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Clinics in Orthopedic Surgery Feb 2024In bone sarcomas, chemotherapy has improved the prognosis with advances in diagnostic and surgical technologies, which has led to attempts to save limbs. As early... (Review)
Review
Feasibility of a Novel Local Tumor Ablation and Recycling Machine Based on Radiofrequency Dielectric Heating: In-depth Review on Research Background and Preliminary Report of an Experimental Study.
BACKGROUND
In bone sarcomas, chemotherapy has improved the prognosis with advances in diagnostic and surgical technologies, which has led to attempts to save limbs. As early detection and multidisciplinary treatment have improved the survival rate, curative surgery is considered for selected patients with metastatic bone carcinomas. Limb salvage procedures may vary in relation to the reconstruction method, which is accompanied by different complications. To overcome them, we devised a novel concept, local tumor ablation and recycling machine based on radiofrequency (RF)-induced heating and intended experiments to demonstrate its feasibility.
METHODS
The fresh femurs of 6-month-old pigs were used after removing the epiphyses; the distal parts were placed in a heating chamber. Fiber-optic temperature sensors were inserted in the metaphysis, meta-diaphysis, and diaphysis. Temperatures were measured six times each during heating at 27.12 MHz at various powers. Additionally, the compressive and bending stiffnesses were measured six times each for the unprocessed, RF-treated, and pasteurized bones, and the results were compared.
RESULTS
Under 200 W power output, the temperatures at all measurement sites reached 70 ℃ or higher in 6 minutes, and the temperatures were maintained. The median compressive stiffness of RF-heated bones was 79.2% higher than that of pasteurized bones, but the difference was statistically insignificant. The median bending stiffness of RF-heated bones was approximately 66.3% of that of unprocessed bones, which was 20% higher than that of pasteurized bones.
CONCLUSIONS
The feasibility to rapidly attain and maintain temperatures for tumor ablation is shown, which favorably preserves bone stiffness through the local tumor ablation and recycling based on RF heating. The problem of nonuniform temperature distribution might be solved by an optimal design determined from simulation research and additional experiments.
Topics: Animals; Catheter Ablation; Computer Simulation; Feasibility Studies; Heating; Hot Temperature; Neoplasms; Swine
PubMed: 38304211
DOI: 10.4055/cios23186 -
Clinics in Orthopedic Surgery Feb 2024Aneurysmal bone cysts (ABCs) are infrequent, benign, and locally destructive lesions that most commonly occur during the first two decades of life. They usually affect...
BACKGROUND
Aneurysmal bone cysts (ABCs) are infrequent, benign, and locally destructive lesions that most commonly occur during the first two decades of life. They usually affect the metaphysis of the long bones, but the pelvis is involved in 8%-12% of the cases. The management of pelvic ABCs is a challenging issue due to difficulties in choosing the appropriate approach, adjacent neurovascular bundles, the risk of intraoperative bleeding with difficulty achieving good hemostasis, and the risk of injury to the hip or sacroiliac joints. Limited data exist concerning the use of denosumab as a non-surgical treatment for pelvic ABCs. Our hypothesis was that denosumab might be an effective and safe solo treatment of cases with ABCs in the pelvis.
METHODS
We retrospectively assessed 20 patients with ABCs in the pelvis, who were treated by denosumab as a solo agent without surgery. Patients were assessed regarding disease control, the incidence of recurrence and non-oncological complications, and functional outcome.
RESULTS
The mean follow-up period was 38.5 months. Disease control was achieved in 16 patients (80%), with no local recurrence. Tolerable drug-related complications occurred in 15% of cases. The mean Musculoskeletal Tumor Society score was 92.3%.
CONCLUSIONS
Denosumab may provide a reliable option in the nonsurgical treatment of ABCs of pelvic origin with expected lower morbidity than the surgical solution and tolerable complications. Further studies on the safety profile and long-term effects of denosumab especially in skeletally immature patients are required.
Topics: Humans; Denosumab; Bone Cysts, Aneurysmal; Retrospective Studies; Pelvis; Bone and Bones
PubMed: 38304208
DOI: 10.4055/cios22228 -
Journal of Orthopaedic Case Reports Jan 2024Osteoblastoma is a rare, benign, bone-forming tumor accounting for <1% of all primary bone tumors. It has a predilection for the posterior elements of the spine and...
INTRODUCTION
Osteoblastoma is a rare, benign, bone-forming tumor accounting for <1% of all primary bone tumors. It has a predilection for the posterior elements of the spine and metaphysis and diaphysis of long bones. The occurrence of this tumor in the metatarsal region is rare. We report such the case of a metatarsal osteoblastoma which was treated with wide excision and non-vascularized fibular autograft: a reliable method of reconstruction.
CASE REPORT
A 25-year-old woman presented with progressive pain and swelling over the right foot for 4 years. On examination, there was a gross swelling over the fourth metatarsal region over the dorsum of the foot. Radiographs revealed a osteoblastic lesion of the fourth metatarsal bone expanding into the intermetatarsal region. Magnetic resonance imaging (MRI) revealed an expansile altered signal intensity lesion which was hypointense on both T1 and T2 - weighted images with no soft-tissue component. With a working diagnosis of locally aggressive bone-forming tumor, she underwent wide excision of the tumor with reconstruction using a non-vascularized fibular autograft. Intraoperative samples sent for histopathological examination confirmed the diagnosis of osteoblastoma. After 2 years of follow-up, the patient is able to weight bear with no pain and imaging shows graft incorporation with no signs of recurrence.
CONCLUSION
Osteoblastoma of the metatarsal region can present a diagnostic conundrum to the treating clinician due to its rare nature. Proper evaluation and reconstruction at an early stage with wide excision and reconstruction with non-vascularized fibular autograft are a reliable treatment option.
PubMed: 38292114
DOI: 10.13107/jocr.2024.v14.i01.4130 -
Cureus Dec 2023Chondromyxoid fibroma is one of the rarest bone tumours, occurring most frequently in adult men in their second and third decades. It generally affects the metaphysis of...
Chondromyxoid fibroma is one of the rarest bone tumours, occurring most frequently in adult men in their second and third decades. It generally affects the metaphysis of long bones, particularly the femur and tibia. Diagnosis can pose differential challenges with various tumor types, particularly chondrosarcoma, requiring separate management. We present a case of chondromyxoid fibroma of the distal tibia detected by soft tissue swelling. Clinical, epidemiological and radiological aspects will be discussed.
PubMed: 38288196
DOI: 10.7759/cureus.51319 -
JBJS Essential Surgical Techniques 2023The Reconstructive Allograft Preparation by Toronto Sarcoma (RAPTORS) protocol is reliable and reproducible without substantially adding to the surgical reconstruction...
BACKGROUND
The Reconstructive Allograft Preparation by Toronto Sarcoma (RAPTORS) protocol is reliable and reproducible without substantially adding to the surgical reconstruction time or cost. Our technique includes clearance of debris, lavage of the medullary canal, pressurized filling of the medullary canal with antibiotic-laden cement for its mechanical and antimicrobial properties, and insertion of cancellous autograft at the allograft-host junctional ends prior to dual-plate compression to fix the allograft into the defect. Our experience with large intercalary allograft reconstruction has demonstrated high rates of long-term success and addresses the most common causes of large allograft failure (infection, fracture, and nonunion), as shown in our long-term outcome study.
DESCRIPTION
Once the tumor is resected, it is used as a template for cutting and shaping the allograft to fit the bone defect and to restore length and anatomy. The frozen allograft is thawed in a container with povidone iodine and bacitracin saline solution until it reaches room temperature. The allograft is size-matched, and clearance of its intramedullary marrow contents is performed with use of curets and intramedullary reamers. If 1 end of the allograft includes the metaphysis and is covered by dense cancellous bone, we try not to ream through this end because maintaining this metaphyseal cancellous surface will expedite bone healing. The segment is then thoroughly lavaged with "triple wash" solutions to clear out any remaining marrow contents and to ensure sterilization of the allograft. This serial-wash technique involves the use of 3 discrete antiseptic modalities and has been utilized at our institution with low rates of allograft infection. These antiseptic modalities include 10% weight-per-volume povidone iodine diluted 1:1 with normal saline solution, 3% weight-per-volume hydrogen peroxide diluted 1:1 with normal saline solution, and 50,000 units of sterile bacitracin lyophilized powder dissolved in 500 mL of normal saline solution. Following the triple wash, the medullary canal is filled with antibiotic-laden methylmethacrylate bone cement. If both ends are open, the far end of the segment is first plugged with the surgeon's finger or with gauze, or if 1 end is covered with cancellous bone, then retrograde filling of the canal with cement is performed from the open end. The cement is then pressurized to ensure complete filling of the intramedullary space. Before it sets, 1 cm of cement is removed from each open end of the allograft to allow for packing of autograft bone cancellous chips and to ensure that cement does not impede anatomic reduction of the allograft-host bone junction. For this step, cancellous autograft from the iliac crest is harvested with use of a separate sterile surgical setup in order to prevent contamination of the autograft site by instruments used for tumor resection. The cancellous autograft is packed into the space created after recessing the cement at the end(s) of the allograft and, using a bone tamp, the autograft is compressed into this cavity and into the corresponding end of the host long bone in order to improve the healing potential at the allograft-host bone junction(s). Finally, a dual compression plate construct is utilized for upper as well as lower-extremity reconstructions in most cases. The cement in the allograft must be completely hardened before drilling into it. The allograft-host bone junctions are sequentially compressed at both the proximal and distal ends to allow for maximal apposition of the osseous surfaces. Only 1 or 2 unicortical screws are placed into the allograft to hold it in place and to facilitate maximal compression at both bone junctions. Patient compliance during postoperative rehabilitation is essential to optimize healing and provide reliable and durable outcomes. Postoperative care following the RAPTORS technique includes limited early rehabilitation and long periods of non-weight-bearing until radiographic union is noted across both bone junctions, followed by gradual resumption of weight-bearing and more aggressive physiotherapy. See the Appendix for further details regarding each step of the procedure.
ALTERNATIVES
Intercalary reconstruction alternatives include various biological or endoprosthetic constructs. The other biological reconstruction options include the use of a free vascularized bone graft, distraction osteogenesis, combined vascularized fibula and allograft (i.e., the Capanna technique), or recycled tumor bones. Intercalary prostheses offer another reconstruction option for diaphyseal defects, but their feasibility is more limited in cases of periarticular segments with very short residual medullary canals. In such cases, there may be inadequate stem length for fixation, or the segment may require a custom implant that takes time to design and manufacture, which can be associated with high costs.
RATIONALE
Major factors limiting the widespread use of allografts include infection, graft fracture, graft nonunion, and, in some locations, availability. Our technique of allograft preparation with dual compression plating and triple-washing to provide mechanical and antimicrobial protection as well as augmented healing has shown reproducible results with low complication rates compared with the literature.
EXPECTED OUTCOMES
There have been high rates of long-term allograft survival (84.4%) following intercalary long-bone reconstruction at our institution, with lower complication rates than those presented in the literature.
IMPORTANT TIPS
Transverse osteotomies of the allograft, made perpendicular to the long axis of the diaphysis/anatomical axis, are important to replicate the resected host bone. Transverse osteotomies, while inherently less stable than step-cut ones, allow for adjusting the rotation of the allograft segment as needed for maximal contact and compression, as well as restoration of anatomical limb rotation.It is important to perform meticulous clearance of the intramedullary contents while preserving the endosteal bone and allograft integrity. We would utilize hand-reaming rather than a power drill device, in order to prevent overreaming or breaking through the allograft bone.Place as few unicortical screws as possible into the allograft-cement construct in order to maintain its structural strength and minimize potential sites for vascular ingrowth and bone resorption.
ACRONYMS & ABBREVIATIONS
K-wires = Kirschner wiresW/V = weight per volume.
PubMed: 38274144
DOI: 10.2106/JBJS.ST.22.00011 -
BioRxiv : the Preprint Server For... Jan 2024Absent in Melanoma (AIM) 2 is a gene that is induced by interferon and acts as a cytosolic sensor for double-stranded (ds) DNA. It forms the AIM2 inflammasome, leading...
Absent in Melanoma (AIM) 2 is a gene that is induced by interferon and acts as a cytosolic sensor for double-stranded (ds) DNA. It forms the AIM2 inflammasome, leading to the production of interleukin (IL)-1β and IL-18. Our previous research demonstrated that mice lacking AIM2 exhibit spontaneous obesity, insulin resistance, and inflammation in adipose tissue. In this study, we aimed to explore the impact of AIM2 gene deletion on bone structure in adult and aged mice. Utilizing micro-computed tomography (micro-CT), we discovered that female mice lacking AIM2 showed an increase in the total cross-sectional area at 5 months of age, accompanied by an increase in cortical thickness in the mid-diaphysis of the femur at both 5 and 15 months of age. At 15 months of age, the cortical bone mineral density (BMD) significantly decreased in AIM2 null females compared to wild-type (WT) mice. In AIM2 null mice, both trabecular bone volume and BMD at the distal metaphysis of the femur significantly decreased at 5 and 15 months of age. Similarly, micro-CT analysis of the L4 vertebra revealed significant decreases in trabecular bone volume and BMD in aged AIM2 null females compared to WT mice. Histological examination of femurs from aged mice demonstrated increased bone marrow adiposity in AIM2 null mice, accompanied by a significant increase in CD45-/CD31-/Sca1+/Pdgfa+ adipose progenitor cells, and a decrease in the ratio of CD31-/CD31+ osteogenic progenitor cells, as determined by flow cytometry of bone marrow cells. Our findings suggest that AIM2 deficiency affects bone health by promoting adipogenesis in bone marrow cells and inducing a pro-inflammatory environment, potentially contributing to the decreased bone mineral density.
PubMed: 38260661
DOI: 10.1101/2024.01.05.574199 -
Cureus Dec 2023The earliest stages of osteosarcomas are primitive mesenchymal cells. It generally occurs close to the long bones' metaphysis and typically affects the long bones, such...
The earliest stages of osteosarcomas are primitive mesenchymal cells. It generally occurs close to the long bones' metaphysis and typically affects the long bones, such as the arm and leg. This case report underscores the pivotal role of physiotherapy in the rehabilitation of a 14-year-old male diagnosed with osteosarcoma, who underwent above-knee amputation. The structured six-week rehabilitation program, encompassing passive, active-assisted, and active exercises for the affected limb, alongside strength training for unaffected joints, produced notable gains in the pain rating scale and the lower-extremity functional scale in just 15 days. These outcomes underscore the significance of early and targeted physiotherapy interventions in optimizing functional outcomes and quality of life for young patients with osteosarcoma after surgery.
PubMed: 38259366
DOI: 10.7759/cureus.50859 -
Frontiers in Pediatrics 2023This study reported a case of radius flexible intramedullary nailing complicated by temporary paralysis of the posterior interosseous nerve due to compression of the...
This study reported a case of radius flexible intramedullary nailing complicated by temporary paralysis of the posterior interosseous nerve due to compression of the ESIN on the nerve in an 8-year-old boy. The nerve damage resulted from an essential misconception at the surgery. Despite bad decisions made during qualifications and the procedure undertaken, restoring the nerve function, and gaining satisfactory functional fracture recovery was possible. Although it is generally acknowledged to perform retrograde flexible intramedullary nailing from the level of the distal radial metaphysis, the presentation of our case aims to emphasize the real risk of damage to the motor branch of the radial nerve when approaching the proximal metaphysis.
PubMed: 38250596
DOI: 10.3389/fped.2023.1325459 -
Zhongguo Xiu Fu Chong Jian Wai Ke Za... Jan 2024To review the biomechanical research progress of internal fixation of tibial plateau fracture in recent years and provide a reference for the selection of internal... (Review)
Review
OBJECTIVE
To review the biomechanical research progress of internal fixation of tibial plateau fracture in recent years and provide a reference for the selection of internal fixation in clinic.
METHODS
The literature related to the biomechanical research of internal fixation of tibial plateau fracture at home and abroad was extensively reviewed, and the biomechanical characteristics of the internal fixation mode and position as well as the biomechanical characteristics of different internal fixators, such as screws, plates, and intramedullary nails were summarized and analyzed.
RESULTS
Tibial plateau fracture is one of the common types of knee fractures. The conventional surgical treatment for tibial plateau fracture is open or closed reduction and internal fixation, which requires anatomical reduction and strong fixation. Anatomical reduction can restore the normal shape of the knee joint; strong fixation provides good biomechanical stability, so that the patient can have early functional exercise, restore knee mobility as early as possible, and avoid knee stiffness. Different internal fixators have their own biomechanical strengths and characteristics. The screw fixation has the advantage of being minimally invasive, but the fixation strength is limited, and it is mostly applied to Schatzker typeⅠfracture. For Schatzker Ⅰ-Ⅳ fracture, unilateral plate fixation can be used; for Schatzker Ⅴand Ⅵ fracture, bilateral plates fixation can be used to provide stronger fixation strength and avoid the stress concentration. The intramedullary nails fixation has the advantages of less trauma and less influence on the blood flow of the fracture end, but the fixation strength of the medial and lateral plateau is limited; so it is more suitable for tibial plateau fracture that involves only the metaphysis. Choosing the most appropriate internal fixation according to the patient's condition is still a major difficulty in the surgical treatment of tibial plateau fractures.
CONCLUSION
Each internal fixator has good fixation effect on tibial plateau fracture within the applicable range, and it is an important research direction to improve and innovate the existing internal fixator from various aspects, such as manufacturing process, material, and morphology.
Topics: Humans; Biomechanical Phenomena; Bone Plates; Fracture Fixation, Internal; Fracture Fixation, Intramedullary; Tibial Fractures; Tibial Plateau Fractures
PubMed: 38225850
DOI: 10.7507/1002-1892.202309077 -
Advanced Science (Weinheim,... Mar 2024The Ilizarov technique has been continuously innovated to utilize tensile stress (TS) for inducing a bone development-like regenerative process, aiming to achieve...
The Ilizarov technique has been continuously innovated to utilize tensile stress (TS) for inducing a bone development-like regenerative process, aiming to achieve skeletal elongation and reconstruction. However, it remains uncertain whether this distraction osteogenesis (DO) process induced by TS involves the pivotal coupling of angiogenesis and osteogenesis mediated by type H endothelial cells (THECs). In this study, it is demonstrated that the Ilizarov technique induces the formation of a metaphysis-like architecture composed of THECs, leading to segmental bone regeneration during the DO process. Mechanistically, cell-matrix interactions-mediated activation of yes-associated protein (YAP)/transcriptional co-activator with PDZ-binding motif (TAZ) transcriptionally upregulates the expression of Notch1 and Delta-like ligand 4, which act as direct positive regulators of THECs phenotype, in bone marrow endothelial cells (BMECs) upon TS stimulation. Simultaneously, the Notch intracellular domain enhances YAP/TAZ activity by transcriptionally upregulating YAP expression and stabilizing TAZ protein, thus establishing the YAP/TAZ-Notch circuit. Additionally, TS-stimulated BMECs secrete exosomes enriched with vital molecules in this positive feedback pathway, which can be utilized to promote segmental bone defect healing, mimicking the therapeutic effects of Ilizarov technique. The findings advance the understanding of TS-induced segmental bone regeneration and establish the foundation for innovative biological therapeutic strategies aimed at activating THECs.
Topics: Adaptor Proteins, Signal Transducing; Signal Transduction; Trans-Activators; YAP-Signaling Proteins; Endothelial Cells; Exosomes; Cell Cycle Proteins; Transcription Factors; Bone Regeneration
PubMed: 38225729
DOI: 10.1002/advs.202309133