Research
Primary cancellous bone formation around micro-chambered beads
Formación de hueso esponjoso con esferas microcompartimentales
a Center of Orthopaedic Sciences, Munich, Germany
b Clinic for Restorative Dentistry and Periodontology, Ludwig Maximilian University, Munich, Germany
c Department of Trauma-, Hand-, and Reconstructive Surgery, Saarland University, Homburg, Germany
d Departamento de Traumatología, Clínica Berka, Universidad de Madrid, Madrid, Spain
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Draenert, Y. Draenert, K. Draenert, T. Pohlemann, M. Erler" "autores" => array:5 [ 0 => array:4 [ "nombre" => "M.E." "apellidos" => "Draenert" "email" => array:1 [ 0 => "mdraener@dent.med.uni-muenchen.de" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Y." "apellidos" => "Draenert" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "K." "apellidos" => "Draenert" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "T." "apellidos" => "Pohlemann" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 4 => array:3 [ "nombre" => "M." "apellidos" => "Erler" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Center of Orthopaedic Sciences, Munich, Germany" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Clinic for Restorative Dentistry and Periodontology, Ludwig Maximilian University, Munich, Germany" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Department of Trauma-, Hand-, and Reconstructive Surgery, Saarland University, Homburg, Germany" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Departamento de Traumatología, Clínica Berka, Universidad de Madrid, Madrid, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Formación de hueso esponjoso con esferas microcompartimentales" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 734 "Ancho" => 1800 "Tamanyo" => 133995 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">(A–C) Pathological fracture of the fifth metacarpal due to enchondroma in a 42-year-old male patient. After the tumor was treated by curettage, the defect was filled with HA beads (Ceraball<span class="elsevierStyleSup">®</span> HA) and osteosynthesis. At 18 months after surgery, the fracture had healed: the HA replacement remained present.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Occasionally, in epiphyseal and metaphyseal fractures, particularly in osteoporotic bones, tumors, cysts, after an infection, in loosened implants and in open wedge osteotomies, large cancellous bone defects are created which are difficult to fill. There are very few studies on cancellous bone repair,<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> and it has even been reported that trabecular bone defects cannot be repaired.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> After studying biopsies taken from patients treated with compression arthrodesis, Charnley and Baker<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> indicated that cancellous bone healing offers low osteogenic activity. Based on this observation, Radin and Rose<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> explained the pathogenesis of osteoarthritis noting that the calcified cartilage plate distributed the stresses of the underlying elastic cancellous bone, so that any defects in the trabecular bone altered the distribution of impacts on the joint surface. However, most studies have focused on proving joint incongruity, insufficient reduction, instability or metabolic changes in the joint cartilage caused by the inflammation itself or by cellular necrosis, following joint trauma.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">After their reduction, epiphyseal fractures leave large cancellous bone defects which are responsible for deformities and secondary displacement or epiphyseal subsidence.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Therefore, the use of allografts,<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> iliac crest autografts<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> and bone substitutes<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8–11</span></a> is recommended for the treatment of tibial plateau fractures. The question is whether these methods are able to reproduce the original structure. In some cases, such as metaphyseal fractures in elderly patients with defects or with brittle bones or in tumoral pathological fractures, they have been treated with internal fixation (osteosynthesis) and bone cement (polymethylmethacrylate [PMMA]).<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> PMMA has also been recommended for the treatment of collapses of proximal tibial metaphyseal fractures in elderly patients, in order to enable early load.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> Moreover, benign bone tumors, paratumoral lesions and those with a low grade of malignancy (giant cell tumors) are often treated by curettage and the defect is filled with PMMA.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> On the other hand, bone cysts and open osteotomies have often been filled with granulated bone substitutes<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> which do not reproduce the trabecular structure.<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16–18</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The aim of our study was to determine if defects caused in benign skeletal lesions can be treated with osteoconductive ceramics, and whether these treatments regenerate cancellous bone so that it can withstand loads.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Materials and methods</span><p id="par0020" class="elsevierStylePara elsevierViewall">Bone defects in the epiphysis and metaphysis of long bones were filled in 9 patients (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). These defects were filled with micro-chambered beads made of β-tricalcium phosphate (β-TCP) or hydroxyapatite (HA) or a mixture of both. The beads had a diameter of 4 and 6<span class="elsevierStyleHsp" style=""></span>mm (Ceraball<span class="elsevierStyleSup">®</span>, Karl Storz Endoskope LLC & Co. KG, Tuttlingen, Germany) (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The study was approved by the Ethics Committee of the University, and all patients signed informed consent documents. Osteosynthesis plates (Synthes Inc., Freiburg, Germany) were used in all cases of fracture.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">We treated 3 fractures with collapsed lateral condyles of the proximal end of the tibia, 2 distal tibial fractures, 2 comminuted calcaneal fractures, 1 chondroma of the distal femur, 1 enchondroma with pathological fracture of the fifth metacarpal bone and 2 open wedge osteotomies (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).</p><p id="par0030" class="elsevierStylePara elsevierViewall">After fracture reduction or curettage of benign tumors, the spaces were filled with beads and fixed with the appropriate osteosynthesis to stabilize the bone, without destroying the ceramic material. The spheres were placed using a trocar, which was also used to lift the tibial plateau. In the remaining cases, placement was carried out directly into the fracture or within the wedge produced by the osteotomy itself.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Our study included 6 females and 3 males, with a mean age of 45 years (range: 25–65 years), with a mean follow-up period of 22 months (range: 7–48 months) and a minimum follow-up of 6 months. We excluded from the study 1 woman who died after 8 months and whose last radiograph took place at 2 weeks. Monitoring of the defects was performed through X-ray images in 2 perpendicular planes (anteroposterior and lateral), and through computed tomography (CT) in the case of tumors. The assessment was conducted by 3 independent orthopedic surgeons, who analyzed the cancellous bone structure. The trabecular structure was considered complete if there were no radiolucent cavities and no deformation of the joint surface. The KSS, AOFAS and Dash scales were applied to evaluate clinical outcome, according to the study area.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0040" class="elsevierStylePara elsevierViewall">During the intervention, we noted that the beads had a hemostatic effect and were not destroyed by the osteosynthesis screws. Also, Ceraball<span class="elsevierStyleSup">®</span> beads remained in place when the blood became coagulated after vacuuming.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Two of the fractures in the proximal end of the tibia were reduced with good results. One case was excluded from the radiographic evaluation. In another case, 8 months after the operation the β-TCP had been almost fully absorbed, although the contour of the beads could be discerned and there were some TCP residues which were replaced by cancellous bone (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). The KSS score of the patient was 85. Another reconstruction of the tibial plateau did not produce the expected result (KSS score of 55), as it revealed a deformity on the plateau requiring further surgery. However, the cancellous bone structure had been completely reconstructed and the contrast of the HA beads was pronounced, while the β-TCP beads had been reabsorbed.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">One year after the operation, the distal tibial fracture presented complete healing with an anatomical reduction. The HA beads and the contours of the β-TCP beads were visible between the screws, revealing an adequate cancellous bone structure. Some of the Ceraball<span class="elsevierStyleSup">®</span> beads presented contrast, while others had been replaced by newly formed bone.</p><p id="par0055" class="elsevierStylePara elsevierViewall">In comminuted calcaneal fractures the anatomy was reconstructed, with a satisfactory result being obtained in 1 of the 2 cases, which formed new cancellous bone, although leaving a persistent defect with a sclerotic edge which was visible in both planes (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). The β-TCP beads had been reabsorbed and were barely recognizable 22 months after surgery. Moreover, the score reached 89 points on the AOFAS scale. The other case of highly comminuted calcaneal fracture (Sanders type IV) was not anatomically reduced. The healing process left a severe deformity and a poor clinical outcome (AOFAS score of 49). Nevertheless, it presented a normal cancellous bone structure, with visible HA beads. The patient had to undergo subtalar arthrodesis.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">The case of distal femoral chondroma presented a cavity which was filled with 20<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">3</span> of beads and showed a complete restoration of the cancellous bone structure on the CT scan. Meanwhile, the pathological fracture of the fifth metacarpal by an enchondroma treated with curettage and filling of the cavity with HA beads and osteosynthesis, presented a stable condition after 1.5 years, with a good integration of the HA beads (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>).</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">Open osteotomy, in a 25-year-old patient, was bilateral and treated on the right side with β-TCP beads and a Tomofix<span class="elsevierStyleSup">®</span> plate (Mathys Medizinaltechnik AG, Bettlach, Switzerland), with incomplete filling of the bone defect. The patient began partial load at 2 weeks and complete load at 8 weeks. At 15 months, radiographs revealed an irregular cancellous bone structure on the right side, indicating persistent defects in the anterior and lateral portions, visible at 21 months (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>). Meanwhile, the defect on the left side was completely filled (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>). The radiograph at 14 weeks revealed new bone formation in the medial third of the defect, with almost complete resorption of the β-TCP beads. At 7 months, the contour of the beads was no longer visible (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>).</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0070" class="elsevierStylePara elsevierViewall">The limitations of our study are clear, as it was based on a small number of patients suffering various pathologies and undergoing different situations and surgical techniques. Since we were unable to compare the evolution of defects with other treatments, we decided to observe the behavior in the integration with HA and β-TCP beads in cancellous bone defects.</p><p id="par0075" class="elsevierStylePara elsevierViewall">Cancellous bone does not regenerate by itself and requires support for its repair.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> Despite being very common lesions which in many cases affect the cartilage and lead to the development of osteoarthritis, there are very few works on epiphyseal and metaphyseal bone repair.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2,17</span></a> Therefore, we believe that all large, trabecular bone defects should be filled with grafts or substitutes,<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> and their use is particularly interesting in open osteotomies and epiphyseal reconstructions reporting pain, functional disability and those presenting a risk of pathological fracture.<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">19,20</span></a> Clear examples are the distortions and inconsistencies in tibial plateau fractures.<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">21,22</span></a> Autologous bone grafts are limited and entail pain in the donor area,<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> while allografts may be reabsorbed very rapidly, in addition to the usual complications.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Treatment with HA bone substitutes has, from our perspective, 3 main drawbacks: they are difficult to manage in order to fill a defect, the fixation screws can cause fractures<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> and integration requires an excessively long remodeling process.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> Meanwhile, calcium phosphate cements withstand stresses better than autologous grafts.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Another aspect to consider is that the trabecular structure does not regenerate with inorganic bone cements.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> The micro-chambered beads used in our study have shown rapid bone growth, revealing a mineralized laminar bone contrast and formation of a normal trabecular structure.<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17,18</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">In metaphyseal defects there is no doubt that, for elderly patients suffering comminuted intertrochanteric or tibial plateau fractures with a brittle bone or in patients with tumoral cavities, cement increases the stability of the osteosynthesis and can represent the best option.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12–14,25,26</span></a> PMMA has sometimes been recommended in bone cysts and benign or low-grade malignant tumors in order to make the most of the heat generated by polymerization and destroy any cells remaining after tumor resection or curettage.</p><p id="par0085" class="elsevierStylePara elsevierViewall">However, it also entails problems, as it is difficult to remove<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14,27</span></a> and is often associated with a radiolucent area, an image of osteolysis, as is the case with HA beads which are not reabsorbed.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> The use of β-TCP or HA blocks to fill large cavities offers incomplete results, while granular material is combined with autologous bone and does not allow an adequate reconstruction of the trabecular morphology.<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17,28</span></a> The use of micro-chambered beads of 4 or 6<span class="elsevierStyleHsp" style=""></span>mm diameter enables a complete filling of the large cavities and has a hemostatic effect, since the beads arrest the hemorrhage of the cavities themselves and do not interfere with the positioning of the screws of a stable implant.</p><p id="par0090" class="elsevierStylePara elsevierViewall">Spontaneous filling of the space created by wedge osteotomies is difficult and radiographs show a slow and incomplete formation of new bone, leaving persistent defects.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> The two cases presented in our work showed that HA beads were pushed against the plate by the bleeding itself, leaving persistent defects in the central and lateral parts of the osteotomy, despite allowing full load 2 weeks earlier than recommended according to the literature.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> However, the osteoconduction process on the side filled with β-TCP beads was fast, a normal trabecular architecture was obtained and full load with no pain was achieved 4 weeks sooner than on the right side, which had an incomplete filling.</p><p id="par0095" class="elsevierStylePara elsevierViewall">β-TCP beads allowed any kind of defect to be filled and could be implanted with a syringe containing Ringer's solution and a damp towel to prevent them from being displaced by the bleeding itself. The blood mixed with them and, once it coagulated, stabilized their position.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> The spherical shape of the substitute employed also helped bone formation,<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> while commercial preparations in granules were not suitable for the formation of a trabecular structure. Furthermore, HA beads must be combined with ground autologous bone<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> or with β-TCP.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> Micro-chambered beads are a three-dimensional replica of the characteristic trabeculae of cancellous bone; they resemble a negative mold of the intertrabecular spaces that is easily colonized by new bone which can undergo load from the start, without requiring remodeling. This is the fastest method for the reconstruction of a cancellous defect. Another advantage is that it can be combined with some drugs, such as BMP.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> In addition, their spherical morphology allows them to be easily displaced when the screws of the osteosynthesis are applied, moving them without destroying them.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Level of evidence</span><p id="par0100" class="elsevierStylePara elsevierViewall">Level of evidence IV.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Ethical responsibilities</span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Protection of people and animals</span><p id="par0105" class="elsevierStylePara elsevierViewall">The authors declare that this investigation adhered to the ethical guidelines of the Committee on Responsible Human Experimentation, as well as the World Medical Association and the Declaration of Helsinki.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Confidentiality of data</span><p id="par0110" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their workplace on the publication of patient data and that all patients included in the study received sufficient information and gave their written informed consent to participate in the study.</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Right to privacy and informed consent</span><p id="par0115" class="elsevierStylePara elsevierViewall">The authors declare having obtained written informed consent from patients and/or subjects referred to in the work. This document is held by the corresponding author.</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Conflict of interests</span><p id="par0120" class="elsevierStylePara elsevierViewall">The authors have no conflict of interests to declare and have not received financial support to elaborate the present work. ZOW, an orthopedic science research center, which is a private research center, was financially supported through grants from the government and a family foundation.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:2 [ "identificador" => "xres337287" "titulo" => array:5 [ 0 => "Abstract" 1 => "Objectives" 2 => "Materials and methods" 3 => "Results" 4 => "Conclusion" ] ] 1 => array:2 [ "identificador" => "xpalclavsec318823" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres337286" "titulo" => array:5 [ 0 => "Resumen" 1 => "Objetivo" 2 => "Material y métodos" 3 => "Resultados" 4 => "Conclusión" ] ] 3 => array:2 [ "identificador" => "xpalclavsec318822" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Materials and methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Level of evidence" ] 9 => array:3 [ "identificador" => "sec0030" "titulo" => "Ethical responsibilities" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0035" "titulo" => "Protection of people and animals" ] 1 => array:2 [ "identificador" => "sec0040" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0045" "titulo" => "Right to privacy and informed consent" ] ] ] 10 => array:2 [ "identificador" => "sec0050" "titulo" => "Conflict of interests" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2013-11-19" "fechaAceptado" => "2013-11-23" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec318823" "palabras" => array:5 [ 0 => "Bone substitute" 1 => "Cancellous bone" 2 => "Bone defect" 3 => "Fracture" 4 => "Open wedge osteotomy" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec318822" "palabras" => array:5 [ 0 => "Sustitutivo óseo" 1 => "Hueso esponjoso" 2 => "Defecto óseo" 3 => "Fractura" 4 => "Osteotomía de apertura" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0010">Objectives</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The question has been raised whether benign bone defects in patients can be treated with bone forming osteoconductive ceramics achieving primarily a cancellous bone scaffold, which is under load from the beginning.</p> <span class="elsevierStyleSectionTitle" id="sect0015">Materials and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Ten reconstructions were performed in 9 patients (6 women and 3 male), with a mean age of 49 (25–65)<span class="elsevierStyleHsp" style=""></span>years, suffering a high variety of epi- and metaphyseal defects, four tibial fractures, two calcaneal fractures, one pathological phalangeal fracture, one chondroma of the distal femur and two open-wedge osteotomies were filled with micro-chambered ceramic beads of 4 and 6<span class="elsevierStyleHsp" style=""></span>mm in diameter. The mean follow-up was 22 (7–8)<span class="elsevierStyleHsp" style=""></span>months. X-rays and CT-scans formed the basis for the evaluation of the reconstruction of the cancellous bone scaffolds.</p> <span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">All cancellous structures were rebuilt, if completely filled with bone-forming elements. If the filling was incomplete, no physiological cancellous bone scaffold resulted. The β-TCP micro-chambered beads were completely reabsorbed or sandwich-like incorporated at the time of evaluation. The HA micro-chambered beads revealed a contrast enhancement and were integrated in the osseous construction of the bone scaffold.</p> <span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Primary cancellous bone formation can be achieved with osteoconductive ceramic micro-chambered beads and can be combined with any osteosynthesis for stable fixation.</p>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Analizar el resultado del tratamiento y la evolución de los defectos en el hueso trabecular en pacientes tratados con cerámicas osteoconductivas.</p> <span class="elsevierStyleSectionTitle" id="sect0040">Material y métodos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Se estudiaron 10<span class="elsevierStyleHsp" style=""></span>reconstrucciones efectuadas en 9<span class="elsevierStyleHsp" style=""></span>pacientes (6<span class="elsevierStyleHsp" style=""></span>mujeres y 3<span class="elsevierStyleHsp" style=""></span>hombres) con defectos epifisarios y metafisarios, con una edad media de 49 (rango: 25-65)<span class="elsevierStyleHsp" style=""></span>años en diferentes etiologías, 4<span class="elsevierStyleHsp" style=""></span>fracturas de tibia, 2<span class="elsevierStyleHsp" style=""></span>fracturas del calcáneo, una fractura patológica de metatarsiano, un condroma de fémur distal y 2<span class="elsevierStyleHsp" style=""></span>osteotomías de apertura. Los defectos se rellenaron con esferas de cerámica de β-fosfato tricálcico (β-TCP) e hidroxiapatita, de 4 y 6<span class="elsevierStyleHsp" style=""></span>mm de diámetro. El tiempo medio de seguimiento fue de 22 (7-48)<span class="elsevierStyleHsp" style=""></span>meses. La evaluación de la reparación se realizó con radiografías y TC.</p> <span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">En todos los casos observamos la reconstrucción trabecular. Cuando el relleno era completo se observó la formación de hueso; por el contrario, si era incompleto no se apreció la formación de hueso trabecular. Las esferas fueron completamente reabsorbidas o integradas en el momento de la evaluación. Por su parte, las esferas de hidroxiapatita mostraron un mayor contraste en las imágenes, aunque se integraron en el esqueleto óseo.</p> <span class="elsevierStyleSectionTitle" id="sect0050">Conclusión</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La formación primaria de hueso esponjoso se puede lograr con cerámicas osteoconductivas que se pueden combinar con cualquier tipo de osteosíntesis.</p>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Draenert ME, Draenert Y, Draenert K, Pohlemann T, Erler M. Formación de hueso esponjoso con esferas microcompartimentales. Rev Esp Cir Ortop Traumatol. 2014;58:131–137.</p>" ] ] "multimedia" => array:6 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1150 "Ancho" => 832 "Tamanyo" => 181961 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">(A) Micro-chambered beads (Ceraball<span class="elsevierStyleSup">®</span>) of 6 and 4<span class="elsevierStyleHsp" style=""></span>mm diameter with interconnected pores. MicroCT of sections and 3D reconstruction (μ-CT Scanco 40). (B) MicroCT section of a Ceraball<span class="elsevierStyleSup">®</span> β-TCP bead showing its network of interconnected pores.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1460 "Ancho" => 1301 "Tamanyo" => 194142 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">(A–F) Comminuted, lateral, tibial plateau fracture in a 59-year-old male patient. The collapse was elevated and the defect was filled with beads (Ceraball<span class="elsevierStyleSup">®</span>). The plate was removed at 8 months. The shadows of the beads were recognizable (arrows).</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 521 "Ancho" => 1950 "Tamanyo" => 103739 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">(A–C) Comminuted fracture of the calcaneus in a 35-year-old female patient treated with osteosynthesis and β-TCP beads (Ceraball<span class="elsevierStyleSup">®</span>). The implant was removed at 22 months after surgery: resorption of the bone replacement and trabecular reconstruction.</p>" ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 734 "Ancho" => 1800 "Tamanyo" => 133995 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">(A–C) Pathological fracture of the fifth metacarpal due to enchondroma in a 42-year-old male patient. After the tumor was treated by curettage, the defect was filled with HA beads (Ceraball<span class="elsevierStyleSup">®</span> HA) and osteosynthesis. At 18 months after surgery, the fracture had healed: the HA replacement remained present.</p>" ] ] 4 => array:7 [ "identificador" => "fig0025" "etiqueta" => "Figure 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 1383 "Ancho" => 1497 "Tamanyo" => 261250 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">(A–C) Open wedge osteotomy in a 25-year-old male patient treated with osteosynthesis (Tomofix<span class="elsevierStyleSup">®</span> plate) and incomplete filling of the defect with Ceraball<span class="elsevierStyleSup">®</span> β-TCP beads. Monitoring for 21 months with partial filling and permanence of lateral and anterior defects. (D–F) Osteotomy in the contralateral tibia using the same treatment with a follow-up period of 7 months: the beads are visible but replaced by bone. At 7 months they were completely resorbed.</p>" ] ] 5 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">CT: computed tomography; HA: hydroxyapatite; RX: radiograph; TCP: β-tricalcium phosphate.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Age (years) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Gender \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Etiology \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Technique \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Bone substitute \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Control \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Observations \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">59 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Male \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Comminuted fracture of the external condyle of the right tibia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Osteosynthesis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Ceraball<span class="elsevierStyleSup">®</span> 600 TCP \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">RX 3, 8 months \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">87 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Female \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Fracture and collapse of the external condyle of the right tibia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Osteosynthesis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Ceraball<span class="elsevierStyleSup">®</span> 600 TCP \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">RX 3 days, 2 weeks \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Death \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">65 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Female \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Fracture and collapse of the external condyle of the left tibia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Osteosynthesis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Ceraball<span class="elsevierStyleSup">®</span> 600, TCP/HA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">RX 1 day, 1, 10 and 48 months \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Osteoporosis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">59 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Female \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Distal fracture of the left tibia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Osteosynthesis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Ceraball<span class="elsevierStyleSup">®</span> 600, TCP/HA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">RX 1 day, 1, 12 months; CT 1 month \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">55 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Male \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Comminuted fracture of the left calcaneous \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Plate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Ceraball<span class="elsevierStyleSup">®</span> 600, TCP \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">RX 1 day, 9 months; CT 1 day, 10, 12, 18, 36 months \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">35 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Female \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Comminuted fracture of the right calcaneous \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Plate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Ceraball<span class="elsevierStyleSup">®</span> 600, TCP \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">RX 12 months; CT 1, 3 day, 15, 24 months \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Subtalar arthrodesis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">42 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Female \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Chondroma of the right distal femur \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Resection \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Ceraball<span class="elsevierStyleSup">®</span> 600, TCP \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">RX 1 day; CT 48 months; RM 36 months \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">42 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Female \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Pathological fracture of the fifth metacarpal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Osteosynthesis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Ceraball<span class="elsevierStyleSup">®</span> 600, HA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">RX 87 day, 2 months; CT 13, 17 months \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">25 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Male \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Right <span class="elsevierStyleItalic">genu varo</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Wedge osteotomy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Ceraball<span class="elsevierStyleSup">®</span> 600, TCP \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">RX 2 day, 1, 3, 15 months \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">25 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Male \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Left <span class="elsevierStyleItalic">genu varo</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Wedge osteotomy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Ceraball<span class="elsevierStyleSup">®</span> 600, HA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">RX 2 day, 1, 2, 3 months \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab497149.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Demographic data of the studied population.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:28 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Comparison arthrodesis of the knee: a clinical and histological study" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "J. Charnley" 1 => "S.L. Baker" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "J Bone Joint Surg (Br)" "fecha" => "1952" "volumen" => "34-B" "paginaInicial" => "187" "paginaFinal" => "199" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Histo-morphologie des spongiosadefektes und die heilung des autologen spongiosatransplantates" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "K. Draenert" 1 => "Y. Draenert" 2 => "H.W. Springorum" 3 => "G. Gauer" 4 => "M.E. Mueller" 5 => "H. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 3 | 2 | 5 |
| 2024 October | 19 | 3 | 22 |
| 2024 September | 18 | 8 | 26 |
| 2024 August | 25 | 9 | 34 |
| 2024 July | 15 | 6 | 21 |
| 2024 June | 20 | 3 | 23 |
| 2024 May | 17 | 5 | 22 |
| 2024 April | 21 | 17 | 38 |
| 2024 March | 23 | 7 | 30 |
| 2024 February | 24 | 4 | 28 |
| 2024 January | 24 | 5 | 29 |
| 2023 December | 9 | 10 | 19 |
| 2023 November | 19 | 7 | 26 |
| 2023 October | 14 | 13 | 27 |
| 2023 September | 13 | 7 | 20 |
| 2023 August | 13 | 8 | 21 |
| 2023 July | 20 | 4 | 24 |
| 2023 June | 13 | 4 | 17 |
| 2023 May | 33 | 4 | 37 |
| 2023 April | 40 | 2 | 42 |
| 2023 March | 30 | 3 | 33 |
| 2023 February | 23 | 8 | 31 |
| 2023 January | 32 | 11 | 43 |
| 2022 December | 23 | 3 | 26 |
| 2022 November | 28 | 3 | 31 |
| 2022 October | 19 | 22 | 41 |
| 2022 September | 14 | 6 | 20 |
| 2022 August | 23 | 7 | 30 |
| 2022 July | 15 | 5 | 20 |
| 2022 June | 11 | 7 | 18 |
| 2022 May | 14 | 5 | 19 |
| 2022 April | 25 | 5 | 30 |
| 2022 March | 21 | 15 | 36 |
| 2022 February | 10 | 6 | 16 |
| 2022 January | 14 | 2 | 16 |
| 2021 December | 11 | 3 | 14 |
| 2021 November | 19 | 7 | 26 |
| 2021 October | 16 | 11 | 27 |
| 2021 September | 22 | 14 | 36 |
| 2021 August | 20 | 9 | 29 |
| 2021 July | 9 | 5 | 14 |
| 2021 June | 12 | 9 | 21 |
| 2021 May | 11 | 4 | 15 |
| 2021 April | 23 | 21 | 44 |
| 2021 March | 6 | 6 | 12 |
| 2021 February | 11 | 13 | 24 |
| 2021 January | 10 | 11 | 21 |
| 2020 December | 1 | 0 | 1 |
| 2018 February | 17 | 3 | 20 |
| 2018 January | 6 | 0 | 6 |
| 2017 December | 13 | 1 | 14 |
| 2017 November | 10 | 0 | 10 |
| 2017 October | 14 | 8 | 22 |
| 2017 September | 16 | 4 | 20 |
| 2017 August | 14 | 6 | 20 |
| 2017 July | 11 | 3 | 14 |
| 2017 June | 23 | 5 | 28 |
| 2017 May | 20 | 8 | 28 |
| 2017 April | 18 | 14 | 32 |
| 2017 March | 20 | 14 | 34 |
| 2017 February | 13 | 2 | 15 |
| 2017 January | 5 | 3 | 8 |
| 2016 December | 17 | 5 | 22 |
| 2016 November | 14 | 1 | 15 |
| 2016 October | 19 | 12 | 31 |
| 2016 September | 22 | 6 | 28 |
| 2016 August | 12 | 1 | 13 |
| 2016 July | 17 | 2 | 19 |
| 2016 June | 27 | 16 | 43 |
| 2016 May | 19 | 12 | 31 |
| 2016 April | 0 | 7 | 7 |
| 2016 March | 0 | 8 | 8 |
| 2016 February | 0 | 2 | 2 |
| 2016 January | 0 | 5 | 5 |
| 2015 December | 0 | 1 | 1 |
| 2015 July | 0 | 1 | 1 |
| 2014 September | 0 | 1 | 1 |
| 2014 July | 0 | 1 | 1 |
| 2014 June | 2 | 2 | 4 |
| 2014 May | 3 | 1 | 4 |
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