ChronOS inject in children with benign bone lesions--does it increase the healing rate?

Results of Allografts and Synthetic Grafts in Humeral Simple Bone Cysts

PURPOSE OF THE STUDY

Simple bone cysts (SBCs) are the most common benign bone lesions in childhood. There are many different methods in the treatment of SBCs. There is no consensus on which method to use in the treatment. In this study, we compared the results of allogeneic bone graft or synthetic bone graft in addition to fl exible intramedullary nail (FIN) for SBC located in the humerus.

MATERIAL AND METHODS

This retrospective study comparing the data of 19 (group 1: 8 curettage, allograft and FIN; group 2: 11 curettage, synthetic graft and FIN) patients with a mean age of 11.4 (6 to 26; seven female, twelve male) who were surgically treated in our hospital for humeral SBC between April 2014 and January 2020. Patient data included age, sex, anatomical side, stage of the cyst, pathological fracture, previous treatments and complications.

RESULTS

The mean follow-up period was 33.7 months (12 to 61). The average last follow-up Musculoskeletal Tumor Society functional scores for groups 1 and 2 were 27.8 (20 to 30) and 28.6 (21 to 30) (P > 0.05). Complete or signifi cant partial radiographic healing rates were achieved in group 1 (75%) compared with group 2 (81.9%). The reoperation rates for groups 1 and 2 were 62.5% (5/8; three for nails removed, two for recurrence) and 36.3% (4/11; two for nails removed, two for recurrence). One patient in group 2 had a 15° varus deformity due to recurrence. No other complications were observed.

CONCLUSIONS

The combination of curettage-grafonage FIN is a common treatment method in recent years, as it provides early cyst healing and limb mobilization in SBCs located in the upper extremity. For defects after curettage of the bone cysts, allogeneic or synthetic grafts (granule b-tricalcium phospate) which have similar results in terms of healing can be used as an alternative to each other.

KEY WORDS

allografts, bone cysts, bone nails, synthetic grafts, humerus.

Efficient adsorptive removal of Cobalt(II) ions from water by dicalcium phosphate dihydrate

Although the radionuclide ⁶⁰Co is widely used, its presence in various effluents demands its removal to preclude environmental pollution and detrimental effects on human health. This study investigated the batch adsorption performance of a potential cobalt adsorbent, dicalcium phosphate dihydrate (DCPD), in immobilizing Co²⁺ from water. The influences of solution pH, contact time, initial concentration, and competing cations were examined and discussed. Stable cobalt uptake was observed at pH 4-8. The sorption kinetics showed a multi-stage uptake profile, implying that several mechanisms are involved in the adsorption process. Microscopy and structural analysis revealed that DCPD decomposes to its anhydrous form during adsorption, which explains the multistep curve over the entire adsorption period. However, the non-apatitic transformation is not exclusive to cobalt uptake. Intraparticle diffusion also contributed to the overall removal kinetics of Co²⁺ from water. Considering the Sips isotherm model, the maximum Co²⁺ adsorption capacity of DCPD was 441 mg g^-1. Cobalt uptake selectivity dropped in the presence of Ca²⁺ ions, from 1.21 × 10⁴ to 207 mL g^-1, indicating DCPD would be more applicable in treating soft ⁶⁰Co-contaminated waters. Structural analysis, elemental mapping, and qualitative analysis of solid residues confirmed that ion exchange is involved in the removal of cobalt from aqueous solutions.

Natural Polymeric Scaffolds in Bone Regeneration

Despite considerable advances in microsurgical techniques over the past decades, bone tissue remains a challenging arena to obtain a satisfying functional and structural restoration after damage. Through the production of substituting materials mimicking the physical and biological properties of the healthy tissue, tissue engineering strategies address an urgent clinical need for therapeutic alternatives to bone autografts. By virtue of their structural versatility, polymers have a predominant role in generating the biodegradable matrices that hold the cells in situ to sustain the growth of new tissue until integration into the transplantation area (i.e., scaffolds). As compared to synthetic ones, polymers of natural origin generally present superior biocompatibility and bioactivity. Their assembly and further engineering give rise to a wide plethora of advanced supporting materials, accounting for systems based on hydrogels or scaffolds with either fibrous or porous architecture. The present review offers an overview of the various types of natural polymers currently adopted in bone tissue engineering, describing their manufacturing techniques and procedures of functionalization with active biomolecules, and listing the advantages and disadvantages in their respective use in order to critically compare their actual applicability potential. Their combination to other classes of materials (such as micro and nanomaterials) and other innovative strategies to reproduce physiological bone microenvironments in a more faithful way are also illustrated. The regeneration outcomes achieved in vitro and in vivo when the scaffolds are enriched with different cell types, as well as the preliminary clinical applications are presented, before the prospects in this research field are finally discussed. The collection of studies herein considered confirms that advances in natural polymer research will be determinant in designing translatable materials for efficient tissue regeneration with forthcoming impact expected in the treatment of bone defects.

Bone substitutes: a review of their characteristics, clinical use, and perspectives for large bone defects management

Bone replacement might have been practiced for centuries with various materials of natural origin, but had rarely met success until the late 19th century. Nowadays, many different bone substitutes can be used. They can be either derived from biological products such as demineralized bone matrix, platelet-rich plasma, hydroxyapatite, adjunction of growth factors (like bone morphogenetic protein) or synthetic such as calcium sulfate, tri-calcium phosphate ceramics, bioactive glasses, or polymer-based substitutes. All these substitutes are not suitable for every clinical use, and they have to be chosen selectively depending on their purpose. Thus, this review aims to highlight the principal characteristics of the most commonly used bone substitutes and to give some directions concerning their clinical use, as spine fusion, open-wedge tibial osteotomy, long bone fracture, oral and maxillofacial surgery, or periodontal treatments. However, the main limitations to bone substitutes use remain the management of large defects and the lack of vascularization in their central part, which is likely to appear following their utilization. In the field of bone tissue engineering, developing porous synthetic substitutes able to support a faster and a wider vascularization within their structure seems to be a promising way of research.

In Situ Synchrotron X-ray Diffraction Analysis of the Setting Process of Brushite Cement: Reaction and Crystal Growth

Brushite cements are fast self-setting materials that can be used as bone substitute materials. Although tracing their fast setting process is a challenge, it is important for the understanding of the same, which in turn is important for the material's further development and use in the clinics. In this study, the setting rate, phase formation, and crystal growth of brushite cements were quantitatively studied by in situ synchrotron powder X-ray diffraction (SXRD) on a time scale of seconds. The influence of reactant ratios and a retardant (citric acid) on the setting reaction were analyzed. To complement the in situ investigations, scanning electron microscopy was carried out for ex situ morphological evolution of crystals. The initial reaction followed a four-step process, including a fast nucleation induction period, nucleation, crystal growth, and completion of the setting. The brushite crystal size grew up to the micro scale within 1 min, and the brushite content increased linearly after the nucleation until all monocalcium phosphate monohydrate (MCPM; Ca(H₂PO₄)₂·H₂O) had dissolved within minutes, followed by a slow increase until the end of the monitoring. By adjusting the MCPM to the β-tricalcium phosphate (β-TCP, β-Ca₃(PO4)₂) ratio in the starting powders, the brushite/monetite ratio in the cements could be modified. In the presence of citric acid, the formation of brushite nuclei was not significantly retarded, whereas the increase in brushite content and the growth of crystal size were effectively hindered. The amount of monetite also increased by adding citric acid. This is the first time that the brushite setting process has been characterized in the first seconds and minutes of the reaction by SXRD.

[Bone substitution materials in therapy of cystic tumors of the immature skeleton]

The primary goal in the treatment of cystic bone tumors in children is the restoration of bone integrity and normal function. It is assumed that filling of the cavity defect after removal of the tumor will facilitate bone healing. In order to reduce the complications observed with autografts and allografts use bone graft substitutes were developed. The current literature review shows that the application of substances with potential immunogenic, toxic or cancerogenic properties should be avoided. Among the purely synthetic mineral materials, tricalcium phosphate has the biochemical properties most compatible with new bone formation and calcium phosphate cements can be used to provide immediate stability in cases of existing or imminent fractures. However, there is currently insufficient evidence that the use of bone grafts or bone graft substitutes provides a real benefit to the patient, especially in comparison with no graft at all. Prospective randomized studies are necessary in order to delineate the indications for bone grafting or use of bone graft substitutes for the treatment of cystic bone tumors in children.

Bone graft substitutes currently available in orthopaedic practice: the evidence for their use

We reviewed 59 bone graft substitutes marketed by 17 companies currently available for implantation in the United Kingdom, with the aim of assessing the peer-reviewed literature to facilitate informed decision-making regarding their use in clinical practice. After critical analysis of the literature, only 22 products (37%) had any clinical data. Norian SRS (Synthes), Vitoss (Orthovita), Cortoss (Orthovita) and Alpha-BSM (Etex) had Level I evidence. We question the need for so many different products, especially with limited published clinical evidence for their efficacy, and conclude that there is a considerable need for further prospective randomised trials to facilitate informed decision-making with regard to the use of current and future bone graft substitutes in clinical practice.

Influence of water content on hardening and handling of a premixed calcium phosphate cement

Handling of calcium phosphate cements is difficult, where problems often arise during mixing, transferring to syringes, and subsequent injection. Via the use of premixed cements the risk of handling complications is reduced. However, for premixed cements to work in a clinical situation the setting time needs to be improved. The objective of this study is to investigate the influence of the addition of water on the properties of premixed cement. Monetite-forming premixed cements with small amounts of added water (less than 6.8 wt.%) were prepared and the influence on injectability, working time, setting time and mechanical strength was evaluated. The results showed that the addition of small amounts of water had significant influence on the properties of the premixed cement. With the addition of just 1.7 wt.% water, the force needed to extrude the cement from a syringe was reduced from 107 (±15) N to 39 (±9) N, the compression strength was almost doubled, and the setting time decreased from 29 (±4) min to 19 (±2) min, while the working time remained 5 to 6h. This study demonstrates the importance of controlling the water content in premixed cement pastes and how water can be used to improve the properties of premixed cements.

The use of bone graft substitutes in large cancellous voids: any specific needs?

Bone graft is the second most common transplantation tissue, with blood being by far the commonest. Autograft is considered ideal for grafting procedures, providing osteoinductive growth factors, osteogenic cells and an osteoconductive scaffold. Limitations, however, exist regarding donor site morbidity and graft availability. Allograft on the other hand poses the risk of disease transmission. Synthetic graft substitutes lack osteoinductive or osteogenic properties. Composite grafts combine scaffolding properties with biological elements to stimulate cell proliferation and differentiation and eventually osteogenesis. We present here an overview of bone graft substitutes available for clinical application in large cancellous voids.

Elastic Stable Intramedullary Nailing (ESIN), Orthoss® and Gravitational Platelet Separation--System (GPS®): an effective method of treatment for pathologic fractures of bone cysts in children

Background

The different treatment strategies for bone cysts in children are often associated with persistence and high recurrence rates of the lesions. The safety and clinical outcomes of a combined mechanical and biological treatment with elastic intramedullary nailing, artificial bone substitute and autologous platelet rich plasma are evaluated.

Methods

From 02/07 to 01/09 we offered all children with bone cysts the treatment combination of elastic intramedullary nailing (ESIN), artificial bone substitute (Orthoss^®) and autologous platelet rich plasma, concentrated by the Gravitational Platelet Separation (GPS^®) - System. All patients were reviewed radiologically for one year following the removal of the intramedullary nailing, which was possible because of cyst obliteration.

Results

A cohort of 12 children (4 girls, 8 boys) was recruited. The mean patient age was 11.4 years (range 7-15 years). The bone defects (ten humeral, two femoral) included eight juvenile and four aneurysmal bone cysts. Five patients suffered from persistent cysts following earlier unsuccessful treatment of humeral bone cyst after pathologic fracture; the other seven presented with acute pathologic fractures. No peri- or postoperative complications occurred. The radiographic findings showed a total resolution of the cysts in ten cases (Capanna Grade 1); in two cases a small residual cyst remained (Capanna Grade 2). The intramedullary nails were removed six to twelve months (mean 7.7) after the operation; in one case, a fourteen year old boy (Capanna Grade 2), required a further application of GPS^® and Orthoss^® to reach a total resolution of the cyst. At follow-up (20-41 months, mean 31.8 months) all patients showed very good functional results and had returned to sporting activity. No refracture occurred, no further procedure was necessary.

Conclusions

The combination of elastic intramedullary nailing, artificial bone substitute and autologous platelet rich plasma (GPS^®) enhances the treatment of bone cysts in children, with no resulting complications.

Bone substitutes in the Netherlands - a systematic literature review

Autologous bone grafting is currently considered as the gold standard to restore bone defects. However, clinical benefit is not guaranteed and there is an associated 8-39% complication rate. This has resulted in the development of alternative (synthetic) bone substitutes. The aim of this systematic literature review was to provide a comprehensive overview of literature data of bone substitutes registered in the Netherlands for use in trauma and orthopedic surgery. Brand names of selected products were used as search terms in three available databases: Embase, PubMed and Cochrane. Manuscripts written in English, German or Dutch that reported on structural, biological or biomechanical properties of the pure product or on its use in trauma and orthopedic surgery were included. The primary search resulted in 475 manuscripts from PubMed, 653 from Embase and 10 from Cochrane. Of these, 218 met the final inclusion criteria. Of each product, structural, biological and biomechanical characteristics as well as their clinical indications in trauma and orthopedic surgery are provided. All included products possess osteoconductive properties but differ in resorption time and biomechanical properties. They have been used for a wide range of clinical applications; however, the overall level of clinical evidence is low. The requirements of an optimal bone substitute are related to the size and location of the defect. Calcium phosphate grafts have been used for most trauma and orthopedic surgery procedures. Calcium sulphates were mainly used to restore bone defects after tumour resection surgery but offer minimal structural support. Bioactive glass remains a potential alternative; however, its use has only been studied to a limited extent.

Recent developments in treatment for simple bone cysts

PURPOSE OF REVIEW

The purpose of this paper is to review treatment strategies for simple bone cysts (SBCs).

RECENT FINDINGS

Recent studies have focused on disrupting the wall of the cyst in combination with injectable bone substitutes. Bone substitutes are minimally invasive, provide an osteoconductive scaffold, and are relatively easy to use. Many of these studies, however, have methodological issues (uncontrolled, not randomized, unblinded outcome assessment, or short-term follow-up) and inconsistent radiographic outcomes making it difficult to determine the benefits of these newer treatment strategies.

SUMMARY

Based on a single randomized clinical trial, steroids are the only evidence-based treatment for SBCs. Further basic science is needed to understand the pathoetiology and to develop future biologic solutions. Multimodal treatment strategies with opening of the medullary canal and disruption of the cyst wall, filling defect with a bone substitute, and possible biologic treatment of the cyst membrane may be the best strategy. When considering cysts of the lower extremity, structural support may be required in addition to treatment of the cyst.