We reviewed the results of 51 patients with benign bone tumours treated by curettage and implantation of calcium hydroxyapatite ceramic (CHA). The mean ...
Calcium hydroxyapatite ceramic implants in bone tumour surgery A LONG-TERM FOLLOW-UP STUDY
A. Matsumine, A. Myoui, K. Kusuzaki, N. Araki, M. Seto, H. Yoshikawa, A. Uchida From Mie University School of Medicine and Osaka University Medical School, Japan
A. Matsumine, MD, Assistant Professor K. Kusuzaki, MD, Associate Professor M. Seto, MD, Assistant Professor A. Uchida, MD, Professor Department of Orthopaedic Surgery, Mie University School of Medicine, 2-174 Edobashi, Tsu-city, Mie 5148507, Japan. A. Myoui, MD, Assistant Professor H. Yoshikawa, MD, Professor Department of Orthopaedic Surgery, Osaka University Medical School, 2-2 Yamadaoka, Suita, Osaka 565-0871, Japan. N. Araki, MD, Chief of the Department Department of Orthopaedic Surgery, Osaka Medical Center for Cancer and Cardiovascular Diseases, 13-3 Nakamichi, Higashinariku, Osaka 537-0025, Japan. Correspondence should be sent to Dr A. Matsumine. ©2004 British Editorial Society of Bone and Joint Surgery doi:10.1302/0301-620X.86B5. 14242 $2.00 J Bone Joint Surg [Br] 2004;86-B:719-25. Received 5 February 2003; Accepted after revision 20 January 2004 VOL. 86-B, No. 5, JULY 2004
We reviewed the results of 51 patients with benign bone tumours treated by curettage and implantation of calcium hydroxyapatite ceramic (CHA). The mean follow-up was 11.4 years (10 to 15.5). Post-operative fractures occurred in two patients and three had local recurrences; three had slightly limited movement of the adjacent joint and one had mild osteoarthritis. There were no allergic or neoplastic complications. In all cases, radiographs showed that the CHA was well incorporated into the host bone. Statistical analysis showed that absorption of the implanted CHA was greater in males (odds ratio, 6.2; 95% CI, 1.6 to 23.7) and younger patients (odds ratio, 0.6 for increase in age of 10 years; 95% CI, 0.91 to 0.99). However, the implanted CHA was not completely absorbed in any patient. We conclude that CHA is a useful and safe bone substitute for the treatment of benign bone tumours.
Large bone defects remaining after resection and curettage of benign bone tumours should be filled with a substitute to restore mechanical strength as soon as possible. Autologous bone grafts have the advantage of low risk of disease transmission and good osteoinduction. However, it may be difficult to obtain the quantity of bone graft required, particularly when the tumour is large or the patient is a child. The choices available include corticocancellous autograft, cortical or cancellous allograft, composite graft, ceramics, polymethylmethacrylate bone cement, bone marrow and demineralised bone matrix. The ideal bone substitute must be easily fabricated and preserved, biocompatible and biodegradable. In 1990, our short-term follow-up study of hydroxyapatite ceramic (CHA) for bone tumour surgery was the first to show that this material is biocompatible with bone and bone marrow.1 Others have also reported short-term results2-7 but there have been no reports of long-term clinical and radiographic studies of CHA in bone tumour surgery. Here, we present a series of 51 patients with benign bone tumours followed for a minimum of ten years after treatment by resection and curettage followed by implantation of CHA.
Patients and Methods We retrospectively reviewed the results of 51 patients with benign bone tumours sequen-
tially treated by curettage followed by implantation of CHA between April 1986 and January 1991 (Table I). The series comprised 32 males and 19 females, with a mean age of 24.6 years (7 to 59). The histological diagnoses were as follows: simple bone cysts, 13 patients; giant cell tumour of bone, 11; enchondroma, nine; fibrous dysplasia, eight; nonossifying fibroma, three; osteofibrous dysplasia, three; aneurysmal bone cyst, three; chondroblastoma, one. The locations were as follows: tibia, 16 patients; femur, 14; humerus, nine; phalanx, five; calcaneum, two; pelvis, two; scapula, one; fibula, one; talus, one. The mean follow-up was 11.4 years (10 to 15.5). Calcium hydroxyapatite ceramic implants. We used CHA in the form of granules (granule size 300 to 3000 µm) or porous blocks resembling pumice (porosity 35% to 48%; pore diameter 50 to 300 µm) (BONECERAM; Central Research Institute of Sumitomo Cement, Tokyo, Japan). The hydroxyapatite was sintered at 1150˚C; the bending strength of each block was between 130 and 200 kgf/cm2. The spatial dimensions of the blocks varied according to the shape and volume of the cavities. Operative technique. The tumour was exposed through an appropriately sized bone window. Careful and thorough curettage was performed using a curette and an airtome until cancellous bone was visible. Blocks and granules of gas-sterilized CHA were pressed in to 719
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A. MATSUMINE, A. MYOUI, K. KUSUZAKI, N. ARAKI, M. SETO, H. YOSHIKAWA, A. UCHIDA
Table I. Details of 51 patients with benign bone tumours treated by resection and curettage followed by implantation of calcium hydroxyapatite ceramic
Age Number (yrs)
Gender
Bone*
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51
F F M M M M M M M M F M M M M M M M F F F F F M M M M M M M F M F M M M F F F M M F F F F M M F M F M
Femur Tibia Humerus Humerus Calcaneus Tibia Femur Femur Humerus Femur Scapula Iliac bone Femur Femur Tibia Tibia Femur Humerus Femur Tibia Tibia Humerus Humerus Femur Femur Humerus Tibia Femur Femur Tibia p-phalanx Tibia Tibia Femur Tibia Tibia Pubis Tibia p-phalanx Metacarpal Humerus p-phalanx Tibia Tibia Calcaneus Tibia Talus m-phalanx Femur Humerus Fibula
32 25 17 7 15 12 11 37 53 15 29 8 54 48 46 30 50 53 47 17 19 32 14 12 11 11 15 10 5 8 59 30 11 23 20 14 12 41 10 12 28 11 49 20 20 11 23 43 33 31 9
Site in bone*† d-ME p-ME p-M D D d-M p-M p-M p-MD
D p-M p-ME p-M p-ME p-M p-M D D d-MD p-MD p-M p-M D D p-M p-M D p-M p-ME D d-ME p-M d-M p-MD p-MD D p-M D p-ME D D p-M d-M p-MD D
Diagnosis‡
Symptom at first visit
Combination Volume of with Duration Radiographic the cavity autologous of follow- staging at final (ml) bone graft Complication up (yrs) follow-up
GCT GCT SBC SBC SBC FD EC FD SBC FD GCT SBC EC GCT NOF GCT GCT ABC FD FD FD FD SBC SBC SBC SBC OFD SBC SBC OFD EC GCT OFD GCT GCT GCT SBC FD EC EC ABC EC GCT EC CB NOF ABC EC NOF EC SBC
Knee pain Knee pain Shoulder pain No symptom Heel pain Leg pain Knee pain Thigh pain No symptom Thigh pain Shoulder pain No symptom No symptom Hip pain No symptom Knee pain Knee pain No symptom Thigh pain Leg pain Leg pain Fracture Shoulder pain Hip pain Hip pain Brachialgia No symptom Hip pain Thigh pain Leg pain Finger pain Knee pain Leg pain Knee pain Knee pain Ankle pain Pubic pain No symptom Swelling Swelling Shoulder pain Swelling Knee pain Leg pain Heel pain No symptom Ankle pain Swelling No symptom Brachialgia Leg pain
36 72 26 57 4 23 12 24 48 48 6 16 48 72 112 80 130 36 8 32 11 24 21 18 20 11 19 6 2 12 0.5 80 40 110 30 3 10 63 1.5 0.8 60 0.5 120 12 0.5 5 4 0.6 48 29 6
Yes Yes No No No No Yes No No Yes No No No Yes No Yes Yes No No No No No No No No No Yes No No Yes No Yes No Yes Yes No No No No No No No Yes Yes No No No No No No No
No No No Recurrence No No No No No Fracture No No No No No No No Limited ROM No No No Limited ROM Recurrence No No No Fracture No No No No OA No No No No No No No No No No Recurrence No No No No Limited ROM No No No
11.8 11.1 11.3 11.6 10.9 11.5 10.8 10.3 10.5 10.5 11.7 10.8 15.3 15.5 11.3 15.2 10.3 10.1 11 11 10 11.4 11.7 10.4 11.9 10.6 11.6 10.4 11 13.3 10.4 11.7 11 13.1 10.9 11.6 11.3 10.8 11.6 11.3 14.9 14.6 10.2 10.6 10.2 10.6 10.6 10.1 10.1 10.1 10.4
2 3A 3A 2 3B 3B 3A 3A 2 3B 2 3B 2 3A 2 3B 2 2 3B 3A 2 3A 3A 3B 3B 3B 3B 3B 3B 3B 2 3B 2 3B 3A 3A 2 2 3A 3B 3B 2 3B 2 2 2 3A 2 3A 2 3B
* p-; proximal; m, middle; d-, distal † E, epiphysis; M, metaphysis; D, diaphysis ‡ GCT, giant cell tumour; SBC, simple bone cyst; FD, fibrous dysplasia; OFD, osteofibrous dysplasia; EC, enchondroma; NOF, non-ossifying fibroma; ABC, aneurysmal bone cyst; CB, chondroblastoma
fill the bone defect. No other adjuvant treatment such as phenol or cryotherapy was used. The mean volume of the bone cavity was 32.5 ml (0.5 to 130). In 14 patients, CHA was used in combination with autologous bone graft. In six patients, internal fixation using plates and screws was used in addition to curettage, if the patient’s bone was deemed to
be too fragile. In 19 patients, the growth plate was still open at the time of the procedure. Assessment and statistical analysis. Assessment was based on clinical examination and radiography at the final followup. All assessments were performed by the musculoskeletal tumour service teams of Osaka University Medical School THE JOURNAL OF BONE AND JOINT SURGERY
CALCIUM HYDROXYAPATITE CERAMIC IMPLANTS IN BONE TUMOUR SURGERY
Stage 1 Clear margin
Stage 2 Hazy margin
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Stage 3 Absorbed < 50% of the margin
> 50% of the margin
A
B
Fig. 1 Diagram showing the three stage radiographic classification. Stage 1, clear margin; stage 2, hazy margin; stage 3, absorbed margin. Stage 3 was subdivided into stage 3A, absorption less than 50% of the margin of CHA and stage 3B, absorption more than 50% of the margin of CHA.
Table II. Relationship between radiographic staging at final follow-up and various factors
Characteristics Number of patients Gender F M Age (yrs)
