3d printed custom made bone solutions (clinical ... · 3d printed custom made bone solutions...
TRANSCRIPT
3D Printed Custom Made
Bone Solutions
(clinical implementation)
Joris J.W. Ploegmakers, MD, PhD
Department of Orthopaedic Surgery
Complex orthopaedic reconstruction
Revision PJI Oncology
University Medical Center Groningen
The author declares that the research for and communication of this independent body of work does not constitute any financial or other conflict of interest.UMCG-employed
StrykerKCI
Disclosure statement
Introduction
• Physiology of bone and homeostasis• Classic surgical innovations• New possibilities• “Tips & Tricks”
Physiology
4-types of cells: form-maintain-remodel
Osteogenic cell Osteoblast Osteocyte Osteoclast
1. Osteogenic(Formation of new bone by the cells contained within the graft)
2. OsteoinductivityChemically active process: Ability to promote cellular functions leading to new bone
formation.
(Bone Morphogenetic proteins convert cells into bone forming cells. Active process)
3. Osteoconductivity(Physically: using a scaffold, for growing bone from host bone)
The ability of a scaffold to facilitate new bone formation in direct apposition to the
biomaterial by allowing attachment, proliferation, migration and phenotypic expression
of bone cells. Passive process
Definition
Osteopromotive (DBMs)
Osteostimulative(bioglass)
Osteosupportive (hybrid )
Stability
DefinitionThe perfect graft
Elliot D.A. et al. A unified theory of bone healing an donunion. BJJ 2016
Pentagon Model
OsteoinductiveBMP7 BMP2 TGF-β FGF
Giannoudis PV et al. Fracture healing: the diamond concept. Injury 2007: 38Giannoudis PV et al. The diamond concept-open questions. Injury 2008: 39
Critical Size Defect
Pentagon Model
Giannoudis PV et al. Fracture healing: the diamond concept. Injury 2007: 38Giannoudis PV et al. The diamond concept-open questions. Injury 2008: 39
Growth factorsBMP7 BMP2 TGF-β FGF
2014 2014 2014 2017
Graft
1668 First bone graft (v Meekeren)
1912 Nobel Prize (vasc anasto)
1945 First bone bank (VS)
1953 Substitute (Osteo-RCT)**
1960 Dutch bone bank -20°C
1979 BIG (T. Slooff)*Rusell A. Hibbs, An operation for progressive spinal deformities, NY Med J93(1911):1013-16.
**Leonard F. Peltier. The Use of Plaster of Paris to Fill Defects in Bone, Clin Orthop 21 (1961):1-31.
GraftGraft Modality Substance / implant Osteo genic Osteo ind Osteo conduct Remodeling Structural support
Autograft Cancellous bone +++ ++ +++ +++ -
Cortical bone + +/- +/- ++ ++
Bone marrow aspirate ++ +/- - - -
Allograft Fresh - +/- ++ + ++
Frozen - +/- + - ++
Cancellous bone - +/- + - +
Demineralized bone matrix - +/- + - +
Ceramics Hydroxyapatite - - + - +/-
TriCalciumPhosphate - - + - +/-
Growth factors BMP-2 BMP-7 - ++ - - -
PMMA - - - - +++
Scaffold + AB
Scaffold
Graft implanted Acute inflam
Chronic inflam
Bone formation
(fusion)
Angiogenesis
Scar tissue
(no fusion)
0
hrs
24
hrs
72
hrs
3
wks
6 - 12
wks
Coagulation
0
hrs
24
hrs
72
hrs
3
wks
6 - 12
wks
Inflammation
Neutrophils
Maturation & remodeling
VascularisationMacrophages
Granulation tissue
Lukas A. van Dijk Biphasic calcium phosphate with submicron surface topography
in an Ovine model of instrumented posterolateral spinal fusion. JOR Spine 2018 .
Classical solutions & limitations
Intercalary allograft
pro’s & cons
Biology ? Ingrowth 2mm > depends vascPreserves joint Preserves function Long rehabLong lasting Failure
2012 2013
2014 2015 2016
Vascularised fibula
pro’s & consbiology Non weight bearing vascularised OR time
54% thrombose 1/60Necrosis 9/60Graft # 13/60
BJJ 2017. Houdek MT. The outcome and complications of vascularised fibular grafts., Bayne CO, Bishop AT, Shin AY.Plast Recon Surg. 2002. Arai. Complications of vascularized fibula graft for reconstruction of long bones.
OR 12011 17 yr OstS.
It does not always heal
2015OR 2
2016OR 3
2017OR 4
2018OR 5
OR 6
2018 24 yr
Distraction osteogensis(Masquelet technique)
pro’s & consBiology vascularyt
Safe and effective (3-24cm)
Distraction histogenesis results in
functional matrix
No grafts required
Rehabilitatoin
Timely (Up to 2 yr)
2x OR
SSI
Pain & discomfort
Meticulous planning
Intercalary prosthesis
pro’s & cons Preserves joint 10 cm docking stemWeight bearing No biology
No vascularisation
120mm
100mm
J. I. Albergo. Failure rates and functional results for intercalary femur recon after
tumour resection. Muscul surg 2019.
Classical solutions & limitations
Ongrowth: 2 mmRemodeling: 10*-35** mm (1 year) BIG vascA femur is not a tibia (femur osteo distraction < tibia)#,##
Biology / Angiogenesis is time consuming
*Butscheidt. Incorporation and Remodeling of Structural Allografts in Acetabular Reconstruction: Multiscale, Micro-Morphological Analysis of 13 Pelvic Explants. JBJS Am 2018. **Sörensen. Rapid bone and blood flow formation in impacted morselized allografts: positron emission tomography (PET) studies on allografts in 5 femoral component revisions of total hip arthroplasty. Acta OS 2003. # Houdek MT The outcome and complications of vascularised fibular grafts. BJJ 2017.## Arai Complications of vascularized fibula graft for reconstruction of long bones. Plast Reconstr Surg. 2002.
We would like to see this
2014
2013. 57yr, PJI
HypothesisProblems:Compromised soft tissueTime is of essence
Biological affinity Durable Loadable Resistant to Infection
Amputation NA +++ + +
Prosthesis - + +++ -
Allograft + -/+ - -
Fibula +++ ++ - +
Allo + Fib ++ ++ + -/+
Osteo distr +++ ++ - +
Cage prost ++ ++ ++ -/+
Goal:Early mobilisation by stabilityBiological incorporation for durabilityBiological incorporation for PI prevention
1. Measurements “bone defect”
2. Plan CT3. Planning with tech
14 yr, OstSarc
Bram Merema
1. Measure “ bone defect”2. Plan CT3. Planning with technicians4. ComSol
1. Measure “ bone defect”2. Plan CT3. Planning with technicians4. ComSol5. Discuss concept6. Improve
Autograft
Reamer Irrigator Aspirator
*Marchand LS et al. Is This Autograft Worth It?: The Blood Loss and Transfusion Rates Associated With Reamer Irrigator Aspirator Bone Graft Harvest. J Orthop Trauma. 2017 Apr;31(4):205-209.
30cc
Scaffold + AB
Scaffold
2-stage due to #
FDG Pet 18
Work proces1. Measure “critical bone defect”2. Plan CT3. Planning with technicians4. ComSol5. Discuss concept6. Improve7. Plan CAS & 3d8. Work-process CE
Work-proces CE
Tips & Tricks• Start with easy cases (C spacer / 3d guides / C implant)• Take time to plan (from CT to sterilisation, 6wk)• Take time to plan (CAS)• Certify work- process (May 2020 new legislation)
UnfortunatelyMechanostat
1. Instability2. No remodelling
hypertrofic non-union3. Implant failure
Questions
2018, 28y OstSarc
Work process example• Plan Ct
• Technician• CE certification
• CAS + custom guide
Work process example