Use of arthroscopy and interporous hydroxyapatite as a bone graft substitute in tibial plateau fractures

Tibial plateau fractures in 17 patients were managed arthroscopically, using interporous hydroxypatite (HA) as a bone graft substitute. Soft-tissue repair and intra-articular lavages were carried out arthroscopically, and depression of the articular surface was done by elevation of the subchondral plate by the bone compactor through a small window under image intensification and filling with HA through the tibial outer rim. Follow-up periods averaged 2 years and 6 months. According to roentgenograms and computed tomograms no development of arthrosis could be found. All of the patients have been followed to fracture union and have returned to their previous activity levels.     

自体骨移植与骨替代物手术治疗胫骨平台骨折的Meta分析

目的：通过Meta分析系统评价自体骨移植和骨替代物治疗胫骨平台骨折的临床疗效。方法：计算机检索2005年1月至2022年8月PubMed、Web of Science、中国知网、万方等数据库已发表的关于自体骨移植和骨替代物治疗胫骨平台骨折的病例对照研究文献。根据纳排标准进行文献筛选及数据提取,对入选的随机对照研究（randomized controlled trial,RCT）采用Cochrane手册中的干预性Meta分析标准进行质量评价。采用RevMan 5.3软件对两种方法的关节凹陷、关节面二次塌陷率、失血量、手术时间和感染率进行Meta分析。结果：共纳入7项RCT研究,424例患者,其中骨替代物组296例,自体骨移植组128例。两组手术时间[MD=-16.79,95%CI(-25.72,-7.85),P=0.000 2],出血量[MD=-70.49,95%CI(-79.34,-61.65),P<0.000 01]比较,差异有统计学意义。而关节凹陷[MD=-0.17,95%CI(-0.91,0.58),P=0.66],关节面二次塌陷率[RR=-0.74,95%CI(0.35,...     

Coralline hydroxyapatite bone graft substitute in hindfoot surgery

BACKGROUND: Coralline hydroxyapatite bone graft substitute material is created by the conversion of the calcium carbonate structure of coral into hydroxyapatite. The microstructure of the material resembles cancellous bone and provides an osteoconductive scaffold for bone ingrowth. The use of this material is reported in the orthopedic oncology and trauma literature. Short-term reports in foot procedures have been reported. METHOD: A retrospective review identified 10 patients who had undergone hindfoot arthrodesis with coralline hydroxyapatite bone graft. The charts were reviewed for outcomes, operative complications, and time to union. Nine of the 10 patients were available for additional examination. RESULTS: The average followup was 6 years. There were three complications. One patient had sural nerve numbness with partial resolution which was unrelated to the graft material. A rheumatoid patient on methotrexate and prednisone developed a deep wound infection 9 months after surgery. One patient had a nonunion of the talonavicular joint. Eight of the 10 patients reported good or excellent results. Radiographs continued to demonstrate the presence of the graft material at 6 years. Radiographs showed extrusion of the graft from the joint in all patients. No patient had symptoms from the extruded material. DISCUSSION: Coralline hydroxyapatite bone graft substitute appears to be a clinically effective material for use in foot procedures. No adverse events could be linked to the graft material. The graft material is difficult to contain and extrusion was present in all patients. The slow resorption is a concerning characteristic of the graft material. At 6-year followup, the continued presence of the material has not shown any adverse effect.     

Porous hydroxyapatite as a bone graft substitute in diaphyseal defects: a histometric study

Porous hydroxyapatite (IP200), formed by conversion of the Poritidae porites exoskeleton, has pores averaging 230 microns and pore interconnections averaging 190 microns in diameter. In the distal radial diaphyses of 14 dogs, bilateral 7.5 X 20 mm cortical windows were created and fitted with 5 X 7.5 X 20 mm blocks of IP200 implants and iliac autografts. Both implanted and contralateral grafted radius specimens were retrieved at 3, 6, 12, 24, and 48 months. Unstained undecalcified sections were examined by microradiography and UV epi-illumination. Stained undecalcified sections were examined by light microscopy and quantitated by histometric methods. Implant specimens demonstrated good union and bone ingrowth at all time intervals. The implant specimens were composed of (mean +/- SE) 10.6% +/- 1.0% soft tissue, 51.2% +/- 1.3% bone, and 38.2% +/- 1.0% IP200. The graft specimens showed good union with little apparent ingrowth at 3 months, followed by progressive appositional closure of cancellous spaces. The graft specimens contained 21.9% +/- 0.9% bone at 3 months with increases at each time interval to 73.1% +/- 8.7% at 48 months. The volume fraction and mean width of IP200 did not change with time, confirming the absence of implant biodegradation. The volume fraction and mean width of bone remained stable in the implant but increased in the graft specimens, corresponding to graft neocortex formation. It is concluded that implants initially filled in with bone while grafts initially replaced much of their spongiosa and subsequently filled in with bone. Histometry of untreated defects and measurement of mechanical properties are suggested for further study.     

双侧锁定钢板结合植骨治疗复杂型胫骨平台骨折

目的:探讨复杂型胫骨平台骨折手术治疗的有效方法和效果。方法:2008年5月至2011年4月收治复杂型胫骨平台骨折28例,男21例,女7例;年龄21～65岁,平均43岁。SchatzkerⅤ型11例,Ⅵ型17例。应用间接复位技术,双侧锁定钢板固定,结合自体髂骨植骨手术治疗。参照Rasmussen评价系统从临床和放射方面评定疗效。结果:28例获得随访,时间7～36个月,平均21.5个月。骨折愈合时间3～8个月,平均5.5个月。Rasmussen评价结果:临床评分:疼痛4.50±1.32,行走能力4.32±1.63,膝关节活动度4.07±1.34,膝关节稳定性4.78±1.27,伸膝关节4.85±1.12;放射评分:关节面塌陷5.07±0.92,平台增宽5.00±0.98,膝内外翻5.14±0.85;疗效结果:优8例,良15例,可3例,差2例。结论:复杂型胫骨平台骨折的治疗,充分评估并尽可能保护受损的软组织,选择合适的手术时机和手术切口,应用间接复位技术,有限切开及有效内固定,恢复关节面平整和良好下肢力线,早期功能锻炼,以达到最大程度恢复关节功能。     

Experimental tibial plateau fractures augmented with calcium phosphate cement or autologous bone graft

BACKGROUND: Depression fractures of the tibial plateau are often managed with use of internal fixation and autologous bone-grafting to maintain an anatomical reduction. Bone-grafting, however, provides only limited stability. As calcium phosphate cements have appropriate mechanical properties, they may provide a more suitable alternative. The objective of this study was to compare the effect of a calcium phosphate cement with that of impacted cancellous autograft for maintaining an anatomical reduction in an experimental model of a tibial plateau fracture. METHODS: Standardized cylindrical subchondral defects that were 8 mm in diameter and 10 mm deep were created bilaterally beneath the subchondral bone of the articular cartilage in the lateral tibial plateau of goats. An osteotome was used to fracture the overlying subchondral plate and articular cartilage. The plateau fracture fragment was completely depressed into the subchondral defect and then was anatomically reduced. The defects were randomly filled with either calcium phosphate cement or cancellous autograft. No internal fixation was used. The tibiae were harvested at varying time-periods that ranged from twenty-four hours to eighteen months. The stiffness of the healing augmented plateau fractures was determined. Histological specimens were assigned a score for degenerative changes. Loss of anatomic reduction was demonstrated in photomicrographs, and the amount of subsidence of the osteochondral fragment was measured in whole-mount histological sections. RESULTS: The prevalence and degree of fracture subsidence was significantly reduced at all time-points in the defects treated with calcium phosphate cement compared with those filled with autograft (p < 0.05). There were no significant differences in fracture stiffness between the two treatment groups at any of the time-points examined. The calcium phosphate cement was rapidly resorbed, and the volume fraction of the calcium phosphate cement was decreased to 4% at six months. The trabecular bone volume in the defects was restored to that of the intact controls at six months in both treatment groups. CONCLUSIONS: Cancellous autograft did not maintain an anatomical reduction of the tibial plateau fractures in this model. In contrast, augmentation with calcium phosphate cement prevented subsidence of the fracture fragment and maintained articular congruency as the fracture healed. The improved articular congruency reduced the prevalence and severity of degenerative changes in the joint.     

Tantalum is a good bone graft substitute in tibial tubercle advancement

Background  

Porous tantalum is reportedly a good substitute for structural bone graft in several applications. So far, its use has not been reported in tibial tuberosity anteriorization (TTA) for treatment of isolated degenerative chondral lesions of the patellofemoral joint.     

Use of bone allograft in tibial plateau fractures

To determine the behaviour of bone allografts in the treatment of tibial plateau fractures, 20 recipients of frozen bone allograft for a depressed tibial plateau fracture were studied. Incorporation of grafts took place in all cases, and no complication secondary to the allograft use has been detected. To avoid donor site morbidity associated with harvesting iliac crest, the use of frozen bone allograft is a good alternative in the treatment of depressed tibial plateau fractures. Received: 6 February 1997     

A coralline hydroxyapatite bone graft substitute. Preliminary report

Experimental histologic and biomechanical studies were performed in 52 dogs by use of a bone substitute composed of hydroxyapatite converted from sea coral calcite. The results demonstrate some potentially useful practical applications. The material was totally incorporated in bone. Although initially too weak to tolerate physiologic stresses, once incorporated it becomes almost as strong as the native bone. Clinical experience with internal fixation of fractures with hydroxyapatite in 18 patients is encouraging.     

Patellar graft for late disability following tibial plateau fractures

Patellar autografting as a primary procedure for depressed fractures of the lateral tibial plateau has been well discussed (Wilson and Jacobs, 1965). Three cases are documented in which this technique has been used as a salvage operation for late disability following severely comminuted fractures of one medial and two lateral tibial plateaux. All three patients had undergone previous attempts (one operative and two conservative) to reconstitute the depression in the proximal articular surface of the tibia.     

Tricalcium phosphate as a bone graft substitute

A clinical trial is reported that was conducted in an attempt to establish a timeframe for replacement of tricalcium phosphate by bone. In 20 cases, an 8.5mm by 3mm disc of tricalcium phosphate was implanted into the cut surface of the tibia at the time of total knee replacement. When followed radiographically, the disc of tricalcium phosphate generally could not be identified at six months. At two years, no untoward effects have occurred and no vestigial shadows remain, indicating that the block has fully incorporated and largely been absorbed and replaced by host bone. The experience in this series of cases indicates that tricalcium phosphate is a useful resorbable bone filler material.     

复合珊瑚羟基磷灰石人工骨的研制及其成骨效应

目的 自行研制复合珊瑚羟基磷灰石人工骨并评估其成骨效应。方法 取南海澄黄滨珊瑚碳酸钙在特定条件下经过“热液交换反应”，制成单纯珊瑚羟基磷灰石(coralline Hydroxyapatite，CHA)人工骨，并将其与基因重组骨形态发生蛋白(rhBMP2)和几丁糖复合制成了三种复合珊瑚羟基磷灰石(composite Coralline Hydroxyapatite，CCHA)人工骨，将此三种不同配型的复合人工骨和单纯CHA人工骨分别植入四组24只SD大白鼠肌肉内。手术后2、4、6、8周取材进行组织学观察，计数高倍单位视野内的成骨细胞数量和炎性细胞数量。采用SPSS8.0统计软件处理系统分析。结果 术后各时期取材结果显示：B组(CHA rhBMP2)和D组(CHA rhBM2P 几丁糖)的单位视野内成骨细胞数量明显多于A组(单纯CHA)和C组(CHA 几丁糖)：而C组和D组的单位视野内炎性细胞数量明显少于A组和B组。即D组人工骨的单位视野内的成骨细胞数量多、炎性细胞少。结论 rhBMP2-几丁糖／CHA复合人工骨不但具有显著的成骨诱导作用，还具有炎症反应轻及持续的诱导成骨作用，是一良好的骨移植替代物。     

An injectable calcium phosphate cement as a bone-graft substitute in the treatment of displaced lateral tibial plateau fractures

In the treatment of displaced tibial plateau fractures, filling the resultant metaphyseal defect is essential for maintaining reduction. This study reports on 14 patients with an average age of 53 (range 34-63) years who sustained such a fracture and whose tibial defect was augmented with an injectable calcium phosphate cement under arthroscopic and fluoroscopic control. Eight fractures were treated with subcortical percutaneous screw fixation, plates were used in four cases and two fractures were treated with bone cement only. Full weight-bearing was allowed after 6-12 weeks. At the last follow-up which averaged 28 (range 18-47) months, the reduction achieved at the index operation was not altered in any of the patients except one. Most patients recorded little or no pain with an average VAS score of 1.2 (0-3.4). Ten patients had no limitation of their walking distance. Patient satisfaction was good or excellent in 12 cases. Flexion averaged 140 degrees (range 130-150 degrees ) and extension was unlimited in 13 patients. The Lysholm knee score averaged 80 and the Knee Society score 180 (range 127-195). In our opinion the injectable calcium phosphate cement used here is a promising alternative for filling metaphyseal defects in the treatment of displaced tibial plateau fractures.     

Coralline hydroxyapatite as bone substitute in orthopedic oncology

We retrospectively reviewed the results of 71 consecutive patients managed with coralline hydroxyapatite (Pro-Osteon 500; Interpore Cross International) for bone defects produced as a result of surgical extirpation of bone tumors. All patients underwent a thorough physical examination and a radiographic evaluation at baseline and follow-up by the same senior surgeon (R.B.I.). Seventy-one patients were followed up for an average of 2.4 years (range, 8.1 months to 3.5 years); mean age of female patients was 39.8 years and that of male patients was 30 years. The functional status of patients at follow-up was evaluated based on comparison with preoperative functional status. Radiographic evaluation was performed and graded as follows: stage I (obvious margins), stage II (hazy margins), and stage III (obvious incorporation). The average time of return of preoperative function was 7.6 weeks. There were 3 major and 9 minor complications. We conclude that coralline hydroxyapatite graft in the form of Pro-Osteon 500 is a viable option for the management of bone defects in orthopedic oncology.     

Comparative fixation of tibial plateau fractures using alpha-BSM, a calcium phosphate cement, versus cancellous bone graft

OBJECTIVES: To compare the compressive strength of a bone substitute material (alpha-BSM) to cancellous bone when used to fill a defect void in a cadaver model of a Schatzker II split depression fracture of the lateral tibial plateau. DESIGN: Randomized, paired design. SETTING: Biomedical engineering laboratory. PATIENTS: Twenty-six human tibias were harvested from 13 cadavers. Three pairs of tibia fractured during preparation and were excluded. The remaining 10 matched pairs were randomized to fixation by using the bone substitute material or cancellous bone. INTERVENTION: A split depression fracture of the lateral tibial plateau was created in each tibia by using reproducible methods. This fracture was stabilized with a stainless steel L-plate and screws and either alpha-BSM or cancellous bone to fill the defect void. MAIN OUTCOME MEASUREMENTS: Stiffness of the elevated fragment in compression, total depression of the joint at 1000 N. RESULTS: The alpha-BSM bone substitute displayed significantly greater stiffness than cancellous bone constructs in Schatzker II split depression fractures of the lateral tibial plateau (P < 0.0001). Plateau defects displaced significantly less at 1000 N when using alpha-BSM in comparison to cancellous bone (P < 0.0001). CONCLUSIONS: In this cadaveric study, alpha-BSM is an effective bone substitute compared with cancellous bone graft for stabilizing split depression fractures of the lateral tibial plateau.     

High-energy tibial plateau fractures

The severity of a tibial plateau fracture and the complexity of its treatment depend on the energy imparted to the limb. Low-energy injuries typically cause unilateral depression-type fractures, whereas high-energy injuries can lead to comminuted fractures with significant osseous, soft-tissue, and neurovascular injury. Evaluation includes appropriate radiographs and careful clinical assessment of the soft-tissue envelope. Treatment is directed at safeguarding tissue vascularity and emphasizes restoration of joint congruity and the mechanical axis of the limb. Temporary joint-spanning external fixation facilitates soft-tissue recovery, whereas minimally invasive techniques and anatomically contoured plates can limit damage to the soft tissues and provide stable fixation. Alternatively, the use of limited internal fixation and definitive external fixation can minimize soft-tissue disruption, avoid complications, and allow fracture union. Complications, including infection, loss of fixation, and malalignment, are best avoided by following these biologically respectful treatment principles.     

Evaluation of hydroxyapatite and beta-tricalcium phosphate mixed with bone marrow aspirate as a bone graft substitute for posterolateral spinal fusion

Background:

Autologous cancellous bone is the most effective biological graft material. However, harvest of autologous bone is associated with significant morbidity. Since porous hydroxyapatite and beta-tricalcium phosphate are biodegradable materials and can be replaced by bone tissue, but it lacks osteogenic property. We conducted a study to assess their use as a scaffold and combine them with bone marrow aspirate for bone regeneration using its osteogenic property for posterolateral spinal fusion on one side and autologous bone graft on the other side and compare them radiologically in terms of graft incorporation and fusion.

Materials and Methods:

Thirty patients with unstable dorsal and lumbar spinal injuries who needed posterior stabilization and fusion were evaluated in this prospective study from October 2005 to March 2008. The posterior stabilization was done using pedicle screw and rod assembly, and fusion was done using hydroxyapatite and beta-tricalcium phosphate mixed with bone marrow aspirate as a bone graft substitute over one side of spine and autologous bone graft obtained from iliac crest over other side of spine. The patients were followed up to a minimum of 12 months. Serial radiographs were done at an interval of 3, 6, and 12 months and CT scan was done at one year follow-up. Graft incorporation and fusion were assessed at each follow-up. The study was subjected to statistical analysis using chi-square and kappa test to assess graft incorporation and fusion.

Results:

At the end of the study, radiological graft incorporation and fusion was evident in all the patients on the bone graft substitute side and in 29 patients on the autologous bone graft side of the spine (P > 0.05). One patient showed lucency and breakage of distal pedicle screw in autologous bone graft side. The interobserver agreement (kappa) had an average of 0.72 for graft incorporation, 0.75 for fusion on radiographs, and 0.88 for the CT scan findings.

Conclusion:

Hydroxyapatite and beta-tricalcium phosphate mixed with bone marrow aspirate seems to be a promising alternative to conventional autologous iliac bone graft for posterolateral spinal fusion.     

The efficacy of a nanosynthetic bone graft substitute as a bone graft extender in rabbit posterolateral fusion

BACKGROUND CONTEXTSynthetic bone graft substitutes are commonly used in spinal fusion surgery. Preclinical data in a model of spinal fusion to support their efficacy is an important component in clinical adoption to understand how these materials provide a biological and mechanical role in spinal fusion.PURPOSETo evaluate the in vivo response of a nanosynthetic silicated calcium phosphate putty (OstP) combined with autograft compared to autograft alone or a collagen-biphasic calcium phosphate putty (MasP) combined with autograft in a rabbit spinal fusion model.STUDY DESIGNEfficacy of a nanosynthetic silicated calcium phosphate putty as an extender to autograft was studied in an experimental animal model of posterolateral spinal fusion at 6, 9, 12 and 26 weeks, compared to a predicate device.METHODSSkeletally mature female New Zealand White rabbits (70) underwent single level bilateral posterolateral intertransverse process lumbar fusion, using either autograft alone (AG), a nanosynthetic silicated calcium phosphate putty (OstP) combined with autograft (1:1), or a collagen-biphasic calcium phosphate putty (MasP) combined with autograft (1:1). Iliac crest autograft was harvested for each group, and a total of 2 cc of graft material was implanted in the posterolateral gutters per side. Fusion success was assessed at all time points by manual palpation, radiographic assessment, micro-CT and at 12 weeks only using non-destructive range of motion testing. Tissue response, bone formation and graft resorption were assessed by decalcified paraffin histology and by histomorphometry of PMMA embedded sections.RESULTSAssessment of fusion by manual palpation at the 12 week endpoint showed 7 out of 8 (87.5%) bilateral fusions in the OstP extender group, 4 out of 8 (50%) fusions in the MasP extender group, and 6 out of 8 (75%) fusions in the autograft alone group. Similar trends were observed with fusion scores of radiographic and micro-CT data. Histology showed a normal healing response in all groups, and increased bone formation in the OstP extender group at all timepoints compared to the MasP extender group. New bone formed directly on the OstP granule surface within the fusion mass while this was not a feature of the Collagen-Biphasic CaP material. After 26 weeks the OstP extender group exhibited 100% fusions (5 out of 5) by all measures, whereas the MasP extender group resulted in bilateral fusions in 3 out of 5 (60%), assessed by manual palpation, and fusion of only 20 and 0% by radiograph and micro-CT scoring, respectively. Histology at 26 weeks showed consistent bridging of bone between the transverse processes in the Ost P extender group, but this was not observed in the MasP extender group.CONCLUSIONSThe nanosynthetic bone graft substituted studied here, used as an extender to autograft, showed a progression to fusion between 6 and 12 weeks that was similar to that observed with autograft alone, and showed excellent fusion outcomes, bone formation and graft resorption at 26 weeks.CLINICAL SIGNIFICANCEThis preclinical study showed that the novel nanosynthetic silicated CaP putty, when combined with autograft, achieved equivalent fusion outcomes to autograft. The development of synthetic bone grafts that demonstrate efficacy in such models can eliminate the need for excessive autograft harvest and results from this preclinical study supports their effective use in spinal fusion surgery.