Filling of bone defects with tricalcium phosphate beta in traumatology

AIM OF STUDY: Synthetic bone substitutes like calcium phosphate ceramics have been used in orthopaedic surgery for several years. The aim of this study was to assess the results of the use of tricalcium phosphate beta for filling bone defects in trauma cases. PATIENTS AND METHOD: beta tricalcium phosphate was used in 24 trauma cases. The GESTO classification (Association pour l'étude des Greffes et Substituts Tissulaires en Orthopédie) and a qualitative scale were used to estimate the integration. RESULTS: With a mean follow-up of 20 months, integration was excellent in 41.2%, good in 29.2% and moderate in 17.4%. No fibrous encapsulation was observed around the implants in any case. Sepsis occurred in 3 cases with open fractures. CONCLUSION: beta-Tricalcium phosphate seems in our experience to be an excellent bone substitute for filling bone defects in trauma cases.     

Application of a biphasic macroporous synthetic bone substitutes CERAFORM®: clinical and histological results

Missing bone is a challenging situation in orthopaedic surgery. Due to specific chemical and structural properties, biphasic ceramics are used as bone substitutes. We investigated intraoperative manoeuvrability, clinical tolerability, radiological and histological integration of a biphasic synthetic ceramic (CERAFORM^®). Present study reports 5-year follow-up of 43 cases requiring bone substitution: bone tumours; spinal fusions; revision arthroplasty; nonunions; fractures; osteitis. GESTO (Greffes ET Substitutes Tissulaires en Orthopedie) patient form was used for evaluation and follow up. Radiological survey was performed at 3, 6, 9, 12 and 18 months. We used CERAFORM^® as single substitute or mixed with allo- or autograft. Clinical and radiological integration occurred 9–12 months after implantation. Bone biopsy documented new bone formation. CERAFORM allows good filling of the defect, additional autograft or osteosynthesis is needed for higher mechanical stability. Radiological aspect after implantation stands for a rapid integration in the host bone. Histological examination confirmed bone remodelling.     

Major bone defect treatment with an osteoconductive bone substitute

A bone defect can be provoked by several pathological conditions (e.g. bone tumours, infections, major trauma with bone stock loss) or by surgical procedures, required for the appropriate treatment. Surgical techniques currently used for treating bone defects may count on different alternatives, including autologous vascularized bone grafts, homologous bone graft provided by musculoskeletal tissue bank, heterologous bone graft (xenograft), or prostheses, each one of them dealing with both specific advantages and complications and drawbacks. The main concerns related to these techniques respectively are: donor site morbidity and limited available amount; possible immune response and viral transmission; possible animal-derived pathogen transmission and risk of immunogenic rejection; high invasiveness and surgery-related systemic risks, long post-operative. physical recovery and prostheses revision need. Nowadays, an ideal alternative is the use of osteoconductive synthetic bone substitutes. Many synthetic substitutes are available, used either alone or in combination with other bone graft. Synthetic bone graft materials available as alternatives to autogeneous bone include calcium sulphates, special glass ceramics (bioactive glasses) and calcium phosphates (calcium hydroxyapatite, HA; tricalcium phosphate, TCP; and biphasic calcium phosphate, BCP). These materials differ in composition and physical properties fro each other and from bone (De Groot in Bioceramics of calcium phosphate, pp 100–114, 1983; Hench in J Am Ceram Soc 74:1487–1510, 1994; Jarcho in Clin Orthop 157:259–278, 1981; Daculsi et al. in Int Rev Cytol 172:129–191, 1996). Both stoichiometric and non-stoichiometric HA-based substitutes represent the current first choice in orthopedic surgery, in that they provide an osteoconductive scaffold to which chemotactic, circulating proteins and cells (e.g. mesenchymal stem cells, osteoinductive growth factors) can migrate and adhere, and within which progenitor cells can differentiate into functioning osteoblasts (Szpalski and Gunzburg in Orthopedics 25S:601–609, 2002). Indeed, HA may be extemporarily combined either with whole autologous bone marrow or PRP (platelet rich plasma) gel inside surgical theatre in order to favour and accelerate bone regeneration. A case of bifocal ulnar bone defect treated with stoichiometric HA-based bone substitute combined with PRP is reported in here, with a 12-month-radiographic follow-up.     

Significance of synthetic calcium phosphate ceramics as a bone replacement material

With reference to the chemical and crystallographic differences, the line is drawn against bone substitute material produced from biological material. Extensive animal experiments demonstrated the good healing properties when using calcium phosphate ceramics in bony defects. In the long term, there was more new bone formed after filling up the defect with calcium phosphate ceramics than when using autologous bone grafts. Clinically, there is an indication for using this material to fill up bone cysts and defects if there is enough time for biodegradation; in other cases, a mixture using an autologous spongoid graft is necessary.     

Bone substitutes: new concepts

Summary The filling of bone defects resulting from trauma or surgical resections of tumors requires bone grafts or bone substitutes. Bone substitute must be biocompatible, osteoconductive, and must present good mechanical properties. Among biomaterials classicaly used, calcium phosphate ceramic appear to be suitable alternatives to bone grafts. Calcium phosphate are known able to promote new bone formation on contact and have been already used for the repair of periodontal defects, orthopaedic and maxillofacial applications. However, if these ceramics possess osteoconductive characteristics, they do not have no intrinsic osteinductive capability. They were unable to induce new bone formation in extraosseous site. Therefore they are inadapted to fill large bone defects or lesions, especially since they have little contact with bone. Thus, clinical applications may have to be restricted. Two main concepts have been envisaged to develop bone substitutes with osteogenic capacity. The first concern the combination of biomaterials with osteoprogenitors. These osteoprogenitors can be obtained from total bone marrow, mononuclear cell fraction of bone marrow, clone of bone marrow osteoblastic progenitors or bone explants. The second concept concern the association of biomaterials with osteogenic factors or plasmid DNA to develop a drug delivery system. Thus, growth hormone, transforming growth factor, bone morphogentetic protein, antibiotics, anti-cancer drugs or antiosteoporotic agents have been used to improve the osteoinduction of calcium phosphate ceramic. These types of new hybrid material appear as materials of the future.     

Demineralized Bone Matrix Carriers and their Clinical Applications: An Overview

Reconstruction of massive bone defects is challenging for orthopaedic clinicians, especially in cases of severe trauma and resection of tumors in various locales. Autologous iliac crest bone graft (ICBG) is the “gold standard” for bone grafting. However, the limited availability and complications at donor sites resulted in seeking other options like allografts and bone graft substitutes. Demineralized bone matrix (DBM) is a form of allograft using acidic solution to remove mineral components, while leaving much of the proteinaceous components native to bone, with small amounts of calcium‐based solids, inorganic phosphates, and some trace cell debris. It is an osteoconductive and osteoinductive biomaterial and is approved as a medical device for use in bone defects and spinal fusion. To pack consistently into the defect sites and stay firmly in the filling parts, DBM products have various forms combined with biocompatible viscous carriers, including sponges, strips, injectable putty, paste, and paste infused with chips. The present review aims to summarize the properties of various kind of viscous carriers and their clinical use combined with DBM in commercially available products. Given DBM'mercially available products. Given DBM;s long clinical track record and commercial accessibility in standard forms, opportunities to further develop and validate DBM as a versatile bone biomaterial in orthopaedic repair and regenerative medicine contexts are attractive.     

Repair of bone defects with marrow cells and porous ceramic. Experiments in rats

We studied the role of bone-marrow reconstituted porous ceramics in enhancing healing of a 5-mm femoral diaphyseal defect fixed with a rigid polyethylene plate in rats. Osseous repair was evaluated by histologic scoring. When blocks of porous calcium phosphate ceramics alone were introduced into the defects, most cases showed fibrous tissue interposition at the host bone-ceramic junction 1 month after implantation, and only four of 12 defects developed osseous or osteochondral union at both the proximal and distal junctions 2 months after surgery. However, when the ceramic was combined with syngeneic viable marrow cells, new bone formation occurred in isolated pore regions of the ceramic at 1 month, and extensive bone formation was seen in most pore regions 2 months after implantation. Out of 12 implants, complete bone union was seen in eight, and one showed osseous or osteochondral union at both junctions 2 months after surgery. Our results indicated that composite grafts of porous calcium phosphate ceramics and marrow cells may be clinically applicable to enhance osteogenesis and osteoconduction.     

Is there still an indication for bovine xeno-graft in human orthopaedic and trauma surgery?

Summary The author has studied 21 cases of bovine xeno-grafts in human orthopaedic and trauma surgery. The indications were benign tumours (filling of defects with or without structural support), osteotomies for lengthening or passive correction of the limb (support and filling of defects), tibial tubercle elevation and some trauma cases, particularly complex fractures of the lateral tibial plateau. The study showed a lack of graft resorption, no matter the site of implantation. The graft was more or less incorporated according to the site. It incorporated well in the traumatised epiphysis, incompletely in short or flat bones and in the metaphyseal zone, and poorly in the diaphysis. Histological studies were made of 2 cases with follow-up of 2 and 5 years. They both showed a fibrous interface, discrete graft resorption with no sign of consolidation. Without considering the risks of contamination (prion or other), the author rejects this type of graft from a biological view point. Out of the 21 cases, we can however confirm the good mechanical hold of the bovine xenografts, whatever their site of implantation. In conclusion, it seems that the only and rare indications which remain are purely mechanical in the attempt to substitute bone which could add mechanical qualities which are sometimes necessary for good biological results with bone substitutes in osteosynthesis.     

Clinical use of a newly developed calcium phosphate cement (XSB-671D)

Background Several kinds of thermally processed hydroxyapatite have been commonly used for bone defects due to bone diseases or fractures instead of autologous bone grafts. However, these materials do not change in form during surgery and are not absorbed over a long period. To overcome this disadvantage, calcium phosphate bone cements (CPCs) have been developed and are already in use in clinical cases. These materials have merit in that to be formed in situ they are injectable and absorbable, but there are still problems with their handling and their hardening properties. A newly developed CPC called XSB-671D hardens earlier and is more resistant to body fluids than other CPCs. The purpose of this article is to verify the effectiveness, safety and usefulness of this CPC (XSB-671D) as a bone defect filler. Methods We conducted clinical trials at five medical institutions based on a unified protocol in a total of 75 cases (30 males, 45 females). We observed the postoperative constitutional symptoms and local symptoms of the filling sites. The effectiveness of this material was evaluated by radiographs of the filled sites, and blood and urine were examined to evaluate any adverse effects. Results The ratio of the cases determined to be “effective” or “better” among the 74 cases we found qualified was 97.3%, and XSB-671D was confirmed to be a highly effective material with beneficial effects of biocompatibility and osteoconduction as a bone defect filler. Additionally, there were no adverse effects caused by XSB-671D except one local skin reaction, which disappeared 2 weeks later; its safety was also thus verified. Conclusions We conclude that effective, safe treatment is possible using XSB-671D in cases requiring filling of a bone defect as well as those with serious osteoporosis.     

带血运骨膜管移植和骨充填物修复桡骨长段缺损的研究

目的：探讨联合应用带血运骨膜管移植和骨充填物治疗兔桡骨长段缺损的效果。方法：实验分两部分，分别选用幼兔和成年兔各40只，根据填充物的不同分为4组，将兔双侧桡骨干中段切除3cm制成骨长段缺损模型，保留切骨段骨膜，重新重原缝合后作带血运骨膜管移植模型，左侧分别用自体骨，同种异体脱钙骨，磷酸三钙陶瓷和羟基磷灰石进行填充，右侧不行任何填作为对照。观察3个月。通过X线片，髓强度，骨密度和组织学检查等方法，了解骨缺损的修复效果。结果：幼兔术后6周，所有实验组双侧的骨缺损均得到修复，术后12周，磷酸三钙陶瓷和羟基磷灰石组桡骨抗弯曲强度较差与自体骨组、同种异体脱钙骨组和对照侧比较具有统计学意义（P＜0．05）；骨愈合为膜内成骨和软骨成骨，以膜内成骨为主，成年兔；各组实验侧骨缺损修复率分别为：自体骨组50％；同种异体脱钙骨组40％；磷酸三钙陶瓷和羟基磷灰石组为30％。对照侧骨缺损修复率为42．5％，结论：幼兔单行单血运骨管移植或结合应用骨充填物均可有效修复骨长段缺损，但置换较慢的骨充填物不利于再生骨强度的恢复，成年兔带血运骨膜移植联合应用骨填充物不能有效修复骨长段缺损。     

Use of bone anchors for flap fixation in burned patients

Mitek^® or Arim^® anchors were developed for use in orthopaedic surgery to facilitate soft tissue fixation to bone. We believe this tool can be useful in difficult cases when securing various flaps to bone, we present a retrospective study of deep thickness burns patients.     

Bone ingrowth into three different porous ceramics implanted into the tibia of rats and rabbits

Three different porous ceramics--calcium aluminate, calcium hydroxyapatite, and tricalcium phosphate--were implanted into the proximal tibia in rats and rabbits to study the interactions between these ceramics and a bony site that is abundant in bone marrow. New bone was consistently formed within the bone marrow surrounding and adjacent to all three types of ceramics. Calcium hydroxyapatite and tricalcium phosphate ceramics permitted bone ingrowth into their pores. The newly formed bone was found only in the part of the ceramic intruding into the bone, not in the portion protruding in the soft tissues outside the tibia. Partial replacement of the new bone opposite the medullary portion by new hemopoietic marrow occurred with longer implantation times. In contrast, no bone was seen within the pores of any of the calcium aluminate implants.     

Non-oncologic indication for elbow megaprothesis replacement: 2 cases report

IntroductionTreatment of elbow bone defects is still a huge challenge in orthopaedic in order to restore the shape and function of the elbow joint. Bone defect reconstruction is very difficult due to biomechanical complexity of the elbow joint and the poor coverage tissue of this area, so mega-prothesis can be considered the most optimal solution in these cases.Case reportWe present two clinical cases of megaprosthesis elbow replacement for treatment of bone defects caused by sequelae of trauma. There is one case of 3 cm bone defect at proximal ulna and one case of 3 cm bone defect at distal humerus. In the 1st case, the elbow joint is fusioned and the second case, the elbow joint is degenerated totally after 3 previous surgery. We performed total elbow replacement with a customized megaprosthesis for them. The Mayo elbow function assessment scale [1] pre-surgery was poor at 50 points. The average age is 35 years old. The mean post-operative follow-up time was 14 months. Range of elbow flexed motion was 135 degrees, both patients were maximally extension, the forearm pronation and supination were 90 and 75 degrees, respectively. The Mayo score is very good with 97,5 points. Both patients were completely satisfied with the postoperative results.ConclusionOur results show that megaprosthesis elbow replacement is a very effective option for cases large elbow bone defects due to trauma sequelae. However, careful preoperative preparation is required for the best outcome.     

自固化磷酸钙人工骨修复四肢骨缺损

目的　自固化磷酸钙 (CPC)为非陶瓷型羟基磷灰石类人工骨材料 ,应用 CPC进行临床四肢骨缺损修复。方法　 1998年 5月～ 2 0 0 0年 1月对 32例 36处骨缺损进行修复 ,年龄 4～ 5 9岁 ,平均 2 4 .7岁。骨缺损范围为 1cm× 2 cm～ 5 cm× 2 5 cm。缺损病因依次为骨折、骨囊肿、髂骨取骨后、骨纤维异常增殖症、内生软骨瘤和骨结核。缺损的部位累及股骨、髂骨、胫骨、肱骨、指骨、腓骨、跟骨、距骨和髋臼。结果　手术均获成功 ,术后随访 1～2 3个月 ,平均为 15 .3个月。全部患者未见任何不良的全身反应 ,X线片示 CPC与骨直接愈合 ,其中 12例行 CT扫描 ,并测定血钙、磷值。 CT提示植入 CPC与宿主骨直接愈合 ,无间隙存在 ,血钙、磷值无明显升高。结论　 CPC适用于临床上非负重或低负重部位骨缺损的修复     

多孔磷酸三钙修复骨缺损的临床观察

目的：评估多孔磷酸三钙修复骨缺损的临床效果。方法：对32例骨缺损患者应用新型的具有内连接结构的多孔磷酸三钙进行手术植入治疗，其中24例单纯用多孔磷酸三钙植入，6例取自体红骨髓与多孔磷酸三钙混合后植入，2例取自体髂骨与多孔磷酸三钙混合后植入，进行连续12～18个月的临床观察．结果：所有患者无不良的局部和全身反应．X线片显示，术后1．5～3个月磷酸三钙植入区与缺损周围的骨组织之间界限模糊，有新生骨形成；术后6个月磷酸三钙植入区内明显有新骨长入，磷酸三钙与骨组织融为一体，骨缺损已基本修复。3～6个月磷酸三钙的密度逐渐减低。结论：多孔磷酸三钙具有良好的生物相容性和骨传导作用，其新型的内连接结构既可以保持一定的刚度和强度，又便于骨组织长入；其理想的生物降解效应更有利于骨组织的改建和塑型。     

Hip revision surgery in cases with acetabular bone loss: PPR rings, homologous bone and platelet gel

Abstract Hip revision has several objectives: filling the bone defect, restoring the rotational center of the hip, and restoring limb length and hip function. Recently, through tissue engineering, it became possible to consider a fourth objective: to give a graft improved capability to osteointegrate and to restore bone stock as for amount of bone and bone quality (tissue engineering or bioenhancement). Concerning biomechanical and clinical objectives, rings are the most commonly used prosthesis. We used the Partial Pelvic Replacement (PPR) ring and retrospectively analyzed our patients at a mean follow-up of 27.2 months. We found no signs of radiological failure, no radiolucency or osteolysis, nor implant component ruptures. The mean Harris hip score improved significantly from 35.9 preoperatively to 78.1. As for the anatomical objective of hip revision surgery, homologous bone grafts are the most used means to fill a bone defect. We developed a new method to produce platelet gel as a simple and inexpensive way to obtain autologous growth factors, without any discomfort for the patient. We used platelet gel with PPR rings and homologous bone graft; we report our method and describe the first cases treated, with good results.     

医用硫酸钙OsteoSet修复颌骨缺损的疗效评价

目的评价医用硫酸钙OsteoSet骨移植替代物在颌骨囊性病变切除后骨缺损治疗中的效果。方法 2009年12月-2010年5月,收治15例颌骨囊性病变患者。其中男9例,女6例;年龄15～75岁,平均36.6岁。患者术前均摄颌骨全景断层片(orthopantomography,OPT)测量囊肿大小,范围为1.5 cm×1.5 cm～8.0 cm×3.0 cm。均采用囊肿刮治术加OsteoSet骨移植替代物移植术进行治疗,术中囊肿切除后骨缺损范围为1.5 cm×1.5 cm×1.5 cm～8.0 cm×3.0 cm×3.0 cm,OsteoSet骨移植替代物植入量为2～15 mL。通过影像学方法评估OsteoSet骨移植替代物的成骨效果。结果术后病理检查提示:根尖周囊肿7例、牙源性角化囊肿5例、含牙囊肿3例。15例均获随访,随访时间6～12个月。13例患者切口Ⅰ期愈合;2例术后引流时间延长,分别为5 d和7 d,经加压包扎处理后切口愈合良好。1例术后1个月复查出现肿胀,无感染症状;无1例出现术后感染和排斥反应。所有患者术后1 d均行X线检查,见材料将骨缺损充填良好;术后1个月颌骨OPT复查发现植入的OsteoSet颗粒吸收近半;术后3个月植入的OsteoSet颗粒全部吸收,原囊腔低密度影面积明显变小,囊腔内高密度影增加明显,囊腔边界模糊;术后6个月原囊腔内影像密度与正常骨组织密度差别不明显,囊腔边界消失,新骨基本充满缺损区。结论医用硫酸钙OsteoSet骨移植替代物是一种理想的骨缺损充填材料。     

Treatment of hand enchondroma with injectable calcium phosphate cement: a series of eight cases

The gold standard treatment for enchondroma in the hand is curettage and filling of the defect. The goal of this study was to evaluate the results when injectable calcium phosphate cement is used to fill the bone defect. Eight patients having a mean age of 44 years were operated through a minimally invasive skin incision. After a small bone window was made, curettage of the lesion was performed and verified by intraosseous endoscopy. The defect was filled with injectable calcium phosphate cement (JectOS/AREX^®BONE, Kasios, L’Union France). The mean pain score (out of 10) decreased from 4.1 preoperatively to 1.6 postoperatively. The mean QuickDASH (out of 100) improved from 37.66 to 24.14. At the last follow-up (mean of 16 months), the range of motion in the operated hand had reached 89.3% of the contralateral hand. Based on radiographs, a mean of 69.3% calcium phosphate cement remained in the bone. There were two cases of extraosseous cement leakage, one of which required revision and resulted in a poor outcome. Overall, these results show that curettage of a hand enchondroma followed by filling of the defect with injectable calcium phosphate cement is a simple, reliable technique with no donor site morbidity, as long as cement does not leak out.     

Macroscopical, histological, and morphometric studies of porous bone-replacement materials in minipigs 8 months after implantation.

OBJECTIVE: The aim of this investigation was to test the induction of bone formation and biodegradation of different biomaterials based on calcium phosphate (CaP). Up to now, hydroxyapatite and beta-tricalcium phosphate ceramics have routinely been sintered at temperatures of 1300 degrees C. The new CaP biomaterials tested are fabricated by a sol-gel process at only 700 degrees C. STUDY DESIGN: Critical-size defects (>5 cm(3)) in the mandible of 15 adult Goettingen minipigs were filled with 1 of the 2 new types of CaP biomaterials, or with 1 of 2 well-known old-type ceramics, or with a gelatin sponge (in the control group). Macroscopical, histological, and morphometric examination of the former defect areas were made 8 months postoperatively. RESULTS: Eight months after implantation of the new CaP biomaterials, complete bone formation was observed in the defect area, and at the same time, the foreign material was resorbed almost completely. After implantation of the classical types of ceramics, only incomplete bone formation and a lesser resorption rate of the foreign bodies were noted. The difference in the bone formation rate was significant: more than 93% for the new CaP biomaterials versus less than 58% for the classical types of ceramics (P < 0.01). CONCLUSION: The biological behavior of the new CaP biomaterials was better than that of the old-type sintered ceramic bone-grafting materials. These new CaP matrices are suitable for filling bone defects and are of interest for dentists, including implantologists, craniomaxillofacial and orthopedic surgeons, as well as traumatologists.     

Infection following the use of porous hydroxyapatite ceramic as a bone defect filler in articular fractures

Summary This article is a preliminary report focussed on infection after implantation of porous hydroxyapatite (Endobon®) as a bone defect filler. Eighteen adults received Endobon® implants for cancellous bone defects after trauma, tumoral excision or for arthrodesis. Four patients exhibited osteoarthritis. Infections required debridementand removal of osteosynthesis material and implants. Relevant infectious organisms were Staphylococcus and Enterobacteria. The incidence of postoperative infection, the nature of the organisms and indications are discussed. Further investigations are required in order to understand the causes of infection and undertake their prophylaxis.