Bone tumor surgery involves tumor resection and subsequent reconstruction. With the development of surgical technique and new material, there is a great step toward bone and joint reconstruction in bone tumor surgery. Generally speaking, there are two major reconstructive methods including bio-reconstruction and mechanical reconstruction. In addition, three-dimensional printed prosthesis has been widely applied in the field of bone tumor surgery. The short-term result is encouraged; however, long-term results and related complications are seldom reported.
【Abstract】 Objective To evaluate the effects of allogeneic bone graft for reconstructing bone defect of clavicle aftertumor resection. Methods Nine patients received the surgical procedures for repairing and reconstructing bone defect afterresection of clavicle tumor from January 2000 to January 2006. There were 4 males and 5 females aged 12 to 68 years. Two patientswere diagnosed as having benign tumor and tumor-like lesion(stage Ⅲ according to Campanacci grading), and 7 as having primarymalignant tumor and metastatic cancer. Three lesions were located in acromial end, 2 in sternal end and 4 in shaft of clavicle. Twocases was accompanied by pathological fracture. According to Enneking’s functional evalutation, the results were excellent in 3 cases,good in 3 cases, fair in 1 case and poor in 2 cases. Based on the visual analogue scale (VAS), pain was rated as medium rest-pain in4 cases, as medium move-pain in 3 cases and heavy pain in 2 cases preoperatively. The tumor was resected with en bloc. Defectedclavicles were reconstructed by a part of allograft clavicle and plate. The patients with malignant tumor received neo-adjuvant chemotherapyand radiotherapy postoperatively. The results were evaluated according to control of tumor, rel ief of pain, bone healingand shoulder joint function. Results These patients were followed up 12 to 70 months (mean 34.6 months). There were no localrecurrence and metastases in all patients during the follow-up. No complications of immune rejection and deep infection wereseen. The normal shape of the shoulders was restored. Eight of all patients showed primary bone healing between allograft boneand host bone. The mean healing time was 5.4 months (3.2-6.8 months). Loosening of the plate and nonunion were seen in 1 case;and bone grafting was given again. Fracture of allograft occurred in 1 case after removing internal fixation. According to Enneking’s functional evulation, the results were excellent in 6 cases and good in 3 cases at 3 months after operation; excellent in 4 cases, goodin 1 case and fair in 1 case among 6 patients who were followed up for 24 months. The VAS results of postoperation showed l ightmove-pain in 2 cases at 3 months, l ight move-pain and medium move-pain in 1 case respectively and no pain in 7 cases 12 months after operation. Conclusion Allogeneic clavicle is a useful and rel iable reconstructive material for clavicle defect due to tumor resection. The satisfactory shape and favorable function of the shoulder may be recovered after this procedure.
Objective To design a new custom-made artificial semi-knee joint based on rapid prototyping(RP) technique and to explore a method to solve necroses of allocartilage in hemi-joint allotransplantation. Methods Based on the extracted 3D contour image of the articular cartilage of femoral condyle, the custom-made artificial semi-knee joint was designed with Surfacer 9.0 image processingsoftware. The artificial semi-knee joint design used the femoral condylar 3D contour of the patient as the outer face and the subchondral bone 3D contour of allograft bone as inner face. One dado for medullary nailand two for special designing cages which were used to fix the cartilage into the allograft were added on the inner face. After being converted into RP data format, the computerassisted design was imported into the LPS600 rapid prototyping machine, and the prototype was achieved. Furthermore, the prototype could be modified by hand according to the design. Then the RP model was used as a positive mould to build up a silica gel negativemould, and the negative mould was sent to the factory to manufacture Ti-6Al-4V alloy articular cartilage through ordinary mould-melted founding process. Finally, the whole metal cartilage was completed after melting two special cages on it andpolishing it. Results A new custom-made artificial semi-knee joint was made ad used to treat a 14-year old patient. The custom-made artificial semi-knee joint and the subchondral bone were a perfect match. The operative result was satisfactory. The patient could walk 5 weeks after operation. The bone healing of the auto-bone and allo-bone was achieved 6 months later. A follow-up period lasting 1 yearshowed that the knee joint played a good function. Conclusion The artificial semi-knee joint is a good match for the allograft boneand a good idea to solve necroses of allocartilage in hemijoint allotransplantation.
OBJECTIVE To detect the immunoreaction after osteoblast xenotransplantation and to investigate the possibility of heterogenic osteocyte transplantation and tissue engineered bone reconstruction. METHODS: Rat osteoblasts were isolated by two-part bony digestion/elements in culturing, and incubated in vitro at 37 degrees C, 5% carbon dioxide for 5 days until they multiplied and formed a monolayer on the bottom of dish. Twenty-eight rabbits were divided into 3 groups. Autograft of osteoblasts(group A), xenograft of osteoblasts(group B) and normal saline(group C) were implanted into the rectus abdominus muscle. The immunological and histological observations were performed after 1, 2, 4 and 8 weeks of transplantation. RESULTS: Cultured cells reached confluence within 5 days and was identified as osteoblasts by ALP staining and Bon kossa staining. The result of host versus graft reaction was negative. In group B, specific antibody reaction was detected 2 weeks and 4 weeks after transplantation. Cell mediated cytotoxicity was detected after 2 weeks, reached the peak value 4 weeks later, and then began to decline 8 weeks later. HE staining showed mass inflammatory cells and no ectopic ossification after 8 weeks. CONCLUSION: Heterogenic osteoblast transplantation will lead to an obvious change in host humoral and cellular immunity and lost the ability of bone formation. So, it can not be used for the reliable cell sources for osteocyte transplantation or tissue-engineering bone reconstruction.
Objective To provide the seed cells for bone tissue engineering, to establ ish immortal ized human bone marrow mesenchymal stem cells (MSCxj) and to investigate the ectopic osteogenesis of MSCxj. Methods MSCxjs of the 35thand 128th generations were maintained and harvested when the cell density reached 2 109. Then, these cells were co-cultured with heterogeneous bone scaffold in groups A (the 35th generation, n=12) and group B (the 128th generation, n=12); heterogeneous bone alone was used in group C (n=12). The cell prol iferation was observed by scanning electron microscopy (SEM) after 48 hours and 18 days of osteogenic induction culture. The complex was implanted subcutaneouly through a 3-mm-incision at both sides of the back in 18 nude mice. Tetracycl ine label ing was performed before the animals were sacrificed. Tetracycl ine fluorescence staining, HE staining, ponceau staining, and immunohistochemistry staining for osteocalcin were performed at 4, 8, and 12 weeks after transplantation; the morphologic quantitative analysis was made. Results After 48 hours, SEM showed that MSCxjs adhered to heterogeneous bone and grew well; after 18 days, a large number of new filamentous extracellular matrix and small granules were found to cover the cells. The results of tetracycl ine fluorescence staining, HE staining, and ponceau staining in groups A and B showed that the osteogenesis was not obvious at 4 weeks after transplantation; osteoid matrix deposition was noted around and in theheterogeneous bone at 8 weeks; and osteogenesis was increased at 12 weeks. There was no significant difference in bone formation between groups A and B. Osteogenesis was not observed in group C. The osteocalcin expressions were positive in groups A and B. The bone ingrow percentages of groups A and B were 5.64% ± 2.68% and 4.92% ± 2.95% at 8 weeks, and 13.94% ± 2.21% and 14.34% ± 3.46% at 12 weeks, showing significant differences between 8 weeks and 12 weeks at the same group (P lt; 0.05) and no significant difference between groups A and B at the same time (P gt; 0.05). Conclusion MSCxj has favorable abil ities of ectopic osteogenesis and can be appl ied as seeded cells in bone tissue engineering.
To investigate the cl inical results and the mechanism of bone heal ing for the repair of bone defects following tumor resection with novel interporous TCP bone graft, and to test the hypothesis of “structural transplantation”. Methods From January 2003 to December 2005, 61 cases of various bone defects following the curettage of the benign bone tumors were treated with interporous TCP, with 33 males and 28 females, including bone fibrous dysplasiain 8 cases, bone cyst in 23 cases, eosinophil ic granuloma in 12 cases, enchondroma in 13 cases, non-ossifying fibroma in 2 cases, and osteoblastoma in 3 cases. Tumor sizes varied from 1.5 cm × 1.0 cm to 7.0 cm × 5.0 cm. The plain X-ray, single photon emission computed tomography (SPECT) and histology examination were obtained at various time points after operation. The in vivo biodegradation rate of the implanted TCP was evaluated based on a semi-quantitive radiographic analyzing method. Histopathology examination was performed in 1 revision case. Results All the patients were followed up for 5 to 24 months after operation. They all had good wound heal ing and bone regeneration. There was neither significant reverse reaction to the transplanted material nor locally inflammatory reaction in all of the cases. The bone defects were repaired gradually from 1 to 6 months after operation (bone heal ing at average 2.6 months after surgery) with a bone heal ing rate up to 96.7%. There was only 1 recurrence case (eosinophil ic granuloma in ischium) 3 months after operation. Given revision operation, this case gained bone heal ing. Radiographically, the interface between the implanted bone and host bone became fuzzy 1 month after implantation, indicating the beginning of new bone formation. Three months later, the absorption of the interporous TCP was noticed from peripheral to the center of the implanted bone evidenced by the vague or fuzzy realm. New bone formation could be seen both in peri pheral and central areas. Six months later, implanted bone and host bone merged together and the bone defect was totally repaired, with 78.9% degradation rate of the implanted TCP. Twelve months later, the majority of the implanted bone was absorbed and bone remodel ing was establ ished. In the cases that were followed up for 24 months, the function of affectedextremity was excellent with good bone remodel ing without recurrence. In 2 cases, SPECT showed that nucl ide uptake could be observed in implanted site and the metabol ic activity was high both in the central as well as the peripheral areas of the graft 1 month after implantation, which was an evidence of osteogenesis. Pathologically, the interporous TCP closely contacted the host bone inside the humerus 1 month after grafting. The interface between the implanted bone and host bone became fuzzy, and vascularized tissue began growing inside the implanted graft as a “l ining” structure. Conclusion The interporous TCP proves to be effective for cl inical reparation of bone defects following tumor resection. The inside three-dimensional porous structure simulates the natural bionic bone structure which is suitable for recruitment related cells in-growth into the scaffold, colonizing and prol iferation companied with the process of vascularize, finally with the new bone formation. The novel interporous TCP may boast both bone conductive and bone inductive activities, as an appeal ing “structural transplantation” bone graft.
ObjectiveTo explore the effectiveness of excision and reconstruction of bone tumor by using operation guide plate made by variety of three-dimensional (3-D) printing techniques, and to compare the advantages and disadvantages of different 3-D printing techniques in the manufacture and application of operation guide plate. MethodsBetween September 2012 and January 2014, 31 patients with bone tumor underwent excision and reconstruction of bone tumor by using operation guide plate. There were 19 males and 12 females, aged 6-67 years (median, 23 years). The disease duration ranged from 15 days to 12 months (median, 2 months). There were 13 cases of malignant tumor and 18 cases of benign tumor. The tumor located in the femur (9 cases), the spine (7 cases), the tibia (6 cases), the pelvis (5 cases), the humerus (3 cases), and the fibula (1 case). Four kinds of 3-D printing technique were used in processing operation guide plate:fused deposition modeling (FDM) in 9 cases, stereo lithography appearance (SLA) in 14 cases, 3-D printing technique in 5 cases, and selective laser sintering (SLS) in 3 cases; the materials included ABS resin, photosensitive resin, plaster, and aluminum alloy, respectively. Before operation, all patients underwent thin layer CT scanning (0.625 mm) in addition to conventional imaging. The data were collected for tumor resection design, and operation guide plate was designed on the basis of excision plan. Preoperatively, the operation guide plates were made by 3-D printing equipment. After sterilization, the guide plates were used for excision and reconstruction of bone tumor. The time of plates processing cycle was recorded to analyse the efficiency of 4 kinds of 3-D printing techniques. The time for design and operation and intraoperative fluoroscopy frequency were recorded. Twenty-eight patients underwent similar operations during the same period as the control group. ResultsThe processing time of operation guide plate was (19.3±6.5) hours in FDM, (5.2±1.3) hours in SLA, (8.6±1.9) hours in 3-D printing technique, and (51.7±12.9) hours in SLS. The preoperative design and operation guide plate were successfully made, which was used for excision and reconstruction of bone tumor in 31 cases. Except 3 failures (operation guide plate fracture), the resection and reconstruction operations followed the preoperative design in the other 28 cases. The patients had longer design time, shorter operation time, and less fluoroscopy frequency than the patients of the control group, showing significant differences (P<0.05). The follow-up time was 1-12 months (mean, 3.7 months). Postoperative X-ray and CT showed complete tumor resection and stable reconstruction. Conclusion3-D printing operation guide plates are well adapted to the requirements of individual operation for bone tumor resection and reconstruction. The 4 kinds of 3-D printing techniques have their own advantages and should be chosen according to the need of operation.
Objective To perfect the theory system of minimally invasive treatment for osteonecrosis of the femoral head (ONFH) with β tricalcium phosphate (β-TCP) bioceramic system and evaluate the effectiveness. Methods Eighteen New Zealand white rabbits aged 7-8 months were used to establish an animal model to verify the vascularization of porous β-TCP bioceramic rods. Micro-CT based three-dimensional reconstruction and fluorescence imaging were used to display the new blood vessels at 4, 8, and 12 weeks after operation. The inserting depth, number and diameter of vessels in the encapsulated area were analyzed. Nine pig femoral specimens were randomly divided into 3 groups (n=3): group A was normal femur; group B had cavity (core decompression channel+spherical bone defect in femoral head); in group C, mixed bioceramic granules were implanted to fill the defect in femoral head, and porous β-TCP bioceramic rod was implanted into decompression channel. The stiffness and yield load of specimens were analyzed by biomechanical test. A multicenter retrospective study was conducted to analyze 200 patients (232 hips) with femoral head necrosis treated with bioceramic system in 7 hospitals in China between January 2012 and July 2018. There were 145 males and 55 females, with an average age of 42 years (range, 17-76 years). According to the Association Research Circulation Osseous (ARCO) stage, 150 hips were in stage Ⅱ and 82 hips in stage Ⅲ. Postoperative imaging assessment was carried out regularly, and hip function was evaluated by Harris score. The effectiveness of ARCO stage Ⅱ and Ⅲ was also compared. Results Animal experiments showed that blood vessels could grow into the encapsulated area and penetrate it at 12 weeks. The inserting depth, number and diameter of blood vessels in the encapsulated area gradually increased, and there was significant difference between different time points (P<0.05). Biomechanical tests showed that the stiffness and yield load of specimens in groups B and C were significantly lower than those in group A, while the yield load in group B were significantly lower than that in group C (P<0.05). The stiffness in group C was restored to 41.52%±3.96% in group A, and the yield load was restored to 46.14%±7.85%. Clinical study showed that 200 patients were followed up 6-73 months, with an average of 22.7 months. At last follow-up, 12 patients (16 hips) underwent total hip arthroplasty, and the hip survival rate was 93.10%. According to the imaging evaluation, 184 hips (79.31%) were stable and 48 (20.69%) were worse. Harris score (79.3±17.3) was significantly higher than that before operation (57.3±12.0) (t=18.600, P=0.000). The excellent rate of hip function was 64.22% (149/232). The survival rate of hip joint, imaging score and Harris score of patients in ARCO stage Ⅱ were better than those in ARCO stage Ⅲ (P<0.05). Conclusion β-TCP bioceramic system can guide the abundant blood supply of greater trochanter and femoral neck to the femoral head to promote repair; it can partly restore the mechanical properties of the femoral head and neck in the early stage, providing a new minimally invasive hip-preserving method for patients with ONFH, especially for those in early stage.