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TREATMENT OF LOCALIZED FIBROCYSTIC CAVITIES IN BONE
BY CURETTAGE AND PACKING WITH BONE CHIPS
WALKER E. SWIFT and HALFORD HALLOCK
J Bone Joint Surg Am. 1938;20:411-418.
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Publisher Information The Journal of Bone and Joint Surgery
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www.jbjs.org
TREATMENT OF LOCALIZEI) FIBROCYSTIC CAVITIES IN
BONE BY CURETTAGE ANJ) PACKING WITH BONE CHIPS
BY WALKER E. SWIFT, M.D., AND HALFORD HALLOCK, M.D., F.A.C.S.,
NEW YORK, N. Y.
Prom the New York Ortllopaedic Dispensary (111(1 1IOS/)itt’ll
One of the imiteresting unomnemut-s in an ortiuopaedic surgeouu’s practice
occurs whemu hue examines the roentgenogram of a patient and sees a cavity
in the shaft or near the end of one of the bones. Of thue lesions which can
cause such a cavity, those uluder discussion in this paper comprise a group
which are relatively benign, and yet, if left to their own devices, show a
tendency to progressive expansiomi and absorptiomi of the bone with the
production of pain, deformity, alud disability. According to present-day
pathological conceptiomis, they seem to belong to the same family whiclu
may be called by the surname of localized fibrocyst-ic disease of bone, amid
they seem to exhibit many similarities of climuical appearance amid behavior.
()n the other hiand, they do shuow marked differemices of the actual local
pathology, omu the basis of which they have been divided imuto the following
three groups for purposes of this study: (1) lesions which are found to be
cavities in thue shaft of the bomue, filled with fluidand surrounded by a
limitimug fibrous membrane, called bone cysts ; (2) lesiomis which are cavities
in the shaft of the bomue, filled wit-hi firm, cellular, fibrous tissue, described
as osteit-is fibrosa cystica; (
and3) lesions which are cavities at the epiphu-
ysis, filled with soft-, vascular tissue of characteristic microscopic ap-
pearamuce, diagnosed as giant-cell tumors.
As this paper is concerned wit-h treatment, we shall pass over the
imit-eresting questions which arise in a discussiomi of thie etiology amid IiatUre
of thuese lesions, and confine ourselves to the way
in which they have beemi
treated at the New York Ort-hiopaedic Dispensary and Hospital, and withu
what result-s.
The problem of treatmnent is twofold: how to stop the activity of the
disease, for we know it may progress if left alone ; amid hiow to set the st-age
so that orderly repair processes may restore the bone to a healthy state.
Although some men have handled this problem by the use of roentgeno-
therapy amid others by surgical curettage and cauterization, reporting
more or less satisfactory results, the surgeons at t.he New York Orthuo-
paedic Hospital have dealt with it surgically by curettage of the cavity,
followed by packing it with bone chips without cauterization. The ad-
vantages of t.his approach are several. In the first place, a more exact
diagnosis is possible if the lesion is actually seen amid tissue it from stud-
is
ied microscopically. Second, if the diseased tissue is removed as coin-
* Read at the Annual Meetimug of thie Amuuerican Academny of Orthopaedic Surgeons,
Los Angeles, California, January 20, 1938.
Vol.. XX, NO. 2,APRIL 1938 411
412 W. E. SWIFT AND H. HALLO(’K
4.
FIG. 1-A FIG. 1-B F’io. 1-C
Bone cyst filled with fluid imuthe lower emid of the femur male,
of a three years old.
There were uuo symiuptoms. Svelling of the knee ‘as muoted by the clmil(I’s niotlier.
Fig. 1-A : Cavity before curettage and packimig with bomue chips.
Fig. 1-B: Two nionthis after operation.
Fig. i-C: Two alid OIie-half years after operation. Lesiomi healed.
pletely as l)ossil)le, it w’ould seemuu that the processes of repair w’ould have
thie l)est emiviromumnent imu which to fumict-iomi. Third, if the
cavity is filled
withi small boric chuips, a framework for the miew, vascular, fibroblastic
repair tissue is l)rovi(ledl, as w’ell as a concemutrated source of calciumn amid
l)hiosl)horus salts whuich will be available at the place s’here they are needed
as oomu as local (bondhitiomus are right for the formatiomu of new i)one.
Our conception of tue process of repair that occurs in a cavit-y \\.hui(h
hitis beemi filled w’ith l)Omue (hiips niay be stated h)riefly. Blood or serumu
fills the spaces around individual
the chips. As clotting takes place, the
fibrin uuetw’ork binds the l)ouue chips together, and thue whole area thiemi be-
(JIiiC5 imufiltrated l)y a rapidly grow’imig, vascular, fibroblastic tissue. The
bomue chips themselves quickly lose their individual cells amid, if examiiimied
wider thue microscope aft(lr a few days, will appear like dead i)omue. How-
ever, in spite of this, amid as early as the secomud week, a layer of new bone
is formed around amid imitimnately adheremit tueto outer surface of each
(huip, whuile trabeculae of
hew bone appear iii narrow’
time sptices between
the ehuips. These trabeculae w’ill join thie bone
new formed aroumi(l the
chips, so that a network of trabeculated bomie is developed with tue ap-
paremitly dead chips as integral parts. The 01(1 chips may remuuaimi amid be
recogmuizable for a lomug timne, but they do not seem to act as irritating
foreigmu bodies or sequestra, nor do they appear to emucourage the develop-
memit of giant- cells aroumid their margimis. Evemutually t-imey lose their
identity through some process of resorptiomi as the structure of the bone
approaches nearer to a healtiiy state. is felt
It that the h)omme
(hips add a
TIlE JOURNAL OF BONE ANI) JOINT sURGERY
LO(’ALIZED FIBRO(’YSTI(’ (‘AVITIES IN BONE 413
FIG. 2-A FIG. 2-B FIG. 2-C FIG. 2-D
Bone cyst filled with fluidin upper time end of the hunierus of a fenuale, eight
years old. There were no symiiptomiis until a fracture through the lesion occurred.
The fracture umiited, huttime lesiomi progressed.
Fig.2-A: Cavity in humerus before curettage amid packing with chips.
Fig. 2-B: Five months after operation. Time lesiomi was thought to be healing, but
at the end sixt-eemi
of momuths a recurrence was noted.
Fig. 2-C: Three ears after operatiomi. The lesiomi hiad become amid
larger at op-
eratiomi it was foumid to he filled with fluid. The (‘avitywas curetted and packed with
chips.
Fig. 2-D: Two years after the secon(I operation. Lesion healed.
definite stimulus to the osteogenic-repair Proe and that their presemice
materially hmastemms the hiealing of the cavity.
FIG. 3-A FIG. 3-B FIG. 3-C
O.steitis fibrosa inthe shaft of tue feniur of a female, eighteen (lid.
years The
symptoms were of seven years’ duratiomi. There had been a steady increase ill the
size of the lesion imi spite of thiree courses of roentgenotherapy.
Fig. 3-A: Cavity in feniur before curettage and with
packing (hips.
Fig. 3-B: Five mnonths after operation.
Fig. 3-C: Eight years after operation. Lesiomi healed.
VOL. XX, NO. 2. APRIL 1938
414 W. E. SWIFP AND H. HALLOCK
TABLE I
ANALYSIS AND RESULTS OF SIx CASES OF BONE CYSTS
Number of patients 6
Average age of patients 9 years
Number of recurrent lesions 2 (33 per cent.)
Number of operations forecurrence:
r 2 (2 patients)
Curettage and bone chips..... 2
Average time when recurrence was noted 15 months
Average follow-up period 3 years
Number of lesions healed 6 (100 per cent.)
Number of lesions not healed 0
Number of deaths 0
That this type of repair is a complicated one, involving many chemn-
ical and pathological factors which are not understood, goes without say-
ing, and, therefore, it is t-o be expected that some lesions may not follow
the rule. There are recurrences after curettage and packing bone with
chips, and here again it is hard to understand or to explain factors
the in-
volved. It is interesting that the actual pathology foumid in a recurrent
lesion is usually similar to that which as seen
w in the original cavity,-
that is, the contents will be made up of either fluid, or fibrous tissue, or
giant-cell tumor. It is also interesting thiat recurrent lesions treated by
curettage and packing with bone chips will usually heal satisfactorily, al-
though several operations may be necessary.
The surgeons at the New York Orthopaedic Hospital began imi 1922
to treat fibrocystic cavities in bones by thorough curettage and packing
with small bone chips usually obtained from the shaft of thie tibia. Be-
tween 1922 and 1935, twenty-eight patients whuo presented such lesions
were treated in the manner outlined and the cases were classified according
to the three groups which have already been mentioned,-bomie cysts,
osteit-is fibrosa, and giant-cell tumors.
Bone Cysts
These were six in number and occurred in the youngest age group, the
average age being nine years. Four were in males two and in females.
The humerus was involved three times and the radius, femur, and fibula
each once. Four the
of six lesions were recognized after a fracture at- their
site ; one was discovered because of pain ; and one was found incidental to
an examination for a foot complaint. Eight operations were performed on
these six patients, as two lesions recurred, each recurrent lesion being a
cyst filled with fluid and without any evidence of bone chips. The results
in this group are shown in Table I. Each patient has been with well,
roentgenographic evidence of healthy bone repair, for at least one year
after operation. The average follow-up period is three years.
THE JOURNAL OF BONE AND JOINT SURGERY
LOCALIZED FIBROCYSTIC CAVITIES IN BONE 415
O.s’le it i’.s Ii’,brosa
‘lucre were fifteemi patiemits ill this group,elevemi femuiales amid fotmr
muales of ami average age of twelve years. Tue femnur was imivolved
six
timuies, the tibia amid time
humnerus each timree tinues, amid a muietat.arsal bomue,
a fibula, amid a finger phualamux eaclu omuce. These fifteemi ratiemits required
twemitytimree ol)eratiomis, as six of thiemui hmad lesiomus which recurred after time
first operation. 0mw of thuese lesions, imi a tib)ia, shiowed great persistemice, as
it- ret-urmie(l three timuies the
in origimual location amid omuce higher up, so thmat
thmis ili(hiVi(IIIIIl required five operatiomus 1)efore a (lire was effected. An-
0ti1(’I j)Imtiemmt hmad a lesiomi \Vhii(hi recurre(l after a secomud operatiomu. ( )mme
patiemit Ima(l a large cavity imi the trochant-er amid neck of the femuiur, which
1111(1 h)eemm treated without- effect by roemitgenot-herapy for one and onehalf
years. ‘l’lmis patiemit was operated upmi amid seemned to be doimig well for
temi niomitims, after ivhiicii time thue lesion reci1rm(’(I. This
patient an(l the
)rece(Inmg omic have beemi lost to the Follow_LTp ( ‘link. Anothier patient
huts in time imimmuierus a recurremit lesiomi of miill(hi smuialler
size thiami tue origimial
(aVity, and (luriuig six years it has shiowii no temu(lency to imicrease, so that
its (iiarIIcter has proi)ai)ly 1)eeli altered. A lesiomi in time ujper en(l of time
hiuimuiemims re(urre(l tw’ice, 1)ut. has 1)eemi cure(l by thie thir(1 operatiomi.
‘Ihm(’I(’ W’fls omme re(urremlce ill t lie phualamix of a fiuiger, i)ut t Ime lesiomi has re-
mllmlili(1(l hm(’ale(l after the second (.Imr(lttItgtl amid J)ackimug vith 1)omue (hips.
‘[‘lie fimial results imi this group are shown iii FableI.
I Omie patient, a
child of sevemu, died of siiock 500fl after the operation ivhnchi was performuied
on a hot- sumnmner (lay. The lesion was a large omue in the shaft of tiue
FIG. 4-A FIG. 4-B FIG 4-C
Osteitis fibrosa in the Uppei’ part of the shiaft of the femnur imi a muuale, six old.
years
Pain and a limiiphind been presemit for two nuonthis.
Fig. 4-A: Cavity iii the shiaft of the feniur before curettage and packing with chips.
Fig. 4-B: One mnonth after operation.
Fig. 4-C: Sevemi years after operation. Lesion healed.
VOL. XX, No. 2. APIt1I. 193S
416 W. E. SWIFT AND H. HALLOCK
femur and had been present- for at- least tw’o years, durimug which time there
huad beemi two fractures through the area without any tendency for the
disease to become arrested, although the fractures had united. Eleven of
the patient-s are considered to be entirely healed after a follow’-up period
averaging four years, amid three patients have recurrent lesions.
Giant-Cell Tumors
Seven patients were included in this
group, with an average age at the time of op-
erat-ion of eighteen years. There were five
females and two males. The lower end of the
tibia was involved in tw’o cases, and in the
other five cases the lesions ‘ere located! imi the
upper end of the femur, in the upper end of
the humerus, in thie os calcis, imi thue low’er end
of the ulna, and in the pedicle of the third
lumbar vertebra. In all, twelve operations
were performed Oh these seven pat-iemits. One
patient- with a lesion iii the low’er emid of the
ulna had four operations before a cure was ob-
tamed, because thue lesion recurred tw’ice in
FIG. 5-A the same site and once in the adjacemut- por-
FIG. 5-B FIG. 5-C FIG. 5-D
Giant-cell tumor in the lower end of the ulna of a female, forty-two years old.
There had been a steady increase the size and
in symptoms for four years in spite
of treatment by roentgenotherapy.
Fig. 5-A: Lesion at time of curettage and packing with hone chips.
Fig. 5-B: One year after Operatioli. Recurrent lesion in upper part of original
cavity. A second operation, consisting of resection and a bone graft, was performed.
Fig. 5-C: Two years after second operation. Lesion in ulna healed. New area
of giant-cell tumor in lower end of radius. This curetted
was and packed with
bone chips. Recurrence after one year. Lesion
again curetted and packed.
Fig. 5-D: One and one-half years after fourth
operation. Lesions in ulna and
radius are healed.
THE JOURNAL OF BONE AND JOINT SURGERY
LOCALIZED FIBROCYSTIC CAVITIES IN BONE 417
TABLE II
ANALYSIS AND RESULTS OF FIFTEEN CASES O5TEITI5
OF FIBROSA CYSTICA
Number of patients 15
Average age of patients 12 years
Number of recurrent lesions 6 (40 per cent.)
Number of operations for recurrence 8 (4 patients)
Curettage and bone chips S
Number of recurrent lesions not operated upon 2
Average time when recurrence was noted 12 months
Average follow-up period 4 years
Number of lesions healed 11(73 per cent.)
Number of lesions not healed 3 (20 per cent.)
Number of deaths (operative) 1 ( 7 per cent.)
tion of the radius. Before surgery was used, the patient had had a
long course of roentgenotherapy, sufficient to cause considerable necrosis
of the lesion but not to effect healing. In two cases, a leg was amputated.
In one of these, the lesion was in the os calcis, and for ten months after the
curettage the condition seemed to be healing. Then a recurrence was
noticed and, in spite of treatment by roentgenotherapy over a period of
five months, the lesion continued to increase in size. A second curettage
was advised, but declined, and the patient continued with roentgeno-
therapy until the skin broke down. Four years later the leg was ampu-
tated because of persisting sinuses and continuance of the lesion. In the
other case, the lesion was in the lower end of the tibia, and the leg was
amputated one month after the original curettage because the lesion was
suspected of being malignant. Table III shows the iesults in this group
of giant-cell tumors and demonstrates that all the patients have remained
well for an average follow-up period of five years.
TABLE III
ANALYSIS AND RESULTS OF SEVEN CASES OF GIANT-CELL TUMOR
Numuber of patients .................................... 7
Average age of patients 18 years
Number of recurrent lesions 3 (43 per cent.)
Number of operations for recurrence 5
Curettage and bone chips 3 (1 patient)
Amputation................. 2
Average time when recurrence was noted 10 nuonths
Average follow-up period...................................... 5 years
Number oflesions healed 5 (71 per cent.)
Number of lesions not healed (amputation) 2 (29 per cent.)
Number of deaths 0
VOL. XX, NO. 2. APRIL 1938
418 W. E. SWIFT AND H. HALLOCK
TABLE IV
SUMMARY OF TWENTY-EIGHT CASES OF FIBROCYSTIC LESIONS
TREATED FROM 1922 TO 1935 *
Average
Age of No. of Lesions Which Total Nd).
Diagnosis Patients Patients Recurred of
(Years) No. Per Cent. Operations
Bone cyst 9 6 2 33.0 8
Osteitis fibrosa 12 15 6 ‘ 40.0 23
Giant-cell tumor 18 7 3 43.0 12
Total 28 11 39.0 43
Results
Diagnosis Lesion Healed Lesion Unhealed Amputation Death
Cases Per Cent. Cases Per Cent. Cases Per Cent. Cases Per Cent.
Bone cyst 6 100.0 0 0.0 0 0.0 0 0.0
Osteitis fibrosa... 11 73.0 3 20.0 0 0.0 1 7.0
Giant-cell tumor.. 5 71 .0 0 0.0 2 29.0 0 0.0
Total 22 79.0 3 11.0 2 7.0 1 3.0
* 28 patients had 43 operations: 1 patient died of shock; each of 2 patients had a leg
amputated ; 3 patients have unhealed lesions; 22 patients have healed lesions.
SUMMARY
The results obtained in the twenty-eight patients of the series are
shown in Table IV and reveal several interesting comparisons between the
three groups. These lesions have a marked tendency to recur locally, as
demonstrated by a 39-per-cent. recurrence in this series. It is import-ant
to realize that the average time when the recurrences were noted was as
late as one year, so that a long follow-up period is necessary. The local
recurrences can be treated successfully in the same way as the original
lesions, even though some cases may require several procedures before a
cure is obtained. The three patients who still have unhealed lesions are
all in the osteitis-fibrosa group, and two of them have been lost to the
Follow-Up Clinic without having had the second operation which was
advised. In the other case there is an unhealed area which has not in-
creased at all over a period of six years. It is so small that furtluer treat-
ment has not been advised.
Although 79 per cent-. of the lesions have healed satisfactorily, the
variations in the percentage of success among the three groups must be
noted. Because of the similarities which have been observed in the
behavior of these lesions under treatment, it is believed that curettage and
packing with bone chips is an effective method of dealing wit-h them, and
that, as larger numbers are accumulated, the percentage result in each
group will tend to be more satisfactory.
THE JOURNAL OF BONE AND JOINT SURGERY
