measures(PROM's) seen using VAS score, SF-12 score and ROM of the involved extremity. Radiologically volume of tumour and cortico-medullary ratio were calculated. All patients received single dose of injection polidocanol and were followed up to 6 months.

Results

The mean age of patients was 9.5 years, with slight female predominance. Most cases had Campana grade 1. Mean VAS score improved from 9/10 to 1/10, ROM of the proximal and distal joints of the involved bone improved from 60 % (± 20 %) to 100 %. Mean SF12 score increased from 41 (±7): 47 (±3) to 54 (±2): 58 (±2) at the end of 6 months(p < 0.05).Mean volume of the lesion decreased from 6.30 cc (± 1.30) to 2.86 cc (±1.34) (p < 0.0005) with a reduction of MCR from 4.8 (±0.6) to 3.6 (±0.5) on a similar time span (p < 0.0005) at end of 6 months. 2 patients showed recurrence with none of the patients showing any complication.

Conclusion

Single dose of Injection Polidocanol for Aneurysmal Bone Cysts is a unique study, not described in literature before. The smaller lesion in initial staging can be treated effectively with single dose of polidocanol reducing morbidity and treatment cost to the patient. It is as good as giving multiple doses of Polidocanol as per as functionality of the limb is concerned.Also, we propose a new parameter "Medullary-cortical ratio", which is an effective way to assess the improvement and resolution of ABC after administration of Polidocanol.

Sclerotherapy as a primary or salvage procedure for aneurysmal bone cysts: A single-center experience

BACKGROUND

Aneurysmal bone cysts (ABC) are benign cystic bone tumors of an osteolytic and locally aggressive nature. As an alternative to the primary treatment of choice, which consists of curettage with bone grafting, alternative treatment methods with promising results have been described. At our department, we have, in recent years, used percutaneous sclerotherapy with polidocanol. The objective of this study was to identify the healing rate and safety of sclerotherapy with polidocanol.

AIM

To identify the efficacy and safety of sclerotherapy with polidocanol in primary and recurrent ABC.

METHODS

Twenty-two consecutive patients (median age 12.5 years; range 1-27) with 23 ABCs treated with sclerotherapy with polidocanol from 2016-2021 were included retrospectively. Eleven patients (48%) had undergone different forms of previous treatment with recurrence. Under general anesthesia and fluoroscopic guidance, repeated percutaneous injections of 4mg polidocanol/kg body weight were performed. Through review of the electronic medical records, the following were identified: healing and recurrence rate, number of treatments, gender, age, comorbidity, location of the tumor and side effects / complications, as well as any previous surgery for ABC. The median length of radiographic follow-up was 19.5 mo.

RESULTS

All ABCs except one (96%) showed healing or stable disease after a median of 4 (range 1-8) injections. Complete clinical and radiographic healing was observed in 16 cysts (70%), while partial radiographic healing with resolution of pain was seen in 6 cases (26%) and considered as stable disease. The cyst that failed to heal had previously undergone curettage twice with recurrence. One patient with a large pelvic ABC experienced, right after two injections, a sudden drop in blood pressure, which could quickly be reversed. One patient with a juxtaphyseal ABC in the femoral neck showed a minor limb length discrepancy because of deformity. Beyond that, no complications were observed.

CONCLUSION

Percutaneous sclerotherapy with polidocanol appears to be a safe alternative for treatment of aneurysmal bone cysts. In our series of both primary and recurrent cysts, it showed the ability to achieve healing or stable disease in 22 of 23 cases (96%). Further studies are needed to decide if this provides a long-lasting effect.

The treatment of aneurysmal bone cysts

PURPOSE OF REVIEW

Aneurysmal bone cysts are rare, locally aggressive bone tumors. Optimal treatment of ABCs is still matter of debate as therapies including sclerotherapy, selective arterial embolization and systemic treatment with denosumab are increasingly utilized, in addition to or instead of traditional curettage. The purpose of this review is to discuss current concepts and difficulties in diagnosing and treating primary ABCs, based on latest available literature.

RECENT FINDINGS

In diagnostics, multiple new fusion partners of USP-6 have been described on next-generation sequencing specifically for primary ABCs. In a recent systematic review, failure rates of percutaneous injections and surgery were comparable. In a literature review, the use of denosumab seemed effective but resulted in multiple cases of severe hypercalcemia in children.

SUMMARY

Accurately diagnosing primary ABC is crucial for treatment decisions. Curettage remains a valid treatment option, especially with adjuvant burring, autogenous bone grafting and phenolization. Percutaneous sclerotherapy represents a solid alternative to surgery, with polidocanol showing good results in larger studies. Systematic therapy with denosumab exhibits favorable results but should be reserved in the pediatric population for unresectable lesions, as it may result in severe hypercalcemia in children. When selecting a treatment option, localization, stability and safety should be considered.

Stabilisation of Pathologic Proximal Femoral Fracture near the Growth Plate with Use of a Locking Plate and Transphyseal Screws

Aneurysmal bone cyst (ABC) is a benign osseus lesion with a high pathologic fracture risk. The described treatment options are varied and inconsistent. For successful treatment results, it is essential to prevent recurrence and sufficiently stabilise the weakened bone. Lesions close to the growth plates, especially in the femoral neck region, are challenging to stabilise in children. In this study, 27 clinics, including 11 sarcoma centres, 15 paediatric orthopaedic clinics, and one sarcoma/paediatric orthopaedic centre, were surveyed and asked about their treatment approaches for an exemplary case of ABC in the femoral neck causing a pathological fracture in a 20-month-old infant, with a response rate of 81%. The heterogeneity of treatment options described in the literature is consistent with the survey results. The most favoured approach was curettage, defect filling of any kind, and surgical stabilisation. However, the lesion stabilisation option introduced in this paper, which involves the use of transphyseal screws, was not mentioned in the survey and has not been reported in the literature. Contrary to the existing concepts, our technique offers high stability without significant growth restriction. Transphyseal screws are also suitable for the treatment of femoral neck fractures of other aetiologies in children.

Minimally invasive treatment of aneurysmal bone cysts: Systematic literature review

INTRODUCTION

The optimal treatment of aneurysmal bone cysts (ABC) remains controversial. Surgery has long been considered as the treatment that yields the best outcomes. Some authors now prefer using less invasive options as the primary treatment. The primary objective of this systematic literature review was to determine if treatments that are less invasive than surgery are also effective in curing the ABC. The secondary objective was to determine the respective role of each treatment in the therapeutic arsenal.

HYPOTHESIS

Less invasive treatments can replace surgery as the base treatment for ABC.

PATIENTS AND METHODS

A PubMed® search was carried out for this review. The inclusion criteria were ABC treatment without cyst removal, case series, clinical case reports, reviews, publication in French or English. Excluded were articles that described the results of surgical treatment only, cranial or maxillofacial cysts, secondary ABC, duplicates, no abstract available. Based on the first six items of the "MINOR criteria", we selected 42 studies. For each selected study, we analyzed the number of cases, clinical response to treatment, radiological healing, recurrence or failure rate, complications and side effects of the treatment.

RESULTS

This review found that less invasive treatments generate results that are at least as good as surgery, often with fewer complications. Thus, in certain cases, these treatments can be recommended as first-line therapy. This category includes selective arterial embolization, sclerotherapy (alcohol, polidocanol) and injection of demineralized bone matrix.

DISCUSSION

Selective arterial embolization yields good results. While this is a difficult, operator-dependent technique that is not suitable for all ABCs (no identifiable feeding vessel), we recommend it as the primary treatment for spinal ABCs. For ABCs in other locations, sclerotherapy can be used as the primary treatment. However, this treatment becomes inconvenient if the number of injections is too high. Radiation therapy is not a first-line treatment because of its side effects. Bisphosphonates and denosumab can be used when the other treatments are contraindicated.

Current strategies for the treatment of solitary and aneurysmal bone cysts: A review of the literature

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SBCs can mostly be treated conservatively.

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In ABCs a biopsy is compulsory.

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ABCs can be treated by polidocanol instillations adequately.

This review of the literature aims to compare the etiology, the pathogenesis, the clinical diagnostics and the relevant treatment options of two different types of cystic bone lesions: the solitary bone cyst (SBC) and the aneurysmal bone cyst (ABC). Whereas the clinical symptoms and the radiographic appearance can be similar, the diagnostic pathway and the treatment options are clearly different.

The solitary bone cyst (SBC) represents a tumor-like bone lesion, occurring most frequently in the humerus and femur in children and adolescents. Pain caused by intercurrent pathological fractures is often the first symptom, and up to 87% of the cysts are associated with pathological fractures. In the majority of cases SBCs can be treated conservatively, especially in the upper extremity. However, if a fracture is completely dislocated, joint affecting, unstable or open, surgical treatment is necessary. Pain under weight bearing or regaining the ability to mobilize after fracture timely can necessitate surgical treatment in SBCs affecting the lower extremity. Spontaneous resolution can be seen in rare cases.

The aneurysmal bone cyst (ABC) is a benign, locally aggressive tumor that occurs in childhood and early adulthood. It usually affects the metaphysis of long bones but can also occur in the spine or the pelvis. ABC can be primary but also secondary to other bone pathologies. The diagnosis has to be confirmed by biopsy and histopathological examinations. With cytogenetic studies and the detection of specific translocations of the ubiquitin-specific protease (USP) 6 gene primary ABCs can be differentiated from secondary ABCs and other bone lesions. Among various modalities of treatment i.e. en bloc resection, intralesional curettage with adjuvants, embolization or the systemic application of denosumab, intralesional sclerotherapy using polidocanol is an effective and minimally invasive treatment of primary ABCs.