Xavier Banse

Mechanical properties of adult vertebral cancellous bone: correlation with collagen intermolecular cross-links.

Although the mechanical strength of cancellous bone is well known to depend on its apparent density, little is known about the influence of other structural or biochemical parameters. This study specifically investigates the cross‐linking of the collagen in human vertebral bone samples and its potential influence on their mechanical behavior. Multiple cylindrical samples were cored vertically in the vertebral bodies of nine subjects (aged 44–88 years). Three spinal levels (T9, T12 or L1, and L4) and three sample sites within a vertebral body (anterior, posterior, and lateral) were used, for a total of 68 samples. The density was measured with peripheral quantitative computed tomography (pQCT) and all cylinders were mechanically tested in compression. After mechanical testing, they were unmounted and used for biochemical analysis. The amount of collagen (wt/wt of bone) and its content in reduced immature cross‐links, that is, hydroxylysinonorleucine (HLNL, mol/mol of collagen) and dihydroxylysinornorleucine (DHLNL), as well as stable mature cross‐links, that is, hydroxylysyl‐pyridinoline (HP), lysyl‐pyridinoline (LP), and pyrrole cross‐link were determined for each cylinder. None of the biochemical parameters correlated to the density. On multiple linear regression, the prediction of the mechanical properties was improved by combining density data with direct collagen cross‐link assessment. The HP/LP ratio appeared as a significant predictor to the strength (r = 0.40; p = 0.001) and stiffness (r = 0.47; p < 0.001) samples with a high HP/LP ratio being stronger and stiffer. Additionally, the ultimate strain correlated to the HP or LP concentration (r = 0.38 or 0.49; p < 0.01). Different subjects had different HP/LP ratios and different HP or LP concentrations in their vertebral bone samples, and the location of origin within a subject had no influence on the concentration. These observations suggest that the nature of the organic matrix in adult vertebral bone is variable and that these variations influence its mechanical competence.

Pelvic reconstruction with a structural pelvic allograft after resection of a malignant bone tumor.

BACKGROUND Reconstruction of the pelvic arch after resection of a malignant pelvic tumor remains a major surgical challenge because of the high rate of associated complications. The purpose of this investigation was to assess the functional outcome and complication rate following treatment with a bone allograft to reconstruct the pelvis. METHODS Twenty-four consecutive patients underwent excision of a malignant pelvic bone tumor and reconstruction with a pelvic bone allograft. The living patients were followed for a minimum of twenty-four months. There were nineteen primary malignant bone tumors, sixteen of which were high-grade sarcomas, and there were five isolated metastases. Patients were examined clinically and radiographically and were assessed functionally with the Musculoskeletal Tumor Society score. RESULTS The mean age of the patients at the time of the index surgery was thirty-four years, and the mean duration of follow-up was forty-one months. Eighteen of the twenty-four resections involved the periacetabular area and were followed by reconstruction either with a hip prosthesis (thirteen) or with an osteochondral allograft alone (five). The six other resections involved the iliac bone. All patients received a massive bone allograft that had been sterilely procured without secondary irradiation. At the time of our last evaluation, eight patients were alive and free of disease. Seven patients had a local recurrence. Neurological deficits were present in six patients, and three had a deep infection. Nonunion of three of the sixteen allografts that could be evaluated was observed. Neither graft fracture nor lysis was observed. Eleven patients underwent surgical revision, with nine of these revisions related to the reconstruction. The average Musculoskeletal Tumor Society score at the time of the latest follow-up was 73% of the maximal possible score. The average score was 82% for the eleven patients with an age of less than twenty years at the time of the index procedure and 65% for the thirteen older patients. Ten patients walked without any assistive device, and five of them had normal function with no or only a slight limp. CONCLUSIONS Pelvic reconstruction after a limb-sparing resection is associated with a high risk of surgical complications and usually should be reserved for patients with a primary bone sarcoma. A pelvic allograft can restore the anatomy and provide good functional results, especially in young patients. Nonunion was the most common allograft-related complication.

Inhomogeneity of Human Vertebral Cancellous Bone: Systematic Density and Structure Patterns Inside the Vertebral Body

In the spine, cancellous bone quality is usually assessed for the whole vertebral body in a transverse central slice. Correct identification and assessment of the weakest parts of the cancellous bone may lead to better prediction of fracture risk. The density and structural parameters were systematically investigated inside the thoracic (T-9), thoracolumbar (T12-L1), and lumbar (L-4) vertebral bodies of nine subjects. On both sides of the median sagittal plane, anterior and posterior 8.2 mm vertical cores were harvested in the thoracic vertebra. In the thoracolumbar and lumbar vertebrae, external samples were also cored. Peripheral quantitative computed tomographic (pQCT) density analysis of the 136 cores was performed at four different levels, from the lower to the upper endplate. The relatively thin slice thickness (300 microm) and small pixel size (70 microm x 70 microm) was considered sufficient to investigate the structural parameters on the four transverse slices and in the sagittal and coronal planes (total of 816 images). Using a constant threshold a binary image was generated and the morphometric data were extracted. The binary image was further skeletonized and classical strut analysis was performed. Cancellous bone density was 20% higher in the posterior cores than in the anterior and external cores. Moreover, clear vertical inhomogeneity was noted because the lowest half of the vertebral body presented lower density than the upper half (differences ranging from 25% to 15%). All structural parameters were strongly dependent on the location of the measurement. Structural differences between anterior, posterior, and external areas were mild and followed the density patterns. On the other hand, vertical inhomogeneity of the structural parameters was important. For example, in the thoracolumbar and lumbar vertebrae, the numbers of nodes or node-to-node struts were almost twofold higher in the inferior half than in the superior half (p < 0.01), whereas trabecular thickness and number of free-ends presented a center/close-to-endplate structural pattern, with central trabeculae being 15% thicker (p < 0.05) and presenting 30% fewer free-ends (p < 0.01) than the close-to-endplate ones. Variability of density and structural parameters was high and a substantial part of this variability could be explained by the place inside the vertebral body where the measurement was made. The weak part was not in the center of the body but in its upper half where the lower density did not seem to be compensated by a higher structural architecture. Further clinical investigation could enhance fracture prediction by tracking and focusing on the weakest part of the vertebral body.

Surgical inaccuracy of tumor resection and reconstruction within the pelvis: an experimental study.

Background and purpose Osseous pelvic tumors can be resected and reconstructed using massive bone allografts. Geometric accuracy of the conventional surgical procedure has not yet been documented. The aim of this experimental study was mainly to assess accuracy of tumoral resection with a 10-mm surgical margin, and also to evaluate the geometry of the host-graft reconstruction. Methods An experimental model on plastic pelvises was designed to simulate tumor resection and reconstruction. 4 experienced surgeons were asked to resect 3 different tumors and to reconstruct pelvises. 24 resections and host-graft junctions were available for evaluation. Resection margins were measured. Several methods were created to evaluate geometric properties of the host-graft junction. Results The probability of a surgeon obtaining a 10-mm surgical margin with a 5-mm tolerance above or below, was 52% (95% CI: 37–67). Maximal gap, gap volume, and mean gap between host and graft was 3.3 (SD 1.9) mm, 2.7 (SD 2.1) cm3 and 3.2 (SD 2.1) mm, respectively. Correlation between these 3 reconstruction measures and the degree of contact at the host-graft junction was poor. Interpretation 4 experienced surgeons did not manage to consistently respect a fixed surgical margin under ideal working conditions. The complex 3-dimensional architecture of the pelvis would mainly explain this inaccuracy. Solutions to this might be to increase the surgical margin or to use computer- and robotic-assisted technologies in pelvic tumor resection. Furthermore, our attempt to evaluate geometry of the pelvic reconstruction using simple parameters was not satisfactory. We believe that there is a need to define new standards of evaluation.

Cross-link profile of bone collagen correlates with structural organization of trabeculae

Little is known regarding the mechanisms that govern the structural organization of cancellous bone. In this study, we compare the nature of the collagen in vertebral cancellous bone with the structural organization of its trabecular network. Cylindrical specimens of cancellous bone from vertebrae were obtained from nine autopsy subjects (ages 46-88). In each subject, eight pairs of corresponding samples were obtained from three levels in the spine and three areas within the vertebral body, leading to a total of 68 pairs of samples. The cylinders from one side were used for morphometry and the classical morphometrical parameters were obtained (BV/TV, bone volume fraction; Tb.Th, trabecular thickness; Tb.N, number; Tb.Sp, trabecular spacing) and strut analysis (TSL, total strut length; Nd, number of nodes; Fe, number of free-ends). The amount of osteoid bone was also quantified. The cylinders from the other side were powdered and used for collagen assessment, including the amount of collagen (% w/w), and its content in immature cross-links; such as hydroxylysinonorleucine (mol/mol of collagen) and dihydroxylysinornorleucine, as well as stable mature cross-links, such as hydroxylysylpyridinoline (HP), lysylpyridinoline (LP), and the pyrrole cross-links. A random regression model was used to explore the correlations. None of the biochemical parameters correlated with the BV/TV except the ratio between immature and mature cross-links (eta(2) = 0.34, p < 0.05). There was no relationship between the amount of osteoid bone and the cross-link profile. However, the concentration of pyrrole and HP cross-links in the bone samples correlated with the structural organization of its trabeculae, but in an opposite direction. Hence, the pyrrole/HP ratio was a good predictor of Tb.Th, Tb.N, Tb.Sp, and TSL (eta(2) > 0.65 and p < 0.01) as well as Fe and star marrow space (eta(2) > 0.45 and p < 0.05). The cylinders from subjects with high pyrrole or low HP in their bone collagen had a relatively thick and simple structure. Those with low pyrrole and high HP had relatively thin trabeculae that were more numerous and spread over a complex network. The relative concentrations of the pyrrole and pyridinoline cross-links appear to reflect the structural organization of the trabeculae.

Computer-Assisted Resection and Reconstruction of Pelvic Tumor Sarcoma

Pelvic sarcoma is associated with a relatively poor prognosis, due to the difficulty in obtaining an adequate surgical margin given the complex pelvic anatomy. Magnetic resonance imaging and computerized tomography allow valuable surgical resection planning, but intraoperative localization remains hazardous. Surgical navigation systems could be of great benefit in surgical oncology, especially in difficult tumor location; however, no commercial surgical oncology software is currently available. A customized navigation software was developed and used to perform a synovial sarcoma resection and allograft reconstruction. The software permitted preoperative planning with defined target planes and intraoperative navigation with a free-hand saw blade. The allograft was cut according to the same planes. Histological examination revealed tumor-free resection margins. Allograft fitting to the pelvis of the patient was excellent and allowed stable osteosynthesis. We believe this to be the first case of combined computer-assisted tumor resection and reconstruction with an allograft.

Computer-assisted planning and navigation improves cutting accuracy during simulated bone tumor surgery of the pelvis

Background: Resection of bone tumors within the pelvis requires good cutting accuracy to achieve satisfactory safe margins. Manually controlled bone cutting can result in serious errors, especially due to the complex three-dimensional geometry, limited visibility, and restricted working space of the pelvic bone. This experimental study investigated cutting accuracy during navigated and non-navigated simulated bone tumor cutting in the pelvis. Methods: A periacetabular tumor resection was simulated using a pelvic bone model. Twenty-three operators (10 senior and 13 junior surgeons) were asked to perform the tumor cutting, initially according to a freehand procedure and later with the aid of a navigation system. Before cutting, each operator used preoperative planning software to define four target planes around the tumor with a 10-mm desired safe margin. After cutting, the location and flatness of the cut planes were measured, as well as the achieved surgical margins and the time required for each cutting procedure. Results: The location of the cut planes with respect to the target planes was significantly improved by using the navigated cutting procedure, averaging 2.8 mm as compared to 11.2 mm for the freehand cutting procedure (p < 0.001). There was no intralesional tumor cutting when using the navigation system. The maximum difference between the achieved margins and the 10-mm desired safe margin was 6.5 mm with the navigated cutting process (compared to 13 mm with the freehand cutting process). Conclusions: Cutting accuracy during simulated bone cuts of the pelvis can be significantly improved by using a freehand process assisted by a navigation system. When fully validated with complementary in vivo studies, the planning and navigation-guided technologies that have been developed for the present study may improve bone cutting accuracy during pelvic tumor resection by providing clinically acceptable margins.

Perforations of cortical bone allografts improve their incorporation.

The incorporation of perforated cortical bone allografts was compared with nonperforated allografts. A 5-cm circumferential defect in the middiaphysis at the tibia was created in adult sheep. A frozen tibial allograft was implanted and fixed with a locked nail for 6 months. There was no postoperative immobilization. Group I consisted of eight sheep with nonperforated allografts, whereas Group II was comprised of 10 sheep with perforated allografts. Union was evaluated radiographically, whereas the central part of the allograft had a densitometric evaluation. Creeping substitution was assessed on microradiographs from crosssections of the central 3 cm of graft by measurement of porosity and percentage of new and old bone area within the confines of the graft. The width of periosteal and endosteal callus also was determined. There was no statistical difference between both groups for the union score and bone density. However, the cortical bone graft porosity and the amount of new bone within the cortical bone differed significantly between the perforated allografts and the nonperforated ones. Periosteal callus was similar in both groups, whereas endosteal callus was significantly more wide and extended in the perforated allografts. Perforation of a cortical bone substantially improved the amount of newly formed bone by the host when compared with a nonperforated bone. The creation of channels seemed to increase the interface between living soft tissues of the host and the allografted bone with a resulting enhanced incorporation.

Patient-specific microarchitecture of vertebral cancellous bone: a peripheral quantitative computed tomographic and histological study

This study directly compares peripheral quantitative computed tomography (pQCT) and histology for the assessment of 11 morphological parameters. Sixty-eight cylindrical cancellous bone samples were cored from the thoracic (T-9) thoracolumbar (T-12 or L-1), and lumbar (L-4) vertebral bodies of nine autopsy subjects (aged 44-88 years). Four transverse slices were acquired by pQCT from the bottom to the top of each cylinder. Slice thickness was 300 microm and pixel size was 70 x 70 microm. Thin sections (5 microm) were obtained at the same location in the samples, stained with Von Kossa, and photographed. Classical morphological parameters and strut analysis parameters were measured on all images (272 pQCT and 272 matched histological sections). Because of the partial volume effect and specific thresholding procedure, pQCT overestimated the absolute value of the bone volume fraction (BV/TV) and trabecular thickness (Tb.Th) by a factor 2. The trabecular number (Tb.N), trabecular spacing (Tb.Sp), and total strut length (TSL) were correctly estimated. However, the direct correlation between pQCT and histology was excellent (r2 > 0.85, p < 0.001) for BV/TV, Tb.N, Tb.Sp, TSL, and star surface. For Tb.Th, number of nodes, and number of free ends, the correlation was also good (r(2) > 0.6, p < 0.001). Using a random regression model, we also explored the ability of these parameters to add structural information to the readily available BV/TV or apparent density. The model identified significant (p < 0.001) differences between subjects. For a given BV/TV, some patients had more trabeculae (Tb.N) that were thinner (Tb.Th) and more disconnected (higher free ends and star). This was observed for both histology and pQCT morphometrical data. Our analysis demonstrates the capacity of both histology and pQCT to detect subjects with specific structural patterns in vertebral cancellous bone.

Computer-assisted and robot-assisted technologies to improve bone-cutting accuracy when integrated with a freehand process using an oscillating saw

BACKGROUND In orthopaedic surgery, many interventions involve freehand bone cutting with an oscillating saw. Such freehand procedures can produce large cutting errors due to the complex hand-controlled positioning of the surgical tool. This study was performed to investigate the potential improvements in cutting accuracy when computer-assisted and robot-assisted technologies are applied to a freehand bone-cutting process when no jigs are available. METHODS We designed an experiment based on a geometrical model of the cutting process with use of a simulated bone of rectangular geometry. The target planes were defined by three variables: a cut height (t) and two orientation angles (beta and gamma). A series of 156 cuts were performed by six operators employing three technologically different procedures: freehand, navigated freehand, and robot-assisted cutting. After cutting, we measured the error in the height t, the absolute error in the angles beta and gamma, the flatness, and the location of the cut plane with respect to the target plane. RESULTS The location of the cut plane averaged 2.8 mm after use of the navigated freehand process compared with 5.2 mm after use of the freehand process (p < 0.0001). Further improvements were obtained with use of the robot-assisted process, which provided an average location of 1.7 mm (p < 0.0001). CONCLUSIONS Significant improvements in cutting accuracy can be achieved when a navigation system or an industrial robot is integrated into a freehand bone-cutting process when no jigs are available. The procedure for navigated hand-controlled positioning of the oscillating saw appears to be easy to learn and use.