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Direct Ethibloc Injection of Aneurysmal Bone Cysts

Eric Mascard, MD,^* and Catherine Adamsbaum, MD

^* Department of Orthopedic Surgery, St Vincent de Paul Hospital, 82 avenue Denfert Rochereau, Paris Cedex 14 75674, France. e-mail: svp.radio{at}svp.ap-hop-paris.fr
Department of Radiology, St Vincent de Paul Hospital, 82 avenue Denfert Rochereau, Paris Cedex 14 75674, France. e-mail: svp.radio{at}svp.ap-hop-paris.fr

Editor:

We were very surprised by the article by Dr Topouchian and colleagues (1) in the August 2004 issue of Radiology. The authors reported a high rate of local and general complications after the use of direct Ethibloc injection in the treatment of aneurysmal bone cysts. These data contrast with previous reports and with our own experience after a follow-up period of several years (2–4).

Thereby, the article by Dr Topouchian and colleagues raises some questions about the technical conditions of Ethibloc injection. The published images of Ethibloc infiltration in soft tissues surrounding bone seem to indicate that excessive amounts of Ethibloc were used, leading to the reported complications.

As described by the authors in their method, it is mandatory to inject contrast medium in the tumor with a high level of manual pressure to be sure of the absence of venous drainage, which would be an absolute contraindication to using Ethibloc. Do the authors respect that precaution in the case complicated with pulmonary embolism? In case of moderate venous opacification, it is possible in peripheral locations to use a tourniquet during the Ethibloc injection.

Dr Topouchian and colleagues reported that they used the amount of Ethibloc that would allow complete opacification of the cyst at fluoroscopy. This point should require special attention: In our experience, we avoid the complete filling of the cyst because this would favor venous embolism and subcutaneous fistulae. The Ethibloc injection has to be stopped as soon as some subcutaneous leakage or venous opacification appears on the fluoroscopic image. We also keep the needle in the tumor for several minutes to allow the fibrosing agent to clot and thus decrease the risk of cutaneous fistulization. In our experience, healing of the cyst was not related to the amount of injected Ethibloc, and the goal of the treatment was rather to initialize a thrombogenic and fibrotic reaction.

The general and local inflammatory reactions were reported by Dr Topouchian and colleagues as complications. In contrast, inflammatory reaction is to us an expected event observed in most of the patients and may be predictive of good healing. Moreover, in our study (2) the more intense reactions were correlated with the more efficient treatments. Prevention of fever has to be achieved with an appropriate antipyretic medication.

In our study, we observed three cases of aseptic cutaneous fistula among 25 patients. It was always located in superficial bones (two claviculae and one humerus) and occurred at the beginning of our experience. With the improvement in our injection technique, we have observed no more such complications since 1997. We never observed any deep infection, and all fistulae healed spontaneously. In one deficient scar, a surgical revision was performed for cosmetic reasons. We therefore are very surprised by the report by Dr Topouchian and colleagues (1) of four early surgical revisions. To avoid any fistulae after Ethibloc injection in superficial bones, the needle tract has to be as long as possible.

Finally, our opinion is that direct Ethibloc injection remains an effective and safe method for treatment of aneurysmal bone cysts and is less invasive than surgery. Nevertheless, some precautions have to be highlighted: (a) A definitive histologic diagnosis is mandatory before treatment; (b) contrast medium has to be injected with high pressure prior to Ethibloc injection; (c) Ethibloc has to be injected slowly, with attention to any venous opacification; (d) do not try to completely fill the cyst; (e) wait until clotting of the Ethibloc before removing the needle; and (f) a long subcutaneous needle tract is useful in superficial bones.

With these conditions, we have not observed any severe complication, and our failure rate is 12%.

References

1. Topouchian V, Mazda K, Hamze B, Laredo JD, Pennecot GF. Aneurysmal bone cysts in children: complications of fibrosing agent injection. Radiology 2004; 232(2):522–526.[Abstract/Free Full Text]
2. Adamsbaum C, Mascard E, Guinebretiere JM, Kalifa G, Dubousset J. Intralesional Ethibloc injections in primary aneurysmal bone cysts: an efficient and safe treatment. Skeletal Radiol 2003; 32(10):559–566.[CrossRef][Medline]
3. Garg NK, Carty H, Walsh HP, Dorgan JC, Bruce CE. Percutaneous Ethibloc injection in aneurysmal bone cysts. Skeletal Radiol 2000; 29(4):211–216.[CrossRef][Medline]
4. Guibaud L, Herbreteau D, Dubois J, et al. Aneurysmal bone cysts: percutaneous embolization with an alcoholic solution of zein—series of 18 cases. Radiology 1998; 208(2):369–373.[Abstract/Free Full Text]

This Article Full Text (PDF) Submit a response Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Mascard, E. Articles by Adamsbaum, C. Search for Related Content PubMed PubMed Citation Articles by Mascard, E. Articles by Adamsbaum, C.