A 17-year-old male presented to the OPD with pain and swelling of the left forearm for 2 months due to which he was unable to use his left hand. The patient was nonverbal autistic and the history was provided by the mother of the patient who denied any history of prodromal pain, night pain, or weight loss. The patient had a bony hard tender mass on the volar aspect of the mid-third of the left forearm along the radial aspect. There was no neurovascular deficit. Radiographs demonstrated a sharply demarcated multiloculated eccentric expansile osteolytic lesion with a sclerotic margin and periosteal reaction in the mid-diaphysis of the left radius. The MRI demonstrated a large relatively well-defined lobulated eccentric lesion of size 4.5*2.2*2 cm in the mid diaphysis of radius extending from the medullary canal with large cystic component enhancing septations and multiple fluid-fluid levels. The lesion was abutting the radial vessels. The clinical presentation and radiographs were felt to be most consistent with the aneurysmal bone cyst; however, a biopsy was needed to rule out telangiectatic osteosarcoma. A needle biopsy confirmed the diagnosis of aneurysmal bone cyst.

The relatives were counseled and explained about various management options and subsequently, the patient underwent percutaneous curopsy (percutaneous limited curettage) and polidocanol sclerosant injection.

At the 6-month follow-up, the patient was asymptomatic and had no pain or functional limitations. The radiograph showed progressive healing with gradual ossification of the lesion and reformation of cortical thickness. The patient is currently on active surveillance.

Presentation Xray:

Presentation MRI:

6-month follow-up

Intraoperative fluoroscopic:

Primary aneurysmal bone cysts (ABCs) are benign, expansile locally destructive bone lesions. The goal of treatment in ABC is to promote healing of the cystic cavities to control pain, decrease the risk of pathological fracture, and minimize deformity. They are commonly treated with aggressive curettage with or without adjuvants such as cryotherapy, methacrylate cement, or phenol. Surgical curettage is a major operative intervention with the potential disadvantages of deep infection, shortening of the affected bone, and the need for hospitalization. Selection of the treatment modality depends on the tumor location, extent, risk of tumor recurrence, and comorbidity associated with the treatment. Over the past two e decades, various percutaneous techniques for managing primary aneurysmal bone cysts have been reported with excellent results. Percutaneous injections have the advantage of being minimally invasive with little associated morbidity and cost-effectiveness although several treatment cycles may be required for achieving consolidation of cysts. Polidocanol, a sclerosant, acts by directly damaging the endothelial lining of an ABC, triggering a coagulation cascade with thrombotic occlusion of blood vessels.

The mean success rate of percutaneous sclerotherapy in ABC is reported as 91.1%. Bavan et al reported no statistically significant differences in overall treatment success between the injection and surgical treatment groups (93.3% vs 84.8%) but poorer functional outcomes and a higher number of clinically important complications with surgical management. Puri et al reported a success rate of 84% with curopsy and polidocanol sclerosant injections in their cohort of 56 patients. Among these 44% (n=24) required a single injection. Similarly, in our case, a single procedure led to successful healing of the lesion with excellent functional outcomes.

Conclusion:

The aim of treatment in primary aneurysmal bone cysts (ABC) is to optimize local control while retaining maximum function and minimizing the morbidity of management. Percutaneous sclerotherapy is a safe and effective minimally invasive inexpensive treatment modality of primary ABC of the limbs and pelvis with outcomes comparable to previously advocated methods.

Trust Narayana Health's expertise for precise, minimally invasive treatment solutions like percutaneous sclerotherapy, achieving excellent outcomes in complex cases like aneurysmal bone cysts.

Schedule a consultation with our orthopaedic specialists today to explore advanced, patient-centred care options.