1
|
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.
Collapse
Affiliation(s)
| | - Azadeh Ghouchani
- Biomedical Engineering Department, University of Isfahan, Isfahan, Iran
| | | |
Collapse
|
2
|
Kumar A, Keshav K, Singh S, Singh A. Postoperative Fracture Risk in Giant Cell Tumor: A Case Report and Review of Literature. Cureus 2023; 15:e46192. [PMID: 37905245 PMCID: PMC10613347 DOI: 10.7759/cureus.46192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/29/2023] [Indexed: 11/02/2023] Open
Abstract
Giant cell tumor (GCT) of the proximal femur poses various challenges in its management and recurrence. We present a rare case of GCT of proximal femur in which recurrence and coxa vara deformity were encountered after index surgery. Management of the recurrence was done with intramedullary fixation with extended curettage and bone grafting. Different aspects of management such as the role of defect size, adjuvants, bone cement/bone graft, implants, and bisphosphonates have been highlighted in this article.
Collapse
Affiliation(s)
- Amit Kumar
- Orthopaedics, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, IND
| | - Kumar Keshav
- Orthopaedics, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, IND
| | - Siddhartha Singh
- Orthopaedics, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, IND
| | - Amarendra Singh
- Trauma and Orthopaedics, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, IND
| |
Collapse
|
3
|
Tsukamoto S, Mavrogenis AF, Akahane M, Honoki K, Kido A, Tanaka Y, Donati DM, Errani C. Risk factors of fracture following curettage for bone giant cell tumors of the extremities. BMC Musculoskelet Disord 2022; 23:477. [PMID: 35590280 PMCID: PMC9118605 DOI: 10.1186/s12891-022-05447-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 05/17/2022] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Following curettage of giant cell tumor of bone (GCTB), it is common to fill the cavity with polymethylmethacrylate (PMMA) bone cement, bone allograft, or artificial bone to maintain bone strength; however, there is a 2-14% risk of postoperative fractures. We conducted this retrospective study to clarify the risk factors for fractures after curettage for GCTB of the extremities. METHODS This study included 284 patients with GCTBs of the extremities who underwent curettage at our institutions between 1980 and 2018 after excluding patients whose cavities were not filled with anything or who had additional plate fixation. The tumor cavity was filled with PMMA bone cement alone (n = 124), PMMA bone cement and bone allograft (n = 81), bone allograft alone (n = 63), or hydroxyapatite graft alone (n = 16). RESULTS Fractures after curettage occurred in 10 (3.5%) patients, and the median time from the curettage to fracture was 3.5 months (interquartile range [IQR], 1.8-8.3 months). The median postoperative follow-up period was 86.5 months (IQR, 50.3-118.8 months). On univariate analysis, patients who had GCTB of the proximal or distal femur (1-year fracture-free survival, 92.5%; 95% confidence interval [CI]: 85.8-96.2) presented a higher risk for postoperative fracture than those who had GCTB at another site (100%; p = 0.0005). Patients with a pathological fracture at presentation (1-year fracture-free survival, 88.2%; 95% CI: 63.2-97.0) presented a higher risk for postoperative fracture than those without a pathological fracture at presentation (97.8%; 95% CI: 95.1-99.0; p = 0.048). Patients who received bone grafting (1-year fracture-free survival, 99.4%; 95% CI: 95.7-99.9) had a lower risk of postoperative fracture than those who did not receive bone grafting (94.4%; 95% CI: 88.7-97.3; p = 0.003). CONCLUSIONS For GCTBs of the femur, especially those with pathological fracture at presentation, bone grafting after curettage is recommended to reduce the risk of postoperative fracture. Additional plate fixation should be considered when curettage and cement filling without bone grafting are performed in patients with GCTB of the femur. This should be specially performed for those patients with a pathological fracture at presentation.
Collapse
Affiliation(s)
- Shinji Tsukamoto
- Department of Orthopaedic Surgery, Nara Medical University, 840g, Shijo-cho, Kashihara-city, Nara, 634-8521, Japan.
| | - Andreas F Mavrogenis
- First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, 41 Ventouri Street, 15562 Holargos, Athens, Greece
| | - Manabu Akahane
- Department of Health and Welfare Services, National Institute of Public Health, 2-3-6 Minami, Wako-shi, Saitama, 351-0197, Japan
| | - Kanya Honoki
- Department of Orthopaedic Surgery, Nara Medical University, 840g, Shijo-cho, Kashihara-city, Nara, 634-8521, Japan
| | - Akira Kido
- Department of Rehabilitation Medicine, Nara Medical University, 840, Shijo-cho, Kashihara-city, Nara, 634-8521, Japan
| | - Yasuhito Tanaka
- Department of Orthopaedic Surgery, Nara Medical University, 840g, Shijo-cho, Kashihara-city, Nara, 634-8521, Japan
| | - Davide Maria Donati
- Department of Orthopaedic Oncology, IRCCS Istituto Ortopedico Rizzoli, Via Pupilli 1, 40136, Bologna, Italy
| | - Costantino Errani
- Department of Orthopaedic Oncology, IRCCS Istituto Ortopedico Rizzoli, Via Pupilli 1, 40136, Bologna, Italy
| |
Collapse
|
4
|
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.
Collapse
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.
| |
Collapse
|
5
|
Ghouchani A, Ebrahimzadeh MH. Can Patient-specific Finite Element Models Enter Clinical Practice as a Decision Support System? THE ARCHIVES OF BONE AND JOINT SURGERY 2021; 9:1-4. [PMID: 33778109 DOI: 10.22038/abjs.2020.54579.2722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Azadeh Ghouchani
- Department of Biomedical Engineering, Mashhad Branch, Islamic Azad University, Mashhad, Iran
| | | |
Collapse
|