Testing of a new one-stage bone-transport surgical procedure exploiting the periosteum for the repair of long-bone defects.

BACKGROUND A recently proposed one-stage bone-transport surgical procedure exploits the intrinsic osteogenic potential of the periosteum while providing mechanical stability through intramedullary nailing. The objective of this study was to assess the efficacy of this technique to bridge massive long-bone defects in a single stage. METHODS With use of an ovine femoral model, an in situ periosteal sleeve was elevated circumferentially from healthy diaphyseal bone, which was osteotomized and transported over an intramedullary nail into a 2.54-cm (1-in) critical-sized diaphyseal defect. The defect-bridging and bone-regenerating capacity of the procedure were tested in five groups of seven animals each, which were defined by the absence (Group 1; control) or presence of the periosteal sleeve alone (Group 2), bone graft within the periosteal sleeve (Groups 3 and 5), as well as retention of adherent, vascularized cortical bone chips on the periosteal sleeve with or without bone graft (Groups 4 and 5). The efficacy of the procedure was assessed qualitatively and quantitatively. RESULTS At sixteen weeks, osseous bridging of the defect was observed in all twenty-eight experimental sheep in which the periosteal sleeve was retained; the defect persisted in the remaining seven control sheep. Among the experimental groups 2 through 5, significant differences were observed in the density of the regenerated bone tissue; the two groups in which vascularized bone chips adhered to the inner surface of the periosteal sleeve (Groups 4 and 5) showed a higher mean bone density in the defect zone (p < 0.02) than did the other groups. In these two groups with the highest bone density, the addition of bone graft was associated with a significantly lower callus density than that observed without bone graft (p < 0.05). The volume of regenerate bone (p < 0.02) was significantly greater in the groups in which the periosteal sleeve was retained than it was in the control group. Among the experimental groups (groups 2 through 5), however, with the numbers studied, no significant differences in the volume of regenerate bone could be attributed to the inclusion of bone graft within the sleeve or to vascularized bone chips remaining adherent to the periosteum. CONCLUSIONS The novel surgical procedure was shown to be effective in bridging a critical-sized defect in an ovine femoral model. Vascularized bone chips adherent to the inner surface of the periosteal sleeve, without the addition of morselized cancellous bone graft within the sleeve, provide not only a comparable volume of regenerate bone and composite tissue (callus and bone) but also a superior density of regenerate bone compared with that after the addition of bone graft.

[1]  P Regazzoni,et al.  Bridging bone gaps with the Ilizarov technique. Biologic principles. , 1991, Clinics in plastic surgery.

[2]  U. Knothe,et al.  A novel surgical procedure for bridging of massive bone defects , 2005, World journal of surgical oncology.

[3]  J. Nunley,et al.  Treatment of Segmental Defects of the Radius with Use of the Vascularized Osteoseptocutaneous Fibular Autogenous Graft* , 1997, The Journal of bone and joint surgery. American volume.

[4]  F. Dagher,et al.  Compound tibial fractures with bone loss treated by the Ilizarov technique. , 1991, The Journal of bone and joint surgery. British volume.

[5]  J. L. Marsh,et al.  Segmental bone deficiency after acute trauma. The role of bone transport. , 1994, The Orthopedic clinics of North America.

[6]  A. Ateşalp,et al.  Treatment of tibial bone defects with the Ilizarov circular external fixator in high-velocity gunshot wounds , 1998, International Orthopaedics.

[7]  Jian Yin Liu,et al.  Experimental study of the osteogenic capacity of periosteal allografts: A preliminary report , 1994, Microsurgery.

[8]  A. Mikos,et al.  Guided tissue fabrication from periosteum using preformed biodegradable polymer scaffolds. , 1999, Biomaterials.

[9]  A. Eyre-Brook,et al.  The periosteum: its function reassessed. , 1984, Clinical orthopaedics and related research.

[10]  J. Gugenheim The Ilizarov method. Orthopedic and soft tissue applications. , 1998, Clinics in plastic surgery.

[11]  D. Paley,et al.  Problems, obstacles, and complications of limb lengthening by the Ilizarov technique. , 1990, Clinical orthopaedics and related research.

[12]  D. Janczak,et al.  Vascular complications after the treatment with Ilizarov external fixators. , 2001, VASA. Zeitschrift fur Gefasskrankheiten.

[13]  P. Regazzoni,et al.  The use of the Ilizarov concept with the AO/ASIF tubular fixateur in the treatment of segmental defects. , 1990, The Orthopedic clinics of North America.

[14]  J Aronson,et al.  Limb-lengthening, skeletal reconstruction, and bone transport with the Ilizarov method. , 1997, The Journal of bone and joint surgery. American volume.

[15]  J. Watson,et al.  Management strategies for bone loss in tibial shaft fractures. , 1995, Clinical orthopaedics and related research.

[16]  J. Aronson,et al.  Local bone transportation for treatment of intercalary defects by the Ilizarov technique. Biomechanical and clinical considerations. , 1989, Clinical orthopaedics and related research.

[17]  T. Sugahara,et al.  Prefabricated bone graft induced from grafted periosteum for the repair of jaw defects: an experimental study in rabbits. , 2001, Journal of cranio-maxillo-facial surgery : official publication of the European Association for Cranio-Maxillo-Facial Surgery.

[18]  D. Smrke,et al.  Treatment of extensive bone and soft tissue defects of the lower limb by traction and free-flap transfer. , 2000, Injury.

[19]  M. Saleh,et al.  Limb reconstruction after high energy trauma. , 1999, British medical bulletin.

[20]  R. Canalis,et al.  Studies on the Osteogenic Potential of Vascularized Periosteum: Behavior of Periosteal Flaps Transferred onto Soft Tissues , 1985, Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery.

[21]  D. Paley,et al.  Ilizarov bone transport treatment for tibial defects. , 2000, Journal of orthopaedic trauma.

[22]  D. Marsh,et al.  The Ilizarov method in nonunion, malunion and infection of fractures. , 1997, The Journal of bone and joint surgery. British volume.

[23]  B. Pavolini,et al.  The Ilizarov fixator in trauma: a 10-year experience , 2000, Journal of orthopaedic science : official journal of the Japanese Orthopaedic Association.

[24]  T. Kinnebrew,et al.  Tibial defects. Reconstruction using the method of Ilizarov as an alternative. , 1990, The Orthopedic clinics of North America.

[25]  G. Papachristou,et al.  Treatment of tibial and femoral bone loss by distraction osteogenesis. Experience in 28 infected and 14 clean cases. , 1997, Acta orthopaedica Scandinavica. Supplementum.

[26]  E García-Cimbrelo,et al.  Ilizarov technique. Results and difficulties. , 1992, Clinical orthopaedics and related research.

[27]  M. Brookes,et al.  Blood Supply of Bone: Scientific Aspects , 1998 .

[28]  Toshio Yamamoto,et al.  Cellular origin of endochondral ossification from grafted periosteum , 2001, The Anatomical record.

[29]  Jian Yin Liu,et al.  Use of revascularized periosteal allografts for repairing bony defects: An experimental study , 1994, Microsurgery.

[30]  J. Camilli,et al.  Bone formation by vascularized periosteal and osteoperiosteal grafts , 1994, Archives of Orthopaedic and Trauma Surgery.

[31]  R. Słomka Complications of ring fixators in the foot and ankle. , 2001, Clinical orthopaedics and related research.

[32]  M. Pirela-Cruz,et al.  Management of Posttraumatic Segmental Bone Defects , 2004, The Journal of the American Academy of Orthopaedic Surgeons.