JBJS | The Use of Calcium Sulfate in the Treatment of Benign Bone Lesions : A Preliminary Report

The Journal of Bone & Joint Surgery, Volume 83, Issue 3

Articles | March 01, 2001

The Use of Calcium Sulfate in the Treatment of Benign Bone Lesions : A Preliminary Report

Raffy Mirzayan, MD; Vahé Panossian, MD; Raffi Avedian, BS; Deborah M. Forrester, MD; Lawrence R. Menendez, MD

Investigation performed at the University Hospital, Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California

The Journal of Bone & Joint Surgery. 2001; 83:355-355

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Introduction

Introduction | Materials and Methods | Results | Discussion | References

Bone grafts are widely used by surgeons to correct bone defects resulting from a variety of causes, including tumors, trauma, and infection. Autogenous bone remains the ideal material for grafting because it is not antigenic and it has both osteoinductive and osteogenic properties¹. The harvesting of autogenous bone, however, can be associated with substantial complications. The common problems that have been reported include pain at the donor site, palsy of the lateral femoral cutaneous nerve, injury of the superior gluteal artery, pelvic fracture, hematoma, infection, and gait disturbances². Furthermore, the amount of autogenous bone graft available for harvesting is limited and may be insufficient to fill large osseous defects. The quality of the harvested autogenous bone is also variable¹. Because of the complications associated with harvesting autogenous bone and its limited supply, many surgeons have sought bone-graft-substitute materials.

A bone-graft substitute that has regained popularity recently is calcium sulfate, more commonly known as plaster of Paris. Plaster of Paris is derived from the common mineral gypsum, which contains calcium sulfate dihydrate (CaSO4 • 2 H2O). Calcium sulfate was first used by Dreesman² to obliterate bone cavities caused by tuberculosis. In 1959, Peltier³ became the first American to report on the use of calcium sulfate as a bone-graft substitute. He and Jones found that calcium sulfate is safe to use in a variety of cavitary bone defects⁴, that it is completely resorbed, and that regeneration of bone occurred in a period of weeks to months. However, in spite of its initial success, the use of calcium sulfate was later associated with inconsistent results. This may have been due to impurities and a nonuniform structure of the calcium sulfate crystals. Recently, improvements in the production of calcium sulfate have resulted in a high-grade material that is more suitable for surgical applications. Contemporary medical-grade calcium sulfate is easily sterilized and can be used in various sizes of osseous defects. Its resorption can also be monitored radiographically because it is radiopaque. To date, there have been few reported studies of the efficacy of medical-grade calcium sulfate used to fill osseous defects. The purpose of this study was to assess the efficacy of calcium sulfate as a bone-graft substitute in patients undergoing operative treatment of a benign bone lesion.

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Fig. 1-A:: Figs. 1-A through 1-D Case 2, a sixty-one-year-old woman with an enchondroma of the proximal part of the right humerus.
Fig. 1-A Note the intramedullary calcification.

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Fig. 1-B:: Figs. 1-A through 1-D Case 2, a sixty-one-year-old woman with an enchondroma of the proximal part of the right humerus.
Fig. 1-B Calcium sulfate pellets filling the cavity after curettage.

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Fig. 1-C:: Figs. 1-A through 1-D Case 2, a sixty-one-year-old woman with an enchondroma of the proximal part of the right humerus.
Fig. 1-C At three months, new bone has replaced nearly 70% of the pellets.

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Fig. 1-D:: Figs. 1-A through 1-D Case 2, a sixty-one-year-old woman with an enchondroma of the proximal part of the right humerus.
Fig. 1-D At five months, all of the pellets have been resorbed and replaced by bone.

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TABLE I: Data on the Patients

Case	Age (yr)	Gender	Diagnosis	Location	Procedure	Time to Healing (wk)
?1	54	M	Osteomyelitis	Tibial diaphysis	Irrigation and débridement, curettage	?5
?2	61	F	Enchondroma	Prox. part of humerus	Curettage and cryoablation	21
?3	31	M	Bone cyst	Prox. part of humerus	Curettage	?9
?4	52	F	Enchondroma	Ulnar diaphysis	Curettage and cryoablation	19
?5	55	F	Ganglion cyst	Talus and calcaneus	Curettage	?8
?6	36	M	Fibrous dysplasia	Prox. part of tibia	Curettage and cryoablation	19
?7	44	F	Enchondroma	Prox. part of humerus	Curettage and cryoablation	14
?8	36	M	Bone cyst	Prox. part of tibia	Curettage and cryoablation	16
?9	57	F	Focal fibrosis	Prox. part of femur	Hardware removal	10
10	69	F	Osteomyelitis	Femoral diaphysis	Irrigation and débridement, curettage	12
11	47	F	Fibrous tissue	Distal part of femur	Hardware removal	?9
12	28	M	Unicameral bone cyst	Prox. part of femur	Curettage, cryoablation, internal fixation	24
13	53	F	Fibrous granuloma	Periacetabular	Curettage	?8

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TABLE I: Data on the Patients

Case	Age (yr)	Gender	Diagnosis	Location	Procedure	Time to Healing (wk)
?1	54	M	Osteomyelitis	Tibial diaphysis	Irrigation and débridement, curettage	?5
?2	61	F	Enchondroma	Prox. part of humerus	Curettage and cryoablation	21
?3	31	M	Bone cyst	Prox. part of humerus	Curettage	?9
?4	52	F	Enchondroma	Ulnar diaphysis	Curettage and cryoablation	19
?5	55	F	Ganglion cyst	Talus and calcaneus	Curettage	?8
?6	36	M	Fibrous dysplasia	Prox. part of tibia	Curettage and cryoablation	19
?7	44	F	Enchondroma	Prox. part of humerus	Curettage and cryoablation	14
?8	36	M	Bone cyst	Prox. part of tibia	Curettage and cryoablation	16
?9	57	F	Focal fibrosis	Prox. part of femur	Hardware removal	10
10	69	F	Osteomyelitis	Femoral diaphysis	Irrigation and débridement, curettage	12
11	47	F	Fibrous tissue	Distal part of femur	Hardware removal	?9
12	28	M	Unicameral bone cyst	Prox. part of femur	Curettage, cryoablation, internal fixation	24
13	53	F	Fibrous granuloma	Periacetabular	Curettage	?8

Materials and Methods

Introduction | Materials and Methods | Results | Discussion | References

Clinical Information

Between June 25, 1997, and July 1, 1999, thirteen adults with a total of thirteen benign bone lesions underwent operative treatment by the senior author (L.R.M.); each patient required bone-grafting to fill a nonstructural (cavitary) defect. A retrospective analysis of their charts was performed, and the clinical information is presented in Table I. The bone defects created at the operation did not compromise the overall stability of the affected bone. The defects were filled with calcium sulfate pellets (Osteoset; Wright Medical Technology, Arlington, Tennessee) (Figs. 1-A, 1-B, 1-C, and 1-D). The bone-graft substitute was not used to provide structural continuity of bone.

Radiographic Analysis

The degree of calcium sulfate resorption and bone-healing were determined radiographically by a senior radiologist (D.M.F.) specializing in musculoskeletal radiology. The size of each osseous defect was approximated by measuring its length and width on an anteroposterior radiograph. A volumetric measurement could not be performed because not all patients had a true lateral radiograph of the postoperative defect. The radiograph was analyzed and the size of the defect was measured immediately after surgery and then monthly until the defect had healed completely.

Results

Introduction | Materials and Methods | Results | Discussion | References

All defects healed, and all calcium sulfate pellets were resorbed. All of the defects healed in a centripetal fashion, in which the more peripherally placed calcium sulfate pellets were resorbed first and the more central pellets were the last to disappear. The average time to healing was 13.4 weeks (range, five to twenty-four weeks). The rate of healing depended on the size of the lesion. In one patient, some calcification developed in the adjacent soft tissues because some of the calcium sulfate pellets had spilled out of the cavity intraoperatively. This calcification was seen to have disappeared on a six-month follow-up radiograph.

Discussion

Introduction | Materials and Methods | Results | Discussion | References

The use of autogenous bone graft remains the standard of care in the treatment of osseous defects. However, because of donor site morbidity, variations in quality, and the limited amount of bone available, surgeons have sought a material that could be used effectively in place of autogenous bone. In this series, we examined the feasibility and efficacy of calcium sulfate as a bone-graft substitute to fill nonstructural bone defects. Peltier⁵ established that calcium sulfate can be resorbed and replaced by bone in vivo. Calcium sulfate works in an osteoconductive manner, providing a scaffold into which new bone can grow. Peltier and Jones⁴ demonstrated that osteoconduction requires the bone-graft substitute to have a resorption rate similar to the rate of new-bone formation. If the rate of resorption is faster than the rate of bone growth, the new bone will not have a scaffold on which to travel. Conversely, if the graft material resorbs too slowly it may stay in the osseous defect and block the ingrowth of new bone.

A study by Sidqui et al.⁶ demonstrated that, in vitro, osteoclasts can and do resorb calcium sulfate. Furthermore, a recent study by Ricci et al.⁷ showed that calcium sulfate may stimulate new-bone formation. These properties of calcium sulfate make it an attractive potential alternative to autogenous bone graft. In our thirteen patients, it was completely resorbed in a relatively short amount of time. Because it is radiopaque, we could monitor its resorption and new-bone ingrowth radiographically. It did not cause excessive inflammation, and we saw no evidence of a rejection reaction. On the basis of the results of our study, we concluded that medical-grade calcium sulfate may be an effective substitute for autogenous bone graft in the treatment of nonstructural bone defects.

References

Introduction | Materials and Methods | Results | Discussion | References

Gazdag AR; Lane JM; Glaser D; and Forster RA: Alternatives to autogenous bone graft: efficacy and indications. J Am Acad Orthop Surg,1995.3: 1-8, 31 1995 [PubMed]

Fowler BL; Dall BE; and Rowe DE: Complications associated with harvesting autogenous iliac bone. Am J Orthop,1995.24: 895-903, 24895 1995 [PubMed]

Peltier LF: The use of plaster of Paris to fill large defects in bone. A preliminary report. Am J Surg,1959.97: 311-5, 97311 1959 [PubMed]

Peltier LF, and Jones RH: Treatment of unicameral bone cysts by curettage and packing with plaster-of-Paris pellets. J Bone Joint Surg Am,1978.60: 820-2, 60820 1978 [PubMed]

Peltier LF: The use of plaster of Paris to fill defects in bone. Clin Orthop,1961.21: 1-31, 211 1961 [PubMed]

Sidqui M; Collin P; Vitte C; and Forest N: Osteoblast adherence and resorption activity of isolated osteoclasts on calcium sulphate hemihydrate. Biomaterials.,1995.16: 1327-32, 161327 1995 [PubMed]

Ricci JL, Rosenblum SF, Brezenoff L, Blumenthal NC. Stimulation of bone ingrowth into an implantable chamber through the use of rapidly resorbing calcium sulfate hemihydrate. In:Transactions of the Fourth World Biomaterials Congress; Berlin; April 24-28, 1992. European Society for Biomaterials; 1992

Topics

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Fig. 1-A:: Figs. 1-A through 1-D Case 2, a sixty-one-year-old woman with an enchondroma of the proximal part of the right humerus.
Fig. 1-A Note the intramedullary calcification.

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Fig. 1-B:: Figs. 1-A through 1-D Case 2, a sixty-one-year-old woman with an enchondroma of the proximal part of the right humerus.
Fig. 1-B Calcium sulfate pellets filling the cavity after curettage.

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TABLE I: Data on the Patients

Case	Age (yr)	Gender	Diagnosis	Location	Procedure	Time to Healing (wk)
?1	54	M	Osteomyelitis	Tibial diaphysis	Irrigation and débridement, curettage	?5
?2	61	F	Enchondroma	Prox. part of humerus	Curettage and cryoablation	21
?3	31	M	Bone cyst	Prox. part of humerus	Curettage	?9
?4	52	F	Enchondroma	Ulnar diaphysis	Curettage and cryoablation	19
?5	55	F	Ganglion cyst	Talus and calcaneus	Curettage	?8
?6	36	M	Fibrous dysplasia	Prox. part of tibia	Curettage and cryoablation	19
?7	44	F	Enchondroma	Prox. part of humerus	Curettage and cryoablation	14
?8	36	M	Bone cyst	Prox. part of tibia	Curettage and cryoablation	16
?9	57	F	Focal fibrosis	Prox. part of femur	Hardware removal	10
10	69	F	Osteomyelitis	Femoral diaphysis	Irrigation and débridement, curettage	12
11	47	F	Fibrous tissue	Distal part of femur	Hardware removal	?9
12	28	M	Unicameral bone cyst	Prox. part of femur	Curettage, cryoablation, internal fixation	24
13	53	F	Fibrous granuloma	Periacetabular	Curettage	?8

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TABLE I: Data on the Patients

Case	Age (yr)	Gender	Diagnosis	Location	Procedure	Time to Healing (wk)
?1	54	M	Osteomyelitis	Tibial diaphysis	Irrigation and débridement, curettage	?5
?2	61	F	Enchondroma	Prox. part of humerus	Curettage and cryoablation	21
?3	31	M	Bone cyst	Prox. part of humerus	Curettage	?9
?4	52	F	Enchondroma	Ulnar diaphysis	Curettage and cryoablation	19
?5	55	F	Ganglion cyst	Talus and calcaneus	Curettage	?8
?6	36	M	Fibrous dysplasia	Prox. part of tibia	Curettage and cryoablation	19
?7	44	F	Enchondroma	Prox. part of humerus	Curettage and cryoablation	14
?8	36	M	Bone cyst	Prox. part of tibia	Curettage and cryoablation	16
?9	57	F	Focal fibrosis	Prox. part of femur	Hardware removal	10
10	69	F	Osteomyelitis	Femoral diaphysis	Irrigation and débridement, curettage	12
11	47	F	Fibrous tissue	Distal part of femur	Hardware removal	?9
12	28	M	Unicameral bone cyst	Prox. part of femur	Curettage, cryoablation, internal fixation	24
13	53	F	Fibrous granuloma	Periacetabular	Curettage	?8

Gazdag AR; Lane JM; Glaser D; and Forster RA: Alternatives to autogenous bone graft: efficacy and indications. J Am Acad Orthop Surg,1995.3: 1-8, 31 1995 [PubMed]

Fowler BL; Dall BE; and Rowe DE: Complications associated with harvesting autogenous iliac bone. Am J Orthop,1995.24: 895-903, 24895 1995 [PubMed]

Peltier LF: The use of plaster of Paris to fill large defects in bone. A preliminary report. Am J Surg,1959.97: 311-5, 97311 1959 [PubMed]

Peltier LF, and Jones RH: Treatment of unicameral bone cysts by curettage and packing with plaster-of-Paris pellets. J Bone Joint Surg Am,1978.60: 820-2, 60820 1978 [PubMed]

Peltier LF: The use of plaster of Paris to fill defects in bone. Clin Orthop,1961.21: 1-31, 211 1961 [PubMed]

Sidqui M; Collin P; Vitte C; and Forest N: Osteoblast adherence and resorption activity of isolated osteoclasts on calcium sulphate hemihydrate. Biomaterials.,1995.16: 1327-32, 161327 1995 [PubMed]

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These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.

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Raffy Mirzayan, Vahé Panossian, Raffi Avedian, Deborah M. Forrester, Lawrence R. Menendez; The Use of Calcium Sulfate in the Treatment of Benign Bone Lesions A Preliminary Report. The Journal of Bone & Joint Surgery. 2001 Mar;83(3):355-355.

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