Subperiosteal resection of ABC

of the distal fibula

Subperiosteal resection of ABC

of the distal fibula

Professor Freih Abu Hassan

Professor Akram Shannak

University of Jordan

J Bone Joint Surg [Br], 2009

Aneurysmal bone cyst Benign,

Non-neoplastic,

Expansile,

Osteolytic lesion.

of multifactorial aetiology

Aneurysmal bone cyst

Blood-filled spaces separated by CT septa

containing

= Fibroblasts,

= Osteoclast-type giant cells

= Reactive woven bone.

Rosenberg AE etal, 2002

Pathogenesis

= Unknown

= Post-traumatic reaction to reactive

vascular malformation

= Genetic predisposition.

Cottalorda J, 2007

Incidence

= 1.4 per 100 000 individuals,

= 80% < 20 years.

Leithner A, 1999

Lesions in the distal fibula

7.1% - 16.4%.

Cottalorda etal, 2004

Sites

Metaphysis of long bones, especially

the Tibia, Humerus and Femur.

Ramirez, 2002.

The Periosteum

Double layered tissue which covers the

compact bone.

In adults, it is invisible.

In children (thick and very vascular)

In pathological processes is the same.

Functions1- Isolates & protection of the bone.

2- A route for NVB supply to the bone.

3-Bone growth & repair ( inner layer).

4-It attaches the bone to the deep fascia.

5-Tendons and ligaments insertion.

The main aims of treatment

= Eradicate the cyst,

= Avoid local recurrence,

= Prevent damage to the growth plate,

= Avoid subsequent valgus deformity,

= Maintain the stability of the ankle.

Curettage & bone grafting have

been the usual methods of R/

Lampasi M, 2007

= High rate of recurrence,

= Injury to the growth plate LLD

Cottalorda J, 2006

5 girls and 3 Boys

Mean age of 13.5 years (12 - 17)

Mean follow-up 11.5 Y (2 to 18).

1988 and 2006

Operative technique

Banana Peeling

The mean size of the resected

cysts was 5.2 cm (3.5 to 8.0).

3 W Post op 3 M Post op

A 12 years- old female

1M Post op

17 years old female patient

3M Post op

6M Post op

12M Post op

24M Post op

13 Y

old

male

child

3M Post op

6M Post op

24M Post op

18Y Post op

The mean healing time = Traditional surgical treatment

mean 11.6 months (8 to 15)

= Injection with steroids or bone marrow

mean 13.9 months (15 to 18).

Shoji H etal, JBJS, 1970

= Subperiosteal resection

mean of 4.12 months (3 to 9).

At the final follow-up

= There was no difference in the mean

ROM in the ankle compared with that

of the opposite side.

= No lesions recurred

= There was no injury to the growth plate

or evidence of joint instability.

No previous study has highlighted the

effectiveness of the periosteum alone

in forming new bone after resection of

lesions of the distal fibula.

We assume that the inner layer

of the periosteum has an

osteoblastic capability

invasion of the haematoma in

the tightly sutured periosteal

tube by osteoprogenitor cells.

Picture courtesy Gwen Childs, PhD.

Osteogenesis occurs initially at

the margins of the cavity

moved toward its centre over the

following weeks, Progressive

calcification and ossification

the cavity transformed into a

solid bony mass.

Intramembranous Bone Formation

Picture courtesy Gwen Childs, PhD.

The main advantage of

subperiosteal resection

1-Complete regeneration of the bone defect

2- Absence of local recurrence.

This can be attributed to the presence of a

thick periosteum with substantial regenerative

capacity.

3- Avoids the morbidity associated with other

techniques.