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Khan A, Kyeremateng DK, Khan ZA, Tariq MS, Khan M. Complex Pathological Femoral Fracture in a Multiple Myeloma Patient Undergoing Intertrochanteric Fixation: A Case Report. Cureus 2024; 16:e58224. [PMID: 38689668 PMCID: PMC11058735 DOI: 10.7759/cureus.58224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/14/2024] [Indexed: 05/02/2024] Open
Abstract
Pathological fractures commonly occur in patients with metastatic bone diseases, particularly multiple myeloma. The current optimal management for metastatic pathological lesions affecting the proximal femur is surgical intervention. Surgical planning and appropriate use of imaging modalities are pivotal in the appropriate treatment of pathological fractures. Impending fractures create added layers of complexity in the decision-making process. The appropriateness of different surgical interventions involves a multi-disciplinary approach and the importance of holistic healthcare is paramount in these circumstances.
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Affiliation(s)
- Ameer Khan
- Cardiology, Tameside General Hospital, Ashton-under-Lyne, GBR
| | - Daniel K Kyeremateng
- Medicine, University of Leeds, Leeds, GBR
- Orthopaedics, Tameside General Hospital, Ashton-under-Lyne, GBR
| | - Zeeshan A Khan
- Orthopaedics and Trauma, North Manchester General Hospital, Manchester, GBR
- Orthopaedics and Trauma, Tameside General Hospital, Ashton-under-Lyne, GBR
| | - Muhammad S Tariq
- Internal Medicine, Tameside General Hospital, Ashton-under-Lyne, GBR
| | - Munir Khan
- Medicine, University of Leeds, Leeds, GBR
- Orthopedics and Traumatology, Tameside General Hospital, Ashton-under-Lyne, GBR
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Yang J, Pei Q, Wu X, Dai X, Li X, Pan J, Wang B. Stress reduction through cortical bone thickening improves bone mechanical behavior in adult female Beclin-1 +/- mice. Front Bioeng Biotechnol 2024; 12:1357686. [PMID: 38600946 PMCID: PMC11004267 DOI: 10.3389/fbioe.2024.1357686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 03/13/2024] [Indexed: 04/12/2024] Open
Abstract
Fragility fractures, which are more prevalent in women, may be significantly influenced by autophagy due to altered bone turnover. As an essential mediator of autophagy, Beclin-1 modulates bone homeostasis by regulating osteoclast and chondrocyte differentiation, however, the alteration in the local bone mechanical environment in female Beclin-1+/- mice remains unclear. In this study, our aim is to investigate the biomechanical behavior of femurs from seven-month-old female wild-type (WT) and Beclin-1+/- mice under peak physiological load, using finite element analysis on micro-CT images. Micro-CT imaging analyses revealed femoral cortical thickening in Beclin-1+/- female mice compared to WT. Three-point bending test demonstrated a 63.94% increase in whole-bone strength and a 61.18% increase in stiffness for female Beclin-1+/- murine femurs, indicating improved biomechanical integrity. After conducting finite element analysis, Beclin-1+/- mice exhibited a 26.99% reduction in von Mises stress and a 31.62% reduction in maximum principal strain in the femoral midshaft, as well as a 36.64% decrease of von Mises stress in the distal femurs, compared to WT mice. Subsequently, the strength-safety factor was determined using an empirical formula, revealing that Beclin-1+/- mice exhibited significantly higher minimum safety factors in both the midshaft and distal regions compared to WT mice. In summary, considering the increased response of bone adaptation to mechanical loading in female Beclin-1+/- mice, our findings indicate that increasing cortical bone thickness significantly improves bone biomechanical behavior by effectively reducing stress and strain within the femoral shaft.
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Affiliation(s)
- Jiaojiao Yang
- Key Laboratory for Biorheological Science and Technology of Ministry of Education, College of Bioengineering, Chongqing University, Chongqing, China
- Institute of Life Sciences, College of Basic Medicine, Chongqing Medical University, Chongqing, China
| | - Qilin Pei
- Institute of Life Sciences, College of Basic Medicine, Chongqing Medical University, Chongqing, China
- Department of Biomedical Engineering, Fourth Military Medical University, Xi’an, China
| | - Xingfan Wu
- Institute of Life Sciences, College of Basic Medicine, Chongqing Medical University, Chongqing, China
| | - Xin Dai
- Institute of Life Sciences, College of Basic Medicine, Chongqing Medical University, Chongqing, China
| | - Xi Li
- Institute of Life Sciences, College of Basic Medicine, Chongqing Medical University, Chongqing, China
| | - Jun Pan
- Key Laboratory for Biorheological Science and Technology of Ministry of Education, College of Bioengineering, Chongqing University, Chongqing, China
| | - Bin Wang
- Institute of Life Sciences, College of Basic Medicine, Chongqing Medical University, Chongqing, China
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Lam PW, Putnam D, Mayeda MMS, Gundle KR. Arthroplasty for Treating Proximal Femur Metastatic Lesions May Be Associated with Lower Mortality Rates Compared to Intramedullary Nailing within the VA Healthcare System. J Clin Med 2023; 12:5717. [PMID: 37685783 PMCID: PMC10488453 DOI: 10.3390/jcm12175717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 08/09/2023] [Accepted: 08/30/2023] [Indexed: 09/10/2023] Open
Abstract
Metastatic bony disease is a significant health issue, with approximately 700,000 new cases annually that tend to metastasize to bones. The proximal femur in the appendicular skeleton is commonly affected. Our study aimed to investigate mortality rates and hospital stay duration in patients with pathologic proximal femur fractures treated with either intramedullary nailing or arthroplasty within the Veterans Health Administration system. In total, 679 patients (265 arthroplasty, 414 intramedullary nails) were identified through ICD-9 and CPT codes from 30 September 2010 to 1 October 2015. Hospital stays were similar for both groups (arthroplasty: 10.5 days, intramedullary nails: 11 days, p = 0.1). Mortality was associated with increased age and Gagne comorbidity scores (p < 0.001). Arthroplasty showed a survival benefit in the log-rank test (p = 0.018), and this difference persisted in the multivariate analysis after adjusting for age and comorbidities, with a hazard ratio of 1.3. Our study reported evidence that arthroplasty is associated with increased patient survival even when accounting for age and comorbidities in treating metastatic disease of the proximal femur.
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Affiliation(s)
- Phillip W. Lam
- Department of Orthopaedics & Rehabilitation, Oregon Health & Science University, Portland, OR 97239, USA
| | - David Putnam
- Department of Orthopaedics & Rehabilitation, Oregon Health & Science University, Portland, OR 97239, USA
| | - Marissa M. Song Mayeda
- Department of Orthopaedics & Rehabilitation, Oregon Health & Science University, Portland, OR 97239, USA
| | - Kenneth R. Gundle
- Department of Orthopaedics & Rehabilitation, Oregon Health & Science University, Portland, OR 97239, USA
- Operative Care Division, Portland VA Medical Center, Portland, OR 97239, USA
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Verbruggen ASK, McNamara LM. Mechanoregulation may drive osteolysis during bone metastasis: A finite element analysis of the mechanical environment within bone tissue during bone metastasis and osteolytic resorption. J Mech Behav Biomed Mater 2023; 138:105662. [PMID: 36630755 DOI: 10.1016/j.jmbbm.2023.105662] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 12/22/2022] [Accepted: 01/04/2023] [Indexed: 01/09/2023]
Abstract
Metastatic bone disease occurs in 70-80% of advanced breast cancer patients and bone tissue is accepted to have attractive physical properties that facilitate cancer cell attraction, adhesion, and invasion. Bone cells also facilitate tumour invasion by biochemical signalling and through resorption of the bone matrix (osteolysis), which releases factors that further stimulate tumour cell activity. The evolving mechanical environment during tumour invasion might play an important role in these processes, as the activity of both bone and cancer cells is regulated by mechanical cues. In particular bone loss and altered mineralisation have been reported, yet how these alter the mechanical environment local to bone and tumour cells is unknown. The objective of this study is to quantify changes in the mechanical environment within bone tissue, during bone metastasis and osteolytic resorption, using finite element analysis (FEA) models reconstructed from high-resolution μCT images of metastatic mouse bone. In particular, we quantify time-dependent changes in mechanical stimuli, local to and distant from an invading tumour mass, to investigate putative mechanobiological cues for osteolysis during bone metastasis. We report here that in early metastasis (3 weeks after tumour inoculation), there was a decrease in strain distribution within the proximal femur trabecular and distal cortical bone tissue. These changes in the mechanical environment preceded extensive osteolytic destruction, but coincided with the onset of early osteolysis, cortical thickening and mineralisation of proximal and distal femur bone. We propose that early changes in the mechanical environment within bone tissue may activate resorption by osteoclast cells and thereby contribute to the extensive osteolytic bone loss at later stage (6 weeks) bone metastasis.
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Affiliation(s)
- Anneke S K Verbruggen
- Mechanobiology and Medical Device Research Group (MMDRG), Biomedical Engineering, College of Science and Engineering, University of Galway, Ireland
| | - Laoise M McNamara
- Mechanobiology and Medical Device Research Group (MMDRG), Biomedical Engineering, College of Science and Engineering, University of Galway, Ireland.
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Amendola RL, Miller MA, Kaupp SM, Cleary RJ, Damron TA, Mann KA. Modification to Mirels scoring system location component improves fracture prediction for metastatic disease of the proximal femur. BMC Musculoskelet Disord 2023; 24:65. [PMID: 36694156 PMCID: PMC9872372 DOI: 10.1186/s12891-023-06182-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 01/20/2023] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Correctly identifying patients at risk of femoral fracture due to metastatic bone disease remains a clinical challenge. Mirels criteria remains the most widely referenced method with the advantage of being easily calculated but it suffers from poor specificity. The purpose of this study was to develop and evaluate a modified Mirels scoring system through scoring modification of the original Mirels location component within the proximal femur. METHODS Computational (finite element) experiments were performed to quantify strength reduction in the proximal femur caused by simulated lytic lesions at defined locations. Virtual spherical defects representing lytic lesions were placed at 32 defined locations based on axial (4 axial positions: neck, intertrochanteric, subtrochanteric or diaphyseal) and circumferential (8 circumferential: 45-degree intervals) positions. Finite element meshes were created, material property assignment was based on CT mineral density, and femoral head/greater trochanter loading consistent with stair ascent was applied. The strength of each femur with a simulated lesion divided by the strength of the intact femur was used to calculate the Location-Based Strength Fraction (LBSF). A modified Mirels location score was next defined for each of the 32 lesion locations with an assignment of 1 (LBSF > 75%), 2 (LBSF: 51-75%), and 3 (LBSF: 0-50%). To test the new scoring system, data from 48 patients with metastatic disease to the femur, previously enrolled in a Musculoskeletal Tumor Society (MSTS) cross-sectional study was used. The lesion location was identified for each case based on axial and circumferential location from the CT images and assigned an original (2 or 3) and modified (1,2, or 3) Mirels location score. The total score for each was then calculated. Eight patients had a fracture of the femur and 40 did not over a 4-month follow-up period. Logistic regression and decision curve analysis were used to explore relationships between clinical outcome (Fracture/No Fracture) and the two Mirels scoring methods. RESULTS The location-based strength fraction (LBSF) was lowest for lesions in the subtrochanteric and diaphyseal regions on the lateral side of the femur; lesions in these regions would be at greatest risk of fracture. Neck lesions located at the anterior and antero-medial positions were at the lowest risk of fracture. When grouped, neck lesions had the highest LBSF (83%), followed by intertrochanteric (72%), with subtrochanteric (50%) and diaphyseal lesions (49%) having the lowest LBSF. There was a significant difference (p < 0.0001) in LBSF between each axial location, except subtrochanteric and diaphyseal which were not different from each other (p = 0.96). The area under the receiver operator characteristic (ROC) curve using logistic regression was greatest for modified Mirels Score using site specific location of the lesion (Modified Mirels-ss, AUC = 0.950), followed by a modified Mirels Score using axial location of lesion (Modified Mirels-ax, AUC = 0.941). Both were an improvement over the original Mirels score (AUC = 0.853). Decision curve analysis was used to quantify the relative risks of identifying patients that would fracture (TP, true positives) and those erroneously predicted to fracture (FP, false positives) for the original and modified Mirels scoring systems. The net benefit of the scoring system weighed the benefits (TP) and harms (FP) on the same scale. At a threshold probability of fracture of 10%, use of the modified Mirels scoring reduced the number of false positives by 17-20% compared to Mirels scoring. CONCLUSIONS A modified Mirels scoring system, informed by detailed analysis of the influence of lesion location, improved the ability to predict impending pathological fractures of the proximal femur for patients with metastatic bone disease. Decision curve analysis is a useful tool to weigh costs and benefits concerning fracture risk and could be combined with other patient/clinical factors that contribute to clinical decision making.
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Affiliation(s)
- Richard L Amendola
- grid.411023.50000 0000 9159 4457 Department of Orthopedic Surgery, SUNY Upstate Medical University, 750 East Adams Street, Syracuse, NY 13210 USA
| | - Mark A Miller
- grid.411023.50000 0000 9159 4457 Department of Orthopedic Surgery, SUNY Upstate Medical University, 750 East Adams Street, Syracuse, NY 13210 USA
| | - Shannon M Kaupp
- grid.411023.50000 0000 9159 4457 Department of Orthopedic Surgery, SUNY Upstate Medical University, 750 East Adams Street, Syracuse, NY 13210 USA
| | - Richard J Cleary
- grid.423152.30000 0001 0686 270XDivision of Mathematics and Science, Babson College, 231 Forest St, Babson Park, MA 02457 USA
| | - Timothy A Damron
- grid.411023.50000 0000 9159 4457 Department of Orthopedic Surgery, SUNY Upstate Medical University, 750 East Adams Street, Syracuse, NY 13210 USA
| | - Kenneth A Mann
- grid.411023.50000 0000 9159 4457 Department of Orthopedic Surgery, SUNY Upstate Medical University, 750 East Adams Street, Syracuse, NY 13210 USA
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Sun J, Zhang R, Liu S, Zhao Y, Mao G, Bian W. Biomechanical Characteristics of the Femoral Isthmus during Total Hip Arthroplasty in Patients with Adult Osteoporosis and Developmental Dysplasia of the Hip: A Finite Element Analysis. Orthop Surg 2022; 14:3019-3027. [PMID: 36125198 PMCID: PMC9627064 DOI: 10.1111/os.13474] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 07/05/2022] [Accepted: 07/25/2022] [Indexed: 11/30/2022] Open
Abstract
Objective This study investigated the underlying mechanisms of high fracture incidence in the femoral isthmus from a biomechanical perspective. Methods We retrospectively analyzed a total of 923 primary total hip arthroplasty (THA) patients and 355 osteoporosis (OP) patients admitted from January 2010 to January 2018. Through a series of screening conditions, 47 patients from each group were selected for inclusion in the study. The datasets on the unaffected side and affected side of the patients with unilateral developmental dysplasia of the hip (uDDH) were respectively classified as the normal group (Group I) and he tDDH group (Group II), and that of patients with osteoporosis were classified as the OP group (Group III). In this study, first, we collected computed tomography (CT) images and measured geometric parameters (inner and outer diameters) of the isthmus. Thereafter, to study biomechanical properties, we established six finite element models and calculated values of von Mises stress for each group with the methods of data conversion and grid processing. Results Compared with those of patients in the normal group, the values of the inner and outer diameters of femoral isthmus of patients in the DDH group were significantly lower (P < 0.001), while the inner diameters of patients in the OP group were significantly higher (P < 0.001) and the outer diameters of patients in the OP group showed no significant difference (P> 0.05). The cortical rates of patients in the normal group and the DDH group appeared insignificant (P > 0.05), and those of patients in normal group were significantly higher than those of patients in the OP group (P < 0.001). Moreover, patients in the DDH group showed a higher von Mises stress value than patients in the normal group (P < 0.001), but statistically speaking the values between patients in the OP and normal groups were insignificant (P > 0.05). Conclusions The relatively shorter inner and outer diameters of the isthmus in DDH resulted in intensive von Mises stress under the torque of the hip location, and induced a high fracture incidence. However, in patients in the OP group, the geometric morphology exhibited no anatomical variation, and the fracture was not due to the intensity of von Mises stress.
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Affiliation(s)
- Jianzhong Sun
- Department of Orthopedics, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China.,Xi'an Jiaotong University Health Science Center, Xi'an, China
| | - Rupeng Zhang
- Department of Orthopedics, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Shenghang Liu
- Xi'an Jiaotong University Health Science Center, Xi'an, China
| | - Yuqi Zhao
- Xi'an Jiaotong University Health Science Center, Xi'an, China.,Department of Orthopedics, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Genwen Mao
- Department of Orthopedics, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Weiguo Bian
- Department of Orthopedics, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
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Fu G, Zhong G, Yang Z, Cheng S, Ma L, Zhang Y. Two Cannulated Screws Provide Sufficient Biomechanical Strength for Prophylactic Fixation in Adult Patients With an Aggressive Benign Femoral Neck Lesion. Front Bioeng Biotechnol 2022; 10:891338. [PMID: 35875489 PMCID: PMC9300906 DOI: 10.3389/fbioe.2022.891338] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 05/27/2022] [Indexed: 01/14/2023] Open
Abstract
Background: Two cannulated screws were proposed for prophylactic fixation in adult patients with an aggressive benign femoral neck lesion in recent literature. However, the biomechanical properties of this intervention have not yet been investigated.Methods: After the evaluation of the heterogeneity of bone mineral density and geometry via quantitative computed tomography, 24 embalmed adult human cadaver femurs were randomized into the control, inferior half of the anterior cortical (25%) bone defect, entire anterior cortical (50%) bone defect, and the 50% bone defect and two cannulated screw group. Biomechanical analysis was conducted to compare the stiffness and failure load among the four groups when mimicking a one-legged stance. A CT-based finite element analysis (FEA) was performed to mimic the cortical and cancellous bone defect and the implantation of two cannulated screws of the four groups. Measurements of the maximal displacement and von Mises stress were conducted with the longitudinal load force and boundary conditions being established for a one-leg-standing status.Results: We noted a significant improvement in the failure load after the insertion of two 6.5 mm cannulated screws in femurs with 50% bone defect (+95%, p = 0.048), and no significant difference was found between the screw group and the intact femur. Similar trends were also found in the measurements of stiffness (+23%, p > 0.05) via biomechanical testing and the von Mises stresses (−71%, p = 0.043) by FEA when comparing the screw group and the 50% bone defect group.Conclusion: Our findings suggest that two cannulated screws provided sufficient biomechanical strength for prophylactic fixation in adult patients with an aggressive benign femoral neck lesion even when the entire anterior cortical bone is involved.
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Affiliation(s)
- Guangtao Fu
- Department of Orthopedics, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Guoqing Zhong
- Department of Orthopedics, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
- Shantou University Medical Colleges, Shantou, China
| | - Zehong Yang
- Department of Radiology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Shi Cheng
- Department of Orthopedics, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Limin Ma
- Department of Orthopedics, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
- *Correspondence: Limin Ma, ; Yu Zhang,
| | - Yu Zhang
- Department of Orthopedics, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
- *Correspondence: Limin Ma, ; Yu Zhang,
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Confavreux CB, Follet H, Mitton D, Pialat JB, Clézardin P. Fracture Risk Evaluation of Bone Metastases: A Burning Issue. Cancers (Basel) 2021; 13:cancers13225711. [PMID: 34830865 PMCID: PMC8616502 DOI: 10.3390/cancers13225711] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 11/07/2021] [Accepted: 11/10/2021] [Indexed: 11/16/2022] Open
Abstract
Major progress has been achieved to treat cancer patients and survival has improved considerably, even for stage-IV bone metastatic patients. Locomotive health has become a crucial issue for patient autonomy and quality of life. The centerpiece of the reflection lies in the fracture risk evaluation of bone metastasis to guide physician decision regarding physical activity, antiresorptive agent prescription, and local intervention by radiotherapy, surgery, and interventional radiology. A key mandatory step, since bone metastases may be asymptomatic and disseminated throughout the skeleton, is to identify the bone metastasis location by cartography, especially within weight-bearing bones. For every location, the fracture risk evaluation relies on qualitative approaches using imagery and scores such as Mirels and spinal instability neoplastic score (SINS). This approach, however, has important limitations and there is a need to develop new tools for bone metastatic and myeloma fracture risk evaluation. Personalized numerical simulation qCT-based imaging constitutes one of these emerging tools to assess bone tumoral strength and estimate the femoral and vertebral fracture risk. The next generation of numerical simulation and artificial intelligence will take into account multiple loadings to integrate movement and obtain conditions even closer to real-life, in order to guide patient rehabilitation and activity within a personalized-medicine approach.
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Affiliation(s)
- Cyrille B. Confavreux
- Centre Expert des Métastases Osseuses (CEMOS), Département de Rhumatologie, Institut de Cancérologie des Hospices Civils de Lyon (IC-HCL), Hôpital Lyon Sud, Hospices Civils de Lyon, 69310 Pierre Bénite, France
- Université de Lyon, Université Claude Bernard Lyon 1, 69100 Villeurbanne, France; (H.F.); (J.B.P.); (P.C.)
- Institut National de la Santé et de la Recherche Médicale INSERM, LYOS UMR1033, 69008 Lyon, France
- Correspondence:
| | - Helene Follet
- Université de Lyon, Université Claude Bernard Lyon 1, 69100 Villeurbanne, France; (H.F.); (J.B.P.); (P.C.)
- Institut National de la Santé et de la Recherche Médicale INSERM, LYOS UMR1033, 69008 Lyon, France
| | - David Mitton
- Université de Lyon, Université Gustave Eiffel, Université Claude Bernard Lyon 1, LBMC, UMR_T 9406, 69622 Lyon, France;
| | - Jean Baptiste Pialat
- Université de Lyon, Université Claude Bernard Lyon 1, 69100 Villeurbanne, France; (H.F.); (J.B.P.); (P.C.)
- CREATIS, CNRS UMR 5220, INSERM U1294, INSA Lyon, Université Jean Monnet Saint-Etienne, 42000 Saint-Etienne, France
- Service de Radiologie, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, 69310 Pierre Bénite, France
| | - Philippe Clézardin
- Université de Lyon, Université Claude Bernard Lyon 1, 69100 Villeurbanne, France; (H.F.); (J.B.P.); (P.C.)
- Institut National de la Santé et de la Recherche Médicale INSERM, LYOS UMR1033, 69008 Lyon, France
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Azari F, Sas A, Kutzner KP, Klockow A, Scheerlinck T, van Lenthe GH. Cemented short-stem total hip arthroplasty: Characteristics of line-to-line versus undersized cementing techniques using a validated CT-based finite element analysis. J Orthop Res 2021; 39:1681-1690. [PMID: 33095461 DOI: 10.1002/jor.24887] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 09/03/2020] [Accepted: 10/21/2020] [Indexed: 02/04/2023]
Abstract
Short stems are becoming increasingly popular in total hip arthroplasty as they preserve the bone stock and simplify the implantation process. Short stems are advised mainly for patients with good bone stock. The clinical use of short stems could be enlarged to patients with poor bone stock if a cemented alternative would be available. Therefore, this study aimed to quantify the mechanical performance of a cemented short stem and to compare the "undersized" cementing strategy (stem one size smaller than the rasp) with the "line-to-line" technique (stem and rasp with identical size). A prototype cemented short stem was implanted in eight pairs of human cadaveric femora using the two cementing strategies. Four pairs were experimentally tested in a single-legged stance condition; stiffness, strength, and bone surface displacements were measured. Subject-specific nonlinear finite element models of all the implanted femora were developed, validated against the experimental data, and used to evaluate the behavior of cemented short stems under physiological loading conditions resembling level walking. The two cementing techniques resulted in nonsignificant differences in stiffness and strength. Strength and stiffness as calculated from finite element were 8.7 ± 16% and 9.9 ± 15.0% higher than experimentally measured. Displacements as calculated from finite element analyses corresponded strongly (R 2 ≥ .97) with those measured by digital image correlation. Stresses during level walking were far below the fatigue limit for bone and bone cement. The present study suggests that cemented short stems are a promising solution in osteoporotic bone, and that the line-to-line and undersized cementing techniques provide similar outcomes.
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Affiliation(s)
| | - Amelie Sas
- Biomechanics Section, KU Leuven, Leuven, Belgium
| | - Karl P Kutzner
- Department of Orthopaedic Surgery and Traumatology, St. Josefs Hospital Wiesbaden, Wiesbaden, Germany
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A novel approach to evaluate the effects of artificial bone focal lesion on the three-dimensional strain distributions within the vertebral body. PLoS One 2021; 16:e0251873. [PMID: 34061879 PMCID: PMC8168867 DOI: 10.1371/journal.pone.0251873] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 05/05/2021] [Indexed: 12/14/2022] Open
Abstract
The spine is the first site for incidence of bone metastasis. Thus, the vertebrae have a high potential risk of being weakened by metastatic tissues. The evaluation of strength of the bone affected by the presence of metastases is fundamental to assess the fracture risk. This work proposes a robust method to evaluate the variations of strain distributions due to artificial lesions within the vertebral body, based on in situ mechanical testing and digital volume correlation. Five porcine vertebrae were tested in compression up to 6500N inside a micro computed tomography scanner. For each specimen, images were acquired before and after the application of the load, before and after the introduction of the artificial lesions. Principal strains were computed within the bone by means of digital volume correlation (DVC). All intact specimens showed a consistent strain distribution, with peak minimum principal strain in the range -1.8% to -0.7% in the middle of the vertebra, demonstrating the robustness of the method. Similar distributions of strains were found for the intact vertebrae in the different regions. The artificial lesion generally doubled the strain in the middle portion of the specimen, probably due to stress concentrations close to the defect. In conclusion, a robust method to evaluate the redistribution of the strain due to artificial lesions within the vertebral body was developed and will be used in the future to improve current clinical assessment of fracture risk in metastatic spines.
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Gardegaront M, Allard V, Confavreux C, Bermond F, Mitton D, Follet H. Variabilities in µQCT-based FEA of a tumoral bone mice model. J Biomech 2021; 118:110265. [PMID: 33545571 DOI: 10.1016/j.jbiomech.2021.110265] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Revised: 01/04/2021] [Accepted: 01/16/2021] [Indexed: 01/13/2023]
Abstract
A finite element analysis based on Micro-Quantitative Computed Tomography (µQCT) is a method with high potential to improve fracture risk prediction. However, the segmentation process and model generation are generally not automatized in their entirety. Even with a rigorous protocol, the operator might add uncertainties during the creation of the model. The aim of this study was to evaluate a µQCT-based model of mice tumoral and sham tibias in terms of the variabilities induced by the operator and sensitivity to operator-dependent variables (such as model orientation or length). Two different operators generated finite element (FE) models from µCT images of 8 female Balb/c nude mice tibias aged 10 weeks old with bone tumors induced in the right tibia and with sham injection in the left. From these models, predicted failure load was determined for two different boundary conditions: fixed support and spherical joints. The difference between the predicted and experimental failure load of both operators was large (-122% to 93%). The difference in the predicted failure load between operators was less for the spherical joints boundary conditions (9.8%) than for the fixed support (58.3%), p < 0.001, whereas varying the orientation of bone tibia caused more variability for the fixed support boundary condition (44.7%) than for the spherical joints (9.1%), p < 0.002. Varying tibia length had no significant effect, regardless of boundary conditions (<4%). When using the same mesh and same orientation, the difference between operators is non-significant (<6%) for each model. This study showed that the operator influences the failure load assessed by a µQCT-based finite element model of the tumoral and sham mice tibias. The results suggest that automation is needed for better reproducibility.
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Affiliation(s)
- M Gardegaront
- Univ Lyon, Université Claude Bernard Lyon 1, INSERM, LYOS UMR 1033, 69008 Lyon, France
| | - V Allard
- Univ Lyon, Université Claude Bernard Lyon 1, INSERM, LYOS UMR 1033, 69008 Lyon, France
| | - C Confavreux
- Univ Lyon, Université Claude Bernard Lyon 1, INSERM, LYOS UMR 1033, 69008 Lyon, France; Centre Expert des Métastases et d'Oncologie Osseuses (CEMOS), Service de Rhumatologie Sud, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, Lyon, France
| | - F Bermond
- Univ Lyon, Université Claude Bernard Lyon 1, Univ Gustave Eiffel, IFSTTAR, LBMC UMR_T9406, 69622 Lyon, France
| | - D Mitton
- Univ Lyon, Université Claude Bernard Lyon 1, Univ Gustave Eiffel, IFSTTAR, LBMC UMR_T9406, 69622 Lyon, France
| | - H Follet
- Univ Lyon, Université Claude Bernard Lyon 1, INSERM, LYOS UMR 1033, 69008 Lyon, France.
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12
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Dassa M, Roux C, Tselikas L, Delpla A, Yevich S, Faron M, Teriitehau C, Hakime A, Al Ahmar M, de Baère T, Deschamps F. Image-guided Percutaneous Fixation with Internal Cemented Screws of Impending Femoral Neck Pathologic Fractures in Patients with Metastatic Cancer: Safety, Efficacy, and Durability. Radiology 2020; 297:721-729. [DOI: 10.1148/radiol.2020201341] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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13
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Whyne CM, Ferguson D, Clement A, Rangrez M, Hardisty M. Biomechanical Properties of Metastatically Involved Osteolytic Bone. Curr Osteoporos Rep 2020; 18:705-715. [PMID: 33074529 DOI: 10.1007/s11914-020-00633-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/29/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE OF REVIEW Skeletal metastasis involves the uncoupling of physiologic bone remodeling resulting in abnormal bone turnover and radical changes in bony architecture, density, and quality. Bone strength assessment and fracture risk prediction are critical in clinical treatment decision-making. This review focuses on bone tissue and structural mechanisms altered by osteolytic metastasis and the resulting changes to its material and mechanical behavior. RECENT FINDINGS Both organic and mineral phases of bone tissue are altered by osteolytic metastatic disease, with diminished bone quality evident at multiple length-scales. The mechanical performance of bone with osteolytic lesions is influenced by a combination of tissue-level and structural changes. This review considers the effects of osteolytic metastasis on bone biomechanics demonstrating its negative impact at tissue and structural levels. Future studies need to assess the cumulative impact of cancer treatments on metastatically involved bone quality, and its utility in directing multimodal treatment planning.
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Affiliation(s)
- Cari M Whyne
- Orthopaedic Biomechanics Lab, Sunnybrook Research Institute, University of Toronto, Toronto, Canada.
- Department of Surgery, University of Toronto, Toronto, Canada.
- Biomedical Engineering, University of Toronto, Toronto, Canada.
| | - Dallis Ferguson
- Orthopaedic Biomechanics Lab, Sunnybrook Research Institute, University of Toronto, Toronto, Canada
- Biomedical Engineering, University of Toronto, Toronto, Canada
| | - Allison Clement
- Orthopaedic Biomechanics Lab, Sunnybrook Research Institute, University of Toronto, Toronto, Canada
| | - Mohammedayaz Rangrez
- Orthopaedic Biomechanics Lab, Sunnybrook Research Institute, University of Toronto, Toronto, Canada
| | - Michael Hardisty
- Orthopaedic Biomechanics Lab, Sunnybrook Research Institute, University of Toronto, Toronto, Canada
- Department of Surgery, University of Toronto, Toronto, Canada
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14
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Riglet L, Confavreux C, Chaudier P, Pialat JB, Bermond F, Gardegaront M, Follet H, Mitton D. Ex vivo experiments on femurs to assess metastatic bone strength. Comput Methods Biomech Biomed Engin 2020. [DOI: 10.1080/10255842.2020.1815312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- L. Riglet
- Univ Lyon, Univ Claude Bernard Lyon 1, Univ Gustave Eiffel, LBMC UMR_T 9406, Lyon, France
| | - C. Confavreux
- Univ Lyon, Univ Claude Bernard Lyon 1, INSERM, UMR 1033, Lyon, France
- CEMOS, Service de Rhumatologie, Centre hospitalier Lyon Sud, Institut de Cancérologie des Hospices Civils de Lyon, Lyon, France
| | - P. Chaudier
- Service de Chirurgie Orthopédique, Centre hospitalier Lyon Sud, Lyon, France
| | - J.-B Pialat
- Service de Radiologie, Centre hospitalier Lyon Sud, Lyon, France
| | - F. Bermond
- Univ Lyon, Univ Claude Bernard Lyon 1, Univ Gustave Eiffel, LBMC UMR_T 9406, Lyon, France
| | - M. Gardegaront
- Univ Lyon, Univ Claude Bernard Lyon 1, INSERM, UMR 1033, Lyon, France
| | - H. Follet
- Univ Lyon, Univ Claude Bernard Lyon 1, INSERM, UMR 1033, Lyon, France
| | - D. Mitton
- Univ Lyon, Univ Claude Bernard Lyon 1, Univ Gustave Eiffel, LBMC UMR_T 9406, Lyon, France
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15
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Shinoda Y, Sawada R, Ishibashi Y, Akiyama T, Zhang L, Hirai T, Oka H, Ohki T, Ikegami M, Okajima K, Okuma T, Kobayashi H, Goto T, Haga N, Tanaka S. Prediction of pathological fracture in patients with lower limb bone metastasis using computed tomography imaging. Clin Exp Metastasis 2020; 37:607-616. [PMID: 32737738 DOI: 10.1007/s10585-020-10053-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 07/26/2020] [Indexed: 10/23/2022]
Abstract
Lower limb pathological fractures caused by bone metastases can severely impair activities of daily living, so recognizing fracture risk is essential. Medial cortical involvement (MCI) in the proximal femur has been demonstrated to affect bone strength in biomechanical studies, but it has not been investigated in real patients. Between 2012 and 2019, 161 bone metastases with computed tomography (CT) images were retrospectively examined. Twenty-nine fractures were observed including 14 metastases with pathological fractures at the first examination, and prophylactic surgery was performed for 50 metastases. We extracted clinicopathological data using CT images, including patient's background, MCI in the proximal femur, site, size, circumferential cortical involvement (CCI), pain, and nature of metastasis. Cox proportional hazard regression analyses were performed, and we created integer scores for predicting fractures. We revealed that MCI, CCI, lytic dominant lesion, and pain were significant factors by univariate analyses. By multivariable analysis, MCI and each 25% CCI were significant and integer score 1 was assigned based on hazard ratio. The full score was four points, with MCI in the proximal femur (one point) and ≥ 75% CCI (three points). With integer score two, sensitivity was 88.9% and specificity was 81.2% for predicting fracture within 60 days. In conclusion, MCI and CCI examined by CT images were the risk factors for pathological fracture. CCI ≥ 50% is a widely known risk factor, but in addition, it may be better to consider surgery if MCI in the proximal femur is observed in metastasis with 25-50% CCI.
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Affiliation(s)
- Yusuke Shinoda
- Department of Rehabilitation Medicine, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan. .,Department of Orthopaedic Surgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan.
| | - Ryoko Sawada
- Department of Rehabilitation Medicine, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan.,Department of Orthopaedic Surgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yuki Ishibashi
- Department of Orthopaedic Surgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan.,Department of Musculoskeletal Oncology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan
| | - Toru Akiyama
- Department of Orthopaedic Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Liuzhe Zhang
- Department of Orthopaedic Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Toshihide Hirai
- Department of Orthopaedic Surgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan.,Department of Musculoskeletal Oncology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan
| | - Hiroyuki Oka
- Department of Medical Research and Management for Musculoskeletal Pain, 22nd Century Medical & Research Center, Faculty of Medicine, The University of Tokyo Hospital, Tokyo, Japan
| | - Takahiro Ohki
- Department of Rehabilitation Medicine, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan.,Department of Orthopaedic Surgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Masachika Ikegami
- Department of Orthopaedic Surgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Koichi Okajima
- Department of Musculoskeletal Oncology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan
| | - Tomotake Okuma
- Department of Musculoskeletal Oncology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan
| | - Hiroshi Kobayashi
- Department of Orthopaedic Surgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Takahiro Goto
- Department of Musculoskeletal Oncology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan
| | - Nobuhiko Haga
- Department of Rehabilitation Medicine, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Sakae Tanaka
- Department of Orthopaedic Surgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
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16
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Damron TA, Mann KA. Fracture risk assessment and clinical decision making for patients with metastatic bone disease. J Orthop Res 2020; 38:1175-1190. [PMID: 32162711 PMCID: PMC7225068 DOI: 10.1002/jor.24660] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Revised: 01/17/2020] [Accepted: 02/29/2020] [Indexed: 02/04/2023]
Abstract
Metastatic breast, prostate, lung, and other cancers often affect bone, causing pain, increasing fracture risk, and decreasing function. Management of metastatic bone disease (MBD) is clinically challenging when there is potential but uncertain risk of pathological fracture. Management of MBD has become a major focus within orthopedic oncology with respect to fracture and impending fracture care. If impending skeletal-related events (SREs), particularly pathologic fracture, could be predicted, increasing evidence suggests that prophylactic surgical treatment improves patient outcomes. However, current fracture risk assessment and radiographic metrics do not have high accuracy and have not been combined with relevant patient survival tools. This review first explores the prevalence, incidence, and morbidity of MBD and associated SREs for different cancer types. Strengths and limitations of current fracture risk scoring systems for spinal stability and long bone fracture are highlighted. More recent computed tomography (CT)-based structural rigidity analysis (CTRA) and finite element (FE) analysis methods offer advantages of increased specificity (true negative rate), but are limited in availability. Other fracture prediction approaches including parametric response mapping and positron emission tomography/computed tomography measures show early promise. Substantial new information to inform clinical decision-making includes measures of survival, clinical benefits, and economic analysis of prophylactic treatment compared to after-fracture stabilization. Areas of future research include use of big data and machine learning to predict SREs, greater access and refinement of CTRA/FE approaches, combination of clinical survival prediction tools with radiographically based fracture risk assessment, and net benefit analysis for fracture risk assessment and prophylactic treatment.
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17
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Sas A, Ohs N, Tanck E, van Lenthe GH. Nonlinear voxel-based finite element model for strength assessment of healthy and metastatic proximal femurs. Bone Rep 2020; 12:100263. [PMID: 32322609 PMCID: PMC7163060 DOI: 10.1016/j.bonr.2020.100263] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 03/27/2020] [Accepted: 03/30/2020] [Indexed: 12/18/2022] Open
Abstract
Nonlinear finite element (FE) models can accurately quantify bone strength in healthy and metastatic femurs. However, their use in clinical practice is limited since state-of-the-art implementations using tetrahedral meshes involve a lot of manual work for which specific modelling software and engineering knowledge are required. Voxel-based meshes could enable the transition since they are robust and can be highly automated. Therefore, the aim of this work was to bridge the modelling gap between the tetrahedral and voxel-based approach. Specifically, we validated a nonlinear voxel-based FE method relative to experimental data from 20 femurs with and without artificial metastases that had been mechanically loaded until failure. CT scans of the femurs were segmented and automatically converted into a voxel-based mesh with hexahedral elements. Nonlinear material properties were implemented in an open-source linear voxel-based FE solver by adding an additional loop to the routine such that the material properties could be adapted after each increment. Bone strength, quantified as the maximum force in the force-displacement curve, was evaluated. The results were compared to a previously established nonlinear tetrahedral FE approach as well as to the experimentally measured bone strength. The voxel-based FE model predicted the experimental bone strength very well both for healthy (R2 = 0.90, RMSE = 0.88 kN) and metastatic femurs (R2 = 0.93, RMSE = 0.64 kN). The model precision and accuracy were very similar to the ones obtained with the tetrahedral model (R2 = 0.90/0.93, RMSE = 0.90/0.64 kN for intact/metastatic respectively). The more intuitive voxel-based meshes thus quantified macroscale femoral strength equally well as state-of-the-art tetrahedral models. The robustness, high level of automation and time-efficiency (< 30 min) of the implemented workflow offer great potential for developing FE models to improve fracture risk prediction in clinical practice. A nonlinear voxel-based FE model was evaluated to assess femoral bone strength Both healthy and metastatic femurs were evaluated The FE models predicted bone strength with high accuracy and precision Voxel-based and tetrahedral FE models showed similar accuracy and precision An iterative routine enabled material nonlinearity in a linear FE solver
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Affiliation(s)
- Amelie Sas
- Biomechanics Section, KU Leuven, Leuven, Belgium
| | - Nicholas Ohs
- Institute for Biomechanics, ETH Zurich, Zurich, Switzerland
| | - Esther Tanck
- Orthopaedic Research Laboratory, Radboud Institute for Health Sciences, Radboud university medical center, Nijmegen, the Netherlands
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18
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Sas A, Van Camp D, Lauwers B, Sermon A, van Lenthe GH. Cement augmentation of metastatic lesions in the proximal femur can improve bone strength. J Mech Behav Biomed Mater 2020; 104:103648. [DOI: 10.1016/j.jmbbm.2020.103648] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Revised: 01/15/2020] [Accepted: 01/18/2020] [Indexed: 12/16/2022]
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19
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Delpuech B, Nicolle S, Confavreux CB, Bouazza L, Clezardin P, Mitton D, Follet H. Failure Prediction of Tumoral Bone with Osteolytic Lesion in Mice. ADVANCED STRUCTURED MATERIALS 2020. [DOI: 10.1007/978-3-030-50464-9_2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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20
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Shinoda Y, Kobayashi H, Kaneko M, Ohashi S, Bessho M, Hayashi N, Oka H, Imanishi J, Sawada R, Ogura K, Tanaka S, Haga N, Kawano H. Prediction of the pathological fracture risk during stance and fall-loading configurations for metastases in the proximal femur, using a computed tomography-based finite element method. J Orthop Sci 2019; 24:1074-1080. [PMID: 31521453 DOI: 10.1016/j.jos.2019.08.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2019] [Revised: 07/20/2019] [Accepted: 08/16/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND It is important to assess the fracture risk associated with metastasis in the proximal femur. The study aimed to clarify the effect of tumor location on the risk of pathological fracture of the proximal femur and investigate the fracture risk not only in the stance-loading configuration (SC), but also in the fall-loading configuration (FC) using a computed tomography (CT)-based finite element (FE) method based on a simulated metastatic model. METHODS The axial CT scans of the proximal femora of non-osteoporotic healthy men (n = 4; age range, 42-48 years) and osteoporotic post-menopausal women (n = 4; age range, 69-78 years) were obtained with a calibration phantom, from which the three-dimensional FE models were constructed. A single 15-mm-diameter spherical void simulating a tumor was created at various locations from the neck to subtrochanteric level. Nonlinear FE analyses were performed. RESULTS The mean predicted fracture loads without spherical voids in the SC were 7700 N in men and 4370 N in women. With the void at the medial femoral neck and in the region anteromedial to lesser trochanter, the mean predicted fracture load significantly reduced to 51.3% and 59.4% in men and 34.1% and 64.5% in women, respectively. The mean predicted fracture loads without a spherical void in the FC were 2500 N in men and 1862 N in women. With the void at the medial and posterior femoral neck, the predicted fracture load was significantly reduced to 65.7% and 79.7% in men and 48.3% and 65.4% in women, respectively. CONCLUSIONS These results showed that the risk of pathologic fracture was quite high in both the SC and FC when the lytic lesion existed along the principal compressive trabecular trajectory or posterior neck. Prophylactic intervention should be considered for metastases at these locations.
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Affiliation(s)
- Yusuke Shinoda
- Department of Rehabilitation Medicine, The University of Tokyo Hospital, Tokyo, Japan; Department of Orthopaedic Surgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Hiroshi Kobayashi
- Department of Orthopaedic Surgery, The University of Tokyo Hospital, Tokyo, Japan.
| | - Masako Kaneko
- Department of Orthopaedic Surgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Satoru Ohashi
- Department of Orthopaedic Surgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Masahiko Bessho
- Department of Orthopaedic Surgery, Ichikawa Hospital, International University of Health and Welfare, Chiba, Japan
| | - Naoto Hayashi
- Department of Computational Diagnostic Radiology and Preventive Medicine, The University of Tokyo Hospital, Tokyo, Japan
| | - Hiroyuki Oka
- Department of Medical Research and Management for Musculoskeletal Pain, 22nd Century Medical & Research Center, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Jungo Imanishi
- Department of Orthopaedic Oncology and Surgery, Saitama Medical University International Medical Center, Saitama, Japan
| | - Ryoko Sawada
- Department of Orthopaedic Surgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Koichi Ogura
- Department of Orthopaedic Surgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Sakae Tanaka
- Department of Orthopaedic Surgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Nobuhiko Haga
- Department of Rehabilitation Medicine, The University of Tokyo Hospital, Tokyo, Japan
| | - Hirotaka Kawano
- Department of Orthopaedic Surgery, Teikyo University School of Medicine, Tokyo, Japan
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21
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Worley ML, Patterson TM, Graboyes EM, Wu Y, Brody RM, Hornig J, Walton Z. Association of the Anterolateral Thigh Osteomyocutaneous Flap With Femur Structural Integrity and Assessment of Prophylactic Fixation. JAMA Otolaryngol Head Neck Surg 2019; 144:769-775. [PMID: 30054621 DOI: 10.1001/jamaoto.2018.1014] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Importance The chimeric anterolateral thigh osteomyocutaneous (ALTO) free flap is a recently described microvascular option for head and neck osseous defects associated with complex soft-tissue requirements. To date, the association of ALTO flap harvest with femur structural integrity and the need for routine prophylactic fixation following harvest has been incompletely described. Objective To investigate the association of ALTO flap harvest, with and without prophylactic fixation, on femur structural integrity as measured by 4-point bend and torsional biomechanical testing. Design and Setting At a research laboratory, 24 synthetic fourth-generation composite femurs with validated biomechanical properties underwent 10-cm-long, 30% circumferential osteotomies at the proximal middle third of the femur; 6 femurs served as controls. Osteotomized femurs with and without fixation underwent torsional and 4-point bend biomechanical testing. Femur fixation consisted of intramedullary nail and distal interlock screw placement. Main Outcomes and Measures Force and torque to fracture (expressed in kilonewtons [kN] and Newton meters [N∙m], respectively) were compared between controls, osteotomized femurs without fixation, and osteotomized femurs with fixation. Additional outcome measures included femur stiffness and fracture patterns. Results On posterior to anterior (PA) 4-point bend testing, force to fracture of osteotomized femurs was 22% of controls (mean difference, 8.3 kN; 95% CI, 6.6-10.0 kN). On torsional testing the torque to fracture of osteotomized femurs was 12% of controls (mean difference, 351.1 N∙m; 95% CI, 307.1-395.1 N∙m). Following fixation there was a 67% improvement in PA force to fracture and a 37% improvement in torque to fracture. However, osteotomized femurs with fixation continued to have a reduced PA force to fracture at 37% of controls (mean difference, 6.8 kN; 95% CI, 4.5-9.2 kN) and torque to fracture at 16% of controls (mean difference, 333.7 N∙m; 95% CI, 306.8-360.6 N∙m). On torsional testing, all osteotomized femurs developed similar spiral fractures through a corner of the distal osteotomy site. This fracture pattern changed after prophylactic fixation with femurs developing nondisplaced fractures through the proximal osteotomy site. There were no underlying hardware failures during testing of osteotomized femurs with fixation. Conclusions and Relevance Anterolateral thigh osteomyocutaneous flap harvest results in significant changes in the structural integrity of the femur. Postoperative stabilization should be strongly considered, with future research directed at investigating the clinical significance of residual biomechanical changes following femur fixation.
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Affiliation(s)
- Mitchell L Worley
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston
| | - Travis M Patterson
- Department of Orthopaedic Surgery, Medical University of South Carolina, Charleston
| | - Evan M Graboyes
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston.,Cancer Control Program, Hollings Cancer Center, Charleston, South Carolina
| | - Yongren Wu
- Department of Orthopaedic Surgery, Medical University of South Carolina, Charleston
| | - Robert M Brody
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston
| | - Joshua Hornig
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston
| | - Zeke Walton
- Department of Orthopaedic Surgery, Medical University of South Carolina, Charleston
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22
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Benca E, Synek A, Amini M, Kainberger F, Hirtler L, Windhager R, Mayr W, Pahr DH. QCT-based finite element prediction of pathologic fractures in proximal femora with metastatic lesions. Sci Rep 2019; 9:10305. [PMID: 31311994 PMCID: PMC6635505 DOI: 10.1038/s41598-019-46739-y] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Accepted: 07/04/2019] [Indexed: 11/17/2022] Open
Abstract
Predicting pathologic fractures in femora with metastatic lesions remains a clinical challenge. Currently used guidelines are inaccurate, especially to predict non-impeding fractures. This study evaluated the ability of a nonlinear quantitative computed tomography (QCT)-based homogenized voxel finite element (hvFE) model to predict patient-specific pathologic fractures. The hvFE model was generated highly automated from QCT images of human femora. The femora were previously loaded in a one-legged stance setup in order to assess stiffness, failure load, and fracture location. One femur of each pair was tested in its intact state, while the contralateral femur included a simulated lesion on either the superolateral- or the inferomedial femoral neck. The hvFE model predictions of the stiffness (0.47 < R2 < 0.94), failure load (0.77 < R2 < 0.98), and exact fracture location (68%) were in good agreement with the experimental data. However, the model underestimated the failure load by a factor of two. The hvFE models predicted significant differences in stiffness and failure load for femora with superolateral- and inferomedial lesions. In contrast, standard clinical guidelines predicted identical fracture risk for both lesion sites. This study showed that the subject-specific QCT-based hvFE model could predict the effect of metastatic lesions on the biomechanical behaviour of the proximal femur with moderate computational time and high level of automation and could support treatment strategy in patients with metastatic bone disease.
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Affiliation(s)
- Emir Benca
- Department of Orthopedics and Trauma Surgery, Medical University of Vienna, 1090, Vienna, Austria.
| | - Alexander Synek
- Institute for Lightweight Design and Structural Biomechanics, TU Wien, 1060, Vienna, Austria
| | - Morteza Amini
- Institute for Lightweight Design and Structural Biomechanics, TU Wien, 1060, Vienna, Austria
| | - Franz Kainberger
- Department of Radiology, Medical University of Vienna, 1090, Vienna, Austria
| | - Lena Hirtler
- Division of Anatomy, Center for Anatomy and Cell Biology, Medical University of Vienna, 1090, Vienna, Austria
| | - Reinhard Windhager
- Department of Orthopedics and Trauma Surgery, Medical University of Vienna, 1090, Vienna, Austria
| | - Winfried Mayr
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, 1090, Vienna, Austria
| | - Dieter H Pahr
- Institute for Lightweight Design and Structural Biomechanics, TU Wien, 1060, Vienna, Austria
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23
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Falcinelli C, Di Martino A, Gizzi A, Vairo G, Denaro V. Mechanical behavior of metastatic femurs through patient-specific computational models accounting for bone-metastasis interaction. J Mech Behav Biomed Mater 2019; 93:9-22. [PMID: 30738327 DOI: 10.1016/j.jmbbm.2019.01.014] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Revised: 01/23/2019] [Accepted: 01/27/2019] [Indexed: 12/21/2022]
Abstract
This paper proposes a computational model based on a finite-element formulation for describing the mechanical behavior of femurs affected by metastatic lesions. A novel geometric/constitutive description is introduced by modelling healthy bone and metastases via a linearly poroelastic constitutive approach. A Gaussian-shaped graded transition of material properties between healthy and metastatic tissues is prescribed, in order to account for the bone-metastasis interaction. Loading-induced failure processes are simulated by implementing a progressive damage procedure, formulated via a quasi-static displacement-driven incremental approach, and considering both a stress- and a strain-based failure criterion. By addressing a real clinical case, left and right patient-specific femur models are geometrically reconstructed via an ad-hoc imaging procedure and embedding multiple distributions of metastatic lesions along femurs. Significant differences in fracture loads, fracture mechanisms, and damage patterns, are highlighted by comparing the proposed constitutive description with a purely elastic formulation, where the metastasis is treated as a pseudo-healthy tissue or as a void region. Proposed constitutive description allows to capture stress/strain localization mechanisms within the metastatic tissue, revealing the model capability in describing possible strain-induced mechano-biological stimuli driving onset and evolution of the lesion. The proposed approach opens towards the definition of effective computational strategies for supporting clinical decision and treatments regarding metastatic femurs, contributing also to overcome some limitations of actual standards and procedures.
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Affiliation(s)
- Cristina Falcinelli
- Department of Engineering, Campus Bio-Medico University of Rome, Italy; Department of Civil Engineering & Computer Science, University of Rome "Tor Vergata", Italy
| | - Alberto Di Martino
- Department of Orthopaedics and Trauma Surgery, Campus Bio-Medico University of Rome, Italy; Sideny Kimmel Medical College, Thomas Jefferson University (SKMC), Philadelphia, USA
| | - Alessio Gizzi
- Department of Engineering, Campus Bio-Medico University of Rome, Italy
| | - Giuseppe Vairo
- Department of Civil Engineering & Computer Science, University of Rome "Tor Vergata", Italy.
| | - Vincenzo Denaro
- Department of Orthopaedics and Trauma Surgery, Campus Bio-Medico University of Rome, Italy
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Schweitzer ME. Can Susceptibility-weighted MRI Help Differentiate Osteolytic from Osteoblastic Spine Metastases? Radiology 2018; 290:155-156. [PMID: 30375933 DOI: 10.1148/radiol.2018182244] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Mark E Schweitzer
- From the Department of Radiology, Stony Brook University, 101 Nicolls Rd, HSC Level 4 Room 120, Stony Brook, NY 11794
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25
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Putnam DS, Philipp TC, Lam PW, Gundle KR. Treatment Modalities for Pathologic Fractures of the Proximal Femur Pertrochanteric Region: A Systematic Review and Meta-Analysis of Reoperation Rates. J Arthroplasty 2018; 33:3354-3361. [PMID: 30232017 DOI: 10.1016/j.arth.2018.06.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2018] [Revised: 05/23/2018] [Accepted: 06/07/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The proximal femur represents the most common site of metastatic bone disease in the appendicular skeleton, and associated pathologic pertrochanteric femur fractures contribute to cancer-related morbidity and mortality. Controversy exists as to whether these injuries are best managed with intramedullary nailing (IMN) or with arthroplasty. METHODS A systematic review of the literature was performed using a PubMed search following PRISMA guidelines to identify studies performed within the last 20 years regarding treatment of proximal femur metastatic lesions with either nailing or arthroplasty with a reported reoperation rate. Sixteen studies were selected for inclusion containing 1414 patients. Pooled estimates and 95% confidence intervals (CIs) for reoperation rates associated with IMN and endoprosthetic reconstruction (EPR) were separately calculated. RESULTS The pooled estimate for reoperation for IMN was a median of 9% (95% CI, 5%-14%) and the pooled estimate for reoperation for EPR was a median of 7% (95% CI, 5%-11%). Significant heterogeneity was present in studies reporting on both treatment modalities: for IMN, I2 = 55%, and for EPR, I2 = 51%. CONCLUSION This systematic literature review identified 16 eligible, nonrandomized, retrospective studies that reported on the results of surgical treatment for proximal femur metastatic disease. The pooled estimate of reoperation was similar between patients treated with IMN and EPR. Inconsistencies among follow-up and the study designs used limited evidence-based conclusions. As the oncologic care of patients with metastatic disease continues to evolve and improve, patient-specific needs must be carefully considered when selecting an optimal treatment strategy. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- David S Putnam
- Department of Orthopedics and Rehabilitation, Oregon Health and Science University, Portland, OR; Portland VA Medical Center, Operative Care Division, Portland, OR
| | - Travis C Philipp
- Department of Orthopedics and Rehabilitation, Oregon Health and Science University, Portland, OR; Portland VA Medical Center, Operative Care Division, Portland, OR
| | - Phillip W Lam
- Department of Orthopedics and Rehabilitation, Oregon Health and Science University, Portland, OR; Portland VA Medical Center, Operative Care Division, Portland, OR
| | - Kenneth R Gundle
- Department of Orthopedics and Rehabilitation, Oregon Health and Science University, Portland, OR; Portland VA Medical Center, Operative Care Division, Portland, OR
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26
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Benca E, Willegger M, Wenzel F, Hirtler L, Zandieh S, Windhager R, Schuh R. Biomechanical evaluation of two methods of fixation of a flexor hallucis longus tendon graft. Bone Joint J 2018; 100-B:1175-1181. [DOI: 10.1302/0301-620x.100b9.bjj-2018-0100.r2] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Aims The traditional transosseus flexor hallucis longus (FHL) tendon transfer for patients with Achilles tendinopathy requires two incisions to harvest a long tendon graft. The use of a bio-tenodesis screw enables a short graft to be used and is less invasive, but lacks supporting evidence about its biomechanical behaviour. We aimed, in this study, to compare the strength of the traditional transosseus tendon-to-tendon fixation with tendon-to-bone fixation using a tenodesis screw, in cyclical loading and ultimate load testing. Materials and Methods Tendon grafts were undertaken in 24 paired lower-leg specimens and randomly assigned in two groups using fixation with a transosseus suture (suture group) or a tenodesis screw (screw group). The biomechanical behaviour was evaluated using cyclical and ultimate loading tests. The Student’s t-test was performed to assess statistically significant differences in bone mineral density (BMD), displacement, the slope of the load-displacement curves, and load to failure. Results The screw group showed less displacement (loosening) during cyclical loading, which was significant during 300, 500, 600, 700, 800, 900, and 1000 cycles (p < 0.05: other cycles: 0.079 < p < 0.402). Compared with the suture group, the screw group had higher mean ultimate load values (133.6 N, sd 73.5 vs 110.1 N, sd 46.2; p = 0.416). Conclusion Fixation of the FHL tendon with a tenodesis screw enables a less invasive procedure to be undertaken and shows similar biomechanical behaviour and primary strength compared with fixation using a transosseus suture. Cite this article: Bone Joint J 2018;100-B:1175–81.
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Affiliation(s)
- E. Benca
- Department of Orthopedics and Trauma Surgery,
Medical University of Vienna, Vienna, Austria
| | - M. Willegger
- Department of Orthopedics and Trauma Surgery,
Medical University of Vienna, Vienna, Austria
| | - F. Wenzel
- Department of Trauma Surgery, Trauma Center
Meidling – AUVA, Vienna, Austria
| | - L. Hirtler
- Division of Anatomy, Center for Anatomy
and Cell Biology, Medical University of Vienna, Vienna, Austria
| | - S. Zandieh
- Department of Radiology, Hanusch Hospital, Vienna, Austria
| | - R. Windhager
- Department of Orthopedics and Trauma Surgery,
Medical University of Vienna, Vienna, Austria
| | - R. Schuh
- Department of Orthopedics and Trauma Surgery,
Medical University of Vienna, Vienna, Austria
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27
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Palanca M, Barbanti-Bròdano G, Cristofolini L. The Size of Simulated Lytic Metastases Affects the Strain Distribution on the Anterior Surface of the Vertebra. J Biomech Eng 2018; 140:2686534. [DOI: 10.1115/1.4040587] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Indexed: 12/25/2022]
Abstract
Metastatic lesions of the vertebra are associated with risk of fracture, which can be disabling and life-threatening. In the literature, attempts are found to identify the parameters that reduce the strength of a metastatic vertebra leading to spine instability. However, a number of controversial issues remain. Our aim was to quantify how the strain distribution in the vertebral body is affected by the presence and by the size of a simulated metastatic defect. Five cadaveric thoracic spine segments were subjected to non-destructive presso-flexion while intact, and after simulation of metastases of increasing size. For the largest defect, the specimens were eventually tested to failure. The full-field strain distribution in the elastic range was measured with digital image correlation (DIC) on the anterior surface of the vertebral body. The mean strain in the vertebra remained similar to the intact when the defects were smaller than 30% of the vertebral volume. The mean strains became significantly larger than in the intact for larger defects. The map of strain and its statistical distribution indicated a rather uniform condition in the intact vertebra and with defects smaller than 30%. Conversely, the strain distribution became significantly different from the intact for defects larger than 30%. A strain peak appeared in the region of the simulated metastasis, where fracture initiated during the final destructive test. This is a first step in understanding how the features of metastasis influence the vertebral strain and for the construction of a mechanistic model to predicted fracture.
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Affiliation(s)
- Marco Palanca
- Department of Industrial Engineering, School of Engineering and Architecture, Alma Mater Studiorum—Università di Bologna, Via Terracini 24-28, Bologna 40131, Italy e-mail:
| | - Giovanni Barbanti-Bròdano
- Department of Oncologic and Degenerative Spine Surgery, Rizzoli Orthopaedic Institute, Via G.C. Pupilli 1, Bologna 40136, Italy e-mail:
| | - Luca Cristofolini
- Department of Industrial Engineering, School of Engineering and Architecture, Alma Mater Studiorum—Università di Bologna, Via Terracini 24-28, Bologna 40131, Italy e-mail:
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