SLR - July 2023 - Philip Cynamon, DPM
Title: Allograft Versus Bioactive Glass (BG-S53P4) in Pediatric Benign Bone Lesions A Randomized Clinical TrialReference: Syvänen J, Serlo W, Jalkanen J, Kohonen I, Raitio A, Nietosvaara Y, Helenius I. Allograft Versus Bioactive Glass (BG-S53P4) in Pediatric Benign Bone Lesions: A Randomized Clinical Trial. J Bone Joint Surg Am. 2023 May 3;105(9):659-666. doi: 10.2106/JBJS.22.00716. Epub 2023 Jan 19. PMID: 36727973.
Level of Evidence: Level 1
Scientific Literature Review
Reviewed By: Philip Cynamon, DPM
Residency Program: SUNY Downstate, Brooklyn, NY
Podiatric Relevance: Benign bone lesions in the lower extremity of pediatric patients can be particularly challenging for the foot and ankle surgeon. Common bone lesions include simple bone cysts and aneurysmal bone cysts among others. With a high recurrence rate after grafting, the optimal treatment and filling material are presently unknown. Bioactive glasses are a filling material with osteoconductive bone substitutes with osteoinductive, antimicrobial, and angiogenic properties. This study aims to compare allograft and bioactive glass in the treatment of pediatric benign bone tumors with intralesional curettage. The authors hypothesize that recurrent cysts would be smaller after filling with bioactive glass, because the slowly dissolving glass would be more resistant to resorption by a recurrent tumor.
Methods: In this randomized control trial pediatric patients with benign bone lesions were randomized with 26 patients to the allograft group receiving fresh frozen morselized femoral head allograft, and 25 to the bioactive group receiving BG-S53P4 bioactive glass granules. They hypothesized that bioactive glass would reduce the size of recurrent cysts, and that the glass would not interfere with bone remodeling or cyst resolution. The primary outcome was the volume of the recurrence at 2-year follow-up. The secondary outcomes were the recurrence rate, risk of reoperation, The Musculoskeletal Tumor Society (MSTS) score, and complications.
Results: 46% of the children in the allograft and 40% in the bioactive glass group developed a recurrence during the 2 years of follow-up with no significant difference in recurrence size between the two groups. 15% of the children in the allograft and 24% in the bioactive glass group required a reoperation for a recurrence during the follow-up. There were no growth disturbances, pathologic fractures, or deep surgical site infections. There was one significant complication, one (4%) of the patients in the bioactive glass group, who had a pelvic ABC, had intraoperative bleeding exceeding 50% of his blood volume. In both the allograft group and bioactive glass group MSTS score improved significantly from preoperative scores to the 2-year follow-up, and the difference at 2 years was not significant between the two groups.
Conclusions: In this randomized trial, no significant difference was seen between bioactive glass and allograft following curettage. The authors therefore conclude bioactive glass represents an alternative filling material for pediatric benign bone lesions. Although the ideal filling material for bone cysts after curettage is theoretically autograft bone, it is important to note that adequate volume of autograft bone is not always available, and harvesting an autograft requires an additional procedure that results in pain at the harvest site. To avoid a secondary surgical site a surgeon may choose to proceed with bioactive glass or allograft following curettage. Another factor to note, is that reoperations in patients treated with bioactive glass can be difficult as the extremely hard glass and newly formed bone tissue can make curettage challenging. Nevertheless, bioactive glass represents a viable alternative to autologous bone graft especially in pediatric patients with large cysts for which adequate volume of autograft bone is not available.