Autograft reconstructions for bone defects in primary total knee replacement in severe varus knees

Background:

Large posteromedial defects encountered in severe varus knees during primary total knee arthroplasty can be treated by cementoplasty, structural bone grafts or metallic wedges. The option is selected depending upon the size of the defect. We studied the outcome of autograft (structural and impaction bone grafting) reconstruction of medial tibial bone defects encountered during primary total knee replacement in severe varus knees.

Materials and Methods:

Out of 675 primary varus knees operated, bone defects in proximal tibia were encountered in 54 knees. Posteromedial defects involving 25-40% of the tibial condyle cut surface and measuring more than 5 mm in depth were grafted using a structural graft obtained from cut distal femur or proximal tibia in 48 knees. For larger, peripheral uncontained vertical defects in six cases, measuring >25 mm in depth and involving >40% cut surface of proximal tibial condyle, impaction bone grafting with a mesh support was used.

Results:

Bone grafts incorporated in 54 knees in 6 months. There was no graft collapse or stress fractures, loosening or nonunion. The average followup period was 7.8 years (range 5-10 years). We observed an average postoperative increase in the Knee Society Score from 40 to 90 points. There was improvement in the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores in terms of pain, stiffness and physical function during activities of daily living.

Conclusion:

Bone grafting for defects in primary total knee is justified as it is biological, available then and is cost effective besides preserving bone stock for future revisions. Structural grafts should be used in defects >5 mm deep and involving 25-40% of the cut proximal tibial condyle surface. For larger peripheral vertical defects, impaction bone grafting contained in a mesh should be done.     

Radial bone graft usage for nasal septal reconstruction

Background:

Although various techniques have been described for correction of crooked and saddle nose deformities, these problems are challenging with high recurrence and revision rates. Conventional septal surgery may not be adequate for nose reconstruction in crooked and saddle nose deformities.

Materials and Methods:

Between December 2005 and October 2009, six patients with crooked nose and five patients with saddle nose deformities underwent corrective surgery in our clinic. All patients were male, and the mean age was 21 years (range, 19-23 years). We used rigid radial bone graft to prevent redeviation and recurrence following corrective nasal septal surgery.

Results:

The mean follow-up period was 28 months, ranging from 18 to 46 months. Mean operation time was 4 hours (3-4.5). All patients healed uneventfully. None of the patients required secondary surgery.

Conclusions:

We believe that radial bone grafts offer a long lasting support in treatment of challenging cases with crooked and saddle nose deformities.     

Hydroxyapatite crystals as a bone graft substitute in benign lytic lesions of bone

Background:

Bone grafts are required to fill a cavity created after curettage of benign lytic lesions of the bone. To avoid the problems associated at donor site with autologous bone graft, we require allograft or bone graft substitutes. We evaluated the healing of lytic lesions after hydroxyapatite (HA) grafting by serial radiographs.

Materials and Methods:

Forty cases of benign lytic lesions of bone were managed by simple curettage and grafting using HA blocks. Commercially available HA of bovine origin (Surgiwear Ltd., Shahjahanpur, India) was used for this purpose. Mean duration of followup was 34.8 months (range 12–84 months). Mean patient age was 19.05 years (range 3–55 years). Radiological staging of graft incorporation was done as per criteria of Irwin et al. 2001.

Results:

In our series, two cases were in stage I. A total of 11 cases were in stage II and 27 were in stage III. Graft incorporation was radiologically complete by 15 months. Clinical recovery was observed before radiological healing. The average time taken to return to preoperative function was 3 months. Recurrence was observed in giant cell tumor (n = 3) and chondromyxoid fibroma (n = 1). There was no incidence of graft rejection, collapse, growth plate disturbances or antigenic response.

Conclusions:

We conclude that calcium HA is biologically acceptable bone graft substitute in the management of benign lytic lesions of bone.     

Closed reduction, internal fixation with quadratus femoris muscle pedicle bone grafting in displaced femoral neck fracture

Background:

Management of femoral neck fracture is still considered as an unsolved problem. It is more evident in displaced fractures where this fracture is considered as some sort of vascular insult to the head of the femur. We have used closed reduction, internal fixation and quadratus femoris muscle pedicle bone grafting in fresh displaced femoral neck fractures.

Materials and Methods:

From April 1996 to December 2004 we operated 73 consecutive patients of displaced femoral neck fracture in the age group of 24 to 81 years, mean age being 54.6 years. The patients were operated within one week of injury, the mean delay being 3.6 days. Closed reduction internal fixation along with quadratus femoris muscle pedicle bone grafting was done in all cases. They were followed up for an average period of 5.6 years (range 2-11 years).

Results:

Results were assessed according to modified Harris Hip Scoring system and found to be excellent in 53, good in 12, fair in six and poor in two patients. Bony union occurred in 68 cases, no patient developed avascular necrosis (AVN) till date.

Conclusion:

For fresh displaced femoral neck fracture in physiologically active patients closed reduction, internal fixation and quadratus femoris muscle pedicle bone grafting is a suitable option to secure union and prevent development of AVN.     

Giant cell tumor: Curettage and bone grafting

Background:

Curettage and wide resection are accepted methods of treatment of giant cell tumor (GCT) of bone. The success rate with curettage in different reports varies widely. There is a paucity in the literature regarding selection of cases for curettage. Present study is an analysis of outcome of 34 cases treated by curettage and bone grafting.

Materials and Methods:

Thirty-four cases of GCT of bone, 28 fresh and six with recurrence were treated by curettage and bone grafting. All cases of Campanancci grade 1, 2 and grade 3 which on computerized tomography scan showed break in the cortex confined to one surface and cortical break less than one third of circumference were treated by curettage and bone grafting.

Results:

4 (14%) of these lesions treated primarily by us showed recurrence after one and half year.

Conclusion:

Curettage and bone grafting is a reliable method in the treatment of GCT, provided guidelines regarding selection of cases and principles of tumor surgery are strictly adhered to.     

Use of tubulization (nerve conduits) in repairing nerve defects in children

Background:

Direct neurorrhaphy, nerve grafting interposition and neurotization are the options for nerve repair in children, whereas few reports about using nerve conduits (tubulization) are referred to pediatrics in the literature. The authors present their experience about nerve repairing by means of nerve tubes during the developmental age when the harvesting of nerve grafts and also vein grafts of adequate caliber for bridging nerve defects is difficult. A critical review of their case series offers indications for using nerve conduits in pediatrics.

Materials and Methods:

Fifteen patients were treated using the nerve tubulization; nine patients were affected by obstetrical brachial plexus palsy (OBPP) while six were suffering from peripheral nerve injuries (PNIs).

Results:

In patients suffering from OBPP, we observed 1 good, 3 fair and 5 bad results. In the PNI group, we observed 4 patients who had good results while only 2 had a bad outcome. No fair results were observed.

Conclusions:

In peripheral nerve repairing in children by using nerve conduits, the outcome has been widely effective even when dealing with mixed and motor nerve, thus nerve tubulization might be considered as an alternative to nerve grafting. Conversely, considering the uncertain result obtained in brachial plexus repairing, the conduits cannot be considered as a first choice of treatment in brachial plexus reconstruction.     

Results of Wagner SL revision stem with impaction bone grafting in revision total hip arthroplasty

Background:

As the number of total hip arthroplasties (THAs) performed increases, so do the number of required revisions. Impaction bone grafting with Wagner SL Revision stem is a good option for managing bone deficiencies arising from aseptic osteolysis. We studied the results of cementless diaphyseal fixation in femoral revision after total hip arthroplasty and whether there was spontaneous regeneration of bone stock in the proximal femur after the use of Wagner SL Revision stem (Zimmer, Warsaw, IN, USA) with impaction bone grafting.

Materials and Methods:

We performed 53 hip revisions using impaction bone grafting and Wagner SL Revision stems in 48 patients; (5 cases were bilateral) for variety of indications ranging from aseptic osteolysis to preiprosthetic fractures. The average age was 59 years (range 44-68 years). There were 42 male and 6 female patients. Four patients died after surgery for reasons unrelated to surgery. 44 patients were available for complete analysis.

Results:

The mean Harris Hip Score was 42 before surgery and improved to 86 by the final followup evaluation at a mean point of 5.5 years. Of the 44 patients, 87% (n=39) had excellent results and 10% (n=5) had good results. The stem survival rate was 98% (n=43).

Conclusion:

Short term results for revision THA with impaction bone grafting and Wagner SL revision stems are encouraging. However, it is necessary to obtain long term results through periodic followup evaluation, as rate of complications may increase in future.     

Fate of bone grafting for acetabular defects in total hip replacement

Background:

The use of allografts and autografts in the management of acetabular defects have been reported with varying results. Trabecular metal is an expensive option in the management of these defects. This study aims to assess the fate and efficacy of bone grafting for acetabular bone defects in total hip arthroplasty.

Materials and Methods:

A total of 30 hips in 28 patients with acetabular deficiencies were treated with bone grafting and total hip replacement (THR). Seventeen hips had American Academy of Orthopedic Surgeons (AAOS) type 2 (Paprosky type 2c) deficiency and 13 had AAOS type 3 (Paprosky type 3a) defects of the acetabulum. Allografts were used in 15 patients and autografts were used in the remaining 13. Cemented total hip arthroplasty was done in 18 hips and uncemented THR in 12. Seven patients underwent the procedure for, acetabular erosion and symptoms following hemiarthroplasty (4 out of 7), or, acetabular revision for failure (3 out of 7) following total hip arthroplasty. Acetabular deficiencies in other patients were due to posttraumatic causes, advanced primary hip arthritis and second stage treatment of postinfective arthritis. A mesh was used in 6 hips and screws were used in 13 hips for graft fixation.

Results:

Patients were followed up clinicoradiologically for a period of 10 months to 4 years (mean 23.4 months). One patient required staged revision due to infection. Two patients had early asymptomatic cup migration. One patient had graft lysis and change in cup inclination with persistent pain. He was not keen on further intervention at last followup. Other patients were pain free at the time of followup with radiographs showing maintenance of graft and implant position.

Conclusion:

Bone grafting is a suitable option in the management of acetabular defects in total hip arthroplasty, especially in resource challenged countries.     

Osteonecrosis of femoral head: Treatment by core decompression and vascular pedicle grafting

Background:

Femoral head-preserving core decompression and bone grafting have shown excellent result in preventing collapse. The use of vascularized grafts have shown better clinical results. The vascular pedicle bone graft is an easy to perform operation and does not require special equipment. We analyzed and report a series of patients of osteonecrosis of femoral head treated by core decompression and vascular pedicle grafting of part of iliac crest based on deep circumflex iliac vessels.

Materials and Methods:

The article comprises of the retrospective study of 31 patients of osteonecrosis of femoral head in stage II and III treated with core decompression and vascular pedicle grafting by using part of iliac crest with deep circumflex iliac vessels from January 1990 to December 2005. The young patients with a mean age 32 years (18–52 years) with a minimum follow-up of five years were included for analysis. Sixteen patients had osteonecrosis following alcohol abuse, 12 patients following corticosteroid consumption, 3 patients had idiopathic osteonecrosis. Nine patients were stage IIB, and 22 patients were stage IIIC according to ARCO''s system. The core decompression and vascular pedicle grafting was performed by anterior approach by using part of iliac crest with deep circumflex iliac vessels.

Results:

Digital subtraction arteriography performed in 9 patients at the end of 12 weeks showed the patency of deep circumflex artery in all cases, and bone scan performed in 6 other patients showed high uptake in the grafted area of the femoral head proving the efficacy of the operative procedure. Out of 31 patients, only one patient progressed to collapse and total joint replacement was advised. At the final follow up period of 5–8 years, Harris Hip Score improved mean ± SD of 28.2 ± 6.4 (p < 0.05). Forty-eight percent of patients had an improvement in Harris Hip Score of more that 28 points.

Conclusion:

The core decompression and vascular pedicle grafting reduces the intraosseous tension to achieve early revascularization of ischemic femoral head. The high percentage of marrow and osteogenic cells survive within a vascularized pedicle graft, which helps in early vascularization and we have been able to achieve good outcome.     

Calcar femorale grafting in the hemiarthroplasty of the hip for unstable inter trochanteric fractures

Background:

The sliding screw-plate devices and cephalo-medullary nail devices have performed well in stable inter-trochanteric fractures in patients with reasonably good quality of bone. However, their suboptimal performance in comminuted fractures in the presence of osteoporotic bone has prompted many surgeons to consider bipolar hemiarthroplasty as the primary modality of management of comminuted inter-trochanteric fractures in elderly patients. However, long term stability of the hemiarthroplasty implant also may be compromised due to the presence of postero-medial bone loss at the area of the calcar.

Materials and Methods:

We have presented a simple and effective technique of calcar grafting by harvesting cortical bone strut from the neck of the fractured femur. A total of 34 patients with inter-trochanteric fractures of the femur were treated with calcar grafting. The mean age was 79.2 years. The graft was harvested from the calcar region of the head and neck fragment of the femur and wedged between the medial femoral cortex and medial edge of the prosthesis. The mean followup period was 54.5 months.

Results:

In 32 of 34 (94%) patients in our series, the calcar graft healed well without dislodgement. There was graft resorption in two patients associated with subsidence of the implant and loosening.

Conclusion:

Calcar grafting using this technique provides stability to the implant in the presence of comminution and incorporates well in the majority of patients. Donor site morbidity of graft harvesting is also avoided.     

Gap nonunion of forearm bones treated by modified Nicoll's technique

Background:

The management of an atrophic nonunion with a gap following a fracture of the radius and/or ulna is a challenging problem. Various methods of treatment available in the literature are cortical tibial graft (Boyd), ulnar segment graft (Miller and Phalen), iliac crest graft (Spira), cancellous insert graft (Nicoll), vascularized fibular graft (Jupiter), and bone transport by ring fixator (Tesworth). The present study reports the results of tricorticocancellous bone block grafts using modified Nicoll''s technique, in diaphyseal defects of forearm bones.

Materials and Methods:

A total of 38 forearm bones (either radius or ulna or both) in 23 patients with a gap of 1.5–7.5 cm were treated by debridement and tricorticocancellous bone block graft under compression with intramedullary nail fixation between June 1985 and June 2005. There were 15 male and 8 female patients. Sixteen patients had open and seven patients had closed fractures initially. Time of presentation since the original injury varied from 9 months to 84 months. Eighteen patients had already undergone one to three operations.

Results:

Thirty-six bones showed union at both host graft junctions. The mean duration of union was 17.5 weeks (range, 14–60 weeks). Two bones had union only at one host graft junction and did not show any evidence of callus formation up to 9 months on the other end, hence requiring subsequent procedure in the form of phemister bone grafting. Patients were followed for a minimum period of 2 years (range, 2–7 years). Results were based on the status of union and range of motion (ROM) for elbow/wrist and grip strength at the final follow-up. Complications observed were the reactivation of infection (n = 1) and herniation of the muscles at the donor site (n = 1).

Conclusion:

The tricorticocancellous strut bone grafting under optimal compression, augmented with intramedullary fixation, provides a promising solution to difficult problem of an atrophic nonunion of forearms bones with gap.     

Binder's syndrome (maxillonasal dysplasia) different treatment modalities: Our experience

Aim:

Being an uncommon congenital condition, the treatment modalities of maxillonasal dysplasia are not clearly defined. Our aim is to discuss the availability and utility of various treatment options to achieve optimum results. In patients with Binder''s syndrome, the midface appears flattened, the columella is short and the upper lip slants backwards.

Materials and Methods:

We report here 15 patients with Binder''s syndrome who were operated over a period of 5 years. Different treatment options in the form of correction of the depressed nasal dorsum and maxillary hypoplasia with split cranial bone graft or synthetic materials such as high-density porous polyethylene implant were used. Two patients with Angle class III malocclusion underwent a Le Fort I osteotomy for maxillary advancement. The patients were followed over a period of 3 years.

Results:

We achieved a reasonable augmentation of the nose and the maxilla in our patients. We faced complications in two of our patients; in one patient there was fracture of the dorsal nasal bone graft and the other patient had protrusion of paranasal screws into the palate, which were removed.

Conclusion:

In this series of cases, we were able to utilise various treatment modalities appropriately to achieve satisfactory outcome with no significant complications.KEY WORDS: Binder''s syndrome, maxillonasal dysplasia, split calvarial bone graft     

Giant cell tumor of bone: Multimodal approach

Background:

The clinical behavior and treatment of giant cell tumor of bone is still perplexing. The aim of this study is to clarify the clinico-pathological correlation of tumor and its relevance in treatment and prognosis.

Materials and Methods:

Ninety -three cases of giant cell tumor were treated during 1980-1990 by different methods. The age of the patients varied from 18-58 yrs with male and female ratio as 5:4. The upper end of the tibia was most commonly involved (n=31), followed by the lower end of the femur(n=21), distal end of radius(n=14), upper end of fibula (n=9), proximal end of femur(n=5), upper end of the humerus(n=3), iliac bone(n=2), phalanx (n=2) and spine(n=1). The tumors were also encountered on uncommon sites like metacarpals (n=4) and metatarsal(n=1). Fifty four cases were treated by curettage and bone grafting. Wide excision and reconstruction was performed in twenty two cases. Nine cases were treated by wide excision while primary amputation was performed in four cases. One case required only curettage. Three inaccessible lesions of ilium and spine were treated by radiotherapy.

Results:

19 of 54 treated by curettage and bone grafting showed a recurrence. The repeat curettage and bone grafting was performed in 18 cases while amputation was done in one. One each out of the cases treated by wide excision and reconstruction and wide excision alone recurred. In this study we observed that though curettage and bone grafting is still the most commonly adopted treatment, wide excision of tumor with reconstruction has shown lesser recurrence.

Conclusion:

For radiologically well-contained and histologically typical tumor, curettage and autogenous bone grafting is the treatment of choice. The typical tumors with radiologically deficient cortex, clinically aggressive tumors and tumors with histological Grade III should be treated by wide excision and reconstruction.     

Management of segmental skeletal defects by the induced membrane technique

Background:

Surgical reconstruction of segmental skeletal defects represents a true challenge for the orthopedic surgeons. Recently, Masquelet et al. described a two-stage technique for reconstruction of bone defects, known as the induced membrane technique. The aim of this study is to assess the results of the induced membrane technique in the management of segmental skeletal defects resulting from debridement of bone infection.

Materials and Methods:

Seventeen patients with segmental skeletal defects were treated in our institution by the induced membrane technique. The average age of the patients was 43 years (range 26- 58 years). The causes of the defects were infected gap nonunion in 12 cases and debridement of osteomyelitis in 5 cases. The defects were located in the tibia (n = 13) and the femur (n = 4). The mean defect was 7 cm (range 4 cm - 11 cm). All cases were treated by the induced membrane technique in two-stages.

Results:

Bone union happened in 14 patients. The limb length discrepancy did not exceed 2.5 cm in the healed cases. The mean time of healing was 10 months (range 6-19 months). The complications included nonunion of the graft in five cases, failure of graft maturation in two cases, reactivation of infection in two cases and refracture after removal of the frame in one case. These complications were managed during the course of treatment and they did not affect the final outcome in all patients except three.

Conclusion:

The induced membrane technique is a valid option for the management of segmental skeletal defects. It is a simple and straight forward procedure, but the time required for growth and maturation of the graft is relatively long.     

A retrospective analysis of medial opening wedge high tibial osteotomy for varus osteoarthritic knee

Background:

Medial opening wedge high tibial osteotomy (MOWHTO) has proven to be an effective treatment for varus osteoarthritic knees. Various methods of fixation with different implant types and using either bone grafts or bone substitutes have been reported. We performed non-locking T-buttress plate fixation with autologous iliac bone graft augmentation, which is defined here as the traditional method, and locking compression plate fixation without any bone graft or bone substitute. We aimed to compare bone union and complications of these two MOWHTO techniques.

Materials and Methods:

Between June 2005 and December 2007, 50 patients who underwent MOWHTO (a total of 60 knees) were retrospectively reviewed and classified into two groups: group A, which consisted of 26 patients (30 knees) was treated using T-buttress plate fixation with autologous iliac bone graft augmentation and group B, which consisted of 24 patients (30 knees) was operated upon using a medial high tibial locking compression plate without any augmentation. Demographic characteristics and radiographic outcomes, including union rate, time to union, medial osteotomy defects, and complications, were collected and compared between the two groups. The progress of all patients was followed for at least 2 years.

Results:

All osteotomies united within 12 weeks after surgery. Group B had slightly longer time to union than group A (10.3 weeks and 9.5 weeks, respectively; P = 0.125). A significantly higher incidence of medial defects after osteotomy was reported in the locking compression plate group (P = 0.001). A total of 5 (8.3%) knees had complications. In group A, one knee had a superficial wound infection and another knee had a lateral tibial plateau fracture without significant loss of correction. In group B, one knee had screw penetration into the knee joint and two knees had local irritation that required the removal of the hardware.

Conclusion:

Locking compression plate fixation without the use of bone grafts or bone substitutes provides a satisfactory union rate and an acceptable complication rate when compared to the traditional MOWHTO technique. Thus, we recommend using this technique for treating unicompartmental medial knee osteoarthritis.     

Results of triple muscle (sartorius,tensor fascia latae and part of gluteus medius) pedicle bone grafting in neglected femoral neck fracture in physiologically active patients

Background:

Femoral neck fractures are notorious for complications like avascular necrosis and nonunion. In developing countries, various factors such as illiteracy, low socioeconomic status, ignorance are responsible for the delay in surgery. Neglected fracture neck femur always poses a formidable challenge. The purpose of this study was to evaluate the results of triple muscle pedicle bone grafting using sartorius, tensor fasciae latae and part of gluteus medius in neglected femoral neck fracture.

Materials and Methods:

This is a retrospective study with medical record of 50 patients, who were operated by open reduction, internal fixation along with muscle pedicle bone grafting by the anterior approach. After open reduction, two to three cancellous screws (6.5 mm) were used for internal fixation in all cases. A bony chunk of the whole anterior superior iliac spine of 1 cm thickness, 1 cm width and 4.5 cm length, taken from the iliac crest comprised of muscle pedicle of sartorius, tensor fascia latae and part of gluteus medius. Then the graft with all three muscles mobilized and put in the trough made over the anterior or anterosuperior aspect of the femoral head. The graft was fixed with one or two 4.5 mm self-tapping cortical screw in anterior to posterior direction.

Results:

14 patients were lost to followup. The results were based on 36 patients. We observed that in our series, there was union in 34, out of 36 (94.4%) patients. All patients were within the age group of 15-51 years (average 38 years) with displaced neglected femoral neck fracture of ≥30 days. Mean time taken for full clinicoradiological union was 14 weeks (range-10-24 weeks).

Conclusion:

Triple muscle pedicle bone grafting gives satisfactory results for neglected femoral neck fracture in physiologically active patients.     

Percutaneous autologus bone marrow injection in the treatment of delayed or nonunion

Background:

Bone marrow is a source of osteoprogenitor cells that are key elements in the process of bone formation and fracture healing. The purpose of the study was to ascertain the osteogenic potential of autologous bone marrow grafting and its effectiveness in the management of delayed union and nonunion.

Materials and Methods:

Twenty-eight patients with delayed union and three with nonunion of fracture of the long bones were treated with this procedure. Of these 28 cases, two patients had fracture shaft femur, one had fracture shaft ulna and 25 patients had tibial shaft fractures. The average time duration between procedure and injury was 25 weeks (range 14-53 weeks). The bone marrow was aspirated from the anterior iliac crest and injected percutaneously at the fracture site. The procedure was carried out as an outpatient procedure. All but five cases required one injection of bone marrow.

Results:

Union was observed in 23 cases. The average time of healing after the procedure was 12 weeks (range 7-18 weeks).

Conclusion:

The technique of percutaneous autologous bone marrow injection provides a very safe, easy and reliable alternative to open bone grafting, especially for early intervention in fracture healing process.     

Secondary alveolar bone grafting: An outcome analysis

OBJECTIVE

To review the outcome of secondary alveolar bone grafting in unilateral and bilateral cleft lip and palate.

DESIGN

A surgeon’s experience, by retrospective chart review, of 70 consecutive patients at a tertiary care centre.

OUTCOME MEASURE

Periapical radiographs were taken at least six months after secondary alveolar bone grafting. The Enemark grading system was used to stratify graft-take.

RESULTS

In unilateral clefts, 33% were level 1, 36% were level 2, 20% were level 3 and 11% were level 4. In bilateral clefts, 29% were level 1, 50% were level 2, 14% were level 3 and 7% were level 4. There was no statistically significant difference between the level of take and the type of cleft. Complications encountered were infection (n=3), fistula (n=3), pain (n=4) and bone graft exposure that led to failure (n=2). Two patients required reoperation for bone grafting.

CONCLUSIONS

The iliac crest is a good donor site with excellent results and minimal morbidity.     

Primary xanthoma of calcaneus bone: Case report

INTRODUCTION

Xanthoma (or xanthofibroma) is a benign proliferative lesion, mostly seen in soft tissue. Xanthoma of bone is very rare benign primary bone tumor, more frequently seen in men and in patients over 20 years of age. Histologically, it is characterized by mononuclear macrophage-like cells, abundant foam cells, and multinucleated giant cells. It is sometimes discovered coincidentally and the most frequent symptom is pain.

PRESENTATION OF CASE

We present a 50-year-old healthy male patient with primary xanthoma of the calcaneus, who was treated by curettage and bone cement. He presented with a pathological fracture in a calcaneus bone lesion. Giant cell tumor was suspected on X-ray and MRI. Curettage and bone cementing was done through the posterolateral approach. Lipid profile was normal and histological examination revealed findings consistent with primary xanthoma of calcaneus bone.

DISCUSSION

To avoid an erroneous diagnosis, all material should be examined microscopically, the radiological features of the lesion should be studied properly and lipid profile should be investigated to differentiate between primary and secondary xanthoma. Primary xanthoma may be treated with curettage and bone graft while secondary xanthoma is treated nonsurgically and the skeletal manifestations will disappear with systemic treatment of hyperlipidemia.

CONCLUSION

We present this case to raise the suspicion of this lesion that is rarely described in the literatures. This is the first case of primary xanthoma of calcaneus bone that has been reported in Qatar.     

Calcium phosphate ceramics as bone graft substitutes in filling bone tumor defects

Background:

Synthetic bio-inert materials are currently used as an alternative to autogenous bone graft. Calcium hydroxyapatite (HA) and Beta tri-calcium phosphate (β-TCP), which belong to the calcium phosphate ceramics group, are biocompatible and osteo-conductive. The purpose of this study is to analyse the use of HA and β-TCP in their ceramic forms as a bone graft substitute in filling bone voids after curettage of benign bone tumors.

Materials and Methods:

Twenty-four patients in the age range of 3.5-55 years (mean 14.3 years) having benign bone tumors with bone defects were filled with bone graft substitute following curettage. In 20 patients bone defects were filled with block/granules of HA ceramic and in four with β-TCP. Fibular strut graft was packed with HA in four patients. The patients were followed up for an average of 18 months (range 12-36 months).

Results:

The functional status of the patients at follow-up was evaluated and compared with preoperative functional status. Early incorporation of graft substitutes became evident radiologically between 6 and 10 weeks (Stage I). Complete incorporation (Stage III) was observed in an average of nine months (6-18 months). Clinical healing was observed before radiological healing. The average time taken to return to preoperative function was 14 weeks. There was no recurrence of lesion or growth retardation.

Conclusion:

Calcium hydroxyapatite and β-TCP are excellent bone graft substitutes for autogenous bone graft in filling voids after curettage of benign bone tumors.