Autogenous structural bone graft reconstruction of ≥ 10-mm-deep uncontained medial proximal tibial defects in primary total knee arthroplasty.

BACKGROUND: Management of uncontained medial proximal tibial defects during primary total knee arthroplasty (TKA) can be challenging, especially for defects ≥ 10 mm in depth. This study sought to assess the outcomes of autogenous structural bone grafts to address these defects. MATERIALS AND METHODS: In this prospective study, patients with uncontained medial proximal tibial defects ≥ 10 mm in depth undergoing TKA were managed by autogenous structural bone grafts fixed by screws and were followed up for at least 36 months. Patients were followed-up clinically with Knee Society Score (KSS) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Additionally, radiological follow-up was done to assess bone graft union and implant stability. RESULTS: The study included 48 patients with a mean age of 69.2 ± 4.5 years. The mean body mass index (BMI) was 31.4 ± 3.7 kg/m2. The mean defect depth was 17 ± 3.6 mm. With a mean follow-up period of 52.2 ± 12.3 months, the median KSS improved significantly from 30 preoperatively to 89, P < 0.001. The median WOMAC score reduced significantly from 85 preoperatively to 30.5, P < 0.001. The mean ROM increased significantly from 73 ± 12.4 preoperatively to 124 ± 8.4 degrees, P < 0.001. The mean graft union time was 4.9 ± 1 months. No significant complications were reported. CONCLUSIONS: Autogenous bone graft reconstruction is a safe and effective method of addressing uncontained medial proximal tibial defects in primary TKA. LEVEL OF EVIDENCE: Level IV.

Semi-focal bone transport versus traditional bone transport technique for the management of large tibial bone defects after trauma.

How to deal with large tibial bone defects is still controversial. The purpose of this research was to compare the semi-focal bone transport (SFBT) technique with traditional bone transport (TBT) technique for treating such patients. Sixty-two patients were included and retrospectively analyzed. In all cases, after radical debridement large tibial bone defects remained. Patients were treated by the SFBT or TBT technique. The distraction, consolidation duration and complications were recorded by the patients' medical files. Based on the Association for the Study and Application of Methods of Ilizarov (ASAMI) standard, the bone and functional results were evaluated. The mean bone defect size was 7.7 ± 1.6 cm and 7.5 ± 2.1 cm for SFBT and TBT patients. The mean external fixation index (EFI) was 1.51 ± 0.14 months/cm and 1.89 ± 0.25 months/cm for SFBT and TBT patients (p < 0.05), respectively. With respect to bone and function results, there was no significant differences between the two groups (p > 0.05). The mean number of complications per patient was 1.1 ± 0.6 and 1.6 ± 0.7 for SFBT and TBT patients (p < 0.05). Compared to the traditional bone transport technique, patients using the semi-focal bone transport technique achieved better clinical effects, including shorter EFI and less complications. Therefore, the SFBT technique could be a new option for patients with large tibial bone defects.

Difference Between Screw Cement Filling and Adequate Osteotomy With Thick Liner for Primary Total Knee Arthroplasty in Patients With Rand IIb Tibial Defects.

BACKGROUND: The effectiveness of 2 treatment options, screw-cement fill, and adequate osteotomy with a thick liner, in treating patients with Rand IIb tibial defects (tibial plateau defects to a depth of 5 to 10 millimeters) in primary total knee arthroplasty (TKA) has not yet been demonstrated. Therefore, we performed a retrospective study to evaluate the differences between these 2 treatments. METHODS: We retrospectively analyzed patients who underwent primary TKA for Rand IIb tibial plateau defects from 2015 to 2020 from a department database. Patients were categorized into the screw-cement and thick liner groups based on the different options used to repair tibial defects. We evaluated Knee Society Score, range of motion (ROM), Insall-Salvati index (ISI), and Forgotten Joint Score (FJS) in both groups. We also compared differences in prosthesis survival, stiffness, myasthenia, and joint clicking between the 2 groups at mean 2 years postoperatively (range, 2 to 2.3). A power analysis was performed on the number of cases in the cohort. RESULTS: Postoperative femur-tibia mechanical axis (FTMA) correction was significantly higher in the screw-cement group than in the thick-liner group: 18.8 (±5.6°) versus 15.4 (±5.9°) (P < .01); At mean 2 years after surgery, the American Knee Society Functional Score improvement values were higher in the thick-liner group than in the screw-cement group: 36.3 (±12.4) versus 42.4 (±16.4) (P = .05). Postoperative ISI scores were 0.95 (±0.12) points in the screw-cement group and 0.89 (±0.13) points in the-thick liner group (P = .03). There were no statistically significant differences in the Knee Society Clinical Score, ROM, FJS, stiffness, myasthenia, joint clicking, and revision rate. CONCLUSION: The results of this study showed no significant difference in clinical outcomes between the 2 reconstruction strategies of the screw cement fill technique and the adequate osteotomy and thick liner technique for Rand IIb tibial plateau defects. However, in patients who have FTMA deformities greater than 20° or in younger patients who need to preserve bone volume, we recommend the screw cement filling technique to ensure stable postoperative results and to prepare these patients for possible later surgery.

Evaluation of the efficacy of ipsilateral fibular transfer for reconstruction of large tibial defects in children: a retrospective study.

BACKGROUND: Reconstruction of large tibial defects is often a major challenge in limb salvage. This study aimed to evaluate initial follow-up results of ipsilateral fibula transfer for the treatment of large tibial defects in children. METHODS: A retrospective study was performed between September 2014 and April 2021. Ten children were identified as having large tibial defects. The children underwent ipsilateral fibula transfer. We then evaluated initial healing, tibial length discrepancy, ankle varus/valgus, fibular position, refracture, infection, and function. RESULTS: Five boys and five girls, with an average age of 7.2 years, were evaluated. The transferred fibula was united in the patients. The mean follow-up period after fibular transposition was 43 months. The patients achieved primary bone union; the mean time to union was 8.4 months (range, 4-18 months). Complications included refracture (30%), infection (40%), tibia malunion (30%), ankle varus (30%), sensory loss of toes (10%), and ankle valgus (10%). No other major complications were observed. All 10 patients were able to perform activities of daily living and return to their normal activities. CONCLUSION: Ipsilateral fibula transfer is a salvage surgery for the treatment of large tibial defects in children with congenital pseudoarthrosis of the tibia, traumatic nonunion of the tibia, and/or tibial defect after chronic osteomyelitis. However, long-term results still need to be followed up.

Antibiotic calcium sulfate-loaded hybrid transport versus traditional Ilizarov bone transport in the treatment of large tibial defects after trauma.

BACKGROUND: The purpose of this study was to compare the clinical effects of antibiotic calcium sulfate-loaded hybrid transport (ACSLHT) and traditional Ilizarov bone transport (TIBT) in the treatment of large tibial defects after trauma. METHODS: Eighty-five patients with large tibial defects after trauma were selected for retrospective study. The range of tibial defects was 6-22 cm. After thorough debridement and infection controlled, bone transport technique was used to reconstruct tibial defects. Forty-four patients were treated with ACSLHT technique (the ACSLHT group), while the other 41 were treated with TIBT technique (the TIBT group). Time in external fixator was evaluated by EFI score. Enneking score was used to evaluate limb functions. SAS score was used to evaluate postoperative anxiety status. In addition, complication incidence was compared, including axis deviation, docking site nonunion, infection recurrence and so on. RESULTS: There was no significant difference in preoperative general data between ACSLHT and TIBT group. EFI score in ACSLHT and TIBT group was 0.6 ± 0.1 cm/month and 1.7 ± 0.3 cm/month, respectively (P < 0.05). Enneking score of ACSLHT and TIBT group was 86.5% and 75.1% (P < 0.05). SAS score of ACSLHT group was significantly lower than that of TIBT group (P < 0.05). Complication incidence in ACSLHT group was significantly lower than that in TIBT group (P < 0.05). CONCLUSIONS: Compared with TIBT group, ACSLHT group had shorter time in external fixator, better limb functions, lower postoperative anxiety score and lower complication incidence which is worth of clinical promotion.

Total flavonoids of rhizoma drynariae ameliorates bone formation and mineralization in BMP-Smad signaling pathway induced large tibial defect rats.

Osteogenesis and angiogenesis acts as an essential role in repairing large tibial defects (LTDs). Total flavonoids of rhizoma drynariae (TFRD), a traditional Chinese medicinal herb, is reported to show anabolic effects on fracture healing. However, whether TFRD could improve the bone formation and angiogenesis in LTDs remains unknown. The purpose of this study was to evaluate the effect of TFRD on bone formation and angiogenesis in LTDs in distraction osteogenesis (DO). Using a previously established fracture model, LTD rats was established with circular external fixator (CEF). All rats then randomly divided into TFRD low dosage group (with DO), TFRD medium dosage group (with DO), TFRD high dosage group (with DO), model group (with DO) and blank group (without DO). Twelve weeks after treatment, according to X-ray and Micro-CT, TFRD groups (especially in medium dosage group) can significantly promote the formation of a large number of epiphyses and improve new bone mineralization compared with model group, and the results of HE and Masson staining and in vitro ALP level of BMSC also demonstrated the formation of bone matrix and mineralization in the TFRD groups. Also, angiographic imaging suggested that total flavonoids of TFRD was able to promote angiogenesis in the defect area. Consistently, TFRD significantly increased the levels of BMP-2, SMAD1, SMAD4, RUNX-2, OSX and VEGF in LTD rats based on ELISA and Real-Time PCR. In addition, we found that ALP activity of TFRD medium dosage group reached a peak after 10 days of induction through BMSC cell culture in vitro experiment. TFRD promoted bone formation in LTD through activation of BMP-Smad signaling pathway, which provides a promising new strategy for repairing bone defects in DO surgeries.

Treatment of segmental tibial defects by bone transport with circular external fixation and a locking plate.

OBJECTIVE: To evaluate the effectiveness of bone transport involving circular external fixation and locking plate application for the treatment of segmental tibial defects. METHODS: A retrospective review of 12 patients with segmental tibial defects who underwent bone transport with circular external fixation and locking plate application. We evaluated external fixation time, external fixation index, time to achieve union, and complications. Clinical results were assessed using the Association for the Study and Application of the Methods of Ilizarov (ASAMI) score. Generic health-related outcome was assessed using the 36-Item Short-Form Health Survey questionnaire (SF-36). RESULTS: The mean follow-up was 25.8 months, and the mean defect size was 6.7 cm. All of the patients achieved union at the distraction callus and docking site. The average external fixation time was 299.5 days. The mean external fixation index was 16.5 days/cm, and the mean healing index was 44.9 days/cm. The functional outcomes were excellent in eight cases and good in four. The average SF-36 score was 92. CONCLUSION: Bone transport with external fixation and locking plate application may be a promising method for the treatment of segmental tibial defects.

Does bone marrow aspirate help enhance the integration of gamma irradiated allograft bone?

Bone allografts donated by other individuals offer a viable alternative to autograft. Risks of disease transmission are overcome by sterilizing the bone; unfortunately sterilization methods generally affect bone functional properties including osteogenic potential and biomechanical integrity. This study aimed to determine any enhancement effect when gamma sterilised allografts was impregnated with autologous bone marrow in improving the rate and quality of integration in metaphyseal-tibial defects of rabbits. Almost all subjects showed 50% of the defect being covered by new bones by the third week and smaller residual defect size in the treated group at the fifth week. Hounsfield units at the defect site showed increasing healing in all samples, with the treated group having an apparent advantage although insignificant (p > 0.05). In the histopathological score evaluating healing over cortical and cancellous bone at the fracture site showed only slight variations between the groups (p > 0.05). Therefore no enhanced healing by the autologous bone marrow was observed when added to the bone allografts in treating the unicortical defects.

Addressing large tibial osseous defects in primary total knee arthroplasty using porous tantalum cones.

BACKGROUND: Tibial osseous defects can present a serious challenge in primary total knee arthroplasty. We describe a technique of using porous tantalum cones along with primary arthroplasty implants to address large tibial osseous defects in primary total knee arthroplasty and present the short-term results. METHODS: We present 17 cases (15 patients) in which primary total knee implants and porous tantalum cones were used to address large tibial bony defects. Clinical results were evaluated using Knee Society Scores, pre- and postoperative knee range of motion, and serial radiographs. RESULTS: At an average of 3.5 years of follow-up, all 17 knees had functioning implants with stable metaphyseal cones demonstrating radiographic evidence of osteointegration. At a minimum follow-up of two years, no patient had signs of osteolysis, instability, infection, or systemic complications. All 15 patients had excellent results with an average post-operative Knee Society Score of 94.6. Knee flexion improved by an average of 12.0° and knee extension improved to neutral in all patients. CONCLUSION: Primary total knee arthroplasty with porous tantalum cone augmentation produced excellent short-term results and should be considered an effective method for addressing large tibial osseous defects in primary total knee arthroplasty.

Vascularized fibular medialization for reconstruction of the tibial defects following tumour excision.

PURPOSE: The purpose of this study was to evaluate the functional and oncologic results of fibular medialization when used alone as a single-stage reconstructive technique after wide excision of malignant tumours of the proximal, middle, or distal tibia. METHODS: Between December 2010 and May 2015, 14 patients (six males and eight females) with primary malignant tumours of the tibia (eight proximal, four diaphyseal, two distal) were treated by wide excision. The mean age of the patients at the time of surgery was 23.2 years (11-38). The fibula was mobilized medially with its vascular pedicle to fill the defect and was fixed by a long plate and screws bypassing the graft. The average size of the defects reconstructed was 19.5 cm (18-22). Patients were evaluated functionally using the Musculoskeletal Tumour Society (MSTS) scoring system. RESULTS: The mean follow-up period was 31.3 months (range, 17-54). The average time for complete union was 7.6 months (range, 6-9). At final follow-up all patients had fully united grafts; 11 walked without aids. Chest metastases developed in one patient, superficial wound infection in two patients and leg length discrepancy in four patients; one case had LLD of more than 3 cm. The mean MSTS score was 23/30 points (76.5%). The minimum score was 40% (12/30) and the maximum was 90% (27/30). CONCLUSIONS: Ipsilateral pedicled vascularized fibular centralisation or medialization is a durable reconstruction for tibial defects after wide excision of bone tumours with an acceptable functional outcome. Stable osteosynthesis is the key to union.

Effects of melatonin on tibia bone defects in rats / Efectos de la melatonina sobre defectos óseos en la tibia de ratas

The aim of this study was to evaluate the effects of melatonin healing in a tibial bone defect model in rats by means of histopathological and immunohistochemistry analysis. Twenty one male Wistar albino rats were used in this study. In each animal, bone defects (6 mm length ) were created in the tibias. The animals were divided into three groups. In group 1 control group (rats which tibial defects). Group 2 melatonin (10 mg/kg) + 14 days in the tibial defect group) was administered intraperitoneally to rats. Group 3 melatonin (10 mg/kg) + 28 days in the tibial defect group) was administered intraperitoneally to rats. Histopathological analysis of samples was performed to evaluate the process of osteoblastic activity, matrix formation, trabecular bone formation and myeloid tissue in bone defects. Immunohistochemical and immunoblot analysis demonstrated non-collagenous proteins (osteopontin and osteonectin) differences in tibial bone defects. The expression of osteopontin on tibia was increased by 14 days melatonin treatment. The expression of osteonectin on tibia was dramatically increased by 14 days melatonin treatment.

El objetivo fue evaluar por medio de análisis histopatológico e inmunohistoquímico los efectos cicatrizantes de la melatonina en un modelo de defecto óseo tibial en ratas. Se utilizaron 21 ratas albinas Wistar macho. En cada animal, se crearon defectos óseos en las tibias de 6 mm de longitud. Los animales se dividieron en tres grupos. El Grupo 1 correspondió al grupo control (defectos tibiales sin tratamiento). Al Grupo 2 se administró melatonina por vía intraperitoneal (10 mg/kg) 14 días posteriores al defecto tibial. Al Grupo 3 se administró melatonina por vía intraperitoneal (10 mg/kg) 28 días posteriores al defecto tibial. Se realizó un análisis histopatológico para evaluar los procesos de actividad osteoblástica, formación de matriz, formación de hueso trabecular y tejido mieloide en los defectos óseos. Los análisis inmunohistoquímicos y de inmunotransferencia mostraron diferencias de proteínas no colágenas (osteopontina y osteonectina). La expresión de osteopontina en defectos óseos tibiales se incrementó en el Grupo 2. La expresión de osteonectina en la tibia se incrementó fuertemente bajo el tratamiento con melatonina por 14 días.

The effect of dietary supplements on healing of alloplastic bone grafted defects in rat tibia / Efecto de los suplementos dietarios sobre la cicatrización de defectos injertados con hueso aloplástico en la tibia de ratas

The aim of this investigation was to evaluate the potential effects of the systemically delivered combination of calcium, zinc and vit-d supplementation of the locally applied alloplastic bone graft. 28 male Wistar albino rats were used in this study. In each animal, bone defects (10 mm length ¥ 3 mm width ¥ 2 mm depth) were created in the tibias. The animals were divided into four groups. In Group 1 (Control Group) rats were fed with standard rat diet. In Group 2 (Calcium Group) rats received calcium carbonate (15 mg/kg body weight) suspended in saline. In Group 3 (Calcium/Zinc Group) rats received calcium carbonate (15 mg/kg body weight) and zinc sulfate (4 mg/kg body weight) suspended in saline. In Group 4 (Calcium/Vitamin D Group) rats received calcium carbonate (15 mg/kg body weight) and Vitamin D (500 IU/kg body weight) suspended in olive oil. Histopathological analysis of samples was performed to evaluate the process of osteoblastic activity, matrix formation, trabecular bone formation and myeloid tissue in bone defects. Total amounts of osteoblastic activity, matrix formation, trabecular bone formation and myeloid yissue in Ca Group (p= 0.002), Ca/Zinc Group (p= 0.002), and Ca/Vit.D Group (p= 0.001) were significantly higher than in Control Group. The total amounts of Ca/Vit.D Group were significantly different than Control Group and Ca Group. The results of the present study indicated that the oral calcium carbonate supplementation combination with zinc may have systemic effects on accelerating bone regeneration in alloplastic bone grafted tibial defects. Further human studies involving long-term follow up and different type of bone grafts should be conducted.

El objetivo de esta investigación fue evaluar los efectos potenciales de la combinación sistémica de calcio, zinc y vitamina D como suplemento de la aplicación local de un injerto óseo aloplástico. Fueron utilizadas 28 ratas Wistar albinas (machos). En cada animal, se crearon defectos óseos en las tibias (cuyas medidas fueron: 10 mm de longitud x 3 mm de ancho x 2 mm de profundidad). Los animales fueron divididos en cuatro grupos. En el Grupo 1 (control) las ratas fueron alimentadas con una dieta estándar. En el Grupo 2 (grupo de calcio) las ratas recibieron carbonato de calcio (15 mg/kg de peso corporal) suspendido en solución salina. En el Grupo 3 (grupo de calcio/zinc) las ratas recibieron carbonato de calcio (15 mg/kg de peso corporal) y sulfato de zinc (4 mg/kg de peso corporal) suspendido en solución salina. El Grupo 4 (calcio/vitamina D) recibió carbonato de calcio (15 mg/kg de peso corporal) y vitamina D (500 UI/kg de peso corporal) suspendidos en aceite de oliva. Se realizó un análisis histopatológico de las muestras para evaluar el proceso de actividad osteoblástica, formación de la matriz, hueso trabecular y tejido mieloide en defectos óseos. Las cantidades totales de actividad osteoblástica, formación de matriz, de hueso trabecular y tejido mieloide en los grupos Calcio (p= 0,002), Calcio/Zinc (p= 0,002), y Calcio/Vitamina D (p= 0,001) fueron significativamente mayores que en el grupo de control. Las cantidades totales de Calcio/Vitamina D Grupo fueron significativamente diferentes de los grupos Control y Calcio. Los resultados del presente estudio indican que lacombinación de suplementos de carbonato de calcio por vía oral con zinc puede tener efectos sistémicos sobre la aceleración de la regeneración ósea en defectos tibiales con injertos aloplásticos. Deben llevarse a cabo otros estudios en humanos, que involucren un largo plazo de seguimiento y también diferentes tipos de injertos óseos.

Use of screws and cement in primary TKA with up to 20 years follow-up.

The purpose of this study was to investigate screws and cement for large tibial bone defects during primary TKA. Of 14,686 consecutive primary TKAs performed between December 1988 and February 2010, 256 received screws and cement for tibial defects. Cox regression was used for the analysis. 20-year survival probability was 0.9897 (screws) and 0.9339 (no screws) (P = .4225 log-rank). Tibial bone condition was significantly worse in knees receiving screws (P < .0001) with 73.0% having defects in the screws group and 3.4% (P < .0001) for non-screws. Radiolucency appeared in 13.7% (screws) and 6.4% (no screws) postoperatively. Screws were $137 each, wedges $910 to $2240. Knees with tibial defects and screws performed similarly if not better than knees without defects at substantially lower cost than alternatives.

Tantalum cones for major osteolysis in revision knee replacement.

We report the results of revision total knee replacement (TKR) in 26 patients with major metaphyseal osteolytic defects using 29 trabecular metal cones in conjunction with a rotating hinged total knee prosthesis. The osteolytic defects were types II and III (A or B) according to the Anderson Orthopaedic Research Institute (AORI) classification. The mean age of the patients was 72 years (62 to 84) and there were 15 men and 11 women. In this series patients had undergone a mean of 2.34 previous total knee arthroplasties. The main objective was to restore anatomy along with stability and function of the knee joint to allow immediate full weight-bearing and active knee movement. Outcomes were measured using Knee Society scores, Oxford knee scores, range of movement of the knee and serial radiographs. Patients were followed for a mean of 36 months (24 to 49). The mean Oxford knee clinical scores improved from 12.83 (10 to 15) to 35.20 (32 to 38) (p < 0.001) and mean American Knee Society scores improved from 33.24 (13 to 36) to 81.12 (78 to 86) (p < 0.001). No radiolucent lines suggestive of loosening were seen around the trabecular metal cones, and by one year all the radiographs showed good osteo-integration. There was no evidence of any collapse or implant migration. Our early results confirm the findings of others that trabecular metal cones offer a useful way of managing severe bone loss in revision TKR.