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Lea MA, Elmalky M, Sabou S, Siddique I, Verma R, Mohammad S. Revision pedicle screws with impaction bone grafting: a case series. JOURNAL OF SPINE SURGERY (HONG KONG) 2021; 7:344-353. [PMID: 34734139 PMCID: PMC8511565 DOI: 10.21037/jss-20-684] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 04/14/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND Pedicle screw fixation in spinal constructs can be subject to failure requiring revision surgery. In cases of aseptic loosening various salvage techniques have been described. Revision screws augmented with cement have become popular but are not without risks. Larger diameter screws are often used but result in reducing bone stock or expanding the pedicles. We present a novel technique of pedicle screw revision by impaction bone allografting and a case series. METHODS The failed screws are removed. The screw track is probed to check its integrity. Milled bone allograft is funneled into the screw hole and sequentially impacted, before insertion of a replacement screw. We report a case series and describe a single case where this method has been used. Information was gathered from the electronic patient record in our hospital. RESULTS Ten screws were revised in 7 patients. Mean age at first surgery was 60.86 (48-76) years. Average time between first surgery and revision was 12.6 (4.7-49.9) months. Average follow-up was 26.2 (5.7-62.2) months and no screws showed any signs of loosening. CONCLUSIONS Impaction grafting with bone allograft is a technique for pedicle screw salvage that can be used safely and effectively as an alternative to cemented screws, when pedicle screws have failed by aseptic loosening. It avoids the risks associated with cemented screws and in our series was successful.
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Affiliation(s)
- Matthew Alexander Lea
- Department of Orthopaedic Spinal Surgery, Salford Royal NHS Foundation Trust, Stott Lane, Salford, UK
| | - Mahmoud Elmalky
- Department of Orthopaedic Spinal Surgery, Salford Royal NHS Foundation Trust, Stott Lane, Salford, UK
- Faculty of Medicine, Menoufia University, Al Minufiyah, Egypt
| | - Silviu Sabou
- Department of Orthopaedic Spinal Surgery, Salford Royal NHS Foundation Trust, Stott Lane, Salford, UK
| | - Irfan Siddique
- Department of Orthopaedic Spinal Surgery, Salford Royal NHS Foundation Trust, Stott Lane, Salford, UK
| | - Rajat Verma
- Department of Orthopaedic Spinal Surgery, Salford Royal NHS Foundation Trust, Stott Lane, Salford, UK
| | - Saeed Mohammad
- Department of Orthopaedic Spinal Surgery, Salford Royal NHS Foundation Trust, Stott Lane, Salford, UK
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Abrahams JM, Callary SA, Munn Z, Jang SW, Huang Q, Howie DW, Solomon LB. Acetabular Component Migration Measured Using Radiostereometric Analysis Following Revision Total Hip Arthroplasty: A Scoping Review. JBJS Rev 2020; 8:e0170. [PMID: 32304493 DOI: 10.2106/jbjs.rvw.19.00170] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
* Radiostereometric analysis (RSA) studies of acetabular component migration following revision total hip arthroplasty (THA) have a large variation in their methodology and reporting of results, and, therefore, they may not be directly comparable. Standardization of RSA reporting is recommended.
* In our review of RSA studies, there was a trend for cemented acetabular components to have larger amounts of early proximal migration than uncemented acetabular components. Results regarding cemented and uncemented components should be reported separately. * Cohorts that addressed larger acetabular defects were associated with a larger amount of early migration. * Reporting the migration result at 1 and 2 years postoperatively may enable earlier identification of poorly performing implants.
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Affiliation(s)
- John M Abrahams
- Centre for Orthopaedic and Trauma Research (J.M.A., S.A.C., S.W.J., Q.H., D.W.H., and L.B.S.) and the Joanna Briggs Institute (Z.M.), The University of Adelaide, Adelaide, South Australia, Australia.,Department of Orthopaedics and Trauma, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Stuart A Callary
- Centre for Orthopaedic and Trauma Research (J.M.A., S.A.C., S.W.J., Q.H., D.W.H., and L.B.S.) and the Joanna Briggs Institute (Z.M.), The University of Adelaide, Adelaide, South Australia, Australia.,Department of Orthopaedics and Trauma, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Zachary Munn
- Centre for Orthopaedic and Trauma Research (J.M.A., S.A.C., S.W.J., Q.H., D.W.H., and L.B.S.) and the Joanna Briggs Institute (Z.M.), The University of Adelaide, Adelaide, South Australia, Australia
| | - Sung Won Jang
- Centre for Orthopaedic and Trauma Research (J.M.A., S.A.C., S.W.J., Q.H., D.W.H., and L.B.S.) and the Joanna Briggs Institute (Z.M.), The University of Adelaide, Adelaide, South Australia, Australia.,Department of Orthopaedic Surgery, Pohang SeMyeong Christianity Hospital, Pohang-si, Republic of Korea
| | - Qiang Huang
- Centre for Orthopaedic and Trauma Research (J.M.A., S.A.C., S.W.J., Q.H., D.W.H., and L.B.S.) and the Joanna Briggs Institute (Z.M.), The University of Adelaide, Adelaide, South Australia, Australia.,Orthopedic Department of West China Hospital, Sichuan University, Chengdu City, China
| | - Donald W Howie
- Centre for Orthopaedic and Trauma Research (J.M.A., S.A.C., S.W.J., Q.H., D.W.H., and L.B.S.) and the Joanna Briggs Institute (Z.M.), The University of Adelaide, Adelaide, South Australia, Australia.,Department of Orthopaedics and Trauma, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Lucian Bogdan Solomon
- Centre for Orthopaedic and Trauma Research (J.M.A., S.A.C., S.W.J., Q.H., D.W.H., and L.B.S.) and the Joanna Briggs Institute (Z.M.), The University of Adelaide, Adelaide, South Australia, Australia.,Department of Orthopaedics and Trauma, Royal Adelaide Hospital, Adelaide, South Australia, Australia
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Erivan R, Matthieu PA, Boyer B, Reina N, Rhame M, Rouchy RC, Moreau S, Sanchez T, Roche O, Caton J, Rouvillain JL, Missenard G, Ramdane N, Mulliez A, Descamps S, Boisgard S. Use of morselized allografts for acetabular reconstruction during THA revision: French multicenter study of 508 cases with 8 years' average follow-up. Orthop Traumatol Surg Res 2019; 105:957-966. [PMID: 31147251 DOI: 10.1016/j.otsr.2019.02.025] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 01/29/2019] [Accepted: 02/11/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND In the context of acetabular reconstruction, bone defects can be filled with processed or unprocessed bone allografts. Published data are often contradictory on this topic and few studies have been done comparing processed allografts to fresh-frozen ones. This led us to conduct a large study to measure the factors impacting the survival of THA revision: (1) type of allograft and cup, (2) technical factors or patient-related factors. HYPOTHESIS Acetabular reconstruction can be performed equally well with frozen or processed morselized allografts. MATERIALS AND METHODS This retrospective, multicenter study of acetabular reconstruction included 508 cases with a minimum follow-up of 5 years. The follow-up for the frozen grafts was shorter (7.86 years±1.89 [5-12.32]) than that of the processed grafts (8.22 years±1.77 [5.05-15.48]) (p=0.029). However, the patients were younger at the time of the primary THA procedure in the frozen allograft group (51.5 years±14.2 [17-80]) than in the processed group (57.5 years±13.0 [12-94]) (p<0.001) and were also younger at the time of THA revision (67.8 years±12.2 [36.9-89.3] versus 70 years±11.7 [25-94.5]) (p=0.041). RESULTS There were more complications overall in the frozen allograft group (46/242=19.0%) than the processed allograft group (35/256=13.2%) (p=0.044) with more instances of loosening in the frozen group (20/242 [8.2%]) than in the processed group (6/266 [3.3%])(p=0.001). Conversely, the dislocation rate (16/242=6.6% vs. 17/266=6.4%) (p=0.844) and infection rate (18/242=7.4% vs. 15/266=5.7%) (p=0.264) did not differ between groups. The subgroup analysis reveal a correlation between the occurrence of a complication and higher body mass index (BMI) (p=0.037) with a higher overall risk of complications in patients with a BMI above 30 or under 20 (p=0.006) and a relative risk of 1.95 (95% CI: 1.26-2.93). Being overweight was associated with a higher risk of dislocation (relative risk of 2.46; 95% CI: 1.23-4.70) (p=0.007). Loosening was more likely to occur in younger patients at the time of the procedure (relative risk of 2.77; 95% CI: 1.52-6.51) (p=0.040) before 60 years during the revision. Lastly, patients who were less active preoperatively based on the Devane scale had an increased risk of dislocation (relative risk of 2.51; 95% CI: 1.26-8.26) (p=0.022). DISCUSSION Our hypothesis was not confirmed. The groups were not comparable initially, which may explain the differences found since the larger number of loosening cases in the frozen allograft group can be attributed to group heterogeneity. Nevertheless, morselized allografts appear to be suitable for acetabular bone defect reconstruction. A randomized study would be needed to determine whether frozen or processed allografts are superior. LEVEL OF EVIDENCE III, comparative retrospective study.
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Affiliation(s)
- Roger Erivan
- CNRS, SIGMA Clermont, ICCF, université Clermont Auvergne, CHU Clermont-Ferrand, 58, rue Montalembert, 63000 Clermont-Ferrand, France.
| | - Pierre-Alain Matthieu
- Département d'orthopédie-traumatologie, CHU Limoges, 2, avenue Martin-Luther-King, 87000 Limoges, France
| | - Bertrand Boyer
- Inserm, U1059, 42270 Saint-Étienne, France; Université Saint-Étienne, 42270 Saint-Étienne, France; Service d'orthopédie, hôpital La Charité, hôpital Nord, CHU Saint-Étienne, 44, rue Pointe Cadet, 42055 Saint-Étienne, France
| | - Nicolas Reina
- Hôpital Pierre-Paul-Riquet, Institut Locomoteur, CHU de Toulouse, Allée Jean Dausset, 31059 Toulouse, France
| | - Michel Rhame
- Department of orthopaedic surgery and traumatology, Hautepierre hospital, Strasbourg university hospitals group, 1, avenue Molière, 67098 Strasbourg, France
| | - René-Christopher Rouchy
- Service de chirurgie orthopédique et de traumatologie du sport, urgences, hôpital Sud, CHU de Grenoble, 19, avenue de Kimberley, 38130 Échirolles, France
| | - Sébastien Moreau
- Hôpital Raymond Poincaré, CHU Paris Garches, 104, boulevard Raymond Poincaré, 92380 Garches, France
| | - Thomas Sanchez
- Chirurgie orthopédique et traumatologie du membre inférieur, CHU Lapeyronie, 371, avenue du Doyen Gaston Giraud, 34000 Montpellier, France
| | - Olivier Roche
- Centre Chirurgical Emile Gallé, CHRU Nancy, 49, rue Hermite, 54000 Nancy, France
| | - Jacques Caton
- Institut de chirurgie orthopédique Lyon, 103, rue Coste, 69300 Caluire-et-Cuire, France
| | - Jean-Louis Rouvillain
- Service de chirurgie orthopédique et traumatologique, CHU La Meynard CS90632, 97261 Fort-de-France, Martinique, France
| | - Gilles Missenard
- Orthopaedic department, tumor and spine unit, Bicêtre university hospital, AP-HP, 78, rue du Général Leclerc, 94270 Le Kremlin-Bicêtre, France; JE 2494 université Paris-Sud Orsay, 01405 Orsay, France
| | - Nassima Ramdane
- Unité de méthodologie - biostatistique et Data Management, CHRU de Lille, 59037 Lille, France
| | - Aurélien Mulliez
- Délégation à la recherche clinique et aux innovations (DRCI), CHU Clermont-Ferrand, 63000 Clermont-Ferrand, France
| | - Stéphane Descamps
- CNRS, SIGMA Clermont, ICCF, université Clermont Auvergne, CHU Clermont-Ferrand, 58, rue Montalembert, 63000 Clermont-Ferrand, France
| | - Stéphane Boisgard
- CNRS, SIGMA Clermont, ICCF, université Clermont Auvergne, CHU Clermont-Ferrand, 58, rue Montalembert, 63000 Clermont-Ferrand, France
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- 56, rue Boissonnade, 75014 Paris, France
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Lahr CA, Wagner F, Shafiee A, Rudert M, Hutmacher DW, Holzapfel BM. Recombinant Human Bone Morphogenetic Protein 7 Exerts Osteo-Catabolic Effects on Bone Grafts That Outweigh Its Osteo-Anabolic Capacity. Calcif Tissue Int 2019; 105:331-340. [PMID: 31214730 DOI: 10.1007/s00223-019-00574-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Accepted: 06/07/2019] [Indexed: 11/29/2022]
Abstract
This study aimed to investigate the effects of recombinant human bone morphogenetic protein (rhBMP-7) on human cancellous bone grafts (BGs) while differentiating between anabolic and catabolic events. Human BGs alone or supplemented with rhBMP-7 were harvested 14 weeks after subcutaneous implantation into NOD/Scid mice, and studied via micro-CT, histomorphometry, immunohistochemistry and flow cytometry. Immunohistochemical staining for human-specific proteins made it possible to differentiate between grafted human bone and newly formed murine bone. Only BGs implanted with rhBMP-7 formed an ossicle containing a functional hematopoietic compartment. The total ossicle volume in the BMP+ group was higher than in the BMP- group (835 mm3 vs. 365 mm3, respectively, p < 0.001). The BMP+ group showed larger BM spaces (0.47 mm vs. 0.28 mm, p = 0.002) and lower bone volume-to-total volume ratio (31% vs. 47%, p = 0.002). Immunohistochemical staining for human-specific proteins confirmed a higher ratio of newly formed bone area (murine) to total area (0.12 vs. 0.001, p < 0.001) in the BMP+ group, while the ratio of grafted bone (human) area to total area was smaller (0.14 vs. 0.34, p = 0.004). The results demonstrate that rhBMP-7 induces BG resorption at a higher rate than new bone formation while creating a haematopoietic niche. Clinicians therefore need to consider the net catabolic effect when rhBMP-7 is used with BGs. Overall, this model indicates its promising application to further decipher BMPs action on BGs and its potential in complex bone tissue regeneration.
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Affiliation(s)
- Christoph A Lahr
- Regenerative Medicine, Institute of Health and Biomedical Innovation, Queensland University of Technology (QUT), 60 Musk Avenue, Kelvin Grove, Brisbane, QLD, 4059, Australia
- Department of Orthopaedic Surgery, University of Wuerzburg, Koenig-Ludwig-Haus, Brettreichstrasse 11, 97074, Wuerzburg, Germany
| | - Ferdinand Wagner
- Regenerative Medicine, Institute of Health and Biomedical Innovation, Queensland University of Technology (QUT), 60 Musk Avenue, Kelvin Grove, Brisbane, QLD, 4059, Australia
- Department of Pediatric Surgery, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University Munich, Lindwurmstrasse 4, 80337, Munich, Germany
| | - Abbas Shafiee
- Regenerative Medicine, Institute of Health and Biomedical Innovation, Queensland University of Technology (QUT), 60 Musk Avenue, Kelvin Grove, Brisbane, QLD, 4059, Australia
| | - Maximilian Rudert
- Department of Pediatric Surgery, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University Munich, Lindwurmstrasse 4, 80337, Munich, Germany
| | - Dietmar W Hutmacher
- Regenerative Medicine, Institute of Health and Biomedical Innovation, Queensland University of Technology (QUT), 60 Musk Avenue, Kelvin Grove, Brisbane, QLD, 4059, Australia
| | - Boris Michael Holzapfel
- Regenerative Medicine, Institute of Health and Biomedical Innovation, Queensland University of Technology (QUT), 60 Musk Avenue, Kelvin Grove, Brisbane, QLD, 4059, Australia.
- Department of Orthopaedic Surgery, University of Wuerzburg, Koenig-Ludwig-Haus, Brettreichstrasse 11, 97074, Wuerzburg, Germany.
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5
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Affiliation(s)
- Ameer Elbuluk
- Department of Orthopaedic Surgery, NYU Langone Medical Center, Hospital for Joint Diseases, New York, NY
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6
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Le Cann S, Tudisco E, Turunen MJ, Patera A, Mokso R, Tägil M, Belfrage O, Hall SA, Isaksson H. Investigating the Mechanical Characteristics of Bone-Metal Implant Interface Using in situ Synchrotron Tomographic Imaging. Front Bioeng Biotechnol 2019; 6:208. [PMID: 30719433 PMCID: PMC6348316 DOI: 10.3389/fbioe.2018.00208] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Accepted: 12/18/2018] [Indexed: 12/18/2022] Open
Abstract
Long-term stability of endosseous implants depends on successful bone formation, ingrowth and adaptation to the implant. Specifically, it will define the mechanical properties of the newly formed bone-implant interface. 3D imaging during mechanical loading tests (in situ loading) can improve the understanding of the local processes leading to bone damage and failure. In this study, titanium screws were implanted into rat tibiae and were allowed to integrate for 4 weeks with or without the addition of the growth factor Bone Morphogenetic Protein and the bisphosphonate Zoledronic Acid. Samples were subjected to in situ pullout using high-resolution synchrotron x-ray tomography at the Tomcat beamline (SLS, PSI, Switzerland) at 30 keV with 25 ms exposure time, resulting in a total acquisition time of 45 s per scan, with a 3.6 μm isotropic voxel size. Using a custom-made loading device positioned inside the beamline, screws were pulled out with 0.05 mm increment, acquiring multiple scans until rupture of the sample. The in situ loading protocol was adapted to ensure short imaging time, which enabled multiple samples to be tested with short loading steps, while keeping the total testing time low and reducing dose deposition. Higher trabecular bone content was quantified in the surrounding of the screw in the treated groups, which correlated with increased mechanical strength and stiffness. Differences in screw implantation, such as contact between threads and cortex as well as minor tilt of the screw were also correlated to the mechanical parameters. In situ loading enabled the investigation of crack propagation during the pullout, highlighting the mechanical behavior of the interface. Three typical crack types were observed: (1) rupture at the interface of trabecular and cortical bone tissues, close to the screw, (2) large crack inside the cortex connected to the implant, and (3) first failure away from the screw with cracks propagating toward the screw-bone interface. Mechanical properties of in vivo integrated bone-metal screws rely on a combination of multiple parameters that are difficult to identify and separate one from the other.
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Affiliation(s)
- Sophie Le Cann
- Department of Biomedical Engineering, Lund University, Lund, Sweden
| | - Erika Tudisco
- Division of Geotechnical Engineering, Lund University, Lund, Sweden
| | - Mikael J Turunen
- Department of Applied Physics, University of Eastern Finland, Kuopio, Finland
| | | | | | - Magnus Tägil
- Department of Orthopaedics, Clinical Sciences, Lund University, Lund, Sweden
| | - Ola Belfrage
- Department of Orthopaedics, Clinical Sciences, Lund University, Lund, Sweden
| | - Stephen A Hall
- Division of Solid Mechanics, Lund University, Lund, Sweden
| | - Hanna Isaksson
- Department of Biomedical Engineering, Lund University, Lund, Sweden.,Department of Orthopaedics, Clinical Sciences, Lund University, Lund, Sweden
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7
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Cleemann R, Sorensen M, Bechtold JE, Soballe K, Baas J. Healing in peri-implant gap with BMP-2 and systemic bisphosphonate is dependent on BMP-2 dose-A canine study. J Orthop Res 2018; 36:1406-1414. [PMID: 28976594 DOI: 10.1002/jor.23766] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Accepted: 09/22/2017] [Indexed: 02/04/2023]
Abstract
The bone-implant interface of cementless orthopedic implants can be described as a series of uneven sized gaps with discontinuous areas of direct bone-implant contact. Bridging these voids and crevices by addition of an anabolic stimulus to increase new bone formation can potentially improve osseointegration of implants. Bone morphogenetic protein 2 (BMP-2) stimulates osteoblast formation to increase new bone formation but also indirectly stimulates osteoclast activity. In this experiment, we investigate the hypothesis that osseointegration, defined as mechanical push-out and histomorphometry, depends on the dose of BMP-2 when delivered as an anabolic agent with systemic administration of the anti-resorptive agent zoledronate to curb an increase in osteoclast activity. Four porous coated titanium implants (one with each of three doses of surface-applied BMP-2 (15 µg; 60 µg; 240 µg) and untreated) surrounded by a 0.75 mm empty gap, were inserted into the distal femurs of each of twelve canines. Zoledronate IV (0.1 mg/kg) was administered 10 days into the observation period of 4 weeks. Bone-implant specimens were evaluated by mechanical push-out test and histomorphometry. The 15 µg implants had the best fixation on all mechanical parameters and largest surface area covered with new bone compared to the untreated, 60 and 240 µg implants, as well as the highest volume of new bone in the implant gap compared to 60 and 240 µg implants. The results in a canine implant model demonstrated that a narrow range of BMP-2 doses have opposite effects in bridging an empty peri-implant gap with bone, when combined with systemic zoledronate. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:1406-1414, 2018.
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Affiliation(s)
- Rasmus Cleemann
- Orthopaedic Research Laboratory, Aarhus University Hospital, Denmark.,Elective Surgery Center, Silkeborg Regional Hospital, Silkeborg, Denmark
| | - Mette Sorensen
- Department of Orthopaedic Surgery, Regional Hospital Viborg, Viborg, Denmark
| | - Joan E Bechtold
- University of Minnesota Department of Orthopaedic Surgery, Minneapolis Medical Research Foundation, Minneapolis, Minnesota
| | - Kjeld Soballe
- Department of Orthopaedic Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Jorgen Baas
- Department of Orthopaedic Surgery, Aarhus University Hospital, Aarhus, Denmark
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Lu H, Meng H, Lu S, Qin L, Zhao B, Wang A, Peng J, Xu W, Guo Q, Zhang J. Freeze-dried and irradiated allograft bone combined with fresh autologous coagula promotes angiogenesis in an ectopic bone allograft implantation model. Connect Tissue Res 2018; 59:233-244. [PMID: 28718671 DOI: 10.1080/03008207.2017.1353977] [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: 02/03/2023]
Abstract
BACKGROUND Freeze-dried and irradiated allograft bone (FIAB) is more easily impacted than fresh-frozen allograft bone (FAB), but has weaker incorporation efficiency. We combined FIAB with fresh autologous coagula to enhance donor-host incorporation after impaction during hip revision. METHODS Thirty adult male Sprague-Dawley (SD) rats were sacrificed for bone allograft harvesting, and nine male rats were subjected to ectopic bone allograft implantation. For each rat, the container on the left (study) side was filled with freeze-dried allograft bone powder and fresh autologous blood coagula, whereas the right (control) side was filled with freeze-dried allograft bone powder and physiological saline. The extent of angiogenesis (VEGFα) was investigated at postoperative weeks 1, 4, and 8. The deformability of the material was evaluated by performing a confined-impaction mechanical test. RESULTS At postoperative weeks 4 and 8, angiogenesis within FIAB on the left side was more pronounced than that on the right side. At postoperative week 1, the left side showed significantly higher VEGFα expression than that on the right side. The delta ratios of compression of the allografts were found to be influenced by bone height and impaction frequency, but not by stiffness or elastic modulus (EM). CONCLUSION Supplementation with fresh autologous coagula promoted angiogenesis within the FIABs. Moreover, FIABs were equivalent to FABs in terms of deformability.
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Affiliation(s)
- Haibo Lu
- a Orthopaedic Department , First Affiliated Hospital of General Hospital of the Chinese PLA , Beijing , China
| | - Haoye Meng
- b Institute of Orthopaedics of the Chinese PLA , General Hospital of the Chinese PLA , Beijing , China
| | - Shibi Lu
- b Institute of Orthopaedics of the Chinese PLA , General Hospital of the Chinese PLA , Beijing , China
| | - Ling Qin
- c Musculoskeletal Research Laboratory, Department of Orthopaedics and Traumatology , The Chinese University of Hong Kong , Hong Kong SAR , China
| | - Bin Zhao
- b Institute of Orthopaedics of the Chinese PLA , General Hospital of the Chinese PLA , Beijing , China
| | - Aiyuan Wang
- b Institute of Orthopaedics of the Chinese PLA , General Hospital of the Chinese PLA , Beijing , China
| | - Jiang Peng
- b Institute of Orthopaedics of the Chinese PLA , General Hospital of the Chinese PLA , Beijing , China
| | - Wenjing Xu
- b Institute of Orthopaedics of the Chinese PLA , General Hospital of the Chinese PLA , Beijing , China
| | - Quanyi Guo
- b Institute of Orthopaedics of the Chinese PLA , General Hospital of the Chinese PLA , Beijing , China
| | - Jian Zhang
- a Orthopaedic Department , First Affiliated Hospital of General Hospital of the Chinese PLA , Beijing , China
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Cleemann R, Bechtold JE, Sorensen M, Soballe K, Baas J. Dose-Dependent Resorption of Allograft by rhBMP-2 Uncompensated by New Bone Formation-A Canine Study With Implants and Zoledronate. J Arthroplasty 2018; 33:1215-1221.e1. [PMID: 29248483 DOI: 10.1016/j.arth.2017.11.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Revised: 10/26/2017] [Accepted: 11/07/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Impacted bone allograft is used to restore lost bone in total joint arthroplasties. Bone morphogenetic proteins (BMPs) can induce new bone formation to improve allograft incorporation, but they simultaneously invoke a seemingly dose-dependent allograft resorption mediated by osteoclasts. Bisphosphonates effectively inhibit osteoclast activity. Predicting allograft resorption when augmented with bone morphogenetic protein 2 (BMP-2), we intended to investigate whether a balanced bone metabolism was achievable within a range of BMP-2 doses with systemic zoledronate treatment. METHODS Implants were coated with 1 of 3 BMP-2 doses (15 μg, 60 μg, and 240 μg) or left untreated. Implants were surrounded by a 2.5-mm gap filled with impacted morselized allograft. Each of the 12 dogs included received 1 of each implant (15 μg, 60 μg, 240 μg, and untreated), 2 in each proximal humerus. During the 4-week observation period, zoledronate intravenous (0.1 mg/kg) was administered to all animals 10 days after surgery as anticatabolic treatment. Implant osseointegration was evaluated by histomorphometry and mechanical push-out tests. RESULTS Untreated implants had the best mechanical fixation and superior retention of allograft as compared to any of the BMP-2 implants. Both mechanical implant fixation and retention of allograft decreased significantly with BMP-2 dose increments. Surprisingly, there was no difference among the treatment groups in the amount of new bone. CONCLUSION The use of BMP-2 to augment impaction-grafted implants cannot be recommended even when combined with systemic zoledronate.
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Affiliation(s)
- Rasmus Cleemann
- Orthopaedic Research Laboratory, Aarhus University Hospital, Aarhus, Denmark; Elective Surgery Center, Silkeborg Regional Hospital, Silkeborg, Denmark
| | - Joan E Bechtold
- Department of Orthopaedic Surgery, University of Minnesota, Minneapolis Medical Research Foundation, Minneapolis, Minnesota
| | - Mette Sorensen
- Department of Orthopaedic Surgery, Viborg Regional Hospital, Viborg, Denmark
| | - Kjeld Soballe
- Department of Orthopaedic Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Jorgen Baas
- Department of Orthopaedic Surgery, Aarhus University Hospital, Aarhus, Denmark
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Arzeno A, Wang T, Huddleston JI. Abundant heterotopic bone formation following use of rhBMP-2 in the treatment of acetabular bone defects during revision hip arthroplasty. Arthroplast Today 2018; 4:162-168. [PMID: 29896546 PMCID: PMC5994604 DOI: 10.1016/j.artd.2017.12.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2017] [Revised: 12/12/2017] [Accepted: 12/13/2017] [Indexed: 01/28/2023] Open
Abstract
Revision hip arthroplasty in the setting of periacetabular bone loss presents a significant challenge, as options for restoring bone loss are limited. Recombinant human bone morphogenetic protein-2 may offer a solution by promoting bone growth to restore bone stock before implant reimplantation. Here we present a case of a patient with a periprosthetic acetabulum fracture, resulting in pelvic discontinuity as the result of significant periacetabular bone loss. Using a staged approach, periacetabular bone stock was nearly entirely reconstituted using recombinant BMPs and allograft, which resulted in stable fixation, but with abundant heterotopic bone formation. Recombinant BMP-2 offers a useful tool for restoring bone stock in complex hip arthroplasty revision cases with periacetabular bone loss; however, caution must be used as overabundant bone growth as heterotopic ossification may result.
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Affiliation(s)
- Alexander Arzeno
- Department of Orthopaedic Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Tim Wang
- Department of Orthopaedic Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - James I Huddleston
- Department of Orthopaedic Surgery, Stanford University School of Medicine, Stanford, CA, USA
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Bone morphogenic protein-2 use in revision total hip arthroplasty with acetabular defects. INTERNATIONAL ORTHOPAEDICS 2017; 42:783-789. [PMID: 29098380 DOI: 10.1007/s00264-017-3671-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/20/2017] [Accepted: 10/16/2017] [Indexed: 10/18/2022]
Abstract
INTRODUCTION The restoration of acetabular bone stock during revision hip arthroplasty remains a challenge. There have been no clinical series reporting the efficacy of bone morphogenic protein-2 (rhBMP-2) in the revision hip setting. METHODS We retrospectively reviewed the radiographs and records of 15 patients who received rhBMP-2 mixed with allograft bone chips (+BMP), and 14 who received allograft bone chips alone (-BMP) for their acetabular defect during revision total hip arthroplasty with a mean two-year follow up. Radiographs were evaluated for acetabular defect size, superior cup migration, and changes in the lateral cup abduction angle. Modified Harris hip scores were used for evaluation of clinical outcomes. RESULTS Patients in the +BMP group compared to the -BMP group had significantly larger amounts of cancellous bone chips used (72.1 ± 35.5 cc vs. 38.6 ± 14.1 cc; p = 0.003). Mean rhBMP-2 used per case was 7.4 ± 3.1 mg in the +BMP group. Three patients in the -BMP group had cup migration which was not observed in the +BMP group. Mean Harris hip scores (HHS) improved post-operatively in both groups (40.1 ± 20.9 to 71.9 ± 19, p < .0001). No local adverse reaction was noted in the +BMP group. CONCLUSION rhBMP-2 had modest clinical benefit in the setting of revision THA. Cost of this synthetic biologic versus the added clinical benefit should be carefully considered when being used in the revision hip setting.
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Baas J, Vestermark M, Jensen T, Bechtold J, Soballe K, Jakobsen T. Topical bisphosphonate augments fixation of bone-grafted hydroxyapatite coated implants, BMP-2 causes resorption-based decrease in bone. Bone 2017; 97:76-82. [PMID: 28082076 PMCID: PMC5367933 DOI: 10.1016/j.bone.2017.01.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Revised: 12/27/2016] [Accepted: 01/06/2017] [Indexed: 11/28/2022]
Abstract
Bone allograft is used in total joint arthroplasties in order to enhance implant fixation. BMPs are known to stimulate new bone formation within allograft, but also known to accelerate graft resorption. Bisphosphonates are strong inhibitor of bone resorption. The aim of this study was to investigate whether the bisphosphonate zoledronate was able to counteract the accelerated graft resorption without interfering with the BMP induced bone formation. In the present study the two drugs alone and in combination were studied in our canine model of impaction bone grafting. We included 10 dogs in this study. Cancellous allograft bone grafts were soaked in either saline or zoledronate solution (0.005mg/mL) and then vehicle or BMP2 (0.15mg rhBMP2) was added. This produced four treatment groups: A) control, B) BMP2, C) zoledronate and D) BMP2+zoledronate. The allograft treated with A, B, C or D was impacted into a circumferential defect of 2.5mm around HA-coated porous Ti implants. Each dog received all four treatment groups with two implants in the distal part of each femur. The group with allograft soaked in zoledronate (C) showed better biomechanical fixation than all other groups (p<0.05). It had less allograft resorption compared to all other groups (p<0.005) without any statistically significant change in new bone formation. The addition of BMP2 to the allograft did not increase new bone formation significantly, but did accelerate allograft resorption. This was also the case where the allograft was treated with BMP2 and zoledronate in combination (D). This caused a decrease in mechanical implant fixation in both these groups compared to the control group, however only statistically significant for the BMP2 group compared to control. The study shows that topical zoledronate can be a valuable tool for augmenting bone grafts when administered optimally. The use of BMP2 in bone grafting procedures seems associated with a high risk of bone resorption and mechanical weakening.
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Affiliation(s)
- Jorgen Baas
- Orthopaedic Research Laboratory, Aarhus University Hospital, 8000 Aarhus C, Denmark
| | - Marianne Vestermark
- Orthopaedic Research Laboratory, Aarhus University Hospital, 8000 Aarhus C, Denmark
| | - Thomas Jensen
- Orthopaedic Research Laboratory, Aarhus University Hospital, 8000 Aarhus C, Denmark
| | - Joan Bechtold
- Minneapolis Medical Research Foundation, University of Minnesota, Minneapolis, MN 55415, USA
| | - Kjeld Soballe
- Orthopaedic Research Laboratory, Aarhus University Hospital, 8000 Aarhus C, Denmark
| | - Thomas Jakobsen
- Orthopaedic Research Laboratory, Aarhus University Hospital, 8000 Aarhus C, Denmark.
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Pierannunzii L, Zagra L. Bone grafts, bone graft extenders, substitutes and enhancers for acetabular reconstruction in revision total hip arthroplasty. EFORT Open Rev 2017; 1:431-439. [PMID: 28461922 PMCID: PMC5367522 DOI: 10.1302/2058-5241.160025] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Acetabular bone loss is a relevant concern for surgeons dealing with a failed total hip arthroplasty. Since the femoral head is no longer available, allografts represent the first choice for most reconstructive solutions, either as a structural buttress or impacted bone chips. Even though fresh-frozen bone is firmly recommended for structural grafts, freeze-dried and/or irradiated bone may be used alternatively for impaction grafting. Indeed, there are some papers on freeze-dried or irradiated bone impaction grafting, but their number is limited, as is the number of cases. Xenografts do not represent a viable option based on the poor available evidence but bioactive bioceramics such as hydroxyapatite and biphasic calcium phosphates are suitable bone graft extenders or even substitutes for acetabular impaction grafting. Bone-marrow-derived mesenchymal stem cells and demineralised bone matrix seem to act as reliable bone graft enhancers, i.e. adjuvant therapies able to improve the biological performance of standard bone grafts or substitutes. Among these therapies, platelet-rich plasma and bone morphogenetic proteins need to be investigated further before any recommendations can be made.
Cite this article: EFORT Open Rev 2016;1:431-439. DOI:10.1302/2058-5241.160025
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Affiliation(s)
| | - Luigi Zagra
- IRCCS Galeazzi Orthopedic Institute, Milan, Italy
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The biological approach in acetabular revision surgery: impaction bone grafting and a cemented cup. Hip Int 2016; 25:361-7. [PMID: 26044533 DOI: 10.5301/hipint.5000267] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/02/2015] [Indexed: 02/04/2023]
Abstract
Acetabular impaction bone grafting (IBG) in combination with a cemented cup in revision total hip arthroplasty (THA) is a proven and well-recognised technique which has been used in clinical practice for more than 35 years. Nowadays, with cemented prostheses tending to lose a larger part of the THA market every year in primary and revision cases, and many young surgeons being only trained in implanting uncemented prostheses, this technique is considered by many as technically demanding and time consuming, making its use less appealing. Despite this image and many new innovative techniques using uncemented implants in acetabular revisions over the last 25 years, IBG with a cemented cup is still one of the few techniques that really can reconstitute bone and respects human biology. In this era of many biologically-based breakthroughs in medicine, it is hard to explain that the solution of most orthopaedic surgeons for the extensive bone defects as frequently seen during acetabular revision surgery, consists of implanting bigger and larger metal implants. This review aims to put the IBG method into a historical perspective, to describe the surgical technique and present the clinical results.
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Risedronate does not enhance fixation or BMD in revision cups: randomised study with three years follow-up. Hip Int 2014; 24:49-55. [PMID: 24186676 DOI: 10.5301/hipint.5000081] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/21/2013] [Indexed: 02/04/2023]
Abstract
BACKGROUND Bisphosphonates may improve implant fixation by inhibition of bone resorption and stimulation of osteoblasts by up regulation of BMP-2. However, there are few clinical studies in this area. QUESTIONS/PURPOSE Does treatment with oral bisphosphonates improve implant fixation and bone remodelling around the acetabular component after revision arthroplasty with or without use of morselised allograft? PATIENTS AND METHODS Fifty-three patients received university pharmacy blinded medication for three months: 5 mg risedronate or placebo one dosage and 1 g calcium carbonate and 800IE cholecalciferol per day. Forty-one patients were operated upon with revision of the cup. The revisions were performed with an uncemented (Trilogy, Zimmer, Warsaw, USA) or a cemented (Ogee, Depuy Int, England) cup. Radiostereometric analysis was obtained within one week after the operation, at three and six months, and after one, two and three years to study cup migration. Bone mineral density was measured postoperatively, at six months, one and two years, using DEXA. The presence and extension of radiolucent lines and graft remodelling were studied on conventional radiography. RESULTS The risendronate group revealed less anterior-posterior rotation at 6 months. We found no significant differences in migration at three years, change in bone mineral density, or graft remodelling and radiolucent lines formation between groups. CONCLUSIONS We could not demonstrate any beneficial effects of oral administration of risedronate on the fixation, bone mineral density or bone remodelling of revision cups using various amount of bone graft.
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Walschot LHB, Aquarius R, Verdonschot N, Buma P, Schreurs BW. Porous titanium particles for acetabular reconstruction in total hip replacement show extensive bony armoring after 15 weeks. A loaded in vivo study in 10 goats. Acta Orthop 2014; 85:600-8. [PMID: 25238431 PMCID: PMC4259031 DOI: 10.3109/17453674.2014.960660] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND AND PURPOSE The bone impaction grafting technique restores bone defects in total hip replacement. Porous titanium particles (TiPs) are deformable, like bone particles, and offer better primary stability. We addressed the following questions in this animal study: are impacted TiPs osteoconductive under loaded conditions; do released micro-particles accelerate wear; and are systemic titanium blood levels elevated after implantation of TiPs? ANIMALS AND METHODS An AAOS type-III defect was created in the right acetabulum of 10 goats weighing 63 (SD 6) kg, and reconstructed with calcium phosphate-coated TiPs and a cemented polyethylene cup. A stem with a cobalt chrome head was cemented in the femur. The goats were killed after 15 weeks. Blood samples were taken pre- and postoperatively. RESULTS The TiP-graft layer measured 5.6 (SD 0.8) mm with a mean bone ingrowth distance of 2.8 (SD 0.8) mm. Cement penetrated 0.9 (0.3-1.9) mm into the TiPs. 1 reconstruction showed minimal cement penetration (0.3 mm) and failed at the cement-TiP interface. There were no signs of accelerated wear, metallic particle debris, or osteolysis. Median systemic titanium concentrations increased on a log-linear scale from 0.5 (0.3-1.1) parts per billion (ppb) to 0.9 (0.5-2.8) ppb (p=0.01). INTERPRETATION Adequate cement pressurization is advocated for impaction grafting with TiPs. After implantation, calcium phosphate-coated TiPs were osteoconductive under loaded conditions and caused an increase in systemic titanium concentrations. However, absolute levels remained low. There were no signs of accelerated wear. A clinical pilot study should be performed to prove that application in humans is safe in the long term.
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Affiliation(s)
| | - René Aquarius
- Department of Orthopaedics, Orthopaedic Research Laboratory, Radboud University Medical Centre, Nijmegen
| | - Nico Verdonschot
- Department of Orthopaedics, Orthopaedic Research Laboratory, Radboud University Medical Centre, Nijmegen,Laboratory of Biomechanical Engineering, University of Twente, Enschede, the Netherlands
| | - Pieter Buma
- Department of Orthopaedics, Orthopaedic Research Laboratory, Radboud University Medical Centre, Nijmegen
| | - B Willem Schreurs
- Department of Orthopaedics, Radboud University Medical Centre, Nijmegen
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Madanat R, Mäkinen TJ, Aro HT, Bragdon C, Malchau H. Adherence of hip and knee arthroplasty studies to RSA standardization guidelines. A systematic review. Acta Orthop 2014; 85:447-55. [PMID: 24954489 PMCID: PMC4164860 DOI: 10.3109/17453674.2014.934187] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND AND PURPOSE Guidelines for standardization of radiostereometry (RSA) of implants were published in 2005 to facilitate comparison of outcomes between various research groups. In this systematic review, we determined how well studies have adhered to these guidelines. METHODS We carried out a literature search to identify all articles published between January 2000 and December 2011 that used RSA in the evaluation of hip or knee prosthesis migration. 2 investigators independently evaluated each of the studies for adherence to the 13 individual guideline items. Since some of the 13 points included more than 1 criterion, studies were assessed on whether each point was fully met, partially met, or not met. RESULTS 153 studies that met our inclusion criteria were identified. 61 of these were published before the guidelines were introduced (2000-2005) and 92 after the guidelines were introduced (2006-2011). The methodological quality of RSA studies clearly improved from 2000 to 2011. None of the studies fully met all 13 guidelines. Nearly half (43) of the studies published after the guidelines demonstrated a high methodological quality and adhered at least partially to 10 of the 13 guidelines, whereas less than one-fifth (11) of the studies published before the guidelines had the same methodological quality. Commonly unaddressed guideline items were related to imaging methodology, determination of precision from double examinations, and also mean error of rigid-body fitting and condition number cutoff levels. INTERPRETATION The guidelines have improved methodological reporting in RSA studies, but adherence to these guidelines is still relatively low. There is a need to update and clarify the guidelines for clinical hip and knee arthroplasty RSA studies.
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Affiliation(s)
- Rami Madanat
- Helsinki University Central Hospital, Helsinki,Harris Orthopaedic Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Hannu T Aro
- Turku University Hospital and University of Turku, Turku, Finland
| | - Charles Bragdon
- Harris Orthopaedic Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Henrik Malchau
- Harris Orthopaedic Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Zampelis V, Tägil M, Lidgren L, Isaksson H, Atroshi I, Wang JS. The effect of a biphasic injectable bone substitute on the interface strength in a rabbit knee prosthesis model. J Orthop Surg Res 2013; 8:25. [PMID: 23899023 PMCID: PMC3734137 DOI: 10.1186/1749-799x-8-25] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2013] [Accepted: 07/25/2013] [Indexed: 12/20/2022] Open
Abstract
Background In joint prosthetic surgery, various methods are used to provide implant stability. We used an injectable bone substitute, composed of calcium sulfate/hydroxyapatite, as bone defect filler to stabilize a tibia prosthesis in an experimental rabbit model. The aim of the study was to investigate and compare the stability of prosthetic fixation with and without the use of an injectable bone substitute. Methods Sixteen rabbits were used and the tibia prostheses were implanted bilaterally, one side with the prosthesis alone and the other side with the prosthesis and calcium sulfate/hydroxyapatite (Cerament™). The rabbits were randomly divided into two groups and euthanized after 6 and 12 weeks, respectively. The prosthesis was extracted measuring the pull-out force in an Instron tester, and the bone surrounding the former prosthesis site was analyzed by histology, histomorphometry, and micro-computed tomography. Results At 6 weeks no difference in maximum pull-out force was found between the prostheses fixed with or without Cerament™. At 12 weeks the maximum pull-out force for the prostheses with Cerament™ was significantly higher than that for the prostheses without Cerament™ (p = 0.04). The maximum pull-out force at 12 weeks was significantly higher than that at 6 weeks for the prostheses fixed with Cerament™ (p = 0.03) but not for the prostheses without. Conclusion We conclude that early prosthesis-bone interface strength is not influenced by a bone substitute. However, during remodeling, the bone substitute might provide improved mechanical support for the prosthesis. The results support further studies of the use of injectable calcium sulfate/hydroxyapatite in fixation of prosthetic joint implants.
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Affiliation(s)
- Vasilis Zampelis
- Department of Orthopedics, Clinical Sciences, Lund University, Lund, Sweden.
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20
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Delimar D, Smoljanovic T, Bojanic I. Could the use of bone morphogenetic proteins in fracture healing do more harm than good to our patients? INTERNATIONAL ORTHOPAEDICS 2011; 36:683; author reply 685. [PMID: 22052478 DOI: 10.1007/s00264-011-1397-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/26/2011] [Accepted: 10/14/2011] [Indexed: 12/24/2022]
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Belfrage O, Flivik G, Sundberg M, Kesteris U, Tägil M. Local treatment of cancellous bone grafts with BMP-7 and zoledronate increases both the bone formation rate and bone density: a bone chamber study in rats. Acta Orthop 2011; 82:228-33. [PMID: 21434769 PMCID: PMC3235296 DOI: 10.3109/17453674.2011.566138] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND AND PURPOSE The remodeling of morselized bone grafts in revision surgery can be enhanced by an anabolic substance such as a bone morphogenetic protein (BMP). On the other hand, BMPs boost catabolism and might cause a premature resorption, both of the graft and of the new-formed bone. Bisphosphonates inactivate osteoclasts and can be used to control the resorption. We studied a combination of both drugs as a local admix to a cancellous allograft. METHODS Cancellous bone allografts were harvested and freeze-dried. Either saline, BMP-7, the bisphosphonate zoledronate, or a combination of BMP-7 and zoledronate were added in solution. The grafts were placed in bone conduction chambers and implanted in the proximal tibia of 34 rats. The grafts were harvested after 6 weeks and evaluated by histomorphometry. RESULTS Bone volume/total volume (BV/TV) was 50% in the grafts treated with the combination of BMP-7 and zoledronate and 16% in the saline controls (p < 0.001). In the zoledronate group BV/TV was 56%, and in the BMP group it was 14%. The ingrowth distance of new bone into the graft was 3.5 mm for the combination of BMP-7 and zoledronate and 2.6 mm in the saline control (p = 0.002). The net amount of retained remodeled bone was more than 4 times higher when BMP-7 and zoledronate were combined than in the controls. INTERPRETATION An anabolic drug like BMP-7 can be combined with an anti-catabolic bisphosphonate as local bone graft adjunct, and the combination increases the amount of remaining bone after remodeling is complete.
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Affiliation(s)
- Ola Belfrage
- Department of Orthopedics, Clinical Sciences Lund, Lund University, Sweden
| | - Gunnar Flivik
- Department of Orthopedics, Clinical Sciences Lund, Lund University, Sweden
| | - Martin Sundberg
- Department of Orthopedics, Clinical Sciences Lund, Lund University, Sweden
| | - Uldis Kesteris
- Department of Orthopedics, Clinical Sciences Lund, Lund University, Sweden
| | - Magnus Tägil
- Department of Orthopedics, Clinical Sciences Lund, Lund University, Sweden
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Abstract
Alteration of the bone healing process with bone morphogenetic proteins offers a new perspective in orthopaedic surgery in those adverse situations that necessitate bone grafting. BMPs have been demonstrated to be effective and safe for human application and have an efficacy comparable with that of autologous bone grafting. Nevertheless, clinical trials with level 1 evidence are still limited in their ability to extrapolate robust and safe clinical conclusions for the possible indications mentioned in this article. Future research should refine issues regarding the relative effectiveness of bone morphogenetic proteins, the interaction between bone morphogenetic protein subtypes, and their specific effect on various target cell populations.
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Kanakaris NK, Lasanianos N, Calori GM, Verdonk R, Blokhuis TJ, Cherubino P, De Biase P, Giannoudis PV. Application of bone morphogenetic proteins to femoral non-unions: a 4-year multicentre experience. Injury 2009; 40 Suppl 3:S54-61. [PMID: 20082793 DOI: 10.1016/s0020-1383(09)70013-0] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Fracture non-unions often complicate orthopaedic trauma. BMPs (bone morphogenetic proteins) are currently considered the most appealing osteoinductive agents. Applications of BMP-7 since January 2004 were prospectively recorded in a multicentre registry of aseptic femoral non-unions. The study included 30 patients who had undergone a median of 1 revision operation before BMP-7 application and who were followed up for a median 24 months. In 23/30 cases the application of BMP-7 was combined with revision of the fixation, and in 12 it was combined also with autograft. Non-union healing was verified in 26/30 cases in a median period of 6 months. No adverse events were associated with BMP-7 application. Our case series supports the safety and efficacy of BMP-7 in femoral non-unions. Multicentre networks and systematic, long-term follow-up of patients may improve understanding of this promising osteoinductive bone substitute.
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Affiliation(s)
- N K Kanakaris
- Department of Trauma and Orthopaedics, Leeds Teaching Hospitals NHS Trust, Leeds General Infirmary, Leeds LS1 3EX, UK
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No effect of autologous growth factors (AGF) around ungrafted loaded implants in dogs. INTERNATIONAL ORTHOPAEDICS 2009; 34:925-30. [PMID: 19856178 DOI: 10.1007/s00264-009-0897-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/19/2009] [Revised: 10/08/2009] [Accepted: 10/09/2009] [Indexed: 10/20/2022]
Abstract
Autologous growth factors (AGF) is a growth-factor-rich concentrate of platelets, white blood cells and fibrinogen. Application of AGF was presumed to improve implant fixation and gap healing of non-grafted, loaded implants. We inserted one loaded titanium implant intra-articularly in each medial femoral condyle of eight dogs. Each implant was surrounded by a 0.75 mm gap. One implant in each dog was coated with AGF prior to implantation whereas the contralateral implant served as a control. AGF was prepared by isolating the buffy-coat from blood and further concentrated using an Interpore Cross UltraConcentrator. Platelet counts were increased from a median baseline of 168x10(3)/microl to 1003x10(3)/microl in AGF. However, AGF had no significant effect on implant fixation or bone formation. Even though AGF increased ultimate shear strength and energy absorption by approximately 50%, these differences had a p-value less than 0.05. The sample size in this study was small and any negative conclusions should be taken with caution due to low statistical power. We have previously demonstrated that AGF significantly improves fixation and incorporation of grafted implants. AGF might require mixing with an osteoconductive grafting material in order to provide a scaffold on which to foster bone growth and to keep the growth factors on location for a prolonged period.
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Dallari D, Fini M, Giavaresi G, Del Piccolo N, Stagni C, Amendola L, Rani N, Gnudi S, Giardino R. Effects of pulsed electromagnetic stimulation on patients undergoing hip revision prostheses: a randomized prospective double-blind study. Bioelectromagnetics 2009; 30:423-30. [PMID: 19384914 DOI: 10.1002/bem.20492] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
In this prospective, randomized, double-blind study, the effect of Pulsed Electromagnetic Fields (PEMFs) was investigated in 30 subjects undergoing hip revision using the Wagner SL stem. The subjects were treated for 6 h/day up to 90 days after revision. Study end points were assessed clinically by the functional scale of Merle D'Aubigné and instrumentally by Dual-Energy X-ray Absorptiometry (DXA) at the Gruen zones. Subject improvement according to Merle D'Aubigné scale was higher (P < 0.05) in subjects undergoing active stimulation compared to placebo. In analyzing the DXA findings, we subtracted for each area the postoperative bone mineral density (BMD) values from those measured at 90 days and we considered all results above 3.5% as responders. There were no significant differences in the average BMD values at each Gruen zone between the two groups both postoperatively and at 90 days investigation. In Gruen zones 5 and 6, corresponding to the medial cortex, we observed six responders (40%) in both areas in the control group, while in the stimulated group we observed 14 (93%) and 10 (66%) responders, respectively (both P < 0.05). This study showed that PEMF treatment aids clinical recovery and bone stock restoration.
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Affiliation(s)
- Dante Dallari
- VII Division of Orthopaedic and Traumatology, Rizzoli Orthopaedic Institute, Bologna, Italy
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Seehaus F, Emmerich J, Kaptein BL, Windhagen H, Hurschler C. Experimental Analysis of Model-Based Roentgen Stereophotogrammetric Analysis (MBRSA) on Four Typical Prosthesis Components. J Biomech Eng 2009; 131:041004. [DOI: 10.1115/1.3072892] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Classical marker-based roentgen stereophotogrammetric analysis (RSA) is an accurate method of measuring in vivo implant migration. A disadvantage of the method is the necessity of placing tantalum markers on the implant, which constitutes additional manufacturing and certification effort. Model-based RSA (MBRSA) is a method by which pose-estimation of geometric surface-models of the implant is used to detect implant migration. The placement of prosthesis markers is thus no longer necessary. The accuracy of the pose-estimation algorithms used depends on the geometry of the prosthesis as well as the accuracy of the surface models used. The goal of this study was thus to evaluate the experimental accuracy and precision of the MBRSA method for four different, but typical prosthesis geometries, that are commonly implanted. Is there a relationship existing between the accuracy of MBRSA and prosthesis geometries? Four different prosthesis geometries were investigated: one femoral and one tibial total knee arthroplasty (TKA) component and two different femoral stem total hip arthroplasty (THA) components. An experimental phantom model was used to simulate two different implant migration protocols, whereby the implant was moved relative to the surrounding bone (relative prosthesis-bone motion (RM)), or, similar to the double-repeated measures performed to assess accuracy clinically, both the prosthesis and the surrounding bone model (zero relative prosthesis-bone motion (ZRM)) were moved. Motions were performed about three translational and three rotational axes, respectively. The maximum 95% confidence interval (CI) for MBRSA of all four prosthesis investigated was better than −0.034 to 0.107 mm for in-plane and −0.217 to 0.069 mm for out-of-plane translation, and from −0.038 deg to 0.162 deg for in-plane and from −1.316 deg to 0.071 deg for out-of-plane rotation, with no clear differences between the ZRM and RM protocols observed. Accuracy in translation was similar between TKA and THA components, whereas rotational accuracy about the long axis of the hip stem THA components was worse than the TKA components. The data suggest that accuracy and precision of MBRSA seem to be equivalent to the classical marker-based RSA method, at least for the nonsymmetric implant geometries investigated in this study. The model-based method thus allows the accurate measurement of implant migration without requiring prosthesis markers, and thus presents new opportunities for measuring implant migration where financial or geometric considerations of marker placement have thus far been prohibitive factors.
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Affiliation(s)
- Frank Seehaus
- Department of Orthopaedics, Laboratory for Biomechanics and Biomaterials, Hannover Medical School, Anna-von-Borries-Strasse 1-7, 30625 Hannover, Germany
| | - Judith Emmerich
- Department of Orthopaedics, Laboratory for Biomechanics and Biomaterials, Hannover Medical School, Anna-von-Borries-Strasse 1-7, 30625 Hannover, Germany
| | - Bart L. Kaptein
- Department of Orthopaedics and Division of Image Processing, and Department of Radiology, Leiden University Medical Center, P.O. Box 9600, 2300 RC Leiden, Netherlands
| | - Henning Windhagen
- Department of Orthopaedics, Laboratory for Biomechanics and Biomaterials, Hannover Medical School, Anna-von-Borries-Strasse 1-7, 30625 Hannover, Germany
| | - Christof Hurschler
- Department of Orthopaedics, Laboratory for Biomechanics and Biomaterials, Hannover Medical School, Anna-von-Borries-Strasse 1-7, 30625 Hannover, Germany
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Tsiridis E, Ali Z, Bhalla A, Gamie Z, Heliotis M, Gurav N, Deb S, DiSilvio L. In vitroproliferation and differentiation of human mesenchymal stem cells on hydroxyapatite versus human demineralised bone matrix with and without osteogenic protein-1. Expert Opin Biol Ther 2008; 9:9-19. [DOI: 10.1517/14712590802622473] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Baas J, Elmengaard B, Bechtold J, Chen X, Søballe K. Ceramic bone graft substitute with equine bone protein extract is comparable to allograft in terms of implant fixation: a study in dogs. Acta Orthop 2008; 79:841-50. [PMID: 19085504 DOI: 10.1080/17453670810016948] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND AND PURPOSE We studied whether osseointegration and fixation of plasma-sprayed titanium implants grafted with beta-TCP granules (Ossaplast) can be improved by adding an osteogenic signal (Colloss E). The results were compared to implants grafted with fresh frozen morselized allograft with and without the Colloss E device. METHODS 4 porous-coated Ti implants were placed in the proximal humeri in each of 10 dogs. All implants were surrounded by a 2.5-mm defect, which was grafted with: (A) beta-TCP, (B) beta-TCP+20 mg Colloss E, (C) allograft, or (D) allograft+20 mg Colloss E. The observation time was 4 weeks. RESULTS Mechanical testing showed that the beta-TCP group with Colloss E was twice as well fixed as the control group grafted with beta-TCP granules alone, and comparable to both allograft groups. We found that every control implant in the beta-TCP grafted group was covered by a dense fibrous membrane. No fibrous tissue was seen in the beta-TCP group augmented with Colloss. These implants were well osseointegrated, with new bone covering 10-25% of the implant surface. Both treated groups had increased graft resorption compared to their respective control groups. Colloss E had no effect on new bone formation or fibrous tissue reduction around the allografted implants. INTERPRETATION The Colloss E device improved early osseointegration of implants grafted with beta-TCP granules and increased their mechanical implant fixation to the level of allografted implants. The experiment indicates that ceramic bone substitutes may be a viable alternative to allograft when combined with an osteogenic signal such as Colloss E.
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Affiliation(s)
- Jorgen Baas
- Orthopedic Research Laboratory, Aarhus University Hospital, Denmark.
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Board TN, Rooney P, Kay PR. Strain imparted during impaction grafting may contribute to bony incorporation: an in vitro study of the release of bmp-7 from allograft. ACTA ACUST UNITED AC 2008; 90:821-4. [PMID: 18539680 DOI: 10.1302/0301-620x.90b6.20234] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
In order to investigate the osteoinductive properties of allograft used in impaction grafting and the effect of strain during impaction on these properties, we designed an in vitro experiment to measure strain-related release of bone morphogenetic protein-7 (BMP-7) from fresh-frozen femoral head allograft. A total of 40 10 mm cubes of cancellous bone were cut from ten samples of fresh-frozen femoral head. The marrow was removed from the cubes and the baseline concentrations of BMP-7 were measured. Specimens from each femoral head were allocated to four groups and subjected to different compressive strains with a material testing machine, after which BMP-7 activity was reassessed. It was present in all groups. There was a linear increase of 102.1 pg/g (95% confidence interval 68.6 to 135.6) BMP-7 for each 10% increase in strain. At 80% strain the mean concentration of BMP-7 released (830.3 pg/g bone) was approximately four times that released at 20% strain. Activity of BMP-7 in fresh-frozen allograft has not previously been demonstrated. This study shows that the freezing and storage of femoral heads allows some maintenance of biological activity, and that impaction grafting provides a source of osteoinductive bone for remodelling. We have shown that BMP-7 is released from fresh-frozen femoral head cancellous bone in proportion to the strain applied to the bone. This suggests that the impaction process itself may contribute to the biological process of remodelling and bony incorporation.
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Affiliation(s)
- T N Board
- The Centre for Hip Surgery Wrightington Hospital, Appley Bridge, Wigan WN6 9EP, UK.
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Kanakaris NK, Calori GM, Verdonk R, Burssens P, De Biase P, Capanna R, Vangosa LB, Cherubino P, Baldo F, Ristiniemi J, Kontakis G, Giannoudis PV. Application of BMP-7 to tibial non-unions: a 3-year multicenter experience. Injury 2008; 39 Suppl 2:S83-90. [PMID: 18804578 DOI: 10.1016/s0020-1383(08)70019-6] [Citation(s) in RCA: 106] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The effective treatment of the often debilitating, longlasting and large-asset-consuming complication of fracture non-unions has been in the centre of scientific interest the last decades. The use of alternative bone substitutes to the gold standard of autologous graft includes the osteoinductive molecules named bone morphogenetic proteins (BMPs). A multicenter registry and database (bmpusergroup.co.uk) focused on the application of BMP-7/OP-1 was created in December 2005. We present the preliminary results, using the prospective case-series of aseptic tibial non-unions as an example. Sixty-eight patients fulfilled the inclusion criteria for this observational study, with a minimum follow-up of 12 months. The median duration of tibial non-union prior to BMP-7 application was 23 months (range 9-317 mo). Patients had undergone a median of 2 (range 0-11) revision procedures prior to the administration of BMP-7. In 41% the application of BMP-7 was combined with revision of the fixation at the non-union site. Non-union healing was verified in 61 (89.7%) in a median period of 6.5 months (range 3-15 mo). No adverse events or complications were associated with BMP-7 application. The safety and efficacy of BMP-7 was verified in our case series, and was comparable to the existing evidence. The establishment of multicenter networks and the systematic and long-term follow- up of these patients are expected to provide further information and significantly improve our understanding of this promising osteoinductive bone substitute.
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Harding AK, Aspenberg P, Kataoka M, Bylski D, Tägil M. Manipulating the anabolic and catabolic response in bone graft remodeling: synergism by a combination of local BMP-7 and a single systemic dosis of zoledronate. J Orthop Res 2008; 26:1245-9. [PMID: 18404659 DOI: 10.1002/jor.20625] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Remodeling of a bone graft can be influenced both by anabolic substances, such as a bone morphogenic protein (BMP) and by anticatabolic substances, such as the bisphosphonates. BMPs are potent bone anabolic substances, but also boost catabolism and cause resorption. Bisphosphonates inhibit osteoclast function and can be used to postpone resorption. In the present study a combination of both drugs was explored in a rat bone chamber model. Cancellous bone grafts were treated with either BMP-7 or saline and placed in a bone chamber implanted in the proximal tibia. After 2 weeks, an injection of either zoledronate 0.1 mg/kg or saline was given subcutaneously. The rats were killed after 6 weeks, and bone ingrowth distance into the graft and graft resorption were measured by histomorphometry. BMP-7 significantly (p = 0.007) increased new bone ingrowth distance into the graft from 2.0 mm (SD = 0.98 mm) in the controls to 3.1 mm (SD = 0.93 mm). If bisphosphonate was not given, most of the newly formed and old graft bone was resorbed. A single injection of zoledronate significantly (p < 0.001) increased the trabecular volume/total volume to 40% (SD = 9%) compared to 14% (SD = 10%) in the nonbisphosphonate treated. In total, the net amount of bone increased by 400% when BMP-7 and zoledronate combined was compared to saline. A bone graft can be treated with BMP-7 to increase new bone formation and at the same time be protected against premature catabolism by a single dose of a bisphosphonate. This combination might be useful in various conditions in orthopedic reconstruction.
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Affiliation(s)
- Anna Kajsa Harding
- Department of Orthopedics, Lund University Hospital, SE-221 85 Lund, Sweden
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Abstract
Pelvic discontinuity is a complex entity with a high surgical complication rate and no standardized treatment to date. Revision hip arthroplasty in cases of massive bone loss remains a difficult and unsolved problem. The goal of the surgeon is to preserve limb function by restoring bone stock and the biomechanics of the hip. In cases of severe acetabular bone loss, biologic fixation is often inadequate, requiring extensive bone grafting and reconstructive cages. Reconstructive cages are the most commonly used devices and are designed to bridge bone defects, protect the bone graft, and reestablish the rotation center of the hip. A major limitation of current cages is that they do not allow for biologic fixation. We review the options for treating patients with massive bone loss and pelvic discontinuity and discuss therapeutic options and the clinical and radiological criteria for success.
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Stiehl JB, Ulrich SD, Seyler TM, Bonutti PM, Marker DR, Mont MA. Bone morphogenetic proteins in total hip arthroplasty, osteonecrosis and trauma surgery. Expert Rev Med Devices 2008; 5:231-8. [PMID: 18331183 DOI: 10.1586/17434440.5.2.231] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
This review provides an overview of the use of bone morphogenetic proteins to enhance bone healing and bone graft incorporation in difficult defects created from failed total hip arthroplasties, osteonecrosis of the femoral head and trauma. Multiple publications have demonstrated that bone morphogenetic proteins are osteoinductive in preclinical trials (i.e., animal models); however, there is controversy and limited understanding of the use of this technology in orthopedic surgical practice. The question remains as to whether they are useful in difficult fractures, nonunions and large defects created from failed total hip arthroplasty or femoral head osteonecrosis. There might be a small risk for infection by the process of introducing foreign materials in a clinical situation, but this has not yet been realized to date. In addition, these materials offer an advantage in large defects where there is not enough transplantable material available from the host. We believe that the use of these materials will become more widespread with newer carriers, minimally invasive applications and diminished commercial costs.
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Affiliation(s)
- James B Stiehl
- Orthopaedic Surgeon, Orthopedic Hospital of Wisconsin, 575 W River Woods Parkway, Milwaukee, WI 53212, USA.
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Baas J, Elmengaard B, Jensen TB, Jakobsen T, Andersen NT, Soballe K. The effect of pretreating morselized allograft bone with rhBMP-2 and/or pamidronate on the fixation of porous Ti and HA-coated implants. Biomaterials 2008; 29:2915-22. [DOI: 10.1016/j.biomaterials.2008.03.010] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2008] [Accepted: 03/13/2008] [Indexed: 11/29/2022]
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Leone WA, Naughton M, Gratto-Cox G, Luland CM, Kilgore JE, Hill GE. The effect of preoperative planning and impaction grafting surgical technique on intraoperative and postoperative complication rate for femoral revision patients with moderate to severe bone loss mean 4.7-year results. J Arthroplasty 2008; 23:383-94. [PMID: 18358377 DOI: 10.1016/j.arth.2007.02.017] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2006] [Accepted: 02/28/2007] [Indexed: 02/01/2023] Open
Abstract
This study reports the results of 41 revision hips, implanted by a single surgeon using impaction grafting (mean follow-up, 4.7 years). All hips had Paprosky scores of III or IV. Harris hip scores improved from 43 to 82. There was 1 intraoperative and 2 postoperative fractures. A single stem was revised during the study. Radiographic review showed the 40 unrevised stems to be stable, and graft incorporation was seen in at least 1 zone in 100% of the femurs. There was no stem subsidence greater than 2.5 mm. The results of this study demonstrate that preoperative planning and a surgical technique, which emphasizes femoral support and vigorous impaction grafting, resulted in an acceptable incidence of complications.
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Affiliation(s)
- William A Leone
- Holy Cross Hospital Orthopedic Center, Fort Lauderdale, Florida 33308, USA
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Hannink G, Piek E, Hendriks JMA, Van der Kraan PM, Schreurs BW, Buma P. Biological effects of rinsing morsellised bone grafts before and after impaction. INTERNATIONAL ORTHOPAEDICS 2008; 33:861-6. [PMID: 18200445 PMCID: PMC2903101 DOI: 10.1007/s00264-007-0513-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/09/2007] [Revised: 11/29/2007] [Accepted: 12/02/2007] [Indexed: 11/30/2022]
Abstract
Rinsing bone grafts before or both before and after impaction might have different effects on the incorporation of the graft. Rinsing again after impaction might negatively influence bone induction if growth factors released by impaction are washed away. We studied if transforming growth factor-betas (TGF-betas) and bone morphogenetic proteins (BMPs) are released from the mineralised matrix by impaction and if these released growth factors induce osteogenic differentiation in human mesenchymal stem cells (hMSCs). Rinsed morsellised bone allografts were impacted in a cylinder and the escaping fluid was collected. The fluid was analysed for the presence of TGF-betas and BMPs, and the osteoinductive capacity was tested on hMSCs. Abundant TGF-beta was present in the fluid. No BMPs could be detected. Osteogenic differentiation of hMSCs was inhibited by the fluid. Results from our study leave us only able to speculate whether rinsing grafts again after impaction has a beneficial effect on the incorporation process or not.
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Affiliation(s)
- Gerjon Hannink
- Department of Orthopaedics, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
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Jakobsen T, Baas J, Bechtold JE, Elmengaard B, Søballe K. Soaking morselized allograft in bisphosphonate can impair implant fixation. Clin Orthop Relat Res 2007; 463:195-201. [PMID: 17621234 DOI: 10.1097/blo.0b013e31813c6696] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The use of impacted, morselized allograft is a well-established way to provide initial stability of revision joint replacements. We investigated whether rinsing morselized allograft in bisphosphonate and subsequently impacting it around experimental titanium-coated implants would further facilitate biomechanical implant fixation and graft incorporation. In 10 dogs, a pair of titanium implants surrounded by a 2.5-mm gap was inserted into the proximal part of each humerus during two separate surgeries to allow two observation periods. The gap was filled with impacted, morselized allograft soaked in either bisphosphonate (alendronate, 2 mg/mL) or saline (control). Unbound alendronate was not rinsed away. During the first surgery, one pair of implants (alendronate and control) was inserted into one humerus. Eight weeks later, a second pair of implants was inserted into the contralateral humerus. The first pair of implants was observed for 12 weeks and the second pair for 4 weeks. Implants were evaluated by histomorphometry and biomechanical pushout test. We found substantially decreased biomechanical implant fixation for all implants surrounded by impacted, morselized allograft that had been soaked in alendronate. Furthermore, the alendronate treatment blocked formation of new bone and inhibited resorption of the graft material. Although limited by the specific dose of alendronate used and the omission of rinsing away excess bisphosphonate, this study warrants caution and calls for further experimental research before impacting alendronate-soaked morselized allograft around clinical joint replacements.
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Affiliation(s)
- Thomas Jakobsen
- Orthopaedic Research Laboratory, Department of Orthopaedics, Aarhus University Hospital, Nørrebrogade 44, DK-8000 Aarhus C, Denmark.
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38
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Jensen TB, Overgaard S, Lind M, Rahbek O, Bünger C, Søballe K. Osteogenic protein-1 increases the fixation of implants grafted with morcellised bone allograft and ProOsteon bone substitute: an experimental study in dogs. ACTA ACUST UNITED AC 2007; 89:121-6. [PMID: 17259430 DOI: 10.1302/0301-620x.89b1.17077] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Impacted bone allograft is often used in revision joint replacement. Hydroxyapatite granules have been suggested as a substitute or to enhance morcellised bone allograft. We hypothesised that adding osteogenic protein-1 to a composite of bone allograft and non-resorbable hydroxyapatite granules (ProOsteon) would improve the incorporation of bone and implant fixation. We also compared the response to using ProOsteon alone against bone allograft used in isolation. We implanted two non-weight-bearing hydroxyapatite-coated implants into each proximal humerus of six dogs, with each implant surrounded by a concentric 3 mm gap. These gaps were randomly allocated to four different procedures in each dog: 1) bone allograft used on its own; 2) ProOsteon used on its own; 3) allograft and ProOsteon used together; or 4) allograft and ProOsteon with the addition of osteogenic protein-1. After three weeks osteogenic protein-1 increased bone formation and the energy absorption of implants grafted with allograft and ProOsteon. A composite of allograft, ProOsteon and osteogenic protein-1 was comparable, but not superior to, allograft used on its own. ProOsteon alone cannot be recommended as a substitute for allograft around non-cemented implants, but should be used to extend the volume of the graft, preferably with the addition of a growth factor.
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Affiliation(s)
- T B Jensen
- Orthopaedic Research Group, Odense University Hospital, DK 5000 Odense C, Denmark.
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Hannink G, Schreurs BW, Buma P. No positive effects of OP-1 device on the incorporation of impacted graft materials after 8 weeks: a bone chamber study in goats. Acta Orthop 2007; 78:551-8. [PMID: 17966011 DOI: 10.1080/17453670710014211] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Bone morphogenetic proteins (BMPs) have the potential to improve clinical outcome after hip revision surgery by improving graft incorporation and implant fixation. However, impaction of cancellous bone grafts and TCP/HA bone substitute mixed with OP-1 device in a bone chamber in goats in a previous study led to reduced fibrous tissue ingrowth after 4 weeks. New bone formation was not promoted by OP-1. In the current study we examined whether this reduction represented a final loss of ingrowth or was just a delay, and whether the reduction can be overcome and ultimately results in a better late ingrowth. METHODS Bone chambers with impacted allografts and impacted TCP/HA granules mixed with 2 doses of OP-1 device were implanted in proximal medial goat tibias. Impacted allografts and TCP/HA not treated with OP-1 served as controls. After 8 weeks, the incorporation was evaluated using histology and histomorphometry. RESULTS Histology revealed evidence of bone graft incorporation, which proceeded in a similar way in both allografts and TCP/HA, with and without the addition of OP-1. After 8 weeks, no difference in bone ingrowth was found between the OP-1 groups and their controls. It was only in the allografts that the addition of OP-1 resulted in more fibrous tissue ingrowth. INTERPRETATION We conclude that the previously observed delay in fibrous tissue ingrowth can be only partially overcome.
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Affiliation(s)
- Gerjon Hannink
- Orthopaedic Research Lab, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands
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40
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Hoshino M, Namikawa T, Kato M, Terai H, Taguchi S, Takaoka K. Repair of bone defects in revision hip arthroplasty by implantation of a new bone-inducing material comprised of recombinant human BMP-2, Beta-TCP powder, and a biodegradable polymer: an experimental study in dogs. J Orthop Res 2007; 25:1042-51. [PMID: 17469187 DOI: 10.1002/jor.20424] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
A recombinant BMP-2-retaining putty-form implant in combination with a hip prosthesis was used to reconstruct a canine hip joint with defects similar to those encountered in revision total hip arthroplasty (THA). The bone defects were made by resecting the medial half of the proximal femur and the superior acetabular bone with inner iliac wall perforation in 10 dogs. In five dogs, hip prostheses were implanted with the putty material consisting of a synthetic polymer (poly D,L-lactic acid-polyethylene glycol block copolymer), beta-tricalcium phosphate powder, and recombinant human BMP-2 in each defect (BMP/Polymer/TCP group). In the remaining five dogs, the same material without rhBMP-2 (control group) was implanted. In the BMP/Polymer/TCP group, new radiopaque shadows began to appear 4 weeks after surgery at the defects around the hip prostheses on both the femoral and acetabular sides. At 12 weeks, the defects were completely filled with new bone in contact with the prosthesis. On histology, the rhBMP-2/Polymer/beta-TCP composite putty implants had been completely resorbed and replaced by new bone. Repair of the bone defects was not seen in the control group. The ability of this material to restore bone effectively eliminates the dependency on bone grafts of autogeneic or allogeneic origin for revision hip arthroplasty and thus opens up a potential new treatment approach in hip cases requiring this type of surgery.
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Affiliation(s)
- Masatoshi Hoshino
- Department of Orthopedic Surgery, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-Machi Abeno-Ku Osaka, 545-8585 Japan.
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Tsiridis E, Spence G, Gamie Z, El Masry MA, Giannoudis PV. Grafting for periprosthetic femoral fractures: strut, impaction or femoral replacement. Injury 2007; 38:688-97. [PMID: 17466991 DOI: 10.1016/j.injury.2007.02.046] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2006] [Revised: 02/27/2007] [Accepted: 02/28/2007] [Indexed: 02/02/2023]
Abstract
Peri-prosthetic fractures are technically demanding to treat, as they require the skills of revision arthroplasty as well as those of trauma surgery. [Lindahl H, Malchau H, Herberts P, Garellick G. Periprosthetic femoral fractures classification and demographics of 1049 periprosthetic femoral fractures from the Swedish National Hip Arthroplasty Register. J Arthroplasty 2005;20:857-65.] reporting on 1049 periprosthetic femoral fractures found that the annual incidence varied between 0.045% and 0.13% for all THAs performed in Sweden and that the accumulated incidence for the primary hip arthroplasties was 0.4% while for the revision arthroplasties was 2.1% [Lindahl H, Malchau H, Herberts P, Garellick G. Periprosthetic femoral fractures classification and demographics of 1049 periprosthetic femoral fractures from the Swedish National Hip Arthroplasty Register. J Arthroplasty 2005;20:857-65.]. The elderly population is particularly vulnerable to low energy periprosthetic fractures attributed to osteopenia or osteoporosis leaving limited reconstruction options to the hip revision surgeon. Bone grafting in the form of autograft has well recognized limitations and allograft represents the gold standard of bone augmentation in the majority of the cases. Allograft can be used as morselised in the form of impaction grafting, reconstructing the bone from within out, or in the form of structural allograft. In the latter case, strut onlay plates or whole proximal femoral allografts can be used to augment the deficient bone or to totally replace it respectively. Immune reaction and disease transmission along with delayed revascularization of the cortical allograft can cause failure of the construct in the long term; however, the results to date from their use are promising. We here present an overview of the literature on the use of available bone grafts in the treatment of periprosthetic femoral fractures.
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Affiliation(s)
- Eleftherios Tsiridis
- Academic Department of Trauma & Orthopaedics, School of Medicine, University of Leeds, United Kingdom.
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Heiner AD, Callaghan JJ, Brown TD. Stability of fused versus nonfused THA femoral impaction grafts. J Orthop Res 2007; 25:351-60. [PMID: 17143908 PMCID: PMC2718431 DOI: 10.1002/jor.20316] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2006] [Accepted: 08/18/2006] [Indexed: 02/04/2023]
Abstract
Impaction grafting for THA involves compacting morselized cancellous bone (MCB) into a cavitary defect to build up bone stock. Ideally, the MCB subsequently remodels into a new contiguous cancellous lattice. A recent laboratory model of MCB fusion allows simulating an impaction graft construct in this ideal eventual clinical state. The purpose of the present study was to determine the relative stability of femoral impaction graft constructs in which the MCB has fused versus that for MCB in the freshly impacted nonfused condition. Cemented femoral impaction graft constructs were created in composite femurs. For fused constructs, the MCB was mixed with an amine epoxy that causes the MCB to set up into a contiguous structure biomechanically comparable to intact cancellous bone in compression. The constructs were loaded with 500,000 physiologic gait cycles. Three-dimensional motion was measured between the femur and the stem. The fused femoral impaction grafts were much more stable than the nonfused grafts at the proximal stem location, but MCB fusion had only a modest effect on distal stem stability. These results indicate that most of the opportunity to reduce femoral stem micromotion and migration lies proximal, and that steps to enhance impaction graft remodeling and fusion are most effectively focused proximally.
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Affiliation(s)
- Anneliese D Heiner
- University of Iowa, Department of Orthopaedics and Rehabilitation, Biomechanics Laboratory, 2181 Westlawn Building, Iowa City, Iowa 52242, USA.
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Buma P, Arts JJC, Gardeniers JWM, Verdonschot N, Schreurs BW. No effect of bone morphogenetic protein-7 (OP-1) on the incorporation of impacted bone grafts in a realistic acetabular model. J Biomed Mater Res B Appl Biomater 2007; 84:231-9. [PMID: 17514667 DOI: 10.1002/jbm.b.30865] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Bone morphogenetic proteins (BMPs) accelerate bone repair in experimental and clinical conditions. Impacted Morsellized Cancellous Bone grafts (MCB) are successfully used to reconstruct bone defects after failed hip implants. The main question in this study was if BMP-7 (OP-1) mixed with MCB could accelerate the incorporation of MCB and prevents the formation of a soft tissue interface after remodeling of the MCB. A large loaded defect in the acetabulum of goats was reconstructed with a wire mesh and with MCB or MCB mixed with OP-1. After 6 weeks, no differences were found in the revascularization process, in the number of osteoclasts resorbing the MCB, and in the thickness and appearance of the fibrous interface between MCB with or without OP-1. After 6 weeks, enchondral bone had formed in the bone graft layer and on the periosteal anterior and superior rim in the OP-1 group only. More periosteal bone and more bone in the holes of the mesh had been formed in most OP-1 goats. Most MCB was replaced by new lamellar bone after 15 weeks in both groups. We speculate that during or directly after impaction most of the OP-1 is released from the carrier inducing an early effect outside the reconstructive layer at the periosteal side of the acetabulum. Probably most OP-1 has left the reconstruction by the time new vessels and progenitors reached the bone graft. These results do not support the use of OP-1 in impaction bone grafting in patients.
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Affiliation(s)
- Pieter Buma
- Department of Orthopedics, Radboud University Nijmegen Medical Center, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands.
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