Calcium phosphate bone cement for treatment of distal radius fractures: a preliminary report

Unidirectional Porous β-Tricalcium Phosphate: A New Bone Filling Substitute for Treatment of Distal Radius Fracture in the Elderly Population

Background: A new beta-tricalcium phosphate with unidirectional pore structure (UDPTCP), Affinos^® (Kurray, Okayama, Japan), has been in clinical use since 2015. To date, there have been only a few clinical studies using this material. We report here the first clinical study for distal radial fracture in the elderly population treated with UDPTCP. Methods: Consecutive patients aged 65 years or older with dorsally displaced unstable fracture of the distal radius (n = 36) were treated operatively in our department. Following reduction of the fracture site, a 7 mm size cube of UDPTCP was placed in the gap of the bony defect and the fracture stabilized with mono-axial or poly-axial type locking plates and screws. Remodeling of the UDPTCP was evaluated by plain radiograph and clinical outcomes were also assessed. Results: UDPTCP was significantly resorbed at 2 months after surgery, both at the center and periphery of the material. Complications were only observed in the post-operative period. Significant correction loss of radial alignment was seen in patients stabilized with poly-axial locking plate. The clinical outcome in all cases was excellent. Conclusions: Block UDPTCP is a safe and convenient material for the treatment of distal radius fracture and is replaced within a suitable time period after grafting into the fracture site. UDPTCP and stable internal fixation is therefore a reliable strategy for restoring and preserving anatomical position, especially in the elderly population.

Percutaneous upper extremity fracture fixation using a novel glass-based adhesive

Objective

To develop a surgical technique for percutaneous upper extremity fracture fixation using a novel glass-based adhesive.

Methods

Three intact upper extremity cadaveric specimens with undisturbed soft tissues were obtained. Two were used to model a wrist fracture, and the third to model a proximal humerus fracture. Fractures were produced using a small osteotome in a percutaneous fashion. Banna Bone Adhesive (BBA) was delivered to the fracture site percutaneously using a 16 gauge needle under bi-planar fluoroscopic guidance. After setting of the adhesive, the specimens were dissected to qualitatively assess BBA delivery and placement.

Results

The adhesive could readily be delivered through the 16 gauge needle with an appropriate amount of pressure applied to the syringe. Using the fluoroscope, the adhesive could be seen to flow into the fracture site with minimal extravagation into the surrounding soft tissues. Successful bonding of the fracture fragments was observed.

Conclusions

Percutaneous delivery of BBA into a fracture of the distal radius and proximal humerus may be a feasible fracture fixation technique. Biomechanical testing and animal model testing are required to further develop this procedure.

An Injectable Glass Polyalkenoate Cement Engineered for Fracture Fixation and Stabilization

Glass polyalkenoate cements (GPCs) have potential as bio-adhesives due to their ease of application, appropriate mechanical properties, radiopacity and chemical adhesion to bone. Aluminium (Al)-free GPCs have been discussed in the literature, but have proven difficult to balance injectability with mechanical integrity. For example, zinc-based, Al-free GPCs reported compressive strengths of 63 MPa, but set in under 2 min. Here, the authors design injectable GPCs (IGPCs) based on zinc-containing, Al-free silicate compositions containing GeO₂, substituted for ZnO at 3% increments through the series. The setting reactions, injectability and mechanical properties of these GPCs were evaluated using both a hand-mix (h) technique, using a spatula for sample preparation and application and an injection (i) technique, using a 16-gauge needle, post mixing, for application. GPCs ability to act as a carrier for bovine serum albumin (BSA) was also evaluated. Germanium (Ge) and BSA containing IGPCs were produced and reported to have working times between 26 and 44 min and setting times between 37 and 55 min; the extended handling properties being as a result of less Ge. The incorporation of BSA into the cement had no effect on the handling and mechanical properties, but the latter were found to have increased compression strength with the addition of Ge from between 27 and 37 MPa after 30 days maturation.

Treatment for Staphylococcus aureus infection following open wedge high tibial osteotomy using antibiotic-impregnated calcium phosphate cement

This report describes a case of Staphylococcus aureus infection following open wedge high tibial osteotomy, which was successfully treated with by implant removal and replacement with antibiotic-impregnated calcium phosphate cement along with external fixation. The infection occurred 7 months after primary surgery and was treated by implant removal, debridement, external fixation, and application of vancomycin impregnated calcium phosphate cement to fill the defect. Subsequently, the infection resolved completely, and the osteotomy healed with no correction loss. Compared with conventional bone cement, calcium phosphate cement might be an optimal material for certain cases of infection after open wedge high tibial osteotomy because of its higher antibiotic retention, biocompatibility, osteoconductivity, and compatibility with heatlabile antibiotics.

LEVEL OF EVIDENCE

V.

Calcium phosphate cement augmentation after volar locking plating of distal radius fracture significantly increases stability

PURPOSE

Distal radius fractures represent the most common fractures in adults. Volar locking plating to correct unstable fractures has become increasingly popular. Although reasonable primary reduction is possible in most cases, maintenance of reduction until the fracture is healed is often problematic in osteoporotic bone. To our knowledge, no biomechanical studies have compared the effect of enhancement with biomaterial on two different volar fixed-angle plates.

METHODS

Human fresh-frozen cadaver pairs of radii were used to simulate an AO/OTA 23-A3 fracture. In a total of four groups (n = 7 for each group), two volar fixed-angle plates (Aptus 2.5 mm locking fracture plate, Medartis, Switzerland and VA-LCP two-column distal radius plate 2.4, volar, Synthes, Switzerland) with or without an additional injection of a biomaterial (Hydroset Injectable HA Bone Substitute, Stryker, Switzerland) into the dorsal comminution zone were used to fix the distal metaphyseal fragment. Each specimen was tested load-controlled under cyclic loading with a servo-hydraulic material testing machine. Displacement, stiffness, dissipated work and failure mode were recorded.

RESULTS

Improved mechanical properties (decreased displacement, increased stiffness, decreased dissipated work) were found in both plates if the biomaterial was additionally injected. Improvement of mechanical parameters after biomaterial injection was more evident in the Synthes plate compared to the Aptus plate. Pushing out of the screws was noticed as a failure mode only in samples lacking supplementary biomaterial.

CONCLUSIONS

Injection of a biomaterial into the dorsal comminution zone increases stability after volar locking plating of distal radius fractures in vitro.

The use of beta-tricalcium phosphate bone graft substitute in dorsally plated, comminuted distal radius fractures

BACKGROUND

Intraarticular distal radius fractures can be treated with many methods. While internal fixation with angle stable implants has become increasingly popular, the use of bone graft substitutes has also been recommended to address comminution zones and thus increase stability. Whether a combination of both methods will improve clinical outcomes was the purpose of the study

METHODS

The study was thus conducted as a prospective randomized clinical trial. 39 patients with unilateral, intraarticular fractures of the distal radius were included and randomized to 2 groups, one being treated with internal fixation only, while the second group received an additional bone graft substitute.

RESULTS

There was no statistical significance between both groups in functional and radiological results. The occurrence of complications did also not show statistical significance.

CONCLUSIONS

No advantage of additional granular bone graft substitutes could be seen in this study. Granular bone graft substitutes do not seem to provide extra stability if dorsal angle stable implants are used. Dorsal plates have considerable complication rates such as extensor tendon ruptures and development of CRPS.

Clinical and radiological results of calcium phosphate cement-assisted balloon osteoplasty for Colles' fractures in osteoporotic senile female patients

BACKGROUND

Distal radius fractures in osteoporotic senile female patients often used to be complicated with residual deformity, stiffness, and pain. Recently, however, adequate usage of a palmar locking plate or external fixation has led to fewer subsequent complications. The method proposed here deserves consideration because it is less invasive and more cost-effective.

METHODS

A total of 11 Colles' type fractures (AO type A2) in 11 patients (all female; mean age 78 years) were treated. After a closed reduction, the fractures were fixed by percutaneous pinning, as Kapandji previously described. Through a 5-mm longitudinal skin incision on the dorsoulnar aspect of the fracture site, the barrel of a disposable 1-ml syringe was inserted into the fracture site as a port. Next, a pediatric uromatic balloon was introduced into the fracture site and inflated by contrast medium. The balloon inflation enlarged the void of the fracture site. A compression bandage around the fracture site was applied before calcium phosphate cement injection with a cement gun through the port under an image intensifier. The functional and radiological results were evaluated. The mean follow-up period was 16 months (range 12-25 months).

RESULTS

All results were graded as good or excellent within 3 months, and all were graded as excellent at the final follow-up. The average duration of immobilization was 4 weeks with a short forearm cast. The overall postoperative correction loss in ulnar variance was 1.7 mm. Radial inclination and volar tilt showed no postoperative correction loss. The final volar tilt, radial inclination, and ulnar variance were comparable to those of the nonaffected side.

CONCLUSIONS

Calcium phosphate cement-assisted balloon osteoplasty is a less invasive procedure and can be clinically justified as a therapeutic option for a Colles' fracture in osteoporotic senile female patients.

Calcium phosphate cement-assisted balloon osteoplasty for a Colles' fracture on arteriovenous fistula forearm of a maintenance hemodialysis patient

We report a case of a Colles' fracture on the arteriovenous fistula forearm of a maintenance hemodialysis patient treated with percutaneous pinning with the aid of Chinese finger trap reduction combined with cavity creation using a pediatric uromatic balloon with calcium phosphate cement augmentation. Five months after surgery, the arteriovenous fistula was patent, and the range of motion, grip strength, and radiographic findings were comparable with a non-arteriovenous fistula forearm. Wrist x-rays showed a complete union of the distal radius with progressive absorption of the calcium phosphate cement.

Experimental study of calcium phosphate cement impregnated with dideoxy-kanamycin B

BACKGROUND

The present study was undertaken to examine whether antibiotic-impregnated calcium phosphate cement (CPC) would provide a valid means of treating osteomyelitis.

METHODS

The antibiotic used for the impregnation was dideoxy-kanamycin B (DKB), which is available in two forms (powder and liquid). Columnar test specimens (diameter 7 mm, height 14 mm) were prepared by adding the liquid or powdered DKB. Group A: Three types (6.25-titer, 12.5-titer, 25-titer) of test specimen were prepared by mixing the setting solution and DKB solutions into cement. Group B: Three types (25-titer, 50-titer, 100-titer) of test specimen were prepared by mixing the setting solution and DKB powder into cement. Group C: A control specimen was prepared by mixing the setting solution into the cement. The study included a consistency test, setting-time test, compressive strength test, porosity test, and elution test.

RESULTS

The value for the consistency test was >23 mm in all test groups. The results of the setting-time test showed that the setting time became significantly longer as the DKB content increased for groups A group B. Compressive strength decreased as the antibiotic content increased, although all specimens remained sufficiently strong for clinical application. In group A the porosity did not differ significantly depending on the antibiotic content, whereas in group B the porosity increased significantly as the antibiotic content increased. In the elution test using specimens with the same titer (25 titer), the elution efficiency was higher in group A than in group B, and the duration of elution was longer in group A.

CONCLUSIONS

Although polymethylmethacrylate (PMMA) has been conventionally used as a drug-delivery system (DDS), the results of the present study indicate that CPC shows better elution efficiency than PMMA. It is thus a promising DDS for the treatment of osteomyelitis.

Calcium phosphate cement in musculoskeletal tumor surgery

BACKGROUND AND OBJECTIVES

Calcium phosphate cement (CPC) is an injectable biocompatible bone substitute that has been used for various applications in orthopedic surgery. However, no extensive clinical studies of the use of CPC to fill bone cavities after curettage of musculoskeletal tumors have been reported. The present study reviewed the results for 56 musculoskeletal tumors treated by curettage and CPC implantation.

METHODS

Assessment was based on clinical examination and radiographic findings. Variables for clinical assessment included pain, limb function, and complications. Median follow-up was 18.5 months (range 6-47 months).

RESULTS

One patient experienced post-operative fractures. Three patients displayed local recurrence. One patient developed post-operative superficial wound infection, and two patients with large bony defect exhibited non-infectious serous discharge. No serious adverse effects such as deep venous thrombosis, pulmonary embolism were encountered. In all cases, CPC was radiographically well adapted to the surrounding host bone as of final follow-up.

CONCLUSIONS

CPC appears to offer a useful bone substitute for the treatment of musculoskeletal tumors. As the follow-up period for this study was short, further long-term follow-up studies are needed.

A simple bone cyst located in the pedicle of the lumbar vertebra

A simple bone cyst located in the spine is rare. In the current work, we have documented the first case of a simple bone cyst located in the pedicle of the lumbar vertebra. The patient was a 50-year-old woman with low back pain. Radiographs of the lumbar region of the spine showed a well circumscribed radiolucent lesion with surrounding bone sclerosis in the right pedicle of L3. Computed tomography (CT) showed that the right pedicle was completely occupied by the cyst and slightly expanded. The cystic lesion extended to both the vertebral body and the lamina. T1-weighted magnetic resonance imaging (MRI) showed uniform low intensity, and T2-weighted MRI showed uniform very high intensity. Signal enhancement by gadolinium diethylenetriaminepenta-acetic acid was not observed in the lesion. During the operation, the cavity of the cyst was filled with 2 mL of serosanguinous fluid. Subsequent histologic examination showed a thin layer of connective tissue in the inner surface of the cyst.

The use of an injectable bone graft substitute in tibial metaphyseal fractures

Eight consecutive patients with severely comminuted proximal or distal tibial metaphyseal fractures were surgically treated with a novel injectable, in situ hardening calcium sulfate material to provide temporary intraoperative structural support until instrumentation was appropriately placed. The calcium sulfate bone substitute was also used as a bone void filler to provide an osteoconductive environment following stabilization. Bone regrowth was observed in all patients and, in seven of the eight patients, 90%-100% bone formation was observed within 3 months. The bone substitute had almost completely resorbed by 3 months in all patients. One patient with extensive initial bone loss required a second bone graft. Although the patient sample size was small, the success rate of treating severely comminuted fractures was significantly better than in reports using only internal fixation. Injectable bone substitute for minimally invasive surgery to repair metaphyseal fractures.

Palmar plating with calcium phosphate bone cement for unstable Colles' fractures

A prospective study was done in 20 patients with unstable Colles' fractures with metaphyseal bone defects and who were treated with palmar plating combined with injectable calcium phosphate bone cement. The patients were three men and 17 women with a mean age of 69 years (range, 65-86 years) at the time of the injury. The followup after the operation ranged from 6 to 24 months (mean, 12 months). Union was gained in all the patients. The records of radiographic parameters, including the palmar tilting angle, radial inclination, radial length, and ulnar variance had been maintained since the surgery. According to the rating scale of Gartland and Werley, 16 patients had excellent results and four had good results. There were no neurovascular and tendon injuries as complications.