Bone transport with frozen devitalized bone: an experimental study using rabbits and a clinical application

The process of bone regeneration from devitalization to revitalization after pedicle freezing with immunohistochemical and histological examination in rabbits

The pedicle freezing procedure by liquid nitrogen is a method for the reconstruction of tumor-bearing bone after malignant tumor resection. However, the regenerative mechanism of bone after the pedicle freezing procedure is unclear. We investigated the complete process from devitalization to revitalization of bone after the pedicle freezing procedure in 13 rabbits. After osteotomy the 5 mm distal femurs were immersed in liquid nitrogen, and the specimens were divided into frozen area and sub-frozen area. The bilateral femurs were harvested for evaluation of bone regeneration by histological and immunohistochemical examination (VEGF, CD31, BMP-2 and Runx2) from 1 week to 52 weeks. The diameter of operating femurs was compared with contralateral femurs from 6 weeks to 52 weeks. No viable cells could be found from 1 to 8 weeks in the frozen area, and a mean 1.83 cm necrotic range were detected in the sub-frozen area. The periosteal reaction, massive fibrous tissue and immature bone matrix invaded from the normal area to the necrotic area from 12 weeks. Subsequently, the necrotic bone was gradually replaced by newly formed bone by creeping substitution, with endochondral and intramembrane bone formation. The diameter of frozen femurs was significantly larger than the contralateral femur at the same period from 8 weeks to 52 weeks (P < 0.01). All immunohistochemical factors were positively expressed in both areas at different time points. The active osteoblasts and microvessel migrated from marrow cavity and periosteum into dead bone. This study suggested that the frozen bone not only provides a scaffold but also possesses excellent osteoinductive properties.

Effectiveness of a Collaborative Nursing Care Model for the Treatment of Patients with Diabetic Foot Disease by Transverse Tibial Bone Transport Technique: A Pilot Study

PURPOSE

Medical staff shortages remain a serious challenge, particularly to medical administrators. We aimed to analyze the effectiveness of a collaborative nursing care model in treatment of diabetic foot.

DESIGN

A quasi-experimental pilot study.

METHODS

Twenty-eight patients with diabetic foot treated by transverse tibial bone transport between January 2017 and March 2018 were randomized. The observational group received collaborative nursing care, while the control group received usual nursing care. Postoperative dorsal foot skin temperature, visual analog scale, self-rating anxiety scale (SAS) score, and other endpoints were assessed.

FINDINGS

Postoperative dorsal foot skin temperature was significantly higher in the observation group than in the control group. Visual analog scale and SAS scores were significantly lower in the observational group than in the control group.

CONCLUSIONS

The collaborative nursing care model enhanced collaboration between patient and health care providers, shortened hospital stay, and relieved postoperative pain and anxiety.

Osteofibrous Dysplasia of the Tibia in Children: Outcome Without Resection

BACKGROUND

The proposed association between osteofibrous dysplasia and adamantinoma has led some to advocate resection of the entire lesion, which can require major subsequent reconstruction. However, this link remains unproven and there is some support in more recent literature for a less aggressive approach. This study aims to describe our experience managing pediatric tibial osteofibrous dysplasia with such an approach and to report functional outcomes in children treated thus.

METHODS

A total of 28 cases of osteofibrous dysplasia in 25 patients were managed at a referral center for pediatric bone tumors with observation in the first instance, then limited surgical intervention if required to address pain and deformity. Surgery aimed to restore stability and alignment without excising the lesion. Clinical records provided basic clinical outcome measures involving walking, recreation, orthoses and school/work participation and patients provided a Musculoskeletal Tumour Society score (MSTS) where contactable.

RESULTS

Mean age at presentation was 6.0 years and mean follow-up was 8.3 years. Only 8 patients required surgery. According to basic outcome measures, 13 patients were symptom-free. About 15 patients (17 cases) provided a MSTS and the mean score was 24 of 30. No transformation to adamantinoma was observed. Those who presented at a younger age and with bilateral disease more often required surgery and remained symptomatic.

CONCLUSIONS

A less aggressive approach to pediatric tibial osteofibrous dysplasia achieves good functional outcomes and patient satisfaction in most cases. Surgery is required in the minority of cases. Transformation to adamantinoma was not observed in this series. We recommend patient education, clinical observation and reactive intervention if required, rather than proactive resection and reconstruction.

LEVEL OF EVIDENCE

Level IV-case series.

Prognostic significance of chemotherapy-induced necrosis in osteosarcoma patients receiving pasteurized autografts

Background

Among various reconstruction methods after wide excision for osteosarcoma, pasteurized autograft is often preferred. While the whole area of the tumor can be assessed for chemotherapy-induced necrosis, one of the important prognostic factors, in other reconstructive techniques, only a portion removed from a wide-resection specimen is available when using pasteurized autograft method. The assessment, therefore, may be unreliable. We analyzed the prognostic significance of the chemotherapy-induced necrosis in osteosarcoma patients who underwent reconstruction with pasteurized autografts.

Patients and methods

We reviewed the records of osteosarcoma patients who underwent treatment in our institution from 1998 to 2013. Cases of reconstruction with pasteurized autografts were defined as the patient group, and the same number of patients who underwent other reconstruction methods served as controls. Chemotherapy-induced necrosis was evaluated for removed extra-osseous and curetted intramedullary tumor tissues.

Results

A total of 22 patients were identified; the median age was 15.5 years, and there were 12 males. The most common tumor location was the distal femur. The most common histological subtype was osteoblastic. Median size was 8.1 cm. Disease status was stage IIB in 13 patients and IIA in 9. Median follow-up was 76 months. No differences between the patient and control groups were observed in potential prognostic factors, overall survival, metastasis-free survival, or recurrence-free survival. Univariate analyses demonstrated that histological response was a significant prognostic factor for metastasis-free survival and also significant for recurrence-free survival.

Conclusion

Chemotherapy-induced necrosis grading, using only available tumor tissues, could be a prognostic factor for osteosarcoma patients receiving pasteurized autografts for reconstructive surgery.

Successful correction of tibial bone deformity through multiple surgical procedures, liquid nitrogen-pretreated bone tumor autograft, three-dimensional external fixation, and internal fixation in a patient with primary osteosarcoma: a case report

Background

In a previous report, we described a method of reconstruction using tumor-bearing autograft treated by liquid nitrogen for malignant bone tumor. Here we present the first case of bone deformity correction following a tumor-bearing frozen autograft via three-dimensional computerized reconstruction after multiple surgeries.

Case presentation

A 16-year-old female student presented with pain in the left lower leg and was diagnosed with a low-grade central tibial osteosarcoma. Surgical bone reconstruction was performed using a tumor-bearing frozen autograft. Bone union was achieved at 7 months after the first surgical procedure. However, local tumor recurrence and lung metastases occurred 2 years later, at which time a second surgical procedure was performed. Five years later, the patient developed a 19° varus deformity and underwent a third surgical procedure, during which an osteotomy was performed using the Taylor Spatial Frame three-dimensional external fixation technique. A fourth corrective surgical procedure was performed in which internal fixation was achieved with a locking plate. Two years later, and 10 years after the initial diagnosis of tibial osteosarcoma, the bone deformity was completely corrected, and the patient’s limb function was good.

Conclusion

We present the first report in which a bone deformity due to a primary osteosarcoma was corrected using a tumor-bearing frozen autograft, followed by multiple corrective surgical procedures that included osteotomy, three-dimensional external fixation, and internal fixation.

Evaluation of long-term outcomes of pasteurized autografts in limb salvage surgeries for bone and soft tissue sarcomas

BACKGROUND

Pasteurized autografts used in limb salvage operations for malignant musculoskeletal tumors have several advantages, including reduced disease transmission, economic efficiency, accessibility, and anatomical conformation. However, their use has been associated with bone absorption, fracture, and pseudarthrosis. Few studies exist which have assessed the long-term outcomes of pasteurized autografts. The purpose of this study was to investigate the clinical outcomes of patients treated with pasteurized autografts and to compare these outcomes across various graft types.

METHODS

A retrospective analysis of 46 patients treated with pasteurized autografts between 1992 and 2010 was conducted. The analysis included 22 intercalary bone grafts, 17 inlay grafts, 4 composite grafts, and 3 osteochondral grafts, with the mean follow-up period of 8.7 years (2-17 years).

RESULTS

The 10-year survival rate of the 46 pasteurized autograft cases analyzed was 93.5 %, and the average bone union time between host and pasteurized autogenous bone was 9.5 months. Infections were identified in 6 (13 %) patients, fractures in 7 (15 %) patients, non-union in 8 (17 %) patients, and bone absorption in 6 (13 %) patients. Inlay grafts were completely incorporated with the host bone at the follow-up period. Combination with a vascularized fibular graft significantly reduced the risk of non-union and bone absorption (p < 0.05 and p < 0.01, respectively), with an average functional score of 23.1/30 (83.8 %).

CONCLUSION

Our findings show that pasteurized bone grafts in combination with vascularized fibular grafts have improved outcomes and potential clinical indications.

Bone transport using hydroxyapatite loaded with bone morphogenetic protein in rabbits

The feasibility of bone transport with bone substitute and the factors which are essential for a successful bone transport are unknown. We studied six groups of 12 Japanese white rabbits. Groups A to D received cylindrical autologous bone segments and groups E and F hydroxyapatite prostheses. The periosteum was preserved in group A so that its segments had a blood supply, cells, proteins and scaffold. Group B had no blood supply. Group C had proteins and scaffold and group D had only scaffold. Group E received hydroxyapatite loaded with recombinant human bone morphogenetic protein-2 and group F had hydroxyapatite alone.

Distraction osteogenesis occurred in groups A to C and E which had osteo-conductive transport segments loaded with osteo-inductive proteins. We conclude that scaffold and proteins are essential for successful bone transport, and that bone substitute can be used to regenerate bone.