The Use of Bone Graft Substitute in Hand Surgery: A Prospective Observational Study

Bone Graft Substitutes-What Are My Options?

We examine the range of available bone graft substitutes often used in nonunion and malunion surgery of the upper extremity. Synthetic materials such as calcium sulfate, beta-calcium phosphate ceramics, hydroxyapatite, bioactive glass, and 3D printed materials are discussed. We delve into the advantages, disadvantages, and clinical applications for each, considering factors such as biocompatibility, osteoconductivity, mechanical strength, and resorption rates. This review provides upper extremity surgeons with insights into the available array of bone graft substitutes. We hope that the reviews helps in the decision-making process to achieve optimal outcomes when treating nonunion and malunion of the upper extremity.

Biomimetic, biodegradable and osteoinductive treated dentin matrix/α-calcium sulphate hemihydrate composite material for bone tissue engineering

It is still a huge challenge for bone regenerative biomaterial to balance its mechanical, biological and biodegradable properties. In the present study, a new composite material including treated dentin matrix (TDM) and α-calcium sulphate hemihydrate (α-CSH) was prepared. The optimal composition ratio between TDM and α-CSH was explored. The results indicate that both components were physically mixed and structurally stable. Its compressive strength reaches up to 5.027 ± 0.035 MPa for 50%TDM/α-CSH group, similar to human cancellous bone tissues. Biological experiments results show that TDM/α-CSH composite exhibits excellent biocompatibility and the expression of osteogenic related genes and proteins (ALP, RUNX2, OPN) is significantly increased. In vivo experiments suggest that the addition of TDM for each group (10%, 30%, 50%) effectively promotes cell proliferation and osteomalacia. In addition, 50% of the TDM/α-CSH combination displays optimal osteoconductivity. The novel TDM/α-CSH composite is a good candidate for certain applications in bone tissue engineering.

Comparison of Distal Radius Autograft Technique with Iliac Crest Autograft Technique in Solitary Finger Enchondromas

OBJECTIVES

The purpose of the study was to compare clinical and radiological outcomes of autografts obtained from the iliac crest (IC) and distal radius (DR) and to evaluate their superiority for surgical treatment of solitary finger enchondromas.

METHODS

Twenty-five patients for whom curettage and autografting were carried out for finger enchondroma were retrospectively analyzed. DR autograft was used in eight patients and IC autograft was used in 17 patients. Data on pre-operative total active motion (TAM), disabilities of the arm, shoulder, and hand (DASH) score, and pain visual analog scale (VAS) scores of the involved finger, duration of surgery, amount of bleeding during the operation, length of hospital stay, presence of complications related to anesthesia, and post-operative donor site morbidity were obtained. Pre-operative and post-operative 12^th month radiographies were evaluated for pre-operative tumor volume, post-operative remnant volume, and Tordai radiologic evaluation grade.

RESULTS

No statistically significant difference could be identified between post-operative TAM (p=0.154), DASH (p=0.458), pain VAS scores (p=0.571), remnant volume (p=0.496), Tordai radiologic evaluation grade (p=0.522), duration of surgery (p=0.288), and amount of bleeding (p=0.114) between DR and IC groups. However, mean hospital stay duration was shorter for the DR group (p=0.0001). Recurrence was observed in one patient in the DR group and three patients in the IC group (p=0.996).

CONCLUSION

The clinical and radiological outcomes of grafting from the DR and IC were similar in the treatment of hand enchondromas. However, grafting from the DR may result in shorter hospital stay compared to IC grafting.

Silk Fibroin Microparticle Scaffold for Use in Bone Void Filling: Safety and Efficacy Studies

Silk fibroin (SF) is a natural biocompatible protein polymer extracted from cocoons of silkworm Bombyx mori. SF can be processed into a variety of different forms and shapes that can be used as scaffolds to support bone regeneration. Three-dimensional (3D) SF scaffolds have shown promise in bone-void-filling applications. In in vitro studies, it has been demonstrated that a microparticle-based SF (M-RSF) scaffold promotes the differentiation of stem cells into an osteoblastic lineage. The expression of differentiation markers was also significantly higher for M-RSF scaffolds as compared to other SF scaffolds and commercial ceramic scaffolds. In this work, we have evaluated the in vitro and in vivo biocompatibility of M-RSF scaffolds as per the ISO 10993 guidelines in a Good Laboratory Practice (GLP)-certified facility. The cytotoxicity, immunogenicity, genotoxicity, systemic toxicity, and implantation studies confirmed that the M-RSF scaffold is biocompatible. Further, the performance of the M-RSF scaffold to support bone formation was evaluated in in vivo bone implantation studies in a rabbit model. Calcium sulfate (CaSO₄) scaffolds were chosen as reference material for this study as they are one of the preferred materials for bone-void-filling applications. M-RSF scaffold implantation sites showed a higher number of osteoblast and osteoclast cells as compared to CaSO₄ implantation sites indicating active bone remodeling. The number density of osteocytes was double for M-RSF scaffold implantation sites, and these M-RSF scaffold implantation sites were characterized by enhanced collagen deposition, pointing toward a finer quality of the new bone formed. Moreover, the M-RSF scaffold implantation sites had a negligible incidence of secondary fractures as compared to the CaSO₄ implantation sites (∼50% sites with secondary fracture), implying a reduction in postsurgical complications. Thus, the study demonstrates that the M-RSF scaffold is nontoxic for bone-void-filling applications and facilitates superior healing of fracture defects as compared to commercial calcium-based bone void fillers.

Treatment of Bone Defects Resulted after Excision of Enchondroma of the Hand in 15 Patients, Comparing the Techniques of Autologous Bone Graft, Injectable Bone Substitute and Spontaneous Healing

Background: Enchondroma is the most common benign bone tumor of the hand. Surgical excision of the tumor using curettage is the treatment of choice. The management of the resulting defects is still a controversial topic in the literature. Methods: This retrospective study includes 15 patients diagnosed with solitary enchondroma in the hand bones: eight cases with type A, three cases with type B and four cases with type D according to Takigawa classification. The aim of this study was to compare the course and outcome in the three patient groups treated by curettage associated with natural consolidation of the bone defect, autologous bone graft or injectable synthetic bone substitute in association with plate and screw osteosynthesis. Results: Outcomes were assessed using the DASH score (mean score 2.5) and TAM score (excellent in all patients) with no significant functional differences between the three groups. Defects managed with k-IBS® injectable bone substitute were associated with shorter operating time, simpler surgical technique and less postoperative pain assessed by VAS score. Conclusion: The use of k-IBS® bone substitute is efficient and less technically demanding than autologous bone grafting. The Takigawa classification could be a good indicator for treatment choice.

Surgical Management of Enchondromas of the Hand: A 12-Year Experience

Objective Enchondromas are benign tumours of hyaline cartilage most frequently arising in the bones of the hand and the optimum surgical management strategy for these is debated. We present an audit of the surgical management of 57 enchondromas referred to our tertiary hand surgery department over a period of 12 years (2008–2020) and describe our surgical technique for this procedure as well as a comparison with other studies in the literature.

Materials and Methods Retrospective audit of our practice. Data were extracted from our institutional operative database to identify all patients undergoing surgical management of enchondromas during the time period. The individual electronic patient records were then evaluated to extract demographics and outcome data.

Results Our results demonstrate excellent clearance of enchondroma (74% Tordai group 1 radiological resolution) with very low complication rates and no recurrence. Our results also emphasize the importance of surgical management of enchondromas to allow diagnosis of rare chondrosarcoma (3.5% in this study).

Conclusion A larger randomized controlled trial is still required to adequately determine the differences between the surgical options available and determine the best possible surgical approach to these cases. Level of evidence is III.

An Overview of Bone Replacement Materials – Biological Mechanisms and Translational Research

Bone defects might develop as a result of various pathological entities. Bone grafting is a widely used procedure that involves replacement of the missing tissue with natural or artificial substitute. The idea for artificial replacement of the missing bone tissue has been known for centuries and the evidence for these treatments has been found ever since prehistoric period. Bone grafting has been practiced for centuries with various non-osseous natural materials. The skeletal system plays a crucial role in the structural support, body movement and physical protection of the inner organs. Regeneration of bone defects is crucial for reestablishing of the form and function of the skeletal system,. While most bone defects can heal spontaneously under suitable conditions, bone grafts or substitute biomaterials are commonly used therapeutic strategies for reconstruction of large bone segments or moderate bone defect. An ideal bone grafting material should provide mechanical strength, be both osteoinductive and osteoconductive and should provide space for vascularization. In order to overcome limitations associated with the standard treatment of bone grafts, there is an increasing interest in studying substitute biomaterials, made of naturally derived or synthetic materials. Bone substitutes can be derived from biological products or from synthetic materials. Prior to testing in human subjects, the bone substitute materials should be tested in vitro and in vivo using animal models. Establishing of a suitable animal model is an essential step in the investigation and evaluation of the bone graft materials.

Clinical study on repair of metacarpal bone defects using titanium alloy implantation and autologous bone grafting

Due to various limitations in the use of autologous bone and allogeneic bone in the repair of bone defects, the use of synthetic bone graft substitute has become a hot topic in orthopedic surgery and repair medicine. A total of 53 patients treated for trauma-induced metacarpal bone defects were recruited. These patients were divided into the TiAl₆V₄ titanium alloy implantation group (group A) and the autologous bone graft group (group B). The symptoms of patients in the two groups were closely observed and followed up. The operation time, time to bone fusion, post-surgical pain [visual analog scale (VAS) scores], hand function recovery [total active flexion scale (TAFS) scores] and complications were compared between the two groups. Following surgery, none of the patients had necrosis of fingers or bone non-union. The recovery was rated as excellent and good in up to 91.6% of patients, indicating high clinical efficacy. Compared with the use of autologous bone grafting as the gold standard (group B), there was no significant difference in the excellent and good recovery rate based on TAFS scores at 16 weeks after surgery (91.7 vs. 89.7%, P>0.05), and there was also no significant difference in the incidence of post-operative complications (33.3 vs. 41.3%, P>0.05). The operation time (82.08±6.64 min), time to bone fusion (7.75±1.73 weeks) and VAS scores at 3 days after surgery were all significantly lower in group A than in group B (P<0.05). The values of group B were 104.69±8.63 min, 9.17±2.78 weeks and [5(5, 6)], respectively. However, the hospitalization cost (22,657.8±1,595.4Ұ) was significantly higher than that in group B (14,808.2±2,291.3Ұ; P<0.05). In conclusion, the use of titanium alloy implantation may avoid new injury to the donor site, reduce the operation time and post-operative pain and accelerate bone fusion. Therefore, this method is worthy of popularization for defective bone reconstruction and recovery in the clinic.

Bone Substitutes in Orthopaedic Surgery: Current Status and Future Perspectives

Bone replacement materials have been successfully supplied for a long time. But there are cases, especially in critical sized bone defects, in which the therapy is not sufficient. Nowadays, there are multiple bone substitutes available. Autologous bone grafts remain the "gold standard" in bone regeneration. Yet, donor-site morbidity and the available amount of sufficient material are limitations for autologous bone grafting. This study aimed to provide information about the current status in research regarding bone substitutes. We report on the advantages and drawbacks of several bone substitutes. At the end, we discuss the current developments of combining ceramic substitutes with osteoinductive substances.

Enchondromas of the Hand: A 20-year Experience

Objective  Enchondromas are the commonest tumors of the bones of the hand. Treatment approaches vary. The present article presents the characteristics of the tumors, diagnostic methods, and treatments.

Methods  We discuss the approach used in our institution, where we have treated 48 patients with enchondromas of the hand between 1996 and 2016. Our technique of treatment, which has remained the same over 2 decades, comprises the use of curettage, high-speed burr, and autologous bone graft (harvested with a minimally invasive technique, using a Craig biopsy needle).

Results  Pain and fractures were the most common symptoms leading the patients to consultation, at frequencies of 33.3% and 31.3%, respectively. A total of 27.1% of the cases were asymptomatic, and their lesions were discovered incidentally. The mean age was 34.4 years (SD = 12.9 years). Tumors were more frequently presented in the ulnar side of the hand, in the fifth ray (41.5%) and in the proximal bones (in the proximal phalanges [43.8%], and in the metacarpal [33.3%]). The size of the tumors ranged from 0.2 cm ² to 5.7 cm ² , with a mean of 1.7 cm ² (standard deviation [SD] = 1.0 cm ² ) and were not associated with fracture ( p  = 0.291). Fracture was also not associated with any of the symptoms, neither with the age of the patients ( p  = 0.964). After the treatment, most patients achieved full range of motion (91.7%), with good integration of the bone graft. Three patients presented deficit in range of motion (6.3%) and the incidence of complications was also 6.3% (3 patients). At the end, after the needed surgical revisions, these three patients also recovered full function. They achieved full bone graft integration, regained full range of motion and returned to work. There was no tumor recurrence case during the follow-up period evaluated. For all cases, no donor site complications occurred.

Conclusion  Our method of treatment has consistently provided good outcomes, with only a few minor complications. Therapeutic level of evidence: IV.

Demineralized Bone Matrix Carriers and their Clinical Applications: An Overview

Reconstruction of massive bone defects is challenging for orthopaedic clinicians, especially in cases of severe trauma and resection of tumors in various locales. Autologous iliac crest bone graft (ICBG) is the “gold standard” for bone grafting. However, the limited availability and complications at donor sites resulted in seeking other options like allografts and bone graft substitutes. Demineralized bone matrix (DBM) is a form of allograft using acidic solution to remove mineral components, while leaving much of the proteinaceous components native to bone, with small amounts of calcium‐based solids, inorganic phosphates, and some trace cell debris. It is an osteoconductive and osteoinductive biomaterial and is approved as a medical device for use in bone defects and spinal fusion. To pack consistently into the defect sites and stay firmly in the filling parts, DBM products have various forms combined with biocompatible viscous carriers, including sponges, strips, injectable putty, paste, and paste infused with chips. The present review aims to summarize the properties of various kind of viscous carriers and their clinical use combined with DBM in commercially available products. Given DBM'mercially available products. Given DBM;s long clinical track record and commercial accessibility in standard forms, opportunities to further develop and validate DBM as a versatile bone biomaterial in orthopaedic repair and regenerative medicine contexts are attractive.

Osteomyelitis of the First Metatarsal Head Treated With Joint-Preserving Surgery and a Synthetic Resorbable Bone Graft Substitute: A Case Report

Managing infections of the first metatarsophalangeal joint can be demanding because many patients present with late-stage infection and partial or total amputation of the first ray or the phalanx could be necessary. We describe such a patient who was successfully treated with a calcium-based resorbable bone substitute that preserved the first metatarsophalangeal joint. A 38-year-old female presented to our department with a foot infection. Examination revealed a methicillin-susceptible Staphylococcus aureus infection of the first metatarsophalangeal joint. The histopathologic findings confirmed active osteomyelitis of the first metatarsal head. The metatarsophalangeal joint was debrided with open synovectomy, the metatarsal head was curetted, and the bone defect was filled with 2 mL of a synthetic bone graft substitute. Two years later, she reported no problems with function or pain, the joint had full range of motion, and she had no local or systemic signs of infection. The most recent radiographs revealed no damage to the first metatarsophalangeal joint. A synthetic bone graft substitute can be a good alternative for treating forefoot infections when the soft tissues are intact and the bone defect is not so large that partial or full amputation is necessary.

Early Clinical and Radiological Experience with a Ceramic Bone Graft Substitute in the Treatment of Benign and Borderline Bone Lesions

Substitutes for bone grafts experience increasing popularity, but the need for defect-filling following simple curettage of benign bone lesions is controversial. In this study, we wish to objectively report the radiological changes following bone defect-filling using a composite ceramic bone graft substitute, as well as the clinical results and complications. We evaluated 35 surgically treated benign bone lesions with subsequent defect-filling using two variants of a composite ceramic bone graft substitute (CERAMENT|BONE VOID FILLER or CERAMENT|G, BONESUPPORT AB, SWEDEN). After one year, a normal cortical thickness surrounding the defect was seen in approximately 80% of patients. Inside the defect-cavity, an almost complete product-resorption was seen after one year. The most common complication was a post-operative inflammatory soft-tissue reaction, seen in 7 patients (20%), which resolved without further treatment, although short-term antibiotic treatment was initiated at a local hospital in 6 patients, due to suspected wound infection. In summary, cortical thickness most commonly normalizes after bone tumor removal and filling of the bone defect using this particular composite ceramic bone graft substitute. The ceramic substitute undergoes resorption, which causes progressive changes in the radiological appearance inside the bone defect.

Giant Solitary Cyst at the Site of Knee Osteoarthritis: Treatment with a Synthetic Resorbable Bone Graft Substitute and Primary Total Knee Arthroplasty

A 48-year-old male patient presented in our department with knee osteoarthritis and a giant cystic lesion of the lateral femoral condyle. Bone biopsy of the lesion was performed. Histopathological examination confirmed the presence of a solitary bone cyst. The patient was treated by curettage of the cyst, filling with a synthetic resorbable bone graft substitute (Cerament™), and primary, cruciate-retaining total knee arthroplasty. 4 months after surgery, complete osseointegration of the bone graft substitute was evident on X-rays. The use of modern bone graft substitutes might be a novel alternative to other established techniques in the management of large bone lesions, even at the site of primary total knee replacement.

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.

Erratum: Medicine, Volume 95, Issue 24: Erratum

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