Biphasic bone substitute and fibrin sealant for treatment of benign bone tumours and tumour-like lesions

Abstract

Purpose: Bone defects resulting from tumour resection or curettage are most commonly reconstructed with autologous bone graft which is associated with limited availability and donor site morbidity. Recent research has focussed on synthetic biomaterials as bone graft substitutes. The aim of this study was to assess the safety and efficiency of a bone substitute as an alternative for autologous bone in the treatment of benign bone tumours and tumour-like lesions.

Methods: In the present study, a biphasic ceramic (60% HA and 40% β-TCP) combined with a fibrin sealant was used to reconstruct defects in 51 patients after curettage of benign bone tumours or tumour-like lesions. Patient age ranged from eight to 68 years (mean 29.7), defect size from 2 cm(3) to 35 cm(3) (mean 12.1), and time of follow-up from one to 56 months (mean 22.7).

Results: Radiologic analysis showed complete bony defect consolidation in 50 of 51 patients after up to 56 months. No postoperative fractures were observed. Revision surgery had to be performed in one case. Histological analysis showed new bone formation and good biocompatibility and osseointegration of the implanted material.

Conclusion: In summary, the biphasic ceramic in combination with fibrin sealant was proven an effective alternative to autologous bone grafts eliminating the risk of donor site morbidity for the patient.

Figures

Fig. 1

a Macroscopic appearance of biphasic calcium phosphate granules. b SEM images of bone substitutes macrostructure and microstructure (c). d The material is moistened with 1 ml aqua dest./3.5 cm3 and the diluted fibrin sealant is added to form a mouldable mass (e, f) that can easily be applied to a lesion

Fig. 2

X-ray (a, b) and CT (c, d) images of a 24-year-old female patient diagnosed with an osteoclastoma of the distal tibia. The patient experienced pain when weight-bearing. TricOs bone substitute material was applied in combination with autologous cancellous bone from the iliac crest at a rate of 1:5. The defect had a volume of 10.5 cm3. At 18 months post surgery, CT scans were performed. The lesion was completely filled with newly formed tissue reminiscent of healthy cancellous bone. A sclerotic margin was observed. After 56 months the bone substitute material was radiographically still detectable. Resorption was determined as a stage 2 (e–g). Also, MRI was performed after 56 months to rule out recurrence of the osteoclastoma. A hypointensive zone was seen in the CT images corresponding to the sclerotic margin (h)

Fig. 3

X-ray and MRI images of a 16-year-old male suffering from a large calcaneal cyst (a). Intralesional curettage was performed and the lesion filled with 14 cm3 TricOs®. Radiographs showed complete defect filling postoperatively (b), and after 54 months postoperatively (c). Over time radiolucency decreased especially in the marginal area of the lesion. No signs of osteolysis were evident. The resorption was classified as a stage 2. High dissolution MRI was performed after 12 months postoperatively to assess defect filling. In T1-weighted images (d) the margin of the filled lesion showed no signal intensity. The patient had fully recovered six weeks after surgery and was free of pain

Fig. 4

X-rays and CT image of a 47-year-old female patient with a juvenile cyst of the glenoid (a). The lesion was filled with 7 cm3 of TricOs® (b). Radiologic controls and CT scans showed complete defect filling after 48 months (c, d), the resorption process of the ceramic was staged 3A. Radiologically, the implanted material was still detectable

Fig. 5

a, b Backscattered scanning electron microscopy (BSEM) demonstrating remnants of the transplanted bone substitute (white) material and new bone formation in grey and black. New bone formation is in close apposition to the biomaterial indicating good osseointegration. c Polarized light microscopy (10x) showed both residual granules and newly formed bone with haversian system. d In PMMA sections stained for Movat’s pentachrome (10x) new mineralized bone (green) and some unmineralized osteoid (red) as well as residual granules (light blue) were seen gradually being resorbed by osteoclastic cells