Regenerating the fibula with beta-tricalcium phosphate minimizes morbidity after fibula resection

Fourteen-Year Follow-Up of a Patient With a Hydroxyapatite Ceramic Matrix Reconstruction of and a Bone Graft for a Critical-Size Cortical Bone Defect: A Case Report

A 42-year-old man diagnosed with chondrosarcoma of the proximal femur underwent limb salvage by compartmental excision of the lesion and reconstruction with a custom-made hip prosthesis. The critical-size defect in the proximal femur was reconstructed with ceramic hemicylinders that were tied in place with sutures and augmented with two fibular strut grafts and an autologous cancellous iliac crest bone graft. A fourteen-year follow-up of the same case revealed that substituted ceramic matrices can be converted into dynamic, metabolically active, living bone.

Repair of segmental ulnar bone defect in juvenile caused by osteomyelitis with induced membrane combined with tissue-engineered bone: A case report with 4-year follow-up

Introduction and importance

We used induced membrane combined with tissue-engineered bone (TEB) to repair the 14-cm juvenile ulnar defect formed after osteomyelitis debridement. The TEB was completely transformed into autologous bone after 4-year follow-up.

Case presentation

A 13-year-old male was hospitalized because of right ulna chronic osteomyelitis. After focal debridement, the total length of ular defect was 14 cm. Anti-infective bone cement was filled in the bone defect area. β-Tricalcium phosphate (β-TCP) was used as TEB scaffold. Autologous iliac bone marrow stromal cells (BMSCs) were cultured in vitro and were planted on β-TCP scaffold to form TEB 3 weeks later. 47 months after implantation of TEB, the repaired ulna had continuous and smooth bone cortex, completely ossification of TEB, completely recanalization of medullary cavity. The upper limb function DASH score was 35.

Clinical discussion

Masquelet put forward the concept of “induced membrane” and applied this technique on bone defects treatment formed after debridement of osteomyelitis. β-Tricalcium phosphate (β-TCP) is artificial bone materials commonly used in clinical. In this case, the seed cells used were autologous BMSCs and the culture medium was autologous serum. Cytokines promoting cell growth and differentiation were not used.

Conclusion

The results of this case showed that TEB combined with induced membrane could repair ulna segmental bone defects as long as 14 cm in adolescents. This technique gives one alternative method to repair juvenile bone defects caused by osteomyelities of trauma. More clinical cases are needed to verify the effectiveness of this technique in the next.

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It's the first report of using induced membrane combined with TEB to repair a 14cm bone defect caused by osteomyelities.

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In vitro cultured autologous BMSCs implanted in β-TCP scaffold could repair segmental bone defect.

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BMSCs were cultured with autologous serum without additional cytokines, which is safe and effective.

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This technique gives one alternative method to treat juvenile bone defects caused by osteomyelitis or trauma.

Regeneration of the Fibula with Unidirectional Porous Hydroxyapatite

A fibula graft is one of the most common orthopedic procedures for reconstruction of a bone defect, and some complications related to persistent defects of the fibula have been reported previously. We believe that regeneration of the fibula may be critical for postoperative function and prevention of complications. This report describes a 9-year-old female with Ewing sarcoma of the pelvis who was treated with the double-barrel fibula grafts for pelvic bone defect following tumor resection. The defect after fibular resection was filled with unidirectional porous hydroxyapatite (UDPHAp) implants. A plain radiograph revealed new bone formation and a callus-like structure at one month after surgery and bony union between each UDPHAp implant 5 months after surgery. Resorption of implanted UDPHAp was identified, and partial remodeling of the bone marrow cavity could be seen 1 year 2 months after surgery. A radiograph at final follow-up (5 years 10 months after surgery) demonstrated almost complete absorption of the implanted UDPHAp and clear formation of the cortex and bone marrow in the resected part of the fibula. The patient is able to walk well without any walking supports and to take part in sports activities.

A unidirectional porous beta-tricalcium phosphate material (Affinos®) for reconstruction of bony defects after excision of fibular bone for spinal surgery graft

The aim of this study was to elucidate the bone regeneration-inducing capability of Affinos®, a newly developed, high-porosity unidirectional porous β-TCP artificial bone. We compared the ability of Affinos® and OSferion®, a commercially available β-TCP product, to induce bone regeneration following implantation into bony defects left after fibula harvesting for spinal fusion surgery. Study subjects underwent surgery to harvest non-vascularized fibula grafts for spinal fusion surgery and were implanted with either Affinos® (19 patients) or OSferion® (15 patients, control group) at the defect site. The minimal and mean follow up periods were 6 and 11 months after surgery, respectively. X-rays of the lower leg taken 1-2 weeks after surgery and at the final follow-up visit were used to evaluate fibular-β-TCP continuity and fibula defect filling ratio. There was no significant difference in radiographic continuity in the fibula between the two groups. The fibula defect filling ratio for the Affinos® group decreased from 0.94 ± 0.17 at 1-2 weeks to 0.77 ± 0.14 at 10 months. For the OSferion® control group, the fibula defect filling ratio decreased from 0.94 ± 0.14 at 1-2 weeks to 0.52 ± 0.27 at final follow-up. The Affinos® group showed a significantly higher fibula defect filling ratio compared to that for the OSferion® group (p = 0.003). These results indicate that Affinos® has slow absorption rates and significant defect filling activity compared with OSferion®. Thus, Affinos® could be a suitable substitute to fill bony defects induced by fibula harvesting for spinal reconstruction surgery.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The Role of Three-Dimensional Scaffolds in Treating Long Bone Defects: Evidence from Preclinical and Clinical Literature-A Systematic Review

Long bone defects represent a clinical challenge. Bone tissue engineering (BTE) has been developed to overcome problems associated with conventional methods. The aim of this study was to assess the BTE strategies available in preclinical and clinical settings and the current evidence supporting this approach. A systematic literature screening was performed on PubMed database, searching for both preclinical (only on large animals) and clinical studies. The following string was used: "(Scaffold OR Implant) AND (Long bone defect OR segmental bone defect OR large bone defect OR bone loss defect)." The search retrieved a total of 1573 articles: 51 preclinical and 4 clinical studies were included. The great amount of preclinical papers published over the past few years showed promising findings in terms of radiological and histological evidence. Unfortunately, this in vivo situation is not reflected by a corresponding clinical impact, with few published papers, highly heterogeneous and with small patient populations. Several aspects should be further investigated to translate positive preclinical findings into clinical protocols: the identification of the best biomaterial, with both biological and biomechanical suitable properties, and the selection of the best choice between cells, GFs, or their combination through standardized models to be validated by randomized trials.

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

Background

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

Methods

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

Results

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

Conclusions

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

Biomechanical analysis of the impact of fibular osteotomies at tibiotalar joint: A cadaveric study

BACKGROUND

Osteotomy of the fibula is a common orthopedic procedure performed for various indications, including harvesting fibula for grafting purposes. The effect of fibular osteotomy and need for tibiofibular syndesmotic fixation fusion at different levels on tibiotalar joint is matter of debate. We performed a biomechanical analysis of the impact of fibular osteotomies at different levels and whether the fixation of distal tibiofibular joint mitigates instability caused by the osteotomy.

MATERIALS AND METHODS

Six lower limb specimens from fresh adult cadavers were used to prepare leg-foot models. The specimens were assigned to six status according to the level of osteotomy and whether fixation of distal tibiofibular joint was performed or not. Each specimen was then loaded axially to 700 N by the material testing machine, and the tibiotalar joint contact area and peak pressure were measured using an electronic pressure sensor.

RESULTS

The contact area and the pressure of tibiotalar joint showed significant changes when compared to the normal specimen. All osteotomy specimens had a decreased tibiotalar contact area and an increased peak pressure. This positively correlated with proximity of level of osteotomy to the lateral malleolus.

CONCLUSIONS

Through this study, we found that fibular osteotomy had an adverse effect in terms of decreasing the contact surface of tibiotalar joint that led to increased peak pressure in the joint. However, bone fusion and screw fixation of the distal tibiofibular joint reduced these adverse effects.

Free fibula donor-site morbidity: clinical and biomechanical analysis

The aim of this study was the quantitative assessment of donor-site morbidity after fibula harvest. Ten patients were identified with a unilateral fibula harvesting and healthy contralateral side. The average follow-up time was 32.3 months. The study design included standardized questionnaire; morbidity point-evaluation system; orthopedic-biomechanical evaluation, including true ankle motion, clinical-functional American Orthopedic Foot and Ankle Society (AOFAS) hindfoot score, pedobarography, measurement of maximal voluntary isometric strength, and radiologic examination using an ankle osteoarthritis grading. Average donor-side morbidity score was low, with 2.6 points (range, 0 to 13). Average AOFAS hindfoot score was good, with 87.3 points (range, 74 to 100). Pedobarography showed significant decrease of the big toe pushup force. Isometric strength measurement showed significant reduction of the peroneus longus muscle. Discrete to mild medial ankle osteoarthritis was found in 70% of the cases. The overall donor-side morbidity was low, but an eversion torque deficit could initiate or support a progressive functional ankle instability and in long-term cause or accelerate a ligamentous secondary ankle osteoarthritis.

Repair of long intercalated rib defects using porous beta-tricalcium phosphate cylinders containing recombinant human bone morphogenetic protein-2 in dogs

A new method to repair rib defects with biomaterials containing recombinant human bone morphogenetic protein-2 (rhBMP-2) is presented in this report. We had reported previously the successful regeneration of bony rib defects by placing a short chain of small beta-tricalcium phosphate (beta-TCP) cylinders on the intact periosteum. The multi-cylinder implants were ineffective in promoting rib repair when the periosteum was absent. By adding rhBMP-2 to the beta-TCP cylinders, we were able to promote rib bone regeneration in the presence or absence of the periosteum. The osteogenic capacity of the rhBMP-2/beta-TCP composite implant and the time required to complete regeneration were evaluated in a canine model. An 8cm long section of rib bone, including the periosteum, was removed and replaced with a chain of the rhBMP-2/beta-TCP cylinders. At 6 weeks after implantation, the ribs were restored to their original configuration and mechanical strength. The multi-cylinder beta-TCP implants were degraded and replaced by new bone in 12 weeks. This new degradable bone-inducing implant material has significant clinical potential for rib repair.

Effects of Different Sizes of .BETA.-tricalcium Phosphate Particles on Bone Augmentation within a Titanium Cap in Rabbit Calvarium

This study evaluated the effects of different sizes of beta-TCP particles on bone augmentation within a titanium cap. In 20 rabbits, the calvarium was exposed and a circular groove was prepared. After marrow penetration, a standardized hemispherical titanium cap was placed in the circular grove. The cap was filled with small-sized (100-250 microm) or medium-sized (250-500 microm) beta-TCP particles for the experimental site and without beta-TCP for the control site. After one and three months of healing, the animals were euthanized and examined histologically. There was a statistically significant difference in the amount of mineralized bone generated between the experimental and control groups in the three-month specimens. Furthermore, the medium-sized particles showed significantly more mineralized bone than did the small-sized particles. Based on these findings, we suggested that beta-TCP might be effective for bone formation and that medium-sized particles are more useful than small-sized particles in bone maturation.

Effects of the enamel matrix derivative and β-tricalcium phosphate on bone augmentation within a titanium cap in rabbit calvarium

In vitro studies suggest that enamel matrix derivative (EMD) affects the early stages of osteogenic maturation by stimulating bone cell proliferation. In the present study, we evaluated the effects of EMD and beta-tricalcium phosphate (beta-TCP) on bone augmentation within a titanium cap in rabbit calvaria, using 14 adult male Japanese white rabbits. The calvarium was exposed, a circular groove prepared, the marrow penetrated, and a standard hemispherical titanium cap placed in the groove. The cap was filled with a mixture of beta-TCP and EMD at the experimental site, and was filled with beta-TCP alone at the control site. At 1 and 3 months after cap implantation, animals were euthanized, and histological sections prepared. The sections were stained with basic fuchsin and methylene blue, and were examined using light microscopy. At 1 month, EMD tended to increase the amount of bone, but there was no significant difference in the amount of new tissue and mineralized bone between the experimental and control sites. The present findings indicate that the present mixture of EMD and beta-TCP does not accelerate bone formation, compared with beta-TCP alone.