Three-dimensional-printed titanium prostheses with bone trabeculae enable mechanical-biological reconstruction after resection of bone tumours

doi:10.12336/biomatertransl.2022.02.005

Biomaterials Translational ›› 2022, Vol. 3 ›› Issue (2): 134-141.doi: 10.12336/biomatertransl.2022.02.005

• RESEARCH ARTICLE • Previous Articles Next Articles

Three-dimensional-printed titanium prostheses with bone trabeculae enable mechanical-biological reconstruction after resection of bone tumours

Feifei Pu, Wei Wu, Doudou Jing, Yihan Yu, Yizhong Peng, Jianxiang Liu, Qiang Wu, Baichuan Wang, Zhicai Zhang(), Zengwu Shao()

Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei Province, China

Received:2022-04-01 Revised:2022-04-22 Accepted:2022-05-14 Online:2022-06-28 Published:2022-06-28
Contact: Zhicai Zhang,Zengwu Shao E-mail:zhicaizhang@hust.edu.cn;1985XH0536@hust.edu.cn
About author:Zhicai Zhang, zhicaizhang@hust.edu.cn.
Zengwu Shao, 1985XH0536@hust.edu.cn;
First author contact:#Author Equally.

Abstract

Abstract:

Reconstruction after resection has always been an urgent problem in the treatment of bone tumours. There are many methods that can be used to reconstruct bone defects; however, there are also many complications, and it is difficult to develop a safe and effective reconstruction plan for the treatment of bone tumours. With the rapid development of digital orthopaedics, three-dimensional printing technology can solve this problem. The three-dimensional printing of personalised prostheses has many advantages. It can be used to print complex structures that are difficult to fabricate using traditional processes and overcome the problems of stress shielding and low biological activity of conventional prostheses. In this study, 12 patients with bone tumours were selected as research subjects, and based on individualised reverse-engineering design technology, a three-dimensional model of each prosthesis was designed and installed using medical image data. Ti6Al4V was used as the raw material to prepare the prostheses, which were used to repair bone defects after surgical resection. The operation time was 266.43 ± 21.08 minutes (range 180–390 minutes), and intraoperative blood loss was 857.26 ± 84.28 mL (range 800–2500 mL). One patient had delayed wound healing after surgery, but all patients survived without local tumour recurrence, and no tumour metastasis was found. No aseptic loosening or structural fracture of the prosthesis, and no non-mechanical prosthesis failure caused by infection, tumour recurrence, or progression was observed. The Musculo-Skeletal Tumour Society (MSTS) score of limb function was 22.53 ± 2.09 (range 16–26), and ten of the 12 patients scored ≥ 20 and were able to function normally. The results showed that three-dimensional printed prostheses with an individualised design can achieve satisfactory short-term clinical efficacy in the reconstruction of large bone defects after bone tumour resection.

Key words: bone defect, bone tumour, printed biomechanical reconstruction, prostheses, three-dimensional

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Figures/Tables 8

Figure 1. Image data acquisition and 3D reconstruction of tumour invasion area. (A, B) The CT scan data were imported into the medical image segmentation processing software Mimics 19.0 for image selection processing. The red arrows indicate the tumour. (C) The 3D operation to create the 3D reconstruction data of the tumour site. The blue indicates normal bone, the red indicates the bone invaded by the tumour, and the boundary between blue and purple represent the osteotomy line. B: below; L: left; T: top.

Figure 2. Design of three-dimensional printed customised prostheses. (A, B) Designing the size, fit and screw position of the prosthesis in different viewing angles. The pink and yellow sticks represent screws and connecting rods. (C) The dodecahedral lightweight lattice structure. (D) The gradient mesh designed according to the stress distribution identified by finite element analysis. (E) Design of prosthetic stiffeners and dodecahedron grid array diagram. (F) Design of gradient grid. (G) Physical design of the prosthesis.

Figure 3. Computer simulation cutting and installation. (A-C) Mimics 19.0 software was used to simulate model cutting and prosthetic installation in different viewing angles.

Figure 4. Preparation of three-dimensional printed personalised titanium alloy prostheses. (A, B) Titanium alloy (Ti6Al4V) was used for rapid printing by selective laser melting, and the surface interface of the prosthesis was created with a porous bone trabecular structure.

Figure 5. Three-dimensional printed navigation template design and processing. (A, B) The navigation template was designed according to the patient’s anatomical structure and surgical needs in different viewing angles. The green colour shows the part needing to be removed. (C) Preparation of the navigation template to assist with precise tumour resection.

Figure 6. Implantation of a three-dimensional printed prosthesis to reconstruct a bone defect after tumour resection. (A) Surgical position and incision. (B) En bloc resection of the tumour. (C) Gross view of the excised tumour specimen. (D) Installation of the acetabular prosthesis. (E) Placing of the three-dimensional printed prosthesis in the defect. (F) The three-dimensional printed prosthesis was secured with screws.

Table 1. Commonly-used gene- and cell-activated biomaterials

No.	Sex	Age (years)	Pathological type	GTV (cm³)	FU (months)	SD (minutes)	IBL (mL)	PC	TR	DM	MSTS score
1	Male	42	Ewing’s sarcoma	320	16	375	1800	No	No	No	22
2	Female	37	Malignant neurinoma	360	14	260	2500	No	No	No	25
3	Female	58	Osteosarcoma	460	12	265	800	No	No	No	18
4	Male	69	Chondrosarcoma	300	23	270	2500	No	No	No	20
5	Male	58	Chondrosarcoma	350	7	180	2000	Skin necrosis	No	No	23
6	Male	42	Osteosarcoma	290	24	245	1800	No	No	No	20
7	Male	63	Invasive GCTB	340	14	255	2500	No	No	No	21
8	Male	50	Osteosarcoma	260	18	375	2000	No	No	No	24
9	Male	53	Osteosarcoma	280	16	280	2200	No	No	No	26
10	Female	48	Chondrosarcoma	300	12	320	1500	No	No	No	16
11	Male	53	Chondrosarcoma	260	18	260	2200	No	No	No	24
12	Female	46	Chondrosarcoma	280	22	235	2300	No	No	No	20

Figure 7. A 53-year-old patient with chondrosarcoma of the pelvis underwent reconstruction with a three-dimensional-printed prosthesis to repair the bone defect after tumour resection. (A-C) Preoperative X-ray images (A), computed tomography (B), and magnetic resonance imaging (C). The red arrows indicate the tumour. (D) One week postoperatively, X-ray imaging showed good position and stability of the prosthesis. (E) One week postoperatively, the patient was walking with the aid of a walker. (F) Six months after the operation, X-ray imaging showed good fusion of the prosthesis with the bone, without fracture or other complications.

References 28

1.	Strauss, S. J.; Whelan, J. S. Current questions in bone sarcomas. Curr Opin Oncol. 2018, 30, 252-259. doi: 10.1097/CCO.0000000000000456 URL
2.	Zekry, K. M.; Yamamoto, N.; Hayashi, K.; Takeuchi, A.; Alkhooly, A. Z. A.; Abd-Elfattah, A. S.; Elsaid, A. N. S.; Ahmed, A. R.; Tsuchiya, H. Reconstruction of intercalary bone defect after resection of malignant bone tumor. J Orthop Surg (Hong Kong). 2019, 27, 2309499019832970.
3.	Gangi, A.; Tsoumakidou, G.; Buy, X.; Quoix, E. Quality improvement guidelines for bone tumour management. Cardiovasc Intervent Radiol. 2010, 33, 706-713. doi: 10.1007/s00270-009-9738-9 URL
4.	Piccioli, A.; Rossi, B.; Sacchetti, F. M.; Spinelli, M. S.; Di Martino, A. Fractures in bone tumour prosthesis. Int Orthop. 2015, 39, 1981-1987. doi: 10.1007/s00264-015-2956-7 URL
5.	Severyns, M.; Briand, S.; Waast, D.; Touchais, S.; Hamel, A.; Gouin, F. Postoperative infections after limb-sparing surgery for primary bone tumors of the pelvis: Incidence, characterization and functional impact. Surg Oncol. 2017, 26, 171-177. doi: 10.1016/j.suronc.2017.03.005 URL
6.	Pu, F.; Liu, J.; Shi, D.; Huang, X.; Zhang, J.; Wang, B.; Wu, Q.; Zhang, Z.; Shao, Z. Reconstruction with 3D-printed prostheses after sacroiliac joint tumor resection: a retrospective case-control study. Front Oncol. 2021, 11, 764938. doi: 10.3389/fonc.2021.764938 URL
7.	Wang, B.; Hao, Y.; Pu, F.; Jiang, W.; Shao, Z. Computer-aided designed, three dimensional-printed hemipelvic prosthesis for peri-acetabular malignant bone tumour. Int Orthop. 2018, 42, 687-694. doi: 10.1007/s00264-017-3645-5 URL
8.	Liu, W.; Shao, Z.; Rai, S.; Hu, B.; Wu, Q.; Hu, H.; Zhang, S.; Wang, B. Three-dimensional-printed intercalary prosthesis for the reconstruction of large bone defect after joint-preserving tumor resection. J Surg Oncol. 2020, 121, 570-577. doi: 10.1002/jso.25826 URL
9.	Hu, H.; Liu, W.; Zeng, Q.; Wang, S.; Zhang, Z.; Liu, J.; Zhang, Y.; Shao, Z.; Wang, B. The personalized shoulder reconstruction assisted by 3D printing technology after resection of the proximal humerus tumours. Cancer Manag Res. 2019, 11, 10665-10673. doi: 10.2147/CMAR.S232051 URL
10.	Wu, J.; Xie, K.; Luo, D.; Wang, L.; Wu, W.; Yan, M.; Ai, S.; Dai, K.; Hao, Y. Three-dimensional printing-based personalized limb salvage and reconstruction treatment of pelvic tumors. J Surg Oncol. 2021, 124, 420-430. doi: 10.1002/jso.26516 URL
11.	Bolia, I. K.; Savvidou, O. D.; Kang, H. P.; Chatzichristodoulou, N.; Megaloikonomos, P. D.; Mitsiokapa, E.; Mavrogenis, A. F.; Papagelopoulos, P. J. Cross-cultural adaptation and validation of the Musculoskeletal Tumor Society (MSTS) scoring system and Toronto Extremity Salvage Score (TESS) for musculoskeletal sarcoma patients in Greece. Eur J Orthop Surg Traumatol. 2021, 31, 1631-1638. doi: 10.1007/s00590-021-02921-5 URL
12.	Chen, X.; Xu, L.; Wang, Y.; Hao, Y.; Wang, L. Image-guided installation of 3D-printed patient-specific implant and its application in pelvic tumor resection and reconstruction surgery. Comput Methods Programs Biomed. 2016, 125, 66-78. doi: 10.1016/j.cmpb.2015.10.020 URL
13.	Hao, Y.; Luo, D.; Wu, J.; Wang, L.; Xie, K.; Yan, M.; Dai, K.; Hao, Y. A novel revision system for complex pelvic defects utilizing 3D-printed custom prosthesis. J Orthop Translat. 2021, 31, 102-109. doi: 10.1016/j.jot.2021.09.006 URL
14.	Li, X.; Ji, T.; Huang, S.; Wang, C.; Zheng, Y.; Guo, W. Biomechanics study of a 3D printed sacroiliac joint fixed modular hemipelvic endoprosthesis. Clin Biomech (Bristol, Avon). 2020, 74, 87-95. doi: 10.1016/j.clinbiomech.2020.02.014 URL
15.	Ji, T.; Yang, Y.; Tang, X.; Liang, H.; Yan, T.; Yang, R.; Guo, W. 3D-printed modular hemipelvic endoprosthetic reconstruction following periacetabular tumor resection: early results of 80 consecutive cases. J Bone Joint Surg Am. 2020, 102, 1530-1541. doi: 10.2106/JBJS.19.01437 URL
16.	Wei, R.; Guo, W.; Ji, T.; Zhang, Y.; Liang, H. One-step reconstruction with a 3D-printed, custom-made prosthesis after total en bloc sacrectomy: a technical note. Eur Spine J. 2017, 26, 1902-1909. doi: 10.1007/s00586-016-4871-z URL
17.	Cai, H.; Liu, Z.; Wei, F.; Yu, M.; Xu, N.; Li, Z. 3D printing in spine surgery. Adv Exp Med Biol. 2018, 1093, 345-359.
18.	Xie, K.; Guo, Y.; Zhao, S.; Wang, L.; Wu, J.; Tan, J.; Yang, Y.; Wu, W.; Jiang, W.; Hao, Y. Partially melted Ti6Al4V particles increase bacterial adhesion and inhibit osteogenic activity on 3D-printed implants: an in vitro study. Clin Orthop Relat Res. 2019, 477, 2772-2782. doi: 10.1097/CORR.0000000000000954 URL
19.	Jing, Z.; Zhang, T.; Xiu, P.; Cai, H.; Wei, Q.; Fan, D.; Lin, X.; Song, C.; Liu, Z. Functionalization of 3D-printed titanium alloy orthopedic implants: a literature review. Biomed Mater. 2020, 15, 052003. doi: 10.1088/1748-605X/ab9078 URL
20.	Hua, L.; Lei, T.; Qian, H.; Zhang, Y.; Hu, Y.; Lei, P. 3D-printed porous tantalum: recent application in various drug delivery systems to repair hard tissue defects. Expert Opin Drug Deliv. 2021, 18, 625-634. doi: 10.1080/17425247.2021.1860015 URL
21.	Wang, H.; Su, K.; Su, L.; Liang, P.; Ji, P.; Wang, C. Comparison of 3D-printed porous tantalum and titanium scaffolds on osteointegration and osteogenesis. Mater Sci Eng C Mater Biol Appl. 2019, 104, 109908. doi: 10.1016/j.msec.2019.109908 URL
22.	Wei, X.; Liu, B.; Liu, G.; Yang, F.; Cao, F.; Dou, X.; Yu, W.; Wang, B.; Zheng, G.; Cheng, L.; Ma, Z.; Zhang, Y.; Yang, J.; Wang, Z.; Li, J.; Cui, D.; Wang, W.; Xie, H.; Li, L.; Zhang, F.; Lineaweaver, W. C.; Zhao, D. Mesenchymal stem cell-loaded porous tantalum integrated with biomimetic 3D collagen-based scaffold to repair large osteochondral defects in goats. Stem Cell Res Ther. 2019, 10, 72. doi: 10.1186/s13287-019-1176-2 URL
23.	Zhang, T.; Wei, Q.; Fan, D.; Liu, X.; Li, W.; Song, C.; Tian, Y.; Cai, H.; Zheng, Y.; Liu, Z. Improved osseointegration with rhBMP-2 intraoperatively loaded in a specifically designed 3D-printed porous Ti6Al4V vertebral implant. Biomater Sci. 2020, 8, 1279-1289. doi: 10.1039/C9BM01655D URL
24.	Yin, C.; Zhang, T.; Wei, Q.; Cai, H.; Cheng, Y.; Tian, Y.; Leng, H.; Wang, C.; Feng, S.; Liu, Z. Surface treatment of 3D printed porous Ti6Al4V implants by ultraviolet photofunctionalization for improved osseointegration. Bioact Mater. 2022, 7, 26-38.
25.	Zhang, T.; Wei, Q.; Zhou, H.; Zhou, W.; Fan, D.; Lin, X.; Jing, Z.; Cai, H.; Cheng, Y.; Liu, X.; Li, W.; Song, C.; Tian, Y.; Xu, N.; Zheng, Y.; Liu, Z. Sustainable release of vancomycin from micro-arc oxidised 3D-printed porous Ti6Al4V for treating methicillin-resistant Staphylococcus aureus bone infection and enhancing osteogenesis in a rabbit tibia osteomyelitis model. Biomater Sci. 2020, 8, 3106-3115. doi: 10.1039/C9BM01968E URL
26.	Xu, L.; Qin, H.; Cheng, Z.; Jiang, W. B.; Tan, J.; Luo, X.; Huang, W. 3D-printed personalised prostheses for bone defect repair and reconstruction following resection of metacarpal giant cell tumours. Ann Transl Med. 2021, 9, 1421. doi: 10.21037/atm-21-3400 URL
27.	Xu, L.; Qin, H.; Tan, J.; Cheng, Z.; Luo, X.; Tan, H.; Huang, W. Clinical study of 3D printed personalized prosthesis in the treatment of bone defect after pelvic tumor resection. J Orthop Translat. 2021, 29, 163-169. doi: 10.1016/j.jot.2021.05.007 URL
28.	Beltrami, G.; Ristori, G.; Nucci, A. M.; Galeotti, A.; Tamburini, A.; Scoccianti, G.; Campanacci, D.; Innocenti, M.; Capanna, R. Custom-made 3D-printed implants as novel approach to reconstructive surgery after oncologic resection in pediatric patients. J Clin Med. 2021, 10, 1056. doi: 10.3390/jcm10051056 URL

Three-dimensional-printed titanium prostheses with bone trabeculae enable mechanical-biological reconstruction after resection of bone tumours

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