Adamantinoma of the tibia treated with a new intramedullary diaphyseal segmental defect implant

Design and Analysis of Biomedical Scaffolds Using TPMS-Based Porous Structures Inspired from Additive Manufacturing

Gyroid (G) and primitive (P) porous structures have multiple application areas, ranging from thermal to mechanical, and fall in the complex triply periodic minimal surface (TPMS) category. Such intricate bioinspired constructs are gaining attention because they meet both biological and mechanical requirements for osseous reconstruction. The study aimed to develop G and P structures with varying porosity levels from 40% to 80% by modulating the strut thickness to proportionally resemble the stiffness of host tissue. The performance characteristics were evaluated using Ti6Al4V and important relationships between feature dimension, strut thickness, porosity, and stiffness were established. Numerical results showed that the studied porous structures could decrease stiffness from 107 GPa (stiffness of Ti6Al4V) to the range between 4.21 GPa to 29.63 GPa of varying porosities, which matches the human bone stiffness range. Furthermore, using this foundation, a subject-specific scaffold (made of P unit cells with an 80% porosity) was developed to reconstruct segmental bone defect (SBD) of the human femur, demonstrating a significant decrease in the stress shielding effect. Stress transfer on the bone surrounded by a P scaffold was compared with a solid implant which showed a net increase of stress transfer of 76% with the use of P scaffold. In the conclusion, future concerns and recommendations are suggested.

Union, complication, reintervention and failure rates of surgical techniques for large diaphyseal defects: a systematic review and meta-analysis

To understand the potential and limitations of the different available surgical techniques used to treat large, long-bone diaphyseal defects by focusing on union, complication, re-intervention, and failure rates, summarizing the pros and cons of each technique. A literature search was performed on PubMed, Web of Science, and Cochrane databases up to March 16th, 2022; Inclusion criteria were clinical studies written in English, of any level of evidence, with more than five patients, describing the treatment of diaphyseal bone defects. The primary outcome was the analysis of results in terms of primary union, complication, reintervention, and failure rate of the four major groups of techniques: bone allograft and autograft, bone transport, vascularized and non-vascularized fibular graft, and endoprosthesis. The statistical analysis was carried out according to Neyeloff et al., and the Mantel–Haenszel method was used to provide pooled rates across the studies. The influence of the various techniques on union rates, complication rates, and reintervention rates was assessed by a z test on the pooled rates with their corresponding 95% CIs. Assessment of risk of bias and quality of evidence was based on Downs and Black’s “Checklist for Measuring Quality” and Rob 2.0 tool. Certainty of yielded evidence was evaluated with the GRADE system. Seventy-four articles were included on 1781 patients treated for the reconstruction of diaphyseal bone defects, 1496 cases in the inferior limb, and 285 in the upper limb, with trauma being the main cause of bone defect. The meta-analysis identified different outcomes in terms of results and risks. Primary union, complications, and reinterventions were 75%, 26% and 23% for bone allografts and autografts, 91%, 62% and 19% for the bone transport group, and 78%, 38% and 23% for fibular grafts; mean time to union was between 7.8 and 8.9 months in all these groups. Results varied according to the different aetiologies, endoprosthesis was the best solution for tumour, although with a 22% failure rate, while trauma presented a more composite outcome, with fibular grafts providing a faster time to union (6.9 months), while cancellous and cortical-cancellous grafts caused less complications, reinterventions, and failures. The literature about this topic has overall limited quality. However, important conclusions can be made: Many options are available to treat critical-size defects of the diaphysis, but no one appears to be an optimal solution in terms of a safe, satisfactory, and long-lasting outcome. Regardless of the bone defect cause, bone transport techniques showed a better primary union rate, but bone allograft and autograft had fewer complication, reintervention, and failure rates than the other techniques. The specific lesion aetiology represents a critical aspect influencing potential and limitations and therefore the choice of the most suitable technique to address the challenging large diaphyseal defects.

Experimental Validation and Evaluation of the Bending Properties of Additively Manufactured Metallic Cellular Scaffold Structures for Bone Tissue Engineering

The availability of additive manufacturing enables the fabrication of cellular bone tissue engineering scaffolds with a wide range of structural and architectural possibilities. The purpose of bone tissue engineering scaffolds is to repair critical size bone defects due to extreme traumas, tumors, or infections. This research study presented the experimental validation and evaluation of the bending properties of optimized bone scaffolds with an elastic modulus that is equivalent to the young’s modulus of the cortical bone. The specimens were manufactured using laser powder bed fusion technology. The morphological properties of the manufactured specimens were evaluated using both dry weighing and Archimedes techniques, and minor variations in the relative densities were observed in comparison with the computer-aided design files. The bending modulus of the cubic and diagonal scaffolds were experimentally investigated using a three-point bending test, and the results were found to agree with the numerical findings. A higher bending modulus was observed in the diagonal scaffold design. The diagonal scaffold was substantially tougher, with considerably higher energy absorption before fracture. The shear modulus of the diagonal scaffold was observed to be significantly higher than the cubic scaffold. Due to bending, the pores at the top side of the diagonal scaffold were heavily compressed compared to the cubic scaffold due to the extensive plastic deformation occurring in diagonal scaffolds and the rapid fracture of struts in the tension side of the cubic scaffold. The failure in struts in tension showed signs of ductility as necking was observed in fractured struts. Moreover, the fractured surface was observed to be rough and dull as opposed to being smooth and bright like in brittle fractures. Dimple fracture was observed using scanning electron microscopy as a result of microvoids emerging in places of high localized plastic deformation. Finally, a comparison of the mechanical properties of the studied BTE scaffolds with the cortical bone properties under longitudinal and transverse loading was investigated. In conclusion, we showed the capabilities of finite element analysis and additive manufacturing in designing and manufacturing promising scaffold designs that can replace bone segments in the human body.

Adamantinoma of tibia: excision and reconstruction with free vascularized fibula flap: a case report and review of literature

Adamantinoma is a rare malignant tumour usually affecting the diaphysis of long bones. The tumour most commonly affects the tibia. Conventional management involves excision with a wide margin, reconstruction and sometimes amputation. Multiple options are available, but reconstruction depends upon the size of the bony defect and available resources. None has proved to be the favourable one. We have analysed the advantages and shortcomings of various methods used. In our case, a 33-year-old male patient presented with a large adamantinoma of the midtibial region of the left leg, which was managed with excision and reconstruction of long segment bony defect with free vascularized osteocutaneous fibula flap. There are osseointegration and hypertrophy of the vascularized bone with good functional gain in long term follow-up. Autologous bone reconstruction after adamantinoma excision with microvascular free fibula flap in large bone segment defects salvage the limb with satisfactory functional outcome.

Reconstruction of intercalary bone defect after resection of malignant bone tumor

Due to accurate preoperative imaging techniques, early diagnosis and effective chemotherapy, many tumors arising in the metaphyseo-diaphyseal regions of long bones can be segmentally resected with joint preservation. The intercalary resection of malignant bone tumor results in a bone defect which can represent a challenging reconstructive problem. The most commonly used surgical reconstructive options for these defects include biologic reconstructions such as allografts, vascularized fibular grafts, autogenous extracorporeally devitalized tumor bearing bone graft, combination of allografts or devitalized autografts with vascularized fibular grafts, segmental bone transport, or induced membrane technique. Nonbiologic reconstructions, on the other hand, use intercalary endoprostheses. Every patient should be carefully evaluated and the reconstructive option should be individually selected. The aim of this article is to discuss the surgical options of reconstruction of bone defects after intercalary resection of malignant bone tumors with reviewing of their indications, advantages, disadvantages and complications.

TIBIAL ADAMANTINOMA: ANALYSIS OF SEVEN CONSECUTIVE CASES IN A SINGLE INSTITUTION

Objective:

Adamantinoma accounts for less than 1% of the primary bone neoplasms. The tibia is the most affected bone and it is predominant in male patients between the second and third decades of life. The objective of this study is to obtain epidemiological and clinical information on patients with adamantinoma of the tibia treated surgically between 1989 and 2016.

Methods:

Retrospective series of seven patients diagnosed with adamantinoma of the tibia that underwent surgery at the orthopedic oncology service of our hospital. The information was obtained from the medical records and histopathological reports of our institution.

Results:

A total of 2870 medical records with histological reports were evaluated. Seven cases of adamantinoma of the tibia were included. The mean age was 28.5 (17-49) years. We found a predominance of females (71.4%) and the most affected side was the left one, with four cases (57.1%). The biopsy revealed bone adamantinoma in four (57.1%) patients, while the diagnosis of the other patients was confirmed after the histological examination of the surgical specimen. All the patients underwent surgery as definitive treatment. No positive margins were reported. No local recurrence (LR) was reported and two patients had distant metastasis (DM).

Conclusion:

The prognosis of survival in cases of adamantinoma of the tibia is high. The rates of LR and DM were low. Surgical treatment with extensive tumor resection is the treatment of choice. Level of Evidence IV, Case Series.

Long-Term Follow-Up of Adamantinoma of the Tibia Complicated by Metastases and a Second Unrelated Primary Cancer: A Case Report and Literature Review

Adamantinoma is a rare, low-grade malignant tumor of the bone which grows slowly and typically occurs in the diaphysis of long bones, particularly in the tibia. Adamantinomas have the potential for local recurrence and may metastasize to the lungs, lymph nodes, or bone. We report a case of a 14-year-old female with a tibial adamantinoma who underwent wide resection with limb salvage and has subsequently been followed up for 18 years. The patient went on to have both a local soft tissue recurrence 5 years after the resection and metastases to both an inguinal lymph node and the right lower lobe of the lung 8 years after that recurrence, all of which have been treated successfully with marginal resections. Unique to this case, the patient was also incidentally found to have chromophobe-type renal cell carcinoma when undergoing a partial nephrectomy to resect a presumed metastasis of her adamantinoma. Genetic testing has not revealed any known genetic predisposition to cancer.

Short-term outcomes of reconstruction subsequent to intercalary resection of femoral diaphyseal metastatic tumor with pathological fracture: Comparison between segmental allograft and intercalary prosthesis

Reconstruction of bone defects following femoral diaphyseal tumor resection is challenging. Segmental allograft (SA) and intercalary prosthesis (IP) are the most common reconstruction methods for femoral diaphyseal metastatic tumors with pathological fracture. However, whether the complications and functional outcomes differ between SA and IP remains unclear. To compare the clinical outcomes and complications for patients treated with SA reconstruction or IP replacement for femoral shaft tumors, 34 patients who had undergone intercalary resection for metastatic tumor with pathological fracture in the femoral diaphysis were evaluated. Of these, 18 had received SA and 16 IP. There were 11 males, and 24 females, with a mean age of 64.5±11.3 years. The most common sites of primary metastases were lung (26.5%), breast (17.6%) and liver (14.7%). The visual analog scale (VAS), implant-related complications and the Musculoskeletal Tumor Society (MSTS) scores for each patient were collected. The follow-up period for patients ranged from 2 to 27 months. At the most recent follow-up, 28 patients had succumbed to mortality, with a mean survival time of 6.9±3.7 months for the IP group and 7.4±3.0 months for the SA group. Patients with IP had a significantly shorter time to full weight bearing and hospitalization time than those who received SA (P=0.003 and P=0.002, respectively). The rates of overall complications and implant-related complications were significantly lower for IP as compared with SA (18.8 vs. 66.7%, P=0.007; 12.5 vs. 55.6%, P=0.013). The reoperation rate of the SA group was higher than that of the IP group (38.9 vs. 12.5%), however the difference between the two groups was statistically insignificant (P=0.125). MSTS scores were significantly higher for the IP group as compared with the SA group at one month after surgery (IP, 26.7±1.6 vs. SA, 20.3±1.5; P<0.05), without a significant difference at the final follow-up. There were no statistically significant differences in age, sex, length of resection, follow-up time, operative time or blood loss between the two groups. In summary, IP reconstruction may provide improved early functional outcomes and fewer early complications, particularly for patients with a shorter life expectancy due to femoral metastatic tumors with pathological fracture.

Outcomes of Intercalary Prosthetic Reconstruction for Pathological Diaphyseal Femoral Fractures Secondary to Metastatic Tumors

OBJECTIVE

To evaluate the clinical outcomes and complications of segmental prosthetic reconstruction for pathological diaphyseal femoral fractures secondary to metastatic tumors.

METHODS

Between 2011 and 2015, we retrospectively evaluated 16 patients (6 men and 10 women; 64.5 ± 11.4 years old at diagnosis) who underwent prosthetic reconstruction after segmental resection of diaphyseal femoral fractures due to metastatic lesions. Visual analog scale (VAS), functional outcomes, implant-related complications, and Mean postoperative Musculoskeletal Tumor Society (MSTS) score for each patient were collected.

RESULTS

The mean length of bone defect was 10.2 ± 2.6 cm (range, 8-16 cm); follow-up was 9 ± 6.8 months (range, 2-25 months) for all patients, and 24 months (23 and 25 months) for the 2 patients still alive. At final follow-up, 14 patients were dead, indicating a mean survival of 6.9 ± 3.6 months (range, 2-14 months). Mean preoperative VAS score was 8.5 ± 1.0, which decreased to 2.5 ± 1.3 at day 2 postoperatively, indicating significant pain relief (P < 0.05). The MSTS score for lower extremities was 84.6% (range, 73%-90%). The range of motion and function of adjacent joints was within the normal limits in all cases. Three patients (33%) developed complications, including aseptic loosening because of disease progression (1), infection (1), and peri-prosthesis fracture (1).

CONCLUSION

These findings demonstrated that this approach greatly relieves pain, and yields satisfactory functional outcomes with fewer complications in patients with pathological femoral fractures secondary to metastatic tumors; however, survival was not significantly improved.

Intercalary reconstructions after bone tumor resections: a review of treatments

An intercalary reconstruction is defined as replacement of the diaphyseal portion of a long bone after segmental skeletal resection (diaphysectomy). Intercalary reconstructions typically result in superior function compared to other limb-sparing procedures as the patient's native joints above and below the reconstruction are left undisturbed. The most popular reconstructive options after segmental resection of a bone sarcoma include allografts, vascularized fibula graft, combined allograft and vascularized fibula, segmental endoprostheses, extracorporeal devitalized autograft, and segmental transport using the principles of distraction osteogenesis. This article aims to review the indications, techniques, limitations, pros and cons, and complications of the aforementioned methods of intercalary bone tumor resections and reconstructions in the context of the ever-growing, brave new field of limb-salvage surgery.

Adamantinoma Arising in the Distal End of the Fibula

Adamantinoma is a rare, low-grade, malignant bone tumor. It frequently occurs in the tibia but rarely arise in the distal end of the fibula. This study reported a case of adamantinoma arising in the distal end of the fibula, resulting in good prognosis. A 38-year old female felt left ankle pain, and was suspected as having a bone tumor at the distal end of the fibula by X-ray. She was diagnosed as the classical adamantinoma of the fibula by open biopsy. En bloc wide resection of the tumor, primary arthrodesis of the ankle was performed. During the follow-up period of 7 years after the surgery, she has lived without any metastasis and local recurrence. A wide resection and arthrodesis of the ankle joint can provide a good outcome for adamantinoma arising in the end of the fibula.

Adamantinoma of the tibia mimicking a benign cystic lesion: a case report

Adamantinoma of the long bones is a rare primary malignant bone tumor accounting for less than 1% of all primary malignant bone tumors. Most typical imaging findings include heterogeneous osteolytic cortical lesions showing multiple sharply circumscribed lucent zones of various sizes with sclerotic bone surroundings, interspersing between, and extending above and below the lucent zones by the thinning and bulging cortex. Advanced or recurrent lesions may be associated with destruction of the cortex and soft tissue extension. In this article, the authors present a case report of a patient with a distal tibia adamantinoma mimicking a benign cystic lesion.