Flexible Intramedullary

Nailing for the Treatment of

Unicameral Bone Cysts in Long Bones*
BY ANDREAS ROPOSCH, M.D., VINAY SARAPH, M.S., D.N.B., AND WOLFGANG E. LINHART, M.D.

Investigation performed at the Department of Pediatric Orthopaedic Surgery, Karl-Franzens-University of Graz, Graz, Austria

Abstract
Background: Unicameral bone cyst is characterized
by its tenacity and risk of recurrence. Pathological fracture is common and is often the presenting symptom.
The objective of the present study was to evaluate the
results of flexible intramedullary nailing for the treatment of a unicameral bone cyst with or without a
pathological fracture.
Methods: Flexible intramedullary nailing for the
treatment of a unicameral bone cyst was performed in
thirty-two patients. Thirty of these patients presented
with a pathological fracture; twenty-four were managed immediately with intramedullary nailing, and the
other six had been managed conservatively at other
clinics before they were referred to our department.
The remaining two cysts were detected incidentally.
The cyst was located in the humerus in twenty-one patients, in the femur in nine, and in the radius in two.
The mean age of the patients at the time of surgery was
9.8 years, and the mean duration of follow-up was 53.7
months. Radiographic evaluation was performed according to the criteria of Capanna et al., and the cyst
was classified as completely healed, healed with residual radiolucency (osteolysis), recurred, or having no
response.
Results: The healing period ranged from three to
105 months. Fourteen cysts healed completely, and sixteen healed with residual radiolucent areas visible on
radiographs. There was recurrence of two cysts that had
healed with residual radiolucency. All of the cysts in the
present study responded to treatment. A change of
nails was necessary in nine patients, as the nails had become too short after bone growth. No major complications were observed.
Conclusions: Flexible intramedullary nailing provides early stability, which allows early mobilization
and thus obviates the need for a plaster cast and de*No benefits in any form have been received or will be received
from a commercial party related directly or indirectly to the subject
of this article. No funds were received in support of this study.
Spittelauerlaende 9/21, 1090 Vienna, Austria. E-mail address for
A. Roposch: andreas.roposch@univie.ac.at. Please address requests
for reprints to A. Roposch.
Department of Pediatric Orthopaedic Surgery, Karl-FranzensUniversity of Graz, Auenbruggerplatz 34, 8036 Graz, Austria. E-mail
address for W. E. Linhart: wolfgang.linhart@kfunigraz.ac.at.
Copyright 2000 by The Journal of Bone and Joint Surgery, Incorporated

VOL. 82-A, NO. 10, OCTOBER 2000

creases the prevalence of the most common complication: a pathological fracture. This method of treatment
also allows for an early return to normal activity.
The objective of treatment of unicameral bone cysts
in children is to prevent a pathological fracture and to
elicit healing of the lesion. Since Virchow39 first described this entity in the nineteenth century, numerous
articles have presented results of management. Earlier
treatment methods included crushing of the cyst walls
and the use of onlay grafts2, total resection (diaphysectomy) with bone-grafting10,17,27,28,38, subtotal resection
without bone-grafting26, and subtotal resection with
bone-grafting1,16.
Because of a better understanding of the pathology
of unicameral bone cysts, surgical intervention now
focuses on removing only the pathological bone or on
stimulating osteogenesis within the cyst. Currently performed surgical procedures include curettage combined
with bone-grafting29-31, allografting with freeze-dried
crushed cortical bone37, use of homologous spongiosa
chips3, the application of high-porosity hydroxyapatite19,
and cryosurgery35. Decompression with multiple drillholes11-13,15,21,23,36 and intralesional injections of either steroids4,5,14,18,34 or bone marrow25,40 have also been used to
treat unicameral bone cysts, with variable success.
Flexible intramedullary nailing for the treatment of
unicameral bone cysts has been previously reported23.
This method is rapidly gaining popularity for the treatment of cysts in long bones because it is simple, surgical
intervention is minimal, the results are predictable, and
early mobilization is possible without the need for a
plaster cast9,20,32,33. We have been performing this method
of treatment at the Department of Pediatric Orthopaedic Surgery at Karl-Franzens-University of Graz for
the last eleven years. In the present study, we describe
the surgical technique and present the results of flexible
intramedullary nailing in thirty-two children with a unicameral bone cyst.
Materials and Methods
Thirty-two patients with a unicameral bone cyst were managed
with flexible intramedullary nailing between 1989 and 1997. There
were twenty-five male and seven female patients between two and
15.5 years old (mean, 9.8 years old) at the time of surgery. These patients were followed for a mean of 53.7 months (range, twenty-five to
105 months).

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1448

A. ROPOSCH ET AL.

FIG. 1-A

FIG. 1-B

Figs. 1-A through 1-D: Radiographs of a thirteen-year-old girl with a pathological long spiral fracture in a unicameral bone cyst of the proximal aspect of the right humerus.
Fig. 1-A: Preoperative lateral and anteroposterior radiographs.
Fig. 1-B: Lateral and anteroposterior radiographs made eight weeks after flexible intramedullary nailing. The fracture is stabilized, and the
cyst is occupied by the nails. Note how far the nails can be directed into the metaphysis without causing damage to the growth plate.
The cyst was located in the proximal third of the humerus in
twenty-one patients, in the proximal third of the femur in nine, and in
the distal third of the radius in two. Five of the humeral bone cysts
were located immediately adjacent to the physis. However, the femoral bone cysts were located in the femoral neck and in the pertrochanteric and subtrochanteric regions. Of the thirty-two patients, thirty
presented at our institution with a pathological fracture and twentyfour were managed immediately with intramedullary nail fixation. In
the remaining six patients, the pathological fracture had been managed conservatively, with cast immobilization, at other clinics before
they were referred to our department. The cyst, which was located in
the proximal aspect of the humerus in five of these patients and in the
distal aspect of the radius in one, did not heal, although the pathological fracture healed in every patient. The period between the occurrence of the pathological fracture and nail fixation in these six patients
ranged from two to twelve months. In the remaining two patients in
the series, the bone cyst was detected incidentally on radiographs
made because of minor trauma.

Surgical Technique
Prior to insertion of the nails, a percutaneous biopsy was performed under image-intensifier control. A small incision was made,
and the cortical bone was exposed by blunt dissection. The location of
the hole punch in the lesion was rechecked with the image intensifier,
and adequate tissue was obtained. Histological findings showed a unicameral bone cyst in all of the patients in the present study.
After the biopsy specimen was taken, retrograde nailing was performed. Displaced pathological fractures were first reduced. Children
with a lesion in the upper extremity were placed supine on the operating table, and displaced fractures in these patients were reduced manually. Patients with a lesion in the proximal aspect of the femur were

placed on the fracture table because of the ease of fracture reduction,

the possibility of accurately localizing the cyst and its relation to the
femoral physis, and the ability to position the nails optimally.
We used stainless-steel Pediatric Ender Nails (Herndlofer, Vienna, Austria)24, which are flexible and are inserted retrograde. These
nails are 2.0 to 3.5 millimeters in diameter and thirteen to thirty-five
millimeters in length. The diameter and length of the nails were
selected on the basis of measurements made with a tape on the preoperative anteroposterior radiograph, with the enlargement on radiographs taken into account. The chosen length of the nails was then
rechecked with the image intensifier after placement of the nail on
the anterior surface of the corresponding bone. The longest nails that
did not encroach on the proximal growth plate were used. The diameter of the nails was selected such that two nails would occupy approximately two-thirds of the medullary canal.
Two straight incisions were made in the distal region of the involved part of the extremity, medially and laterally, approximately
three centimeters proximal to the joint line. The cortical bone was exposed by blunt dissection; under image-intensifier control, medial and
lateral holes were made with an awl proximal to the distal growth
plate. Both nails were directed to pass through the bone cyst, one at a
time. The proximal and distal physes were carefully avoided. The distal opening of the nail was left protruding from the bone (Figs. 1-A
through 1-D). The stability of the fixation was checked by rotating the
limb and looking for any movement of the fragments under an image
intensifier. The incision was closed in layers. Muscles and the subcutaneous tissue covered the prominent part of the nails.

Postoperative Rehabilitation
The postoperative mobilization depended on whether there was
a pathological fracture as well as on the stability of the fixation. On
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FLEXIBLE INTRAMEDULLARY NAILING FOR THE TREATMENT OF UNICAMERAL BONE CYSTS

FIG. 1-C

1449

FIG. 1-D

Fig. 1-C: Lateral and anteroposterior radiographs made seven months after the nailing. Both the fracture and the cyst have healed.
Fig. 1-D: Lateral and anteroposterior radiographs made twelve months after the nailing. The nails have been removed, and the cyst has
healed completely. Note the thickening of the cortical margins of the cyst wall.
the average, patients with a pathological fracture of the femur were
allowed non-weight-bearing, crutch-assisted walking on the third
postoperative day (range, first to seventh day). Progressive weightbearing was allowed depending on the stability of the bone. When
there was precarious stability of the bone due to extensive cortical
thinning, non-weight-bearing, crutch-assisted walking was encouraged for two to three weeks. Weight-bearing was gradually allowed
after some healing of the fracture had occurred. Children with stable
fixation of the pathological fracture were allowed to bear weight
sooner. For upper-extremity lesions, the postoperative treatment
consisted of mobilization exercises. Immobilization in a plaster cast
was not used for either upper or lower-extremity cysts. The patients
stayed in the hospital for a mean of seven days (range, five to fourteen days) and then were allowed to attend school after discharge.
Sports activities were permitted once the fracture had healed and
the cyst showed some consolidation. There was no restriction of
sports activities for the patients who did not have a fracture. Clinical
and radiographic follow-up was carried out in the orthopaedic outpatient clinic. Radiographs were first made at six to eight weeks,
three months, and then every six months after the nailing (Figs. 2-A
through 2-D). Healing was assessed on plain radiographs according
to the criteria of Capanna et al.6, and the nails were removed once
the cyst had healed.

Results
Results were evaluated on plain radiographs according to the classification system of Capanna et al.6.
The cyst was classified as healed when it was completely filled with bone and the cortical margins had
thickened. It was classified as healed with residual radiolucency (osteolysis) when most of the cyst was filled
with bone and had healed, it was well consolidated with
VOL. 82-A, NO. 10, OCTOBER 2000

bone, and the cortical margins had thickened but there

were still small, residual areas of radiolucency. The cyst
was classified as a recurrence when it had healed initially and had become filled with bone but large areas
of radiolucency and cortical thinning subsequently developed. It was classified as having no response when
there was no evidence of any effect of treatment. Both
recurrence and no response represented a failure of
treatment.
Of the thirty-two unicameral bone cysts, thirty (94
percent) healed within thirty-six months (range, three to
105 months). Fourteen lesions (44 percent) were classified as completely healed and sixteen (50 percent), as
healed with residual radiolucency. The follow-up period
for the patients with a completely healed lesion ranged
from twenty-five to seventy-eight months, and that for
the patients with a healed lesion with residual radiolucency ranged from twenty-five to 105 months. Each
lesion responded to treatment after the nailing. The patients with healing but residual radiolucency were still
being followed at the time of this writing. The nails were
removed at a mean of forty months (range, thirty-nine
to fifty months) postoperatively.
Two recurrences (6 percent) were observed after
the nails were removed. The first was in an eleven-yearold girl with a lesion in the proximal aspect of the humerus. Fifteen months after nailing, the cyst healed
with residual radiolucency. The nails were then ex-

1450

A. ROPOSCH ET AL.

FIG. 2-A
Figs. 2-A through 2-D: Radiographs of a thirteen-year-old boy with
a comminuted pathological fracture of the proximal aspect of the
right femur through a unicameral bone cyst.
Fig. 2-A: Preoperative anteroposterior radiograph.

tracted. At a follow-up evaluation fourteen months after removal of the nails, a recurrent lesion was seen
distal to the growth plate. A new nailing was performed

and, at the time of this writing, the nails were still in

situ. The second recurrence was in a ten-year-old boy
who had a cyst in the proximal aspect of the femur
(without a pathological fracture) that was classified as
healed with residual radiolucency thirty-two months
after nailing. A new area of osteolysis appeared distal
to the growth plate six months after removal of the
nails. The boy was then lost to follow-up.
The twenty-four bone cysts associated with a pathological fracture that was treated with immediate nailing
healed at a mean of 36.4 months (range, three to 105
months). In the six patients who had intramedullary nail
fixation after the fracture had healed following conservative treatment, the cyst healed at twenty-four to thirtyeight months. In the two patients who presented without
a pathological fracture, the cyst healed at twenty-one and
fifty-seven months. Because of the small number of patients in our study, we could find no statistical relationship between the healing periods for the patients with a
pathological fracture and those for the patients without
a fracture.
A change of nails was required in nine patients (28
percent) because the nails had become too short for the
growing bone. The cyst was located in the humerus in six
of these patients and in the femur in the remaining
three. The age of the patients at the time of the first nailing ranged from 4.8 to 12.8 years, and the healing period
ranged from twenty-seven to 105 months.
Five of the patients had a varus deformity of the
proximal aspect of the femur after consolidation of the
cyst. The deformity was less than 5 degrees in all of the
patients. The articular-trochanteric distance was not altered, and none of the children had a Trendelenburg gait.
Other complications, such as physeal damage, growth
arrest, infection, refracture, or problems related to the

FIG. 2-B
Lateral and anteroposterior radiographs made immediately after flexible intramedullary nailing. After a closed reduction, the nails were
passed through the lesion to stabilize the fracture, with care taken to avoid encroachment of the nails onto the growth plate.
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1451

sional steroid injections, introduced by Scaglietti et al.34,

is based on the postulate that the membranous wall of
the cyst degenerates after the injection of corticosteroids, thus eliminating the production of fluid in the cyst
and the onset of osteoblastic activity. In our review of
the literature, we found rates of healing of 67 to 96 percent, a 13 percent rate of recurrence, and a 6 percent
rate of no response to that treatment4-7,14,18,34. In most of
the studies, multiple injections were used to treat recurrent cysts and cysts showing no response. Capanna et
al.6,7 reported that, of their ninety patients, one had avascular necrosis of the proximal femoral epiphysis after
four steroid injections, seven had a pathological fracture
during the course of treatment, and sixteen had shortening of the limb. Hashemi-Nejad and Cole18 reported on
thirty-two patients and found good results in all nineteen children with a humeral or fibular bone cyst but in
only nine of thirteen patients with a femoral or tibial
lesion. They concluded that the healing response to intralesional steroids is unpredictable and that this treatment is usually ineffective even after multiple injections.
Bone marrow from the iliac crest has been injected

FIG. 2-C
Anteroposterior and lateral radiographs made eight weeks after
the nailing, showing bridging callus and the healing fracture.

protruding nail ends at the insertion site, were not encountered. Extraction of the nails was uneventful in all
of the patients.
Discussion
Unicameral bone cyst is characterized by its tenacity, its prevalence of recurrence after treatment, and
its association with pathological fracture. To some extent, this explains the diverse methods used to achieve
consolidation.
Curettage and bone-grafting has been the traditional
treatment for unicameral bone cysts. Oppenheim and
Galleno31 noted a complication rate of 17 percent, which
included infection, coxa vara, epiphyseal arrest, and
shortening of the limb. They found that the procedure
had a high morbidity rate and concluded that curettage
and bone-grafting should not be considered the treatment of choice for unicameral bone cysts. Major drawbacks of other surgical techniques, such as total or
subtotal resection or saucerization, are physeal damage,
large amounts of intraoperative blood loss, intraoperative fracture, and a prolonged period of postoperative
immobilization1,16,26,38.
Treatment of unicameral bone cysts with intraleVOL. 82-A, NO. 10, OCTOBER 2000

FIG. 2-D
Lateral and anteroposterior radiographs made thirteen months after the nailing. The unicameral bone cyst has healed completely, and
the cortical margins have thickened. The neck-shaft angle is similar to
that on the contralateral, uninvolved side.

1452

A. ROPOSCH ET AL.

percutaneously into the cyst cavity with the aim of stimulating bone formation in the cyst with the osteogenic
elements in the autogenous bone marrow. Lokiec et
al.25 found consolidation of the cyst in all ten patients
managed with this method. Yandow et al.40 reported on
twelve patients managed with this technique. Six of the
cysts healed completely after one injection of bone marrow, and another two showed healing with residual radiolucency after three injections. Pathological fracture
occurred in four of the patients during treatment, and
two of the patients did not respond to treatment initially
but were eventually successfully managed with curettage and bone-grafting.
Treatment with multiple drill-holes in unicameral
bone cysts is based on the concept that the lesions are
caused by the interstitial fluid that is unable to escape
from the bone because of venous obstruction and blockage11,12. Drilling of the cyst with Kirschner wires11-13,37 or
cannulated screws15 leads to a continuous decompression of the cyst because of drainage of fluid through the
cyst wall. The decreasing internal pressure in the cyst is
believed to be the essential feature of this method12. Shinozaki et al.36 reported on twenty-three unicameral cysts
treated with drilling of multiple holes with Kirschner
wires. Twelve patients in their study underwent a second
surgery for the treatment of a recurrence. A third operation was necessary for three patients because of unsatisfactory consolidation of the cyst and the risk of a
pathological fracture. The overall results of their study
showed no recurrences, healing with residual radiolucency in eight patients, and complete healing in fifteen
patients.
In 1981, Catier et al.9 reported successful results of
flexible intramedullary nailing for the treatment of a
unicameral bone cyst in the proximal aspect of the femur in two patients. Knorr et al.20 and Santori et al.32,33
reported complete healing in all of their patients. We
suggest that the essential feature of this method is the
same as that described in earlier series namely, the

continuous decompression of the lesion and the subsequent decrease in the intralesional pressure11-13,21,36.
However, we did not perform measurements of the intralesional pressure, and our assumption is based on the
conclusions drawn by Chigira et al.11.
The results of the present study show that flexible
intramedullary nailing is an effective treatment for unicameral bone cysts. Thirty (94 percent) of the thirty-two
lesions healed, and all of the lesions responded to treatment. In two patients (6 percent), the cyst recurred after
initially healing. On the basis of a retrospective analysis
of the radiographs of these two patients, we believe that
the recurrent cysts grew outward from an area not covered by the nails. We did not observe any major complications in our study.
A review of the literature showed that approximately 50 percent of patients with a bone cyst have a
complete pathological fracture and another 25 percent
have infraction of a thinned cortex at the time of presentation8. Although local methods such as steroid injections, bone-marrow injections, and decompression
produce consolidation in most patients, they offer no
immediate mechanical stability to the weakened bone.
Nailing has the benefits of decompression and providing early stability to the bone, which permits early mobilization, thus obviating the need for a plaster cast and
decreasing the prevalence of the most common complication: a pathological fracture. In addition, this method
of treatment allows for an early return to normal activity. Oppenheim and Galleno31 stated that the ideal treatment for unicameral bone cysts should employ a lowmorbidity procedure that has a low recurrence rate, prevents fracture, and allows a prompt return to normal life
activity. On the basis of the results of our series, we
believe that flexible intramedullary nailing is an effective treatment option for unicameral bone cysts in long
bones. It is less invasive, prevents the occurrence of
fractures, stabilizes pathological fractures, and allows a
prompt return to normal activity.

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