Semistructural allografting in bone defects after curettage

Vertebral Primary Bone Lesions: Review of Management Options

The assessment and treatment of vertebral primary bone lesions continue to pose a unique yet significant challenge. Indeed, there exists little in the literature in the way of compiling and overviewing the various types of vertebral lesions, which can often have complicated intervention strategies. Given the severe consequences of mismanaged vertebral bone tumors-including the extreme loss of motor function-it is clear that such an overview of spinal lesion care is needed. Thus, in the following paper, we aim to address the assessment of various vertebral primary bone lesions, outlining the relevant nonsurgical and surgical interventional methods. We describe examples of primary benign and malignant tumors, comparing and contrasting their differences. We also highlight emerging treatments and approaches for these tumors, like cryoablation and stereotactic body radiation therapy. Ultimately, we aim to emphasize the need for further guidelines in regard to correlating lesion type with proper therapy, underscoring the innate diversity of vertebral primary bone lesions in the literature.

Management of Calcaneal Cysts in the Pediatric Population: A Review

Cysts of the bone are a common pathology that, although benign, are frequently treated because of their tendency to compromise the integrity of affected bone. Two common entities are unicameral bone cysts and aneurysmal bone cysts. Although these are two distinct pathologies, they are treated similarly and thus will be discussed in tandem. The optimal treatment of calcaneal bone cysts in pediatric patients has long been debated among orthopaedic surgeons because of the relatively small number of cases and varied results within the literature. Currently, there are three lines of thought regarding treatment: observation, injection, and surgical intervention. When considering which course of treatment is best for an individual patient, the surgeon must consider the fracture risk without treatment, the risk of complications with treatment, and the recurrence rate with each treatment approach. There are limited data on pediatric calcaneal cysts specifically. Still, there are much data concerning simple bone cysts of long bones in the pediatric population and calcaneal cysts in the adult population. Because of the lack of literature on the subject, there is a need for a review of the available literature and a consensus on the approach to treating calcaneal cysts in the pediatric population.

Study of the efficacy of 3D-printed prosthetic reconstruction after pelvic tumour resection

The purpose of this study is to explore the effect of using 3D printed pelvic prosthesis to reconstruct bone defect after pelvic tumor resection. From June 2018 to October 2021, a total of 10 patients with pelvic tumors underwent pelvic tumor resection and 3D printed customized hemipelvic prosthesis reconstruction in our hospital. Enneking pelvic surgery subdivision method was used to determine the degree of tumor invasion and the site of prosthesis reconstruction. 2 cases in Zone I, 2 cases in Zone II, 3 cases in Zone I + II, 2 cases in Zone II + III and 1 case in Zone I + II + III. Patients had preoperative VAS scores of 6.5 ± 1.3, postoperative VAS scores of 2.2 ± 0.9, preoperative MSTS-93 scores of 9.4 ± 5.3 and postoperative 19.4 ± 5.9(p < 0.05), all patients had improvement in pain after surgery; Postoperative complications included joint dislocation in 2 cases, myasthenia caused by Guillain-Barre syndrome in 1 case, delayed wound healing in 3 cases and wound infection in 2 cases. Postoperative wound-related complications and dislocations were associated with the extent of the tumor. Patients with tumor invasion of the iliopsoas and gluteus medius muscles had higher complication rates and worse postoperative MSTS scores (p < 0.05). The patients were followed up for 8 ∼ 28 months. During the follow-up period, 1 case recurred, 4 cases metastasized and 1 case died. All pelvic CTs reviewed 3-6 months after surgery showed good alignment between the 3D printed prosthesis and the bone contact, and tomography showed the growth of trabecular structures into the bone. Overall pain scores decreased and functional scores improved in patients after 3D printed prosthesis replacement for pelvic tumor resection. Long-term bone ingrowth could be seen on the prosthesis-bone contact surface with good stability.

Aneurysmal bone cyst of the skull: A case report

The authors present a case report of a 14-year-old male with a single temporal scalp nodule. After imaging and surgical resection, the diagnosis of an aneurysmal bone cyst was made. Although aneurysmal bone cysts are benign, they tend to grow rapidly and cause subsequent complications. In this case report, the authors explore the importance of physical examination in order to make more accurate diagnoses.

Aneurysmal bone cyst of the head & neck: A review of reported cases in the literature

The aneurysmal bone cyst (ABC) is a benign, blood-filled bony lesion that notoriously affects the vertebral column and long bones of the body. Rarely, ABCs can manifest in the head and neck (HNABC). The purpose of this paper is to provide a comprehensive review of existing literature on HNABC. This review includes: case reports and case series on ABCs manifesting in the head and neck region published in the English language. All cases identified via PubMed were analyzed individually. Articles were included according to specified eligibility criteria. The total number of cases analyzed were 72 (39 case reports; 33 case series). The average age at the time of HNABC diagnosis was 19.1 years (range: 0.42-62 years). The ratio of prevalence by gender affected exhibited an even 1:1 male-to-female split. CT in combination with MRI proved to be the most prevalent imaging modality utilized (37.2%). HNABC was most commonly detected in the mandible (37.1%), followed by the sinus (14.3%) and cranium (11.4%). The most frequently employed single treatment modality was surgical excision (94.1%). 94.4% of patients were alive with no evidence of disease at follow-up, while 5.6% of patients exhibited disease at follow-up. The average follow-up period was 3.59 years (range: 0.17-17.0 years). Aneurysmal bone cyst of the head and neck region is a rare condition that should be considered in the differential diagnosis of bony, vascular lesions presenting in the aforementioned locations. Since aneurysmal bone cyst of the head and neck region can present as a rapidly growing, expansive and destructive lesion, it is crucial that clinicians are aware of this entity so that patients are accurately diagnosed and treated.

Early postoperative compilations of bone filling in curettage defects

Background

Curettage is widely used in orthopedic oncology; the defect created frequently requires filling for mechanical and functional stability for the bones and adjacent joint. Allograft, bone graft substitute, and polymethyl methacrylate (PMMA) are the most common substances used each with their benefits and drawbacks. The aim of the study is to show that good functional result can be achieved with curettage and bone filler, regardless of type.

Methods

A series of 267 cases were reviewed between 1994 and 2015 who received curettage treatment and placement of a bone filler. Endpoints included fracture, infection, cellulitis, pulmonary embolism, and paresthesia. Complication rates at our single institution were compared against literature values for three study cohorts: allograft, bone graft substitute, and PMMA bone fillers. Friedman test, Wilcoxon test, and Z-score for two populations were used to compare our subset against literature values and between different bone filling types.

Results

Our cases included 18 autografts, 74 allografts, 121 bone graft substitute, and 54 PMMA of which the bulk of complications occurred. Our overall complication rate was 3.37%. Allograft has a complication rate of 1.35%, bone graft substitute of 4.13%, and PMMA of 5.56%. Other techniques did not yield any complications. Combination filling techniques PMMA + allograft and PMMA + bone graft substitute had sample sizes too small for statistical comparison. Statistical comparison yielded no significant difference between complications in any of the filling groups (P = 0.411).

Conclusions

Some has even argued that bone defects following curettage do not require bone filling for good outcome. However, many structural or biologic benefits that aid in earlier return to functionality can be conferred by filling large bone defects. There was no significant difference in postoperative complication rates between allograft, bone graft substitute, and PMMA when compared at our institution and with literature values. Nevertheless, one complication with a large defect filled with allograft, requiring a subsequent reconstruction using vascularized fibular graft. Taking everything into account, we see bone graft substitute as a suitable alternative to other bone filling modalities.

Novel 3D-printed prosthetic composite for reconstruction of massive bone defects in lower extremities after malignant tumor resection

OBJECTIVE

To introduce a novel 3D-printed prosthetic composite for reconstruction of massive bone defects after resection for bone malignancy of lower extremities. The design concept, surgical technique, and the preliminary outcomes were elaborated.

METHODS

Patients with primary malignant tumors of lower extremities requiring tumor resection and reconstruction were recruited between Jun 2015 and Nov 2018. Patient-specific 3D-printed prostheses were designed according to preoperative imaging data. After tumor resection, reconstruction was performed with composites consisting of 3D- printed prosthesis, beta-tricalcium phosphate (β-TCP) bioceramics and/or vascularized fibula. All patients underwent regular follow-up postoperatively. The functional outcomes were assessed by the Musculoskeletal Tumor Society score (MSTS). Oncological outcomes, imaging results, and complications were recorded and analyzed.

RESULTS

Ten cases averaging 12.90 years of age participated in this study. There were five femur and five tibia reconstructions. The mean follow-up period was 16.90 months. At last follow-up, all patients were alive without tumor recurrence. Average MSTS functional score was 80.33 ± 11.05%. All prostheses were intact and stable without failure or systemic breakage. No serious complications occurred after the operation. Postoperative X-ray, computed tomography (CT) and single-photon emission computed tomography (SPECT) showed an ideal integration between the bone and the prosthetic composite. Moreover, vascularized fibula and implanted β-TCP bioceramics indicated relatively high metabolic activity in vivo.

CONCLUSIONS

Patient-specific 3D-printed prostheses combined with β-TCP bioceramics and/or vascularized fibula provide an excellent option for reconstruction of massive bone defects after lower extremity malignant tumor extirpation. Short-term follow up showed promising clinical results in recovering lower limb function, promoting osseointegration and reducing complications.

Treatment of tumor-like lesions in the femoral neck using free nonvascularized fibular autografts in pediatric patients before epiphyseal closure

Objectives

Surgical resection of benign bone tumors and tumor-like lesions at the femoral neck presents a difficult reconstructive challenge. However, the safety and efficacy of free nonvascularized fibular autografts (FNFAs) in the treatment of femoral neck tumor-like lesions before epiphyseal closure in young patients remain unknown.

Methods

Sixteen pediatric patients who had not yet undergone epiphyseal closure were treated with FNFAs after resection of tumor-like lesions in the femoral neck from August 2012 to September 2016. All patients underwent supplementary skeletal traction through the supracondylar femur for 4 to 6 weeks after resection. Demographic data were recorded and clinical and radiological outcomes were evaluated during the follow-up.

Results

All patients could walk with partial weight bearing 4 weeks postoperative, and full weight bearing was permitted after a mean of 8 weeks. Graft union was attained in all 16 patients at a mean of 2 months. The donor site of the fibular cortical strut showed good regeneration in all patients. The Harris hip score significantly improved from 65% to 95%.

Conclusions

Application of an FNFA is a feasible method in the treatment of tumor-like lesions in the femoral neck before epiphyseal closure in pediatric patients.

Level of Evidence

Level IV.

Lower Limb Reconstruction with Tibia Allograft after Resection of Giant Aneurysmal Bone Cyst

Aneurysmal bone cysts (ABCs) are benign, expansible, nonneoplastic lesions of the bone, characterized by channels of blood and spaces separated by fibrous septa, which occur in young patients and, occasionally, with aggressive behavior. Giant ABC is an uncommon pathological lesion and can be challenging because of the destructive effect of the cyst on the bones and the pressure on the nearby structures, especially on weight-bearing bones. In this scenario, en bloc resection is the mainstay treatment and often demands complex reconstructions. This paper reports a difficult case of an unusual giant aneurysmal bone cyst, which required extensive resection and a knee fusion like reconstruction with tibia allograft.

BENIGN BONE TUMORS AND TUMOR-LIKE BONE LESIONS: TREATMENT UPDATE AND NEW TRENDS

The treatment of benign bone tumors (BBT) and tumor-like bone lesions (TBL) has observed the introduction of new drugs, such as intravenous bisphosphonates, which have ossified bone lesions caused by fibrous dysplasia. Aneurismal bone cyst has been treated with sclerosing agents by percutaneous injection, yielding good results. Adjuvants allow joint salvage, maintenance of movements and function, with low rates of recurrence. Among them, the most used ones are bone cement (PMMA), phenol, nitrogen-based cryotherapy, hydrogen peroxide, ethanol and radiotherapy. New methods of treatment include thermal ablation with radiofrequency and laser, mainly utilized for treating osteoid osteoma. Arthroscopy allows resection of benign intra-joint lesions and assists the surgery of subchondral tumors. A great advance is the utilization of synthetic bone substitutes, which are a mixture of osteoinductive growth factors and osteoconductive ceramics, and have presented comparable results to autogenous bone grafts. There is a recent trend for closed treatments, with percutaneous injection of demineralized bone matrix (DBM) and calcium sulfate. Autogenous cancellous bone graft remains as the gold standard. Vascularized fibula graft, on the other hand, incorporates faster in the treatment of large destructive lesions. Also, allogenic cortical support allows structural augmentation for aggressive tumors. Freeze-dried allografts are used to fill contained defects and as expanders of autografts. Joint endoprosthesis may be used in large destructive lesions of the distal femur, hip and shoulder.

Surgical treatment for fibrous dysplasia of femoral neck with mild but prolonged symptoms: a case series

Background

The proximal femur is one of the most common sites involved by fibrous dysplasia. In cases with mild deformity that does not require corrective surgery, occasional patients suffer sustained pain because of repeated microfractures. This study aimed to clarify the outcomes of surgery with autogenous fibular cortical strut grafting and compression hip screw fixation.

Methods

Since 2002, eight consecutive patients (nine hips) with femoral neck fibrous dysplasia without severe deformity were prospectively treated with autogenous fibular strut grafting and compression hip screw fixation.

Results

Mean age of patients was 35 years. Mean follow-up of patients after surgery was 75 months. Most of the patients could walk with full weight-bearing 2 weeks after surgery. Functional score of lower extremity was significantly improved from 65 % to 95 % (P = 0.001). Femoral neck angle was increased from 127 to 130. Donor site of strut cortical fibula showed good regeneration with β-tricalcium phosphate.

Conclusions

Autogenous fibular cortical strut grafting and compression hip screw fixation achieved good post-operative function and provided an early return to work for adult patients with fibrous dysplasia of the femoral neck with mild but prolonged symptoms. Morbidity in the donor site of fibula strut is minimal with the use of β-tricalcium phosphate.

A positive bacterial culture from allograft bone at implantation does not correlate with subsequent surgical site infection

Fresh-frozen allograft bone is frequently used in orthopaedic surgery. We investigated the incidence of allograft-related infection and analysed the outcomes of recipients of bacterial culture-positive allografts from our single-institute bone bank during bone transplantation. The fresh-frozen allografts were harvested in a strict sterile environment during total joint arthroplasty surgery and immediately stored in a freezer at -78º to -68º C after packing. Between January 2007 and December 2012, 2024 patients received 2083 allografts with a minimum of 12 months of follow-up. The overall allograft-associated infection rate was 1.2% (24/2024). Swab cultures of 2083 allografts taken before implantation revealed 21 (1.0%) positive findings. The 21 recipients were given various antibiotics at the individual orthopaedic surgeon’s discretion. At the latest follow-up, none of these 21 recipients displayed clinical signs of infection following treatment. Based on these findings, we conclude that an incidental positive culture finding for allografts does not correlate with subsequent surgical site infection. Additional prolonged post-operative antibiotic therapy may not be necessary for recipients of fresh-frozen bone allograft with positive culture findings.

Cite this article: Bone Joint J 2015;97-B:427–31.

Allograft cortical strut for reconstruction of space-occupying bone lesions

Space-occupying bone lesions present orthopedic surgeons with clinical and operative challenges. Multiple reconstructive procedures have proven successful for small bone lesions but lack the structural support necessary for reconstruction of larger lesions. This study reports the clinical outcomes of patients undergoing excision and reconstruction of large bone lesions with allograft cortical struts without additional internal fixation. This retrospective outcomes study reviewed patients who underwent surgical curettage and cortical strut allograft reconstruction of any space-occupying bone lesion. Clinical, surgical, and imaging data were collected. The primary outcome measures were lesion healing, graft incorporation, long-term pain, return to activity, and presence of complications/recurrences. Seventeen patients met the inclusion criteria. At least partial lesion healing and allograft incorporation was identified in 15 of 17 lesions. Of the 15 patients who did not sustain a recurrence, only 1 did not return to full activities. Mean lesion volume was 107 cc. Average follow-up was 19.6 months. Two recurrences were identified, and no other major complications were identified.

An aggressive aneurysmal bone cyst of the proximal humerus and related complications in a pediatric patient

Clinical behavior of aneurysmal bone cyst (ABC) in younger patients can be more aggressive than that in older children and adults. Angular deformity and shortening can occur due to growth plate destruction or tumor resection. A 11-year-old boy who had been operated twice in another center for an ABC located in the left proximal humerus presented to the author's institution with complaints of pain, deformity and shortening of the left arm. Plain radiographs revealed left proximal humerus nonunion with a large defect. Reconstruction with nonvascularized fibular autograft was applied and left upper extremity was immobilized in a velpou bandage. At the third-month follow-up, graft incorporation was observed in the distal part; however, proximal part did not show adequate healing on radiographs. Additional immobilization in a sling for 3 months was advised to the patient and his family. However, they were lost to follow-up and readmitted to the author's institution at the 12th month postoperatively. Radiographs showed failure of the fibular graft fixation and nonunion of the humerus. Autogenic bone grafts, either vascularized or nonvascularized are the best treatment method for the large defects after tumor curettage or resection. Nonvascularized grafts are technically much easier to use than vascularized grafts and provide excellent structural bone support at the recipient side. However, they may take several months to be fully incorporated. In addition, good therapeutic outcomes require patience and collaboration with the patient and parents. Most importantly, the patient should be monitored closely.

Curettage and graft alleviates athletic-limiting pain in benign lytic bone lesions

BACKGROUND

Solitary bone cysts (SBC), nonossifying fibromas (NOF), and fibrous dysplasia (FD) create benign intramedullary lytic bone lesions. They are typically asymptomatic and treated conservatively. We present a series of lesions that caused performance-limiting pain in young athletes, a symptom phenomenon and possible treatment indication that has been poorly described in the literature.

QUESTIONS/PURPOSES

We asked whether intralesional curettage and defect grafting of these lesions would alleviate pain in young athletes and permit their return to unrestricted athletic activities.

PATIENTS AND METHODS

We retrospectively identified 29 patients (30 lesions) who underwent curettage and grafting for SBC (12 patients), NOF (nine), or FD (eight). All patients had pain predominantly with athletic involvement. The mean age of the patients was 18 years (range, 12-31 years). Tumor locations were the femur (eight lesions), humerus (seven), tibia (six), fibula (five), pubic ramus (two), ulna (one), and calcaneus (one). Signs/symptoms were pain alone (24 patients) and pain plus fracture (five). Surgery involved curettage and packing with allograft cancellous chips, bone substitute, or demineralized bone matrix. Two patients required internal fixation. The mean followup was 21 months (range, 2-114 months).

RESULTS

Twenty-four patients had no pain and five had occasional mild pain at last followup. All patients resumed full activity at a mean of 3.3 months (range, 1.5-8.3 months), excluding two who required repeat surgery.

CONCLUSIONS

Our observations suggest curettage and packing with bone graft/substitute can provide pain relief and allow full athletic recovery for young athletes with benign lytic bone lesions.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Microparticulate cortical allograft: an alternative to autograft in the treatment of osseous defects

Benign bone tumors are commonly diagnosed and treated. Following tumor removal, the defect in the bone can be filled with auto- or allografts, (degradable) bone substitutes or non-degradable polymethylmethacrylate. The ideal substitute for this purpose should provide immediate structural support and readily incorporate into bone over a short period of time. Experimentally, microparticulate allograft has been shown to incorporate quickly in metaphyseal and metadiaphyseal cortico-cancellous defects in primates [1]. Using a combination of small allogeneic cortical graft particles (< 250 µm), bone defects were filled following intralesional excision in 97 consecutive patients with benign and low grade malignant tumors and tumor-like conditions of bone. The clinical results and rate of radiographic incorporation and osseous consolidation were recorded and analyzed. These patients underwent 104 procedures in which osseous defects were packed with microparticulate allograft. The follow-up was from 23 to 49 months. There were 94 (90.3%) closed defects and 10 (9.7%) open defects. The average size of the grafted defect was 42.8 cm³ (0.48 - 315.0 cm³). Internal fixation was used in 11 of the 104 procedures (10.6 %). Radiographically, incorporation was observed in 91% of patients and consolidation in 60%. There were eleven failures (10.6 %), eight (72 %) due to tumor recurrence. Seven of eight patients with tumor recurrence underwent a second resection and grafting procedure that resulted in allograft incorporation and defect healing. There were two deep infections requiring debridement with retention of the graft; both resolved with satisfactory healing.

Both incorporation and consolidation were observed in over 90% of patients with a low rate of complications. The use of small-particle cortical allograft proved to be an effective alternative to autogenous bone graft in patients with metaphyseal and metadiaphyseal surgical bone defects.

Are fibula strut allografts a reliable alternative for periarticular reconstruction after curettage for bone tumors?

Bone tumors occurring in periarticular locations may cause a substantial risk of subchondral fracture and collapse. Poly-methylmethacrylate has been used for reconstruction in these instances because of its immediate structural stability. Allogeneic graft allows for biologic incorporation and remodeling, but it takes longer. Adding a fibula strut graft to the construct seems to provide structural stability during incorporation of the particulate graft. Seventeen of 22 (77.3%) patients returned to their full preoperative level of function after this procedure. We believe adding fibula strut to particulate allograft when using the buttress technique provides structural integrity and biologically active reconstruction, while maintaining a recurrence rate similar to those described for other reconstruction techniques.

Percutaneous reaming of simple bone cysts in children followed by injection of demineralized bone matrix and autologous bone marrow

The authors report the successful treatment of 19 patients (mean age 10 years) with active unicameral bone cysts using a combination of percutaneous reaming and injection of a mixture of demineralized bone matrix and autologous bone marrow. Follow-up ranged from 12 to 42 months (mean 28 months). All patients were asymptomatic at the latest follow-up. Two required a second intervention to accomplish complete cyst healing. Radiographic outcome was improved in all patients according to the Neer classification at the latest follow-up. There were no significant complications related to the procedure, nor did any fracture occur after initiation of the above regimen.

Biaxial flexure testing of calcium phosphate bioceramics for use in tissue engineering

This study analyzes data from 206 CaP specimens (68 HA, 70 BCP, and 68 beta-TCP) fractured via biaxial flexure testing. Specimens were divided into four groups: (a) Group I, dry; (b) Group II, wet (day 0, immersion time approximately 5-10 s); (c) Group III, after immersion in media for 21 days (day 21); and (d) Group IV, after culturing osteoblasts (OBs) on the surface for 21 days (day 21 with cells). X-ray diffraction verified the presence of minor second phases in HA and beta-TCP while BCP was a biphasic mixture of HA and beta-TCP with minor phases present. The statistical significance (p < 0.05) of differences in the measured biaxial flexure fracture strength, S, between groups was assessed via one-way ANOVA with Tukey's test. Also, a two-parameter Weibull analysis assessed the mechanical reliability of each group. Osteoblasts increase the biaxial flexure fracture strength in a statistically significant way compared to both the HA discs in Groups II and III. Scanning electron microscope examination revealed grain boundary grooving on the sintered surfaces and with thermal expansion anisotropy, likely leads to the observed rapid strength decline upon exposure to media found in Groups II, III and IV.

Pathologic fractures of the proximal femur secondary to benign bone tumors

Pathologic fractures of the proximal femur secondary to benign bone tumors often are difficult to treat because of specific anatomic features of this region and the aggressiveness of the tumors. Between 1986 and 1996, 11 patients presented with a pathologic fracture of the proximal femur secondary to a benign bone tumor. All were treated with a uniform approach consisting of biopsy, intralesional curettage, high-speed burring, and reconstruction using morselized allograft, autograft, and a fixed-angle implant. The average followup was 4 years 3 months (range, 24-114 months). One patient was lost to followup. All fractures healed, and there were no local recurrences and no cases of avascular necrosis. Functional evaluation revealed generally good results. Patients scored a mean of 32.6 on the original Musculoskeletal Tumor Society scale and 95.8 on the revised version. The average Toronto Extremity Salvage Score was 91.3. With the numbers available, there were no significant differences between the study group and population norms in the Short Form-36. These results suggest that a uniform approach based on preservation of the femoral head can be applied successfully to the treatment of these lesions with good local tumor control, fracture healing, and acceptable functional outcomes.