The dangers of intraosseous fibrosing agent injection in the treatment of bone cysts. The origin of major complications shown in a rabbit model

Abstract

Direct intraosseous injection of fibrosing agent is widely used in the treatment of aneurysmal bone cysts. The purpose of this study was to evaluate the consequences of fibrosing agent penetrating the medulla of bones. This may be the case when, by mistake, the fibrosing agent is administered into the medulla or when the wall of the cyst ruptures and fibrosing agent is able to drift into the medulla. Twelve rabbits were injected transcutaneously with a fibrosing agent directly into the proximal metaphysis of the tibia. Prior to injection 0.5 ml of liquid-like, bloody, intraosseal tissue was aspirated, then 0.5 ml of fibrosing agent was administered. Fibrosing agent was introduced slowly (20 s) to avoid overpressure. Nine rabbits (75%) died within minutes after the introduction of fibrosing agent. A full body roentgenogram was taken of each rabbit and the animals that died underwent autopsy to find the exact cause of death. Roentgenograms of the chest showed massive multiple pulmonary emboli confirmed in all lethal cases by the autopsy. This animal model was created to draw attention to the dangers of any leakage of the fibrosing agent into the medulla of bones.

Is Sclerotherapy Better than Intralesional Excision for Treating Aneurysmal Bone Cysts?

“…Sclerotherapy using Ethibloc 1 resulted in transient local inflammatory reactions in 37.8% patients (65 of 172 patients) ( Table 5). Fistulation and abscess formation observed by Topouchian et al [45] (four of 15 patients) led them to abandon their study, and others have reported pulmonary and fatal vertebrobasilar system embolisms [22,36,44,45]. We did not encounter such serious complications using polidocanol in the current or previously [38] studied patients.…”

“…This correlates to the requirement of 1.2 procedures in Group 2 in our study, although the data for additional surgery for shortening or infection if required are not readily available from the literature. Hospitalization has been recommended for 24 hours postprocedure to watch for inflammatory and allergic reactions [1,14,22] that may be supported by serious complications reported with Ethibloc 1 use [22,36,44,45]. In our previous experience [38] and in the current study with polidocanol, we believe hospitalization is not required and the procedure can be completed in the outpatient setting as it induces a mild inflammatory reaction if at all to be clinically important, and even if some extravasation inadvertently occurs, it settles clinically within 6 hours.…”

“…Topouchian et al [45] raised concerns regarding the higher treatment failure (27%) and unacceptable complication rates (five of 15 patients). Recently Shisha et al [44] also raised concerns regarding the fatal complications of Ethibloc 1 injection in rabbits. Since 1997, we have used polidocanol as the sclerosing agent, which is popular for treatment of various vascular malformations among surgeons and dermatologists [18].…”

Denosumab: a potential new and innovative treatment option for aneurysmal bone cysts

“…Common treatment options for ABCs include surgical resection [20], curettage and cavity filling (e.g., with bone or bone cement [13]), selective arterial embolization [10], fibrosing agent injection [14], or megavoltage radiotherapy [5]. For spinal ABCs, however, some of these options entail very considerable risks.…”

“…Treatment for ABCs involves surgical resection or curettage with filling of the defect with bone cement [1,13,20], selective arterial embolization [10], fibrosing agent injection [14], or megavoltage radiotherapy [5]. ABCs located in the spine present the difficulty that these treatment strategies often involve risks of neurological impairment, instability, recurrence, or other vital problems [7].…”