"Three-in-One minimally invasive approach to surgical treatment of pediatric pathological fractures with wide bone loss through bone cysts: ESIN, curettage and packing with injectable HA bone substitute. A retrospective series of 116 cases.".

Introduction: The outcome of pathological fracture due to large aggressive benign stage 3 Dormans and Flynn lesions [6] is often unsatisfactory and the rate of recurrence is high. No single technique has been considered safe and successful. Many Authors suggested curettage and bone grafting as the unique effective treatment in cases of large defect but, because of the invasive and complex nature of the operation (it needs a double-step procedure), it is not preferred. The purpose of this study is to examine the effectiveness of a minimally invasive treatment in one step through ESIN, curettage and packing with self-setting calcium phosphate cement.

Patients And Methods: This is a retrospective study of 116 children admitted at the Division of Pediatric Orthopaedics Surgery of Santobono Children Hospital between 2006 and 2014 with a diagnosis of pathological fracture due to large aggressive ostheolytic benign lesions (stage 3 Dormans and Flynn). The size of bone loss was measured on the AP and ML radiographs and all the cysts with a caudo cranial extension from 5 to 8cm and with a medio lateral extension from 3 to 5cm were included. Mean time follow up 24 months was performed.

Results: The three-in-one procedure was applied in all 116 patients. After two years of follow up, 113 patients were classified as healed and just 3 required 3 years to complete heal. No severe life threatening adverse effects or complications associated with the use of ESIN and injectable HA were recorded during the follow up period of 24-36 months. Fracture healing occurred in all cases within 4-6 weeks with adequate periosteal and endosteal callus formation. No second pathological fractures occurred in our series as well as no cysts reoccurred. Patients with humeral localizations showed a more rapid regain of muscular function and reestablishment of a complete range of motion.

Conclusions: The proposed three-in-one procedure has shown to be efficient, cost-effective, associated to high rates of definitive bone healing and low incidence of adverse effects.