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Akhlaghi P, Ghouchani A, Rouhi G. The effect of defect size and location on the fracture risk of proximal tibia, following tumor curettage and cementation: An in-silico investigation. Comput Biol Med 2023; 167:107564. [PMID: 37871436 DOI: 10.1016/j.compbiomed.2023.107564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 09/03/2023] [Accepted: 10/10/2023] [Indexed: 10/25/2023]
Abstract
Even though, proximal tibia is a common site of giant cell tumor and bone fractures, following tumor removal, nonetheless very little attention has been paid to affecting factors on the fracture risk. Here, nonlinear voxel-based finite element models based on computed tomography images were developed to predict bone fracture load with defects with different sizes, which were located in the medial, lateral, anterior, and posterior region of the proximal tibia. Critical defect size was identified using One-sample t-test to assess if the mean difference between the bone strength for a defect size was significantly different from the intact bone strength. Then, the defects larger than critical size were reconstructed with cement and the mechanics of the bone-cement interface (BCI) was investigated to find the regions prone to separation at BCI. A significant increase in fracture risk was observed for the defects larger than 20 mm, which were located in the medial, lateral and anterior regions, and defects larger than 25 mm for those located in the posterior region of the proximal tibia. Furthermore, it was found that the highest and lowest fracture risks were associated with defects located in the medial and posterior regions, respectively, highlighting the importance of selecting the initial location of a cortical window for tumor removal by the surgeon. The results of the BCI analysis showed that the location and size of the cement had a direct impact on the extent of damage and its distribution. Identification of critical regions susceptible to separation at BCI, can provide critical comments to surgeons in selecting the optimal cement augmentation technique, which may ultimately prevent unnecessary surgical intervention, such as using screws and pins.
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Affiliation(s)
| | - Azadeh Ghouchani
- Biomedical Engineering Department, University of Isfahan, Isfahan, Iran
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Ilyas MS, Akram R, Zehra U, Aziz A. Management of Giant Cell Tumor of Talus With Extended Intralesional Curettage and Reconstruction Using Polymethylmethacrylate Cement. Foot Ankle Spec 2022:19386400221079487. [PMID: 35229671 DOI: 10.1177/19386400221079487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
An 18-year-old man presented with complaints of pain and swelling around the left ankle region. Local examination revealed diffuse, hard, mildly tender swelling with ill-defined margins over the medial aspect of the left ankle joint just below the medial malleolus. Radiographic and computed tomographic assessment revealed osteolytic lesion with moderately defined margins. Provisional diagnosis of Campanacci grade 2 giant cell tumor was made, which was later confirmed on histopathology. Extended intralesional curettage and reconstruction with polymethylmethacrylate cement was done under spinal anesthesia. Full weight bearing was allowed at 4 weeks when the below knee back slab was removed. Radiographic assessment was done every 3 months during the first year of follow-up and then every 6 months. No evidence of recurrence of tumor, collapse of talus, or avascular necrosis was found during follow-up. Managing such rare form of bone tumors with extended intralesional curettage and bone cement is an appropriate treatment and gives good functional results.Level of Evidence: Level V.
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Affiliation(s)
- Muhammad Saad Ilyas
- Department of Orthopaedics and Spine Surgery, Ghurki Trust Teaching Hospital, Lahore, Pakistan
| | - Rizwan Akram
- Department of Orthopaedics and Spine Surgery, Ghurki Trust Teaching Hospital, Lahore, Pakistan
| | - Uruj Zehra
- Department of Anatomy, University of Health Sciences, Lahore, Pakistan
| | - Amer Aziz
- Department of Orthopaedics and Spine Surgery, Ghurki Trust Teaching Hospital, Lahore, Pakistan
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Kaya V, Kilic F, Yamak F, Ekin EE, Basar H, Misir A. Biomechanical and fracture characteristics of different filling and fixation methods applied to various proximal tibial metaphyseal defect sizes in an ovine model. Clin Biomech (Bristol, Avon) 2022; 93:105597. [PMID: 35193076 DOI: 10.1016/j.clinbiomech.2022.105597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Revised: 02/15/2022] [Accepted: 02/15/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND Ideal treatment method based on the size of the defect in local aggressive bone tumors is yet to be described. We evaluated the mechanical behavior of different fixation methods for various defect sizes located in the proximal tibia. METHODS Ninety-one sheep tibiae were distributed in five groups. Each study group was further divided into three subgroups, forming 25%, 50%, and 75% metaphyseal defects. The five groups were divided as follows: 1) control group where tibiae remained intact (n = 7); 2) isolated defect created, without filling (n = 21); 3) filling with cement (n = 21); 4) application of two subchondral cortical screws in addition to cement (n = 21); and 5) application of plate-screw fixation in addition to cement (n = 21). A loading test simulating the axial load applied by the distal femur to the tibia plateau was performed. The maximum failure load was compared between groups according to the defect size and fixation method. FINDINGS In 25% defects, group 5 had significantly higher failure load than other groups. However, in 50% and 75% defects, additional fixation did not increase the failure load. Also, additional screw fixation did not increase failure load in all defect sizes. There was a significant positive correlation between fracture morphology and defect size, fixation method, and failure load. INTERPRETATION Additional plate-screw fixation would increase the stability in defects ≤25%. In defects ≥50%, additional fixation does not increase stability. Screw fixation in addition to cementing does not increase stability in all defect sizes.
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Affiliation(s)
| | - Feyzi Kilic
- Health Sciences University Gaziosmanpasa Training and Research Hospital, Department of Orthopedics and Traumatology, Istanbul, Turkey
| | - Fatih Yamak
- Istanbul Technical University, Faculty of Mechanical Engineering, Strength of Materials and Biomechanics Laboratory, Istanbul, Turkey.
| | - Elif Evrim Ekin
- Health Sciences University Gaziosmanpasa Training and Research Hospital, Department of Radiology, Istanbul, Turkey
| | - Hakan Basar
- Health Sciences University Gaziosmanpasa Training and Research Hospital, Department of Orthopedics and Traumatology, Istanbul, Turkey
| | - Abdulhamit Misir
- Medicana International Istanbul Hospital, Department of Orthopedics and Traumatology, Istanbul, Turkey.
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Sukpanichyingyong S, Salang K, Sangkomkamhang T. OUP accepted manuscript. J Surg Case Rep 2022; 2022:rjac197. [PMID: 35530424 PMCID: PMC9071277 DOI: 10.1093/jscr/rjac197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Accepted: 04/16/2022] [Indexed: 11/12/2022] Open
Affiliation(s)
- Sermsak Sukpanichyingyong
- Department of Orthopaedics, Khon Kaen Hospital, Khon Kaen, Thailand
- Correspondence address. Department of Orthopaedics, Khon Kaen Hospital, Khon Kaen, Thailand. Tel: +66866300280; Fax: +6643099900, ext. 1226; E-mail:
| | - Krits Salang
- Department of Orthopaedics, Khon Kaen Hospital, Khon Kaen, Thailand
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Yayan J. Denosumab for Effective Tumor Size Reduction in Patients With Giant Cell Tumors of the Bone: A Systematic Review and Meta-Analysis. Cancer Control 2021; 27:1073274820934822. [PMID: 32869648 PMCID: PMC7710399 DOI: 10.1177/1073274820934822] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Denosumab is a human monoclonal antibody that has been used successfully in the treatment of giant cell tumors of bone. These tumors are rare and, in principle, benign, but they are highly aggressive, locally advanced, osteolytic bone tumors that can metastasize to the lungs. Denosumab is an effective treatment when these tumors cannot be surgically removed or when surgical resection is likely to lead to severe morbidity (eg, loss of limbs or joints). The aim of this systematic review and meta-analysis was to investigate patients with giant cell tumors of bone who experienced tumor progression during treatment with denosumab and to compare them with patients who experienced reduction of their giant cell tumors of bone during treatment with denosumab. METHODS Embase, Cochrane Library, and MEDLINE/PubMed databases were searched for trials submitted by January 7, 2020, that reported the efficacy and safety of denosumab in patients with giant cell tumors of bone. RESULTS Sixty studies were reviewed, involving a total of 1074 patients who had giant cell tumors of bone and were treated with denosumab. Of the 60 studies, 58% of the patients were from case series studies, 39% from open-label phase II studies, and 3% from case reports. The response rate for denosumab as a treatment for giant cell tumors of bone was 97.5%, with statistical significance (P < .0001). Pain in the limbs was statistically the most common adverse event for denosumab treatment in case series studies (P < .0001). No treatment-related deaths occurred in the reviewed studies. CONCLUSION Cumulative evidence supports the addition of surgery to optimal medical therapy with denosumab to reduce tumor size, clinical symptoms, and mortality among patients with giant cell tumors of bone.
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Affiliation(s)
- Josef Yayan
- Department of Internal Medicine, Division of Pulmonary, Allergy, and Sleep Medicine, HELIOS Clinic Wuppertal, 163483Witten/Herdecke University, Witten, Germany
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Ghouchani A, Rouhi G, Ebrahimzadeh MH. Post-operative fracture risk assessment following tumor curettage in the distal femur: a hybrid in vitro and in silico biomechanical approach. Sci Rep 2020; 10:21319. [PMID: 33288803 PMCID: PMC7721712 DOI: 10.1038/s41598-020-78188-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 11/17/2020] [Indexed: 12/26/2022] Open
Abstract
The distal femur is the predominant site for benign bone tumours and a common site for fracture following tumour removal or cementation. However, the lack of conclusive assessment criterion for post-operative fracture risk and appropriate devices for cement augmentation are serious concerns. Hence, a validated biomechanical tool was developed to assess bone strength, depending on the size and location of artificially created tumorous defects in the distal femora. The mechanics of the bone–cement interface was investigated to determine the main causes of reconstruction failure. Based on quantitative-CT images, non-linear and heterogeneous finite element (FE) models of human cadaveric distal femora with simulated tumourous defects were created and validated using in vitro mechanical tests from 14 cadaveric samples. Statistical analyses demonstrated a strong linear relationship (R2 = 0.95, slope = 1.12) with no significant difference between bone strengths predicted by in silico analyses and in vitro tests (P = 0.174). FE analyses showed little reduction in bone strength until the defect was 35% or more of epiphyseal volume, and reduction in bone strength was less pronounced for laterally located defects than medial side defects. Moreover, the proximal end of the cortical window and the most interior wall of the bone–cement interface were the most vulnerable sites for reconstruction failure.
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Affiliation(s)
- Azadeh Ghouchani
- Faculty of Biomedical Engineering, Amirkabir University of Technology, No. 350, Hafez Ave, Valiasr Square, 1591634311, Tehran, Iran
| | - Gholamreza Rouhi
- Faculty of Biomedical Engineering, Amirkabir University of Technology, No. 350, Hafez Ave, Valiasr Square, 1591634311, Tehran, Iran.
| | - Mohammad Hosein Ebrahimzadeh
- Orthopaedic Research Center, Department of Orthopaedic Surgery, Mashhad University of Medical Sciences, Ghaem Hospital, Ahmad Abad Street, Mashhad, Iran
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Mosleh H, Rouhi G, Ghouchani A, Bagheri N. Prediction of fracture risk of a distal femur reconstructed with bone cement: QCSRA, FEA, and in-vitro cadaver tests. Phys Eng Sci Med 2020. [DOI: 10.1007/s13246-020-00848-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Ghouchani A, Rouhi G, Ebrahimzadeh MH. Investigation on distal femoral strength and reconstruction failure following curettage and cementation: In-vitro tests with finite element analyses. Comput Biol Med 2019; 112:103360. [PMID: 31330318 DOI: 10.1016/j.compbiomed.2019.103360] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 07/14/2019] [Accepted: 07/15/2019] [Indexed: 12/28/2022]
Abstract
Cement augmentation following benign bone tumor surgery, i.e. curettage and cementation, is recommended in patients at high risk of fracture. Nonetheless, identifying appropriate cases and devices for augmentation remains debatable. Our goal was to develop a validated biomechanical tool to: predict the post-surgery strength of a femoral bone, assess the precision and accuracy of the predicted strength, and discover the mechanisms of reconstruction failure, with the aim of finding a safe biomechanical fixation. Tumor surgery was mimicked in quantitative-CT (QCT) scanned cadaveric human distal femora, and subsequently tested in compression to measure bone strength (FExp). Finite element (FE) models considering bone material non-homogeneity and non-linearity were constructed to predict bone strength (FFE). Analyses of contact, damage, and crack initiation at the bone-cement interface (BCI) were completed to investigate critical failure locations. Results of paired t-tests did not show a significant difference between FExp and FFE (P > 0.05); linear regression analysis resulted in good correlation between FExp and FFE (R2 = 0.94). Evaluation of the models precision using linear regression analysis yielded R2 = 0.89, with the slope = 1.08 and intercept = -324.16 N. FE analyses showed the initiation of damage and crack and a larger cement debonding area at the proximal end and most interior part of BCI, respectively. Therefore, we speculated that devices that reinforce critical failure locations offer the most biomechanical advantage. The QCT-based FE method proved to be a reliable tool to predict distal femoral strength, identify some causes of reconstruction failure, and assist in a safer selection of fixation devices to reduce post-operative fracture risk.
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Affiliation(s)
- Azadeh Ghouchani
- Faculty of Biomedical Engineering, Amirkabir University of Technology, 424 Hafez Ave, Tehran, Iran.
| | - Gholamreza Rouhi
- Faculty of Biomedical Engineering, Amirkabir University of Technology, 424 Hafez Ave, Tehran, Iran.
| | - Mohammad Hosein Ebrahimzadeh
- Orthopedic Research Center, Department of Orthopedic Surgery, Mashhad University of Medical Sciences, Ahmad Abad Street. Ghaem Hospital, Mashhad, Iran.
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Ghouchani A, Ebrahimzadeh MH, Rouhi G. The Most Appropriate Reconstruction Method Following Giant Cell Tumor Curettage: A Biomechanical Approach. THE ARCHIVES OF BONE AND JOINT SURGERY 2018; 6:85-89. [PMID: 29600259 PMCID: PMC5867362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Affiliation(s)
- Azadeh Ghouchani
- Research performed at the Department of Biomedical Engineering, Amirkabir University of Technology, Tehran, Iran
| | - Mohammad H Ebrahimzadeh
- Research performed at the Department of Biomedical Engineering, Amirkabir University of Technology, Tehran, Iran
| | - Gholamreza Rouhi
- Research performed at the Department of Biomedical Engineering, Amirkabir University of Technology, Tehran, Iran
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