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Wu JH, Bao QW, Wang SK, Zhou PY, Xu SG. Mechanisms of the Masquelet technique to promote bone defect repair and its influencing factors. Chin J Traumatol 2024:S1008-1275(24)00054-3. [PMID: 38734563 DOI: 10.1016/j.cjtee.2024.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 03/21/2024] [Accepted: 04/02/2024] [Indexed: 05/13/2024] Open
Abstract
The Masquelet technique, also known as the induced membrane technique, is a surgical technique for repairing large bone defects based on the use of a membrane generated by a foreign body reaction for bone grafting. This technique is not only simple to perform, with few complications and quick recovery, but also has excellent clinical results. To better understand the mechanisms by which this technique promotes bone defect repair and the factors that require special attention in practice, we examined and summarized the relevant research advances in this technique by searching, reading, and analysing the literature. Literature show that the Masquelet technique may promote the repair of bone defects through the physical septum and molecular barrier, vascular network, enrichment of mesenchymal stem cells, and high expression of bone-related growth factors, and the repair process is affected by the properties of spacers, the timing of bone graft, mechanical environment, intramembrane filling materials, artificial membrane, and pharmaceutical/biological agents/physical stimulation.
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Affiliation(s)
- Jiang-Hong Wu
- Department of Emergency, Xinqiao Hospital, Army Medical University, Chongqing, 400037, China; Department of Trauma Orthopedics, Changhai Hospital, Naval Medical University, Shanghai, 200433, China
| | - Quan-Wei Bao
- Trauma Center, Xinqiao Hospital, Army Medical University, Chongqing, 400037, China
| | - Shao-Kang Wang
- Department of Trauma Orthopedics, Changhai Hospital, Naval Medical University, Shanghai, 200433, China
| | - Pan-Yu Zhou
- Department of Trauma Orthopedics, Changhai Hospital, Naval Medical University, Shanghai, 200433, China
| | - Shuo-Gui Xu
- Department of Trauma Orthopedics, Changhai Hospital, Naval Medical University, Shanghai, 200433, China.
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Wang K, Zhou M, Zhang Y, Jin Y, Xue Y, Mao D, Rui Y. Fibromodulin facilitates the osteogenic effect of Masquelet's induced membrane by inhibiting the TGF-β/SMAD signaling pathway. Biomater Sci 2024; 12:1898-1913. [PMID: 38426394 DOI: 10.1039/d3bm01665j] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
Abstract
Masquelet's induced membrane (IM) technique is a promising treatment strategy for the repair of substantial bone defects. The formation of an IM around polymethylmethacrylate bone cement plays a crucial role in this technique. Several studies have indicated that IMs have bioactivity because they contain abundant blood vessels, a variety of cells, and biological factors. The bioactivity of an IM increases during the initial stages of formation, thereby facilitating bone regeneration and remodeling. Nevertheless, the precise mechanisms underlying the enhancement of IM bioactivity and the promotion of bone regeneration necessitate further investigation. In this study, we successfully developed a Masquelet IM model of critical femur defects in rats. By employing proteomics analysis and biological detection techniques, we identified fibromodulin (FMOD) as a pivotal factor contributing to angiogenesis and the enhanced bioactivity of the IM. A significant increase in angiogenesis and the expression of bioactive factors in the IM was also observed with the upregulation of FMOD expression. Furthermore, this effect is mediated through the inhibition of the transforming growth factor beta (TGF-β)/SMAD signaling pathway. We also demonstrated that administering recombinant human FMOD enhanced osteogenesis in rat bone marrow mesenchymal stem cells and angiogenesis in human umbilical vein endothelial cells in vitro. Furthermore, the negative regulatory effect of the TGF-β signaling pathway was verified. In conclusion, this study provides a novel theoretical basis for the application of IMs in bone-defect reconstruction and explores possible new mechanisms that may play an important role in promoting the bioactivity and osteogenic potential of IMs.
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Affiliation(s)
- Kai Wang
- Department of Orthopedics, Wuxi Ninth People's Hospital Affiliated to Soochow University, Wuxi, 214062, China.
- Suzhou Medical College of Soochow University, Suzhou, 215031, China
| | - Ming Zhou
- Department of Orthopedics, Wuxi Ninth People's Hospital Affiliated to Soochow University, Wuxi, 214062, China.
- Suzhou Medical College of Soochow University, Suzhou, 215031, China
| | - Yuanshu Zhang
- Department of Orthopedics, Wuxi Ninth People's Hospital Affiliated to Soochow University, Wuxi, 214062, China.
| | - Yesheng Jin
- Suzhou Medical College of Soochow University, Suzhou, 215031, China
| | - Yuan Xue
- Department of Orthopedics, Wuxi Ninth People's Hospital Affiliated to Soochow University, Wuxi, 214062, China.
| | - Dong Mao
- Orthopaedic Institute, Wuxi Ninth People's Hospital Affiliated to Soochow University, Wuxi, 214062, China
| | - Yongjun Rui
- Department of Orthopedics, Wuxi Ninth People's Hospital Affiliated to Soochow University, Wuxi, 214062, China.
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Bone Regeneration in Small and Large Segmental Bone Defect Models after Radiotherapy Using Injectable Polymer-Based Biodegradable Materials Containing Strontium-Doped Hydroxyapatite Particles. Int J Mol Sci 2023; 24:ijms24065429. [PMID: 36982504 PMCID: PMC10049363 DOI: 10.3390/ijms24065429] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 02/26/2023] [Accepted: 03/07/2023] [Indexed: 03/14/2023] Open
Abstract
The reconstruction of bones following tumor excision and radiotherapy remains a challenge. Our previous study, performed using polysaccharide-based microbeads that contain hydroxyapatite, found that these have osteoconductivity and osteoinductive properties. New formulations of composite microbeads containing HA particles doped with strontium (Sr) at 8 or 50% were developed to improve their biological performance and were evaluated in ectopic sites. In the current research, we characterized the materials by phase-contrast microscopy, laser dynamic scattering particle size-measurements and phosphorus content, before their implantation into two different preclinical bone defect models in rats: the femoral condyle and the segmental bone. Eight weeks after the implantation in the femoral condyle, the histology and immunohistochemistry analyses showed that Sr-doped matrices at both 8% and 50% stimulate bone formation and vascularization. A more complex preclinical model of the irradiation procedure was then developed in rats within a critical-size bone segmental defect. In the non-irradiated sites, no significant differences between the non-doped and Sr-doped microbeads were observed in the bone regeneration. Interestingly, the Sr-doped microbeads at the 8% level of substitution outperformed the vascularization process by increasing new vessel formation in the irradiated sites. These results showed that the inclusion of strontium in the matrix-stimulated vascularization in a critical-size model of bone tissue regeneration after irradiation.
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Sun H, Godbout C, Ryan G, Hoit G, Higgins J, Schemitsch EH, Nauth A. The induced membrane technique: Optimization of bone grafting in a rat model of segmental bone defect. Injury 2022; 53:1848-1853. [PMID: 35341595 DOI: 10.1016/j.injury.2022.03.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 03/10/2022] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The induced membrane technique (IMT) is a two-stage surgical procedure used to treat fracture nonunion and bone defects. Although there is an increasing number of animal studies investigating the IMT, few have examined the outcomes of bone healing after a second stage grafting procedure. This study aimed at comparing two bone grafting procedures, as part of the IMT, in order to establish a rat model providing consistent healing outcomes. METHODS In male Fischer 344 rats, we created a 5 mm defect in the right femur, stabilized the bone with a plate and screws, and inserted a polymethylmethacrylate spacer into the defect. Four weeks later, the spacer was removed. Bone graft was harvested from a donor rat and placed into the defect, followed by membrane and wound closure. Experiments were conducted in two groups. In group 1 (n = 11), the bone graft contained a variable amount of cortical and cancellous bone, the time from donor euthanasia to grafting was up to 240 min, and one donor rat provided graft for 5-6 recipients. In group 2 (n = 12), we reduced the contribution of cortical bone to the graft, included bone marrow, and kept donor euthanasia to grafting time under 150 min. One donor was used per 3-4 recipients. The volume of graft per recipient and all other elements of the protocol were the same across groups. Bone healing at 12 weeks post grafting was compared radiographically by two orthopaedic surgeons in a blinded fashion, based on union status and a modified Lane & Sandhu score. RESULTS Healing rates improved from 36.4% in Group 1 to 91.6% in Group 2. There was a significant relationship between the methods and resulting union status (p = 0.004). The odds of achieving full union were significantly higher in group 2 compared to group 1 (odds ratio=19.25, 95% confidence interval [1.77-209.55]; p = 0.009). The average radiographic score was also significantly higher in group 2 (p = 0.005). CONCLUSION The revised bone grafting method significantly improved the healing outcomes and contributed to establishing a consistent rat model of the IMT. This model can benefit preclinical investigations by allowing for reliable and clinically-relevant comparisons.
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Affiliation(s)
- Hening Sun
- Division of Orthopaedic Surgery, St. Michael's Hospital, 55 Queen Street East, Suite 800, Toronto, ON M5C 1R6, Canada; Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Charles Godbout
- Division of Orthopaedic Surgery, St. Michael's Hospital, 55 Queen Street East, Suite 800, Toronto, ON M5C 1R6, Canada
| | - Gareth Ryan
- Division of Orthopaedic Surgery, St. Michael's Hospital, 55 Queen Street East, Suite 800, Toronto, ON M5C 1R6, Canada; Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Graeme Hoit
- Division of Orthopaedic Surgery, St. Michael's Hospital, 55 Queen Street East, Suite 800, Toronto, ON M5C 1R6, Canada; Faculty of Medicine, University of Toronto, Toronto, Canada
| | - James Higgins
- Division of Orthopaedic Surgery, St. Michael's Hospital, 55 Queen Street East, Suite 800, Toronto, ON M5C 1R6, Canada; Faculty of Medicine, University of Toronto, Toronto, Canada
| | | | - Aaron Nauth
- Division of Orthopaedic Surgery, St. Michael's Hospital, 55 Queen Street East, Suite 800, Toronto, ON M5C 1R6, Canada; Faculty of Medicine, University of Toronto, Toronto, Canada.
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Effect of Recombinant Human Bone Morphogenetic Protein-2 (rhBMP-2) with Hydroxyapatite Carrier in Induced Membrane Technique: A Retrospective Propensity Score-Matched Study. J Orthop Trauma 2022; 36:301-308. [PMID: 34732658 DOI: 10.1097/bot.0000000000002294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/11/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To determine the effect of recombinant human bone morphogenetic protein-2 (rhBMP-2) with hydroxyapatite (HA) carrier augmentation in managing critical-sized bone defect (CSBD) with induced membrane technique (IMT). DESIGN Retrospective comparative study. SETTING Academic level I trauma center. PATIENTS/PARTICIPANTS The study included 14 patients who underwent rhBMP-2 with HA carrier (rhBMP-2/HA) augmentation in IMT for managing CSBD (BMP group). Moreover, 14 patients who underwent IMT without rhBMP-2 augmentation were matched by propensity score analysis (non-BMP group). INTERVENTION IMT with or without rhBMP-2/HA augmentation. MAIN OUTCOME MEASUREMENT Changes in quality and quantity measurements of grafted bone to regenerated bone using serial computed tomography. RESULTS In the BMP and non-BMP groups, the changes in densities from grafted bone to regenerated bone were +379.63 Hounsfield unit and +248.55 Hounsfield unit (P = 0.034), changes in dense bone percentage were +37.52% and +23.31% (P = 0.027), corticalization rates under the plate were 79.70% and 39.30% (P = 0.007), changes in volume were -20.77% and -23.35% (P = 0.812), union rates were 85.71% and 78.57% (P = 0.622), numbers of patients requiring additional procedures were 4 and 3 (P = 0.663), and time to union were 316.3 and 585.45 days (P = 0.040), respectively. CONCLUSIONS RhBMP-2/HA augmentation increases the density of regenerated bone, enhances corticalization under the plate, and shortens the time to union while managing CSBD with IMT. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Zhu L, Liu Y, Wang A, Zhu Z, Li Y, Zhu C, Che Z, Liu T, Liu H, Huang L. Application of BMP in Bone Tissue Engineering. Front Bioeng Biotechnol 2022; 10:810880. [PMID: 35433652 PMCID: PMC9008764 DOI: 10.3389/fbioe.2022.810880] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 03/01/2022] [Indexed: 01/15/2023] Open
Abstract
At present, bone nonunion and delayed union are still difficult problems in orthopaedics. Since the discovery of bone morphogenetic protein (BMP), it has been widely used in various studies due to its powerful role in promoting osteogenesis and chondrogenesis. Current results show that BMPs can promote healing of bone defects and reduce the occurrence of complications. However, the mechanism of BMP in vivo still needs to be explored, and application of BMP alone to a bone defect site cannot achieve good therapeutic effects. It is particularly important to modify implants to carry BMP to achieve slow and sustained release effects by taking advantage of the nature of the implant. This review aims to explain the mechanism of BMP action in vivo, its biological function, and how BMP can be applied to orthopaedic implants to effectively stimulate bone healing in the long term. Notably, implantation of a system that allows sustained release of BMP can provide an effective method to treat bone nonunion and delayed bone healing in the clinic.
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Affiliation(s)
- Liwei Zhu
- Department of Orthopedics, The Second Hospital of Jilin University, Changchun, China
- Orthopaedic Research Institute of Jilin Province, Changchun, China
| | - Yuzhe Liu
- Department of Orthopedics, The Second Hospital of Jilin University, Changchun, China
| | - Ao Wang
- Department of Orthopedics, The Second Hospital of Jilin University, Changchun, China
| | - Zhengqing Zhu
- Department of Orthopedics, The Second Hospital of Jilin University, Changchun, China
| | - Youbin Li
- Department of Orthopedics, The Second Hospital of Jilin University, Changchun, China
| | - Chenyi Zhu
- Department of Orthopedics, The Second Hospital of Jilin University, Changchun, China
| | - Zhenjia Che
- Department of Orthopedics, The Second Hospital of Jilin University, Changchun, China
| | - Tengyue Liu
- Department of Orthopedics, The Second Hospital of Jilin University, Changchun, China
| | - He Liu
- Department of Orthopedics, The Second Hospital of Jilin University, Changchun, China
- Orthopaedic Research Institute of Jilin Province, Changchun, China
- *Correspondence: He Liu, ; Lanfeng Huang,
| | - Lanfeng Huang
- Department of Orthopedics, The Second Hospital of Jilin University, Changchun, China
- *Correspondence: He Liu, ; Lanfeng Huang,
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Verboket RD, Söhling N, Heilani M, Fremdling C, Schaible A, Schröder K, Brune JC, Marzi I, Henrich D. The Induced Membrane Technique—The Filling Matters: Evaluation of Different Forms of Membrane Filling with and without Bone Marrow Mononuclear Cells (BMC) in Large Femoral Bone Defects in Rats. Biomedicines 2022; 10:biomedicines10030642. [PMID: 35327444 PMCID: PMC8945121 DOI: 10.3390/biomedicines10030642] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 03/07/2022] [Accepted: 03/08/2022] [Indexed: 12/04/2022] Open
Abstract
The Masquelet technique is used to treat large bone defects; it is a two-stage procedure based on an induced membrane. To improve the induced membrane process, demineralized bone matrix in granular (GDBM) and fibrous form (f-DBM) was tested with and without bone marrow mononuclear cells (BMC) as filling of the membrane against the gold standard filling with syngeneic cancellous bone (SCB). A total of 65 male Sprague–Dawley rats obtained a 5 mm femoral defect. These defects were treated with the induced membrane technique and filled with SCB, GDBM, or f-DBM, with or without BMC. After a healing period of eight weeks, the femurs were harvested and submitted for histological, radiological, and biomechanical analyses. The fracture load in the defect zone was lower compared to SCB in all groups. However, histological analysis showed comparable new bone formation, bone mineral density, and cartilage proportions and vascularization. The results suggest that f-DBM in combination with BMC and the induced membrane technique cannot reproduce the very good results of this material in large, non-membrane coated bone defects, nevertheless it supports the maturation of new bone tissue locally. It can be concluded that BMC should be applied in lower doses and inflammatory cells should be removed from the cell preparation before implantation.
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Affiliation(s)
- René D. Verboket
- Department of Trauma, Hand and Reconstructive Surgery, Goethe University Frankfurt, 60590 Frankfurt am Main, Germany; (N.S.); (M.H.); (C.F.); (A.S.); (I.M.); (D.H.)
- Correspondence: ; Tel.: +49-69-6301-7110
| | - Nicolas Söhling
- Department of Trauma, Hand and Reconstructive Surgery, Goethe University Frankfurt, 60590 Frankfurt am Main, Germany; (N.S.); (M.H.); (C.F.); (A.S.); (I.M.); (D.H.)
| | - Myriam Heilani
- Department of Trauma, Hand and Reconstructive Surgery, Goethe University Frankfurt, 60590 Frankfurt am Main, Germany; (N.S.); (M.H.); (C.F.); (A.S.); (I.M.); (D.H.)
| | - Charlotte Fremdling
- Department of Trauma, Hand and Reconstructive Surgery, Goethe University Frankfurt, 60590 Frankfurt am Main, Germany; (N.S.); (M.H.); (C.F.); (A.S.); (I.M.); (D.H.)
| | - Alexander Schaible
- Department of Trauma, Hand and Reconstructive Surgery, Goethe University Frankfurt, 60590 Frankfurt am Main, Germany; (N.S.); (M.H.); (C.F.); (A.S.); (I.M.); (D.H.)
| | - Katrin Schröder
- Center of Physiology, Cardiovascular Physiology, Goethe University Frankfurt, 60590 Frankfurt am Main, Germany;
| | - Jan C. Brune
- German Institute for Cell and Tissue Replacement (DIZG, gemeinnützige GmbH), 12555 Berlin, Germany;
| | - Ingo Marzi
- Department of Trauma, Hand and Reconstructive Surgery, Goethe University Frankfurt, 60590 Frankfurt am Main, Germany; (N.S.); (M.H.); (C.F.); (A.S.); (I.M.); (D.H.)
| | - Dirk Henrich
- Department of Trauma, Hand and Reconstructive Surgery, Goethe University Frankfurt, 60590 Frankfurt am Main, Germany; (N.S.); (M.H.); (C.F.); (A.S.); (I.M.); (D.H.)
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The induced membrane technique in animal models: a systematic review. OTA Int 2022; 5:e176. [PMID: 35282388 PMCID: PMC8900461 DOI: 10.1097/oi9.0000000000000176] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 12/15/2021] [Indexed: 01/10/2023]
Abstract
Objectives: Data Sources: Study Selection: Data Extraction: Data Synthesis: Conclusions:
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Niikura T, Oda T, Jimbo N, Komatsu M, Oe K, Fukui T, Matsumoto T, Hayashi S, Matsushita T, Itoh T, Kuroda R. Immunohistochemical analysis revealed the expression of bone morphogenetic proteins-4, 6, 7, and 9 in human induced membrane samples treated with the Masquelet technique. J Orthop Surg Res 2022; 17:29. [PMID: 35033126 PMCID: PMC8760771 DOI: 10.1186/s13018-022-02922-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 01/06/2022] [Indexed: 01/11/2023] Open
Abstract
Background Induced membrane (IM) is the key component of Masquelet reconstruction surgery for the treatment of bone defects. IM is formed around the cement spacer and is known to secrete growth factors and osteoinductive factors. However, there is limited evidence available concerning the presence of osteoinductive factors in IM. This study aimed to investigate the existence of bone morphogenetic proteins (BMPs) in IM harvested from patients during the treatment of bone defects using the Masquelet technique. Methods This study involved six patients whose bone defects had been treated using the Masquelet technique. The affected sites were the femur (n = 3) and the tibia (n = 3). During the second-stage surgery, 1 cm2 pieces of IM were harvested. Histological sections of IM were immunostained with anti-BMP-4, 6, 7, and 9 antibodies. Human bone tissue served as the positive control. Results The presence of BMP-4, 6, 7, and 9 was observed in all IM samples. Further, immunolocalization of BMP-4, 6, 7, and 9 was observed in blood vessels and fibroblasts in all IM samples. Immunolocalization of BMP-4, 6, 7, and 9 was also observed in bone tissue within the IM in one sample, in which osteogenesis inside the IM was observed. Conclusions This study showed that osteoinductive factors BMP-4, 6, 7, and 9 were present in the IM harvested from patients, providing evidence indicating that the Masquelet technique effectively contributes to healing large bone defects. Therefore, it may be possible for surgeons to omit the addition of BMPs to bone grafts, given the endogenous secretion of BMPs from the IM.
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Affiliation(s)
- Takahiro Niikura
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan.
| | - Takahiro Oda
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Naoe Jimbo
- Department of Diagnostic Pathology, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Masato Komatsu
- Department of Diagnostic Pathology, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Keisuke Oe
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Tomoaki Fukui
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Tomoyuki Matsumoto
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Shinya Hayashi
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Takehiko Matsushita
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Tomoo Itoh
- Department of Diagnostic Pathology, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Ryosuke Kuroda
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
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Mathieu L, Murison JC, de Rousiers A, de l’Escalopier N, Lutomski D, Collombet JM, Durand M. The Masquelet Technique: Can Disposable Polypropylene Syringes be an Alternative to Standard PMMA Spacers? A Rat Bone Defect Model. Clin Orthop Relat Res 2021; 479:2737-2751. [PMID: 34406150 PMCID: PMC8726567 DOI: 10.1097/corr.0000000000001939] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 07/20/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Usually, the two-stage Masquelet induced-membrane technique for extremity reconstruction begins with a polymethylmethacrylate (PMMA) cement spacer-driven membrane, followed by an autologous cancellous bone graft implanted into the membrane cavity to promote healing of large bone defects. In exceptional cases, spacers made of polypropylene disposable syringes were successfully used instead of the usual PMMA spacers because of a PMMA cement shortage caused by a lack of resources. However, this approach lacks clinical evidence and requires experimental validation before being recommended as an alternative to the conventional technique. QUESTIONS/PURPOSES To (1) develop and (2) validate a critical-sized femoral defect model in rats for two stages of the Masquelet technique and to (3) compare the biological and bone healing properties of polypropylene-induced membranes and PMMA-induced membranes in this model. METHODS Fifty male Sprague Dawley rats aged 8 weeks old received a 6-mm femur defect, which was stabilized with an external fixator that was converted into an internal device. In the development phase, the defect was filled with PMMA in 16 rats to determine the most favorable timing for bone grafting. Two rats were excluded since they died of anesthetic complications. The other 14 were successively euthanized after 2 weeks (n = 3), 4 weeks (n = 4), 6 weeks (n = 4), and 8 weeks (n = 3) for induced membrane analyses. In the validation phase, 12 rats underwent both stages of the procedure using a PMMA spacer and were randomly assigned to two groups, whether the induced membrane was preserved or removed before grafting. To address our final objective, we implanted either polypropylene or PMMA spacers into the defect (Masquelet technique Stage 1; n = 11 rats per group) for the period established by the development phase. In each group, 6 of 11 rats were euthanized to compare the biological properties of polypropylene-induced membranes and PMMA-induced membranes using histological qualitative analysis, semiquantitative assessment of the bone morphogenic protein-2 content by immunostaining, and qualitative assessment of the mesenchymal stromal cell (MSC; CD31-, CD45-, CD90+, and CD73+ phenotypes) content by flow cytometry. Quantitative measurements from serum bone turnover markers were also performed. The five remaining rats of each group were used for Masquelet technique Stage 2, in which rat bone allografts were implanted in the induced membrane cavity after the polypropylene or PMMA spacers were removed. These rats recovered for 10 weeks before being euthanized for microCT quantitative measurements and bone histology qualitative assessment to evaluate and compare the extent of bone regeneration between groups. RESULTS Induced membrane analyses together with serum bone turnover measurements indicated that a 4-week interval time between stages was the most favorable. Removal of the induced membrane before grafting led to almost constant early implant failures with poor bone formation. Four-week-old rats with polypropylene-triggered induced membranes displayed similar histologic organization as rats with PMMA-driven induced membranes, without any difference in the cell density of the extracellular matrix (4933 ± 916 cells per mm2 for polypropylene versus 4923 ± 1284 cells per mm2 for PMMA; p = 0.98). Induced membrane-derived MSCs were found in both groups with no difference (4 of 5 with polypropylene versus 3 of 3 with PMMA; p > 0.99). Induced membrane bone morphogenic protein-2 immunolabeling and serum bone turnover marker levels were comparable between the polypropylene and PMMA groups. MicroCT analysis found that bone regeneration in the polypropylene group seemed comparable with that in the PMMA group (29 ± 26 mm3 for polypropylene versus 24 ± 18 mm3 for PMMA; p > 0.99). Finally, qualitative histological assessment revealed a satisfactory endochondral ossification maturation in both groups. CONCLUSION Using a critical-sized femoral defect model in rats, we demonstrated that polypropylene spacers could induce membrane encapsulation with histologic characteristics and bone regenerative capacities that seem like those of PMMA spacers. CLINICAL RELEVANCE In a same bone site, polymers with close physical properties seem to lead to similar foreign body reactions and induce encapsulating membranes with comparable bone healing properties. Polypropylene spacers made from disposable syringes could be a valuable alternative to PMMA. These results support the possibility of a cementless Masquelet technique in cases of PMMA shortage caused by a lack of resources.
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Affiliation(s)
- Laurent Mathieu
- Department of Orthopedic, Trauma and Reconstructive Surgery, Percy Military Hospital, Clamart, France
- French Military Health Service Academy, Ecole du Val-de-Grâce, Paris, France
| | - James Charles Murison
- Department of Orthopedic, Trauma and Reconstructive Surgery, Percy Military Hospital, Clamart, France
| | - Arnaud de Rousiers
- Department of Orthopedic, Trauma and Reconstructive Surgery, Percy Military Hospital, Clamart, France
| | - Nicolas de l’Escalopier
- Department of Orthopedic, Trauma and Reconstructive Surgery, Percy Military Hospital, Clamart, France
| | - Didier Lutomski
- Tissue Engineering and Proteomics Team, Université Paris, Bobigny, France
| | | | - Marjorie Durand
- Military Biomedical Research Institute, Brétigny-sur-Orge, France
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Cho JW, Kim BS, Yeo DH, Lim EJ, Sakong S, Lim J, Park S, Jeong YH, Jung TG, Choi H, Oh CW, Kim HJ, Park JW, Oh JK. 3D-printed, bioactive ceramic scaffold with rhBMP-2 in treating critical femoral bone defects in rabbits using the induced membrane technique. J Orthop Res 2021; 39:2671-2680. [PMID: 33580542 DOI: 10.1002/jor.25007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 12/02/2020] [Accepted: 02/10/2021] [Indexed: 02/04/2023]
Abstract
Although autogenous bone grafts are an optimal filling material for the induced membrane technique, limited availability and complications at the harvest site have created a need for alternative graft materials. We aimed to investigate the effect of an rhBMP-2-coated, 3D-printed, macro/microporous CaO-SiO2 -P2 O5 -B2 O3 bioactive ceramic scaffold in the treatment of critical femoral bone defects in rabbits using the induced membrane technique. A 15-mm segmental bone defect was made in the metadiaphyseal area of the distal femur of 14 rabbits. The defect was filled with polymethylmethacrylate cement and stabilized with a 2.0 mm locking plate. After the membrane matured for 4 weeks, the scaffold was implanted in two randomized groups: Group A (3D-printed bioceramic scaffold) and Group B (3D-printed, bioceramic scaffold with rhBMP-2). Eight weeks after implantation, the radiographic assessment showed that the healing rate of the defect was significantly higher in Group B (7/7, 100%) than in Group A (2/7, 29%). The mean volume of new bone formation around and inside the scaffold doubled in Group B compared to that in Group A. The mean static and dynamic stiffness were significantly higher in Group B. Histological examination revealed newly formed bone in both groups. Extensive cortical bone formation along the scaffold was found in Group B. Successful bone reconstruction in critical-sized bone defects could be obtained using rhBMP-2-coated, 3D-printed, macro/microporous bioactive ceramic scaffolds. This grafting material demonstrated potential as an alternative graft material in the induced membrane technique for reconstructing critical-sized bone defects.
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Affiliation(s)
- Jae-Woo Cho
- Department of Orthopaedic Surgery, Korea University Medical Center, Seoul, Republic of Korea
| | - Beom-Soo Kim
- Department of Orthopaedic Surgery, Dongsan Medical Center, School of Medicine, Keimyung University, Daegu, Republic of Korea
| | - Do-Hyun Yeo
- Department of Orthopaedic Surgery, Korea University Medical Center, Seoul, Republic of Korea
| | - Eic Ju Lim
- Department of Orthopaedic Surgery, Korea University Medical Center, Seoul, Republic of Korea
| | - Seungyeob Sakong
- Department of Orthopaedic Surgery, Korea University Medical Center, Seoul, Republic of Korea
| | - Junyoung Lim
- 3D Innovation Center, R&D of 3D Printing Medical Devices on Bio-ceramics, CGBIO, Gyeonggi-do, Republic of Korea
| | - SungNam Park
- 3D Innovation Center, R&D of 3D Printing Medical Devices on Bio-ceramics, CGBIO, Gyeonggi-do, Republic of Korea
| | - Yong-Hoon Jeong
- Department of Medical Device Development Center, Osong Medical Innovation Foundation, Cheongju-si, Republic of Korea
| | - Tae-Gon Jung
- Department of Medical Device Development Center, Osong Medical Innovation Foundation, Cheongju-si, Republic of Korea
| | - Hyuk Choi
- Department of Medical Sciences, Graduate School of Medicine, Korea University, Seoul, Republic of Korea
| | - Chang-Wug Oh
- Department of Orthopedic Surgery, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Hak Jun Kim
- Department of Orthopaedic Surgery, Korea University Medical Center, Seoul, Republic of Korea
| | - Jong Woong Park
- Department of Orthopaedic Surgery, Korea University Medical Center, Seoul, Republic of Korea
| | - Jong-Keon Oh
- Department of Orthopaedic Surgery, Korea University Medical Center, Seoul, Republic of Korea
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12
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Bjelić D, Finšgar M. The Role of Growth Factors in Bioactive Coatings. Pharmaceutics 2021; 13:1083. [PMID: 34371775 PMCID: PMC8309025 DOI: 10.3390/pharmaceutics13071083] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 07/08/2021] [Accepted: 07/12/2021] [Indexed: 12/26/2022] Open
Abstract
With increasing obesity and an ageing population, health complications are also on the rise, such as the need to replace a joint with an artificial one. In both humans and animals, the integration of the implant is crucial, and bioactive coatings play an important role in bone tissue engineering. Since bone tissue engineering is about designing an implant that maximally mimics natural bone and is accepted by the tissue, the search for optimal materials and therapeutic agents and their concentrations is increasing. The incorporation of growth factors (GFs) in a bioactive coating represents a novel approach in bone tissue engineering, in which osteoinduction is enhanced in order to create the optimal conditions for the bone healing process, which crucially affects implant fixation. For the application of GFs in coatings and their implementation in clinical practice, factors such as the choice of one or more GFs, their concentration, the coating material, the method of incorporation, and the implant material must be considered to achieve the desired controlled release. Therefore, the avoidance of revision surgery also depends on the success of the design of the most appropriate bioactive coating. This overview considers the integration of the most common GFs that have been investigated in in vitro and in vivo studies, as well as in human clinical trials, with the aim of applying them in bioactive coatings. An overview of the main therapeutic agents that can stimulate cells to express the GFs necessary for bone tissue development is also provided. The main objective is to present the advantages and disadvantages of the GFs that have shown promise for inclusion in bioactive coatings according to the results of numerous studies.
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Affiliation(s)
| | - Matjaž Finšgar
- Faculty of Chemistry and Chemical Engineering, University of Maribor, Smetanova ulica 17, 2000 Maribor, Slovenia;
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13
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Alford AI, Nicolaou D, Hake M, McBride-Gagyi S. Masquelet's induced membrane technique: Review of current concepts and future directions. J Orthop Res 2021; 39:707-718. [PMID: 33382115 PMCID: PMC8005442 DOI: 10.1002/jor.24978] [Citation(s) in RCA: 60] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 11/16/2020] [Accepted: 12/28/2020] [Indexed: 02/04/2023]
Abstract
Masquelet's induced membrane technique (MIMT) is a relatively new, two-stage surgical procedure to reconstruct segmental bone defects. First performed by Dr. Masquelet in the mid-1980s, MIMT has shown great promise to revolutionize critical-sized bone defect repair and has several advantages over its alternative, distraction osteogenesis (DO). Also, its success in extremely challenging cases (defects > 15 cm) suggests that its study could lead to discovery of novel biological mechanisms that might be at play during segmental defect healing and fracture non-union. MIMT's advantages over DO have led to a world-wide increase in MIMT procedures over the past decades. However, MIMT often needs to be repeated and so the average initial success rate in adults lags significantly behind that of DO (86% vs 95%, respectively). The autologous foreign-body membrane created during the first stage by the immune system's response to a polymethyl methacrylate bone cement spacer is critical to supporting the morselized bone graft implanted in the second stage. However, the biological and/or physical mechanisms by which the membrane supports graft to bone union are unclear. This lack of knowledge makes refining MIMT and improving the success rates through technique improvements and patient selection a significant challenge and hinders wider adoption. In this review, current knowledge from basic, translational, and clinical studies is summarized. The dynamics of both stages under normal conditions as well as with drug or material perturbations is discussed along with perspectives on high-priority future research directions.
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Affiliation(s)
- Andrea I. Alford
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, MI
| | - Daemeon Nicolaou
- Department of Orthopaedic Surgery, Saint Louis University, St. Louis, MO
| | - Mark Hake
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, MI
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14
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Fenelon M, Etchebarne M, Siadous R, Grémare A, Durand M, Sentilhes L, Catros S, Gindraux F, L'Heureux N, Fricain JC. Comparison of amniotic membrane versus the induced membrane for bone regeneration in long bone segmental defects using calcium phosphate cement loaded with BMP-2. MATERIALS SCIENCE & ENGINEERING. C, MATERIALS FOR BIOLOGICAL APPLICATIONS 2021; 124:112032. [PMID: 33947534 DOI: 10.1016/j.msec.2021.112032] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 03/03/2021] [Accepted: 03/05/2021] [Indexed: 12/12/2022]
Abstract
Thanks to its biological properties, the human amniotic membrane (HAM) combined with a bone substitute could be a single-step surgical alternative to the two-step Masquelet induced membrane (IM) technique for regeneration of critical bone defects. However, no study has directly compared these two membranes. We first designed a 3D-printed scaffold using calcium phosphate cement (CPC). We assessed its suitability in vitro to support human bone marrow mesenchymal stromal cells (hBMSCs) attachment and osteodifferentiation. We then performed a rat femoral critical size defect to compare the two-step IM technique with a single-step approach using the HAM. Five conditions were compared. Group 1 was left empty. Group 2 received the CPC scaffold loaded with rh-BMP2 (CPC/BMP2). Group 3 and 4 received the CPC/BMP2 scaffold covered with lyophilized or decellularized/lyophilized HAM. Group 5 underwent a two- step induced membrane procedure with insertion of a polymethylmethacrylate (PMMA) spacer followed by, after 4 weeks, its replacement with the CPC/BMP2 scaffold wrapped in the IM. Micro-CT and histomorphometric analysis were performed after six weeks. Results showed that the CPC scaffold supported the proliferation and osteodifferentiation of hBMSCs in vitro. In vivo, the CPC/BMP2 scaffold very efficiently induced bone formation and led to satisfactory healing of the femoral defect, in a single-step, without autograft or the need for any membrane covering. In this study, there was no difference between the two-step induced membrane procedure and a single step approach. However, the results indicated that none of the tested membranes further enhanced bone healing compared to the CPC/BMP2 group.
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Affiliation(s)
- Mathilde Fenelon
- Univ. Bordeaux, INSERM, BIOTIS, U1026, F-33000 Bordeaux, France; CHU Bordeaux, Service de chirurgie orale, F-33076 Bordeaux, France.
| | - Marion Etchebarne
- Univ. Bordeaux, INSERM, BIOTIS, U1026, F-33000 Bordeaux, France; CHU Bordeaux, Department of maxillofacial surgery, F-33076 Bordeaux, France
| | - Robin Siadous
- Univ. Bordeaux, INSERM, BIOTIS, U1026, F-33000 Bordeaux, France
| | - Agathe Grémare
- Univ. Bordeaux, INSERM, BIOTIS, U1026, F-33000 Bordeaux, France; CHU Bordeaux, Odontology and Oral Health Department, F-33076 Bordeaux, France
| | - Marlène Durand
- Univ. Bordeaux, INSERM, BIOTIS, U1026, F-33000 Bordeaux, France; CHU Bordeaux, CIC 1401, 33000, Bordeaux, France; INSERM, CIC 1401, 33000 Bordeaux, France
| | - Loic Sentilhes
- CHU Bordeaux, Department of Obstetrics and Gynecology, F-33076, Bordeaux, France
| | - Sylvain Catros
- Univ. Bordeaux, INSERM, BIOTIS, U1026, F-33000 Bordeaux, France; CHU Bordeaux, Service de chirurgie orale, F-33076 Bordeaux, France
| | - Florelle Gindraux
- Service de Chirurgie Orthopédique, Traumatologique et Plastique, CHU Besançon, F-25000 Besançon, France; Laboratoire de Nanomédecine, Imagerie, Thérapeutique EA 4662, Université Bourgogne Franche-Comté, F-25000 Besançon, France
| | | | - Jean-Christophe Fricain
- Univ. Bordeaux, INSERM, BIOTIS, U1026, F-33000 Bordeaux, France; CHU Bordeaux, Service de chirurgie orale, F-33076 Bordeaux, France
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15
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Xie J, Liu D, Wang H, Long H, Zhu Y, Hu Y, Zeng M. Effects of topical mechanical stability on the formation of Masquelet membrane in a rabbit radial defect model. Sci Rep 2020; 10:18939. [PMID: 33144701 PMCID: PMC7609590 DOI: 10.1038/s41598-020-76112-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Accepted: 10/23/2020] [Indexed: 12/24/2022] Open
Abstract
The exact mechanism of Masquelet technique is unknown. This study intends to explore the effects of topical mechanical stability on the formation of Masquelet membrane. Segmental radius shaft defect was created in all rabbits, which were filled with polymethylmethacrylate (PMMA) in Non-fixation group, and with PMMA fixed with plates in Fixation group, and subjected to no disposal in control group. The topical stability of PMMA and plates were monitored via X-ray and mechanical test. And the membranes were excised for further Histological, IHC and Western-Blotting analysis 4 and 6 weeks post-operatively. X-ray revealed no sign of plates loosening, or shift of PMMA. Mechanical tests revealed superior topical stability by plates. Pathological examinations suggested that vascularized and osteogenic membranes were formed around PMMA. IHC and Western-Blotting analysis revealed that both Fixation and Non-fixation group exerted significant effects on the expression of Ki67, COL I, and CD31 positive cells, as well as the protein expression of osteogenic (RUNX2, ALP) and angiogenic (VEGFA, TGF-β1) factors. And compared with membrane in Non-fixation group, Fixing PMMA spacer with plates caused a significant increase in osteogenic and angiogenic expression. This study indicates that rigid fixation provided by plate in Masquelet technique positively alters the quality of membrane formed surrounding PMMA, in terms of significantly osteogenic and angiogenic potential.
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Affiliation(s)
- Jie Xie
- Department of Orthopedics, Xiangya Hospital, Central South University, No. 87 Xiangya Road, Changsha, 410008, Hunan, China
| | - Donghao Liu
- Department of Orthopedics, Xiangya Hospital, Central South University, No. 87 Xiangya Road, Changsha, 410008, Hunan, China
| | - Haoyi Wang
- Department of Orthopedics, Xiangya Hospital, Central South University, No. 87 Xiangya Road, Changsha, 410008, Hunan, China
| | - Haitao Long
- Department of Orthopedics, Xiangya Hospital, Central South University, No. 87 Xiangya Road, Changsha, 410008, Hunan, China
| | - Yong Zhu
- Department of Orthopedics, Xiangya Hospital, Central South University, No. 87 Xiangya Road, Changsha, 410008, Hunan, China
| | - Yihe Hu
- Department of Orthopedics, Xiangya Hospital, Central South University, No. 87 Xiangya Road, Changsha, 410008, Hunan, China
| | - Min Zeng
- Department of Orthopedics, Xiangya Hospital, Central South University, No. 87 Xiangya Road, Changsha, 410008, Hunan, China.
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16
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Gohel N, Senos R, Goldstein SA, Hankenson KD, Hake ME, Alford AI. Evaluation of global gene expression in regenerate tissues during Masquelet treatment. J Orthop Res 2020; 38:2120-2130. [PMID: 32233004 PMCID: PMC7494657 DOI: 10.1002/jor.24676] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 03/19/2020] [Accepted: 03/25/2020] [Indexed: 02/04/2023]
Abstract
The Masquelet induced-membrane (IM) technique is indicated for large segmental bone defects. Attributes of the IM and local milieu that contribute to graft-to-bone union are unknown. Using a rat model, we compared global gene expression profiles in critically sized femoral osteotomies managed using a cement spacer as per Masquelet to those left empty. At the end of the experiment, IM and bone adjacent to the spacer were collected from the Masquelet side. Nonunion tissue in the defect and bone next to the empty defect were collected from the contralateral side. Tissues were subjected to RNA isolation, sequencing, and differential expression analysis. Cell type enrichment analysis suggested the IM and the bone next to the polymethylmethacrylate (PMMA) spacer were comparatively enriched for osteoblastic genes. The nonunion environment was comparatively enriched for innate and adaptive immune cell markers, but only macrophages were evident in the Masquelet context. iPathwayGuide was utilized to identify cell signaling pathways and protein interaction networks enriched in the Masquelet environment. For IM vs nonunion false-discovery rate correction of P values rendered overall pathway differences nonsignificant, and so only protein interaction networks are presented. For the bone comparison, substantial enrichment of pathways and networks known to contribute to osteogenic mechanisms was revealed. Our results suggest that the PMMA spacer affects the cut bone ends that are in contact with it and at the same time induces the foreign body reaction and formation of the IM. B cells in the empty defect suggest a chronic inflammatory response to a large segmental osteotomy.
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Affiliation(s)
- Nishant Gohel
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan
| | - Rafael Senos
- Department of Morphology, Universidade Federal Fluminense, Niteroi, Rio de Janeiro, Brazil
| | - Steven A. Goldstein
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan
| | - Kurt D. Hankenson
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan
| | - Mark E. Hake
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan.,Address correspondence to Mark E. Hake: Department of Orthopaedic Surgery, University of Michigan School of Medicine, 1500 E Medical Center Drive, 2912 Taubman Center SPC 5328; Ann Arbor, MI 48109; fax: +1-734-647-3277; telephone: +734-936-9839;
| | - Andrea I. Alford
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan.,Address correspondence to Andrea I. Alford: Department of Orthopaedic Surgery, University of Michigan School of Medicine, A. Alfred Taubman Biomedical Sciences Research Building, Room 2009, Ann Arbor, MI, 48109; fax: +1-734 -647-0003; telephone: +1-734-615-6104;
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17
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Tanner MC, Hagelskamp S, Vlachopoulos W, Miska M, Findeisen S, Grimm A, Schmidmaier G, Haubruck P. Non-Union Treatment Based on the "Diamond Concept" Is a Clinically Effective and Safe Treatment Option in Older Adults. Clin Interv Aging 2020; 15:1221-1230. [PMID: 32801671 PMCID: PMC7382610 DOI: 10.2147/cia.s241936] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Accepted: 05/07/2020] [Indexed: 12/12/2022] Open
Abstract
Background Patients >60 years suffering from non-unions are often unable to perform activities of daily living and often become dependent on nursing care. Evidence regarding treatment options and outcome is nonexistent. This study sought to determine the clinical effectiveness and safety of one- or two-step non-union therapy in elderly patients. Methods This study was a single-site retrospective database analysis of older adults with long bone non-unions treated via “diamond concept”. All medical records of patients receiving surgical treatment of non-unions between 01/01/2010 and 31/12/2016 were reviewed. Clinical and radiological outcome subsequent to non-union therapy were evaluated. Results A total of 76 patients (37 patients were treated with one-step and 39 patients with Masquelet therapy) suffering from a non-union older than 60 years treated between 01/01/2010 and 31/12/2016 in our institution were included into the current study. Bone consolidation was achieved in 91.9% after one-step and 76.9% after the Masquelet therapy. Analysis of age as a risk factor in the outcome of non-union therapy revealed no significant differences in patients treated with the one-step procedure according to the “diamond concept”. On the contrary, age had a significant negative influence on the outcome of the Masquelet therapy (p = 0.027). Conclusion Non-union therapy according to the “diamond concept” is an effective and reliable treatment option in elderly patients. According to findings of the current study, older adults suffering from an infected non-union benefit from a two-stage procedure, whereas in patients suffering from a non-infected non-union, a one-step surgical treatment is beneficial.
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Affiliation(s)
- Michael C Tanner
- Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Trauma and Reconstructive Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Saskia Hagelskamp
- Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Trauma and Reconstructive Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Wasilios Vlachopoulos
- Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Trauma and Reconstructive Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Matthias Miska
- Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Trauma and Reconstructive Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Sebastian Findeisen
- Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Trauma and Reconstructive Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Andreas Grimm
- Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Trauma and Reconstructive Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Gerhard Schmidmaier
- Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Trauma and Reconstructive Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Patrick Haubruck
- Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Trauma and Reconstructive Surgery, Heidelberg University Hospital, Heidelberg, Germany
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18
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Klein C, Monet M, Barbier V, Vanlaeys A, Masquelet AC, Gouron R, Mentaverri R. The Masquelet technique: Current concepts, animal models, and perspectives. J Tissue Eng Regen Med 2020; 14:1349-1359. [PMID: 32621637 DOI: 10.1002/term.3097] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 06/02/2020] [Accepted: 06/15/2020] [Indexed: 12/20/2022]
Abstract
Bone reconstruction within a critical-sized defect remains a real challenge in orthopedic surgery. The Masquelet technique is an innovative, two-step therapeutic approach for bone reconstruction in which the placement of a poly (methylmethacrylate) spacer into the bone defect induces the neo-formation of a tissue called "induced membrane." This surgical technique has many advantages and is often preferred to a vascularized bone flap or Ilizarov's technique. Although the Masquelet technique has achieved high clinical success rates since its development by Alain-Charles Masquelet in the early 2000s, very little is known about how the process works, and few animal models of membrane induction have been developed. Our successful use of this technique in the clinic and our interest in the mechanisms of tissue regeneration (notably bone regeneration) prompted us to develop a surgical model of the Masquelet technique in rats. Here, we provide a comprehensive review of the literature on animal models of membrane induction, encompassing the defect site, the surgical procedure, and the histologic and osteogenic properties of the induced membrane. We also discuss the advantages and disadvantages of those models to facilitate efforts in characterizing the complex biological mechanisms that underlie membrane induction.
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Affiliation(s)
- Céline Klein
- Department of Pediatric Orthopedic Surgery, Amiens University Medical Center, Jules Verne University of Picardie, Amiens, France.,MP3CV-EA7517, CURS, miens University Medical Center, Jules Verne University of Picardie, Amiens, France
| | - Michael Monet
- MP3CV-EA7517, CURS, miens University Medical Center, Jules Verne University of Picardie, Amiens, France
| | - Vincent Barbier
- Department of Pediatric Orthopedic Surgery, Amiens University Medical Center, Jules Verne University of Picardie, Amiens, France.,MP3CV-EA7517, CURS, miens University Medical Center, Jules Verne University of Picardie, Amiens, France
| | - Alison Vanlaeys
- MP3CV-EA7517, CURS, miens University Medical Center, Jules Verne University of Picardie, Amiens, France
| | - Alain-Charles Masquelet
- Service de Chirurgie Orthopédique, Traumatologie et Chirurgie de la Main, Saint-Antoine Hospital, Paris, France
| | - Richard Gouron
- Department of Pediatric Orthopedic Surgery, Amiens University Medical Center, Jules Verne University of Picardie, Amiens, France.,MP3CV-EA7517, CURS, miens University Medical Center, Jules Verne University of Picardie, Amiens, France
| | - Romuald Mentaverri
- MP3CV-EA7517, CURS, miens University Medical Center, Jules Verne University of Picardie, Amiens, France.,Department of Biochemistry and Endocrine Biology, Amiens University Medical Center, Jules Verne University of Picardie, Amiens, France
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19
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Ferreira N, Tanwar YS. Systematic Approach to the Management of Post-traumatic Segmental Diaphyseal Long Bone Defects: Treatment Algorithm and Comprehensive Classification System. Strategies Trauma Limb Reconstr 2020; 15:106-116. [PMID: 36466309 PMCID: PMC9679593 DOI: 10.5005/jp-journals-10080-1466] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/29/2023] Open
Abstract
BACKGROUND Bone defects remain challenging to manage. The wide array of treatment options is a testament no single strategy works in every patient. This is more complex if consideration is given to the status of the host and the soft tissues. The choice of treatment should be based on specific patient requirements after taking all variables into account. MATERIALS AND METHODS We present a comprehensive classification system and treatment algorithm to assist with decision-making in management. All potential treatment modalities including amputation are discussed with their relevant pearls and pitfalls. CONCLUSION The proposed classification system may potentially assists with communication, enable patient stratification for assigning the most appropriate treatment modality and guide reporting of treatment outcomes. HOW TO CITE THIS ARTICLE Ferreira N, Tanwar YS. Systematic Approach to the Management of Post-traumatic Segmental Diaphyseal Long Bone Defects: Treatment Algorithm and Comprehensive Classification System. Strategies Trauma Limb Reconstr 2020;15(2):106-116.
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Affiliation(s)
- Nando Ferreira
- Division of Orthopaedic Surgery, Department of Surgical Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Yashwant S Tanwar
- Division of Orthopaedic Surgery, Department of Surgical Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
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20
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Valente KP, Brolo A, Suleman A. From Dermal Patch to Implants-Applications of Biocomposites in Living Tissues. Molecules 2020; 25:E507. [PMID: 31991641 PMCID: PMC7037691 DOI: 10.3390/molecules25030507] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2019] [Revised: 01/19/2020] [Accepted: 01/20/2020] [Indexed: 01/21/2023] Open
Abstract
Composites are composed of two or more materials, displaying enhanced performance and superior mechanical properties when compared to their individual components. The use of biocompatible materials has created a new category of biocomposites. Biocomposites can be applied to living tissues due to low toxicity, biodegradability and high biocompatibility. This review summarizes recent applications of biocomposite materials in the field of biomedical engineering, focusing on four areas-bone regeneration, orthopedic/dental implants, wound healing and tissue engineering.
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Affiliation(s)
| | - Alexandre Brolo
- Department of Chemistry, University of Victoria, Victoria, BC V8P 5C2, Canada;
| | - Afzal Suleman
- Department of Mechanical Engineering, University of Victoria, Victoria, BC V8P 5C2, Canada;
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21
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Leiblein M, Koch E, Winkenbach A, Schaible A, Nau C, Büchner H, Schröder K, Marzi I, Henrich D. Size matters: Effect of granule size of the bone graft substitute (Herafill®) on bone healing using Masquelet's induced membrane in a critical size defect model in the rat's femur. J Biomed Mater Res B Appl Biomater 2019; 108:1469-1482. [PMID: 31721435 DOI: 10.1002/jbm.b.34495] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 08/19/2019] [Accepted: 09/16/2019] [Indexed: 12/21/2022]
Abstract
The Masquelet technique for the treatment of large bone defects is a two-stage procedure based on an induced membrane. The size of a scaffold is reported to be a critical factor for bone healing response. We therefore aimed to investigate the influence of the granule size of a bone graft substitute on bone marrow derived mononuclear cells (BMC) supported bone healing in combination with the induced membrane. We compared three different sizes of Herafill® granules (Heraeus Medical GmbH, Wehrheim) with or without BMC in vivo in a rat femoral critical size defect. A 10 mm defect was made in 126 rats and a membrane induced by a PMMA-spacer. After 3 weeks, the spacer was taken out and membrane filled with different granule sizes. After 8 weeks femurs were taken for radiological, biomechanical, histological, and immunohistochemical analysis. Further, whole blood of the rat was incubated with granules and expression of 29 peptide mediators was assessed. Smallest granules showed significantly improved bone healing compared to larger granules, which however did not lead to an increased biomechanical stability in the defect zone. Small granules lead to an increased accumulation of macrophages in situ which could be assigned to the inflammatory subtype M1 by majority. Increased release of chemotactic respectively proangiogenic active factors in vitro compared to syngenic bone and beta-TCP was observed. Granule size of the bone graft substitute Herafill® has significant impact on bone healing of a critical size defect in combination with Masquelet's technique in terms of bone formation and inflammatory potential.
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Affiliation(s)
- Maximilian Leiblein
- Klinik für Unfall-, Hand- und Wiederherstellungschirurgie, Klinikum der Johann Wolfgang Goethe-Universität, Frankfurt am Main, Germany
| | - Elias Koch
- Klinik für Unfall-, Hand- und Wiederherstellungschirurgie, Klinikum der Johann Wolfgang Goethe-Universität, Frankfurt am Main, Germany
| | - Andreas Winkenbach
- Klinik für Unfall-, Hand- und Wiederherstellungschirurgie, Klinikum der Johann Wolfgang Goethe-Universität, Frankfurt am Main, Germany
| | - Alexander Schaible
- Klinik für Unfall-, Hand- und Wiederherstellungschirurgie, Klinikum der Johann Wolfgang Goethe-Universität, Frankfurt am Main, Germany
| | - Christoph Nau
- Klinik für Unfall-, Hand- und Wiederherstellungschirurgie, Klinikum der Johann Wolfgang Goethe-Universität, Frankfurt am Main, Germany
| | | | - Katrin Schröder
- Vascular Research Center, University of Frankfurt, Frankfurt am Main, Germany
| | - Ingo Marzi
- Klinik für Unfall-, Hand- und Wiederherstellungschirurgie, Klinikum der Johann Wolfgang Goethe-Universität, Frankfurt am Main, Germany
| | - Dirk Henrich
- Klinik für Unfall-, Hand- und Wiederherstellungschirurgie, Klinikum der Johann Wolfgang Goethe-Universität, Frankfurt am Main, Germany
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22
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Intramedullary Nails Yield Superior Results Compared With Plate Fixation When Using the Masquelet Technique in the Femur and Tibia. J Orthop Trauma 2019; 33:547-552. [PMID: 31403558 DOI: 10.1097/bot.0000000000001579] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To determine the optimal fixation method [intramedullary nail (IMN) vs. plate fixation (PF)] for treating critical bone defects with the induced membrane technique, also known as the Masquelet technique. DESIGN Retrospective cohort study. SETTING Four Level 1 Academic Trauma Centers. PATIENTS/PARTICIPANTS All patients with critical bone defects treated with the induced membrane technique, or Masquelet technique, between January 1, 2005, and January 31, 2018. INTERVENTION Operative treatment with a temporary cement spacer to induce membrane formation, followed by spacer removal and bone grafting at 6-8 weeks. MAIN OUTCOME MEASUREMENTS Time to union, number/reason for reoperations, time to full weight-bearing, and any complications. RESULTS One hundred twenty-one patients (56 tibias and 65 femurs) were treated with a mean follow-up of 22 months (range 12-148 months). IMN was used in 57 patients and plates in 64 patients. Multiple grafting procedures were required in 10.5% (6/57) of those with IMN and 28.1% (18/64) of those with PF (P = 0.015). Reoperation for all causes occurred in 17.5% (10/57) with IMN and 46.9% (30/64) with PF (P = 0.001). Average time to weight-bearing occurred at 2.44 versus 4.63 months for those treated with IMN and plates, respectively (P = 0.002). The multivariable adjusted analysis showed that PF is 6.4 times more likely to require multiple grafting procedures (P = 0.017) and 7.7 times more likely to require reoperation (P = 0.003) for all causes compared with IMN." CONCLUSIONS This is the largest study to date evaluating the Masquelet technique for critical size defects in the femur and tibia. Our results indicate that patients treated with IMN had faster union, fewer grafting procedures, and fewer reoperations for all causes than those treated with plates, with differences more evident in the femur. The authors believe this is a result of both the development of an intramedullary canal and circumferential stress on the graft with early weight-bearing when using an IMN, as opposed to a certain degree of stress shielding and delayed weight-bearing when using PF. We, therefore, recommend the use of an IMN whenever possible as the preferred method of fixation for tibial and femoral defects when using the Masquelet technique. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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23
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Raina DB, Larsson D, Sezgin EA, Isaksson H, Tägil M, Lidgren L. Biomodulation of an implant for enhanced bone-implant anchorage. Acta Biomater 2019; 96:619-630. [PMID: 31301423 DOI: 10.1016/j.actbio.2019.07.009] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 06/14/2019] [Accepted: 07/04/2019] [Indexed: 12/23/2022]
Abstract
Aseptic loosening of implants is the major cause for revision surgery. By modulating the bone-implant interface, early bone-implant anchorage could be improved. Implant surface manipulation by the addition of osteopromotive molecules locally and systemically to promote implant integration has been described with limited success. This study describes a novel approach by making the implant capable of biologically modulating its surroundings. It was hypothesized that the early implant fixation would improve by filling the interior of the implant with a carrier providing spatio-temporal release of bone active drugs with known osteogenic effect. The implant consisted of a threaded polyether ether ketone (PEEK) hollow chamber with holes at the bottom. The implant was filled with a calcium sulphate (CaS)/hydroxyapatite (HA) carrier, delivering two bone active molecules; zoledronic acid (ZA) and bone morphogenic protein-2 (BMP-2). At first, a rat abdominal muscle pouch model indicated a sustained in-vivo release of both 125I-rhBMP-2 (57%) and 14C-ZA (22%) from the CaS/HA carrier over a period of 4-weeks. The biomodulated implant was then inserted in the proximal tibia in rats with the following experimental groups: G1) Empty implant, G2) Implant + CaS/HA, G3) Implant + CaS/HA + ZA and G4) Implant + CaS/HA + ZA + rhBMP-2. Significantly higher bone volume (BV) was seen around the implant in groups G3 (3.3 ± 0.7 mm3) and G4 (3.1 ± 0.7 mm3) compared to the control (1.3 ± 0.4 mm3) using micro-computed tomography and qualitative histology. Group G3, also exhibited significantly higher pull-out force and absorbed energy when compared to the control group G1. These findings indicate that a low dose of ZA alone, released in a controlled manner from within a fenestrated implant is enough to improve implant anchorage without the need of adding rhBMP-2. This simple method of using a fenestrated implant containing a ceramic carrier releasing bone active molecules improved bone anchorage and could clinically reduce prosthetic failure. STATEMENT OF SIGNIFICANCE: Aseptic loosening remains as a major cause for implant revisions and early reaction of surrounding bone to the prosthesis is important for longevity. A novel approach to enhance early bone-implant anchorage is presented. The implant is filled with a carrier providing controlled release of bone active molecules. In an animal model, a calcium sulphate (CaS)/hydroxyapatite (HA) carrier was used to provide a spatio-temporal release of bone morphogenic protein-2 (BMP-2) and zoledronic acid (ZA). Significantly better bone-implant integration was achieved using ZA alone, thereby eliminating the need for adding BMP-2. The developed method of implant biomodulation holds potential to prevent implant loosening and is an alternative to prosthetic coatings or systemic drug treatment. Importantly, all constituents are approved for clinical use.
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24
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Neuerburg C, Mittlmeier LM, Keppler AM, Westphal I, Glass Ä, Saller MM, Herlyn PKE, Richter H, Böcker W, Schieker M, Aszodi A, Fischer DC. Growth factor-mediated augmentation of long bones: evaluation of a BMP-7 loaded thermoresponsive hydrogel in a murine femoral intramedullary injection model. J Orthop Surg Res 2019; 14:297. [PMID: 31488155 PMCID: PMC6727400 DOI: 10.1186/s13018-019-1315-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 08/14/2019] [Indexed: 12/02/2022] Open
Abstract
Background Due to our aging population, an increase in proximal femur fractures can be expected, which is associated with impaired activities of daily living and a high risk of mortality. These patients are also at a high risk to suffer a secondary osteoporosis-related fracture on the contralateral hip. In this context, growth factors could open the field for regenerative approaches, as it is known that, i.e., the growth factor BMP-7 (bone morphogenetic protein 7) is a potent stimulator of osteogenesis. Local prophylactic augmentation of the proximal femur with a BMP-7 loaded thermoresponsive hydrogel during index surgery of an osteoporotic fracture could be suitable to reduce the risk of further osteoporosis-associated secondary fractures. The present study therefore aims to test the hypothesis if a BMP-7 augmented hydrogel is an applicable carrier for the augmentation of non-fractured proximal femurs. Furthermore, it needs to be shown that the minimally invasive injection of a hydrogel into the mouse femur is technically feasible. Methods In this study, male C57BL/6 mice (n = 36) received a unilateral femoral intramedullary injection of either 100 μl saline, 100 μl 1,4 Butan-Diisocyanat (BDI)-hydrogel, or 100 μl hydrogel loaded with 1 μg of bone morphogenetic protein 7. Mice were sacrificed 4 and 12 weeks later. The femora were submitted to high-resolution X-ray tomography and subsequent histological examination. Results Analysis of normalized CtBMD (Cortical bone mineral density) as obtained by X-ray micro-computed tomography analysis revealed significant differences depending on the duration of treatment (4 vs 12 weeks; p < 0.05). Furthermore, within different anatomically defined regions of interest, significant associations between normalized TbN (trabecular number) and BV/TV (percent bone volume) were noted. Histology indicated no signs of inflammation and no signs of necrosis and there were no cartilage damages, no new bone formations, or new cartilage tissues, while BMP-7 was readily detectable in all of the samples. Conclusions In conclusion, the murine femoral intramedullary injection model appears to be feasible and worth to be used in subsequent studies that are directed to examine the therapeutic potential of BMP-7 loaded BDI-hydrogel. Although we were unable to detect any significant osseous effects arising from the mode or duration of treatment in the present trial, the effect of different concentrations and duration of treatment in an osteoporotic model appears of interest for further experiments to reach translation into clinic and open new strategies of growth factor-mediated augmentation. Electronic supplementary material The online version of this article (10.1186/s13018-019-1315-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Carl Neuerburg
- Department of General, Trauma and Reconstructive Surgery, University Hospital, Ludwig-Maximilians-University Munich, Marchioninistr. 15, 81377, Munich, Germany.
| | - Lena M Mittlmeier
- Department of General, Trauma and Reconstructive Surgery, University Hospital, Ludwig-Maximilians-University Munich, Marchioninistr. 15, 81377, Munich, Germany.,Present Address: Department of Urology, University Hospital, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Alexander M Keppler
- Department of General, Trauma and Reconstructive Surgery, University Hospital, Ludwig-Maximilians-University Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Ines Westphal
- Department of General, Trauma and Reconstructive Surgery, University Hospital, Ludwig-Maximilians-University Munich, Marchioninistr. 15, 81377, Munich, Germany.,LivImplant GmbH, Starnberg, Germany
| | - Änne Glass
- Institute for Biostatistics and Informatics in Medicine and Ageing Research, Research Group Biostatistics, Rostock University Medical Center, Rostock, Germany
| | - Maximilian M Saller
- Department of General, Trauma and Reconstructive Surgery, University Hospital, Ludwig-Maximilians-University Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Philipp K E Herlyn
- Department of Traumatology, Hand- and Reconstructive Surgery, Rostock University Medical Center, Rostock, Germany
| | - Heiko Richter
- LLS ROWIAK LaserLabSolutions GmbH, Hannover, Germany
| | - Wolfgang Böcker
- Department of General, Trauma and Reconstructive Surgery, University Hospital, Ludwig-Maximilians-University Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Matthias Schieker
- Department of General, Trauma and Reconstructive Surgery, University Hospital, Ludwig-Maximilians-University Munich, Marchioninistr. 15, 81377, Munich, Germany.,LivImplant GmbH, Starnberg, Germany
| | - Attila Aszodi
- Department of General, Trauma and Reconstructive Surgery, University Hospital, Ludwig-Maximilians-University Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Dagmar-C Fischer
- Department of Pediatrics, Rostock University Medical Center, Rostock, Germany
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25
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Zhang B, Skelly JD, Maalouf JR, Ayers DC, Song J. Multifunctional scaffolds for facile implantation, spontaneous fixation, and accelerated long bone regeneration in rodents. Sci Transl Med 2019; 11:11/502/eaau7411. [DOI: 10.1126/scitranslmed.aau7411] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Revised: 01/23/2019] [Accepted: 06/05/2019] [Indexed: 12/16/2022]
Abstract
Graft-guided regenerative repair of critical long bone defects achieving facile surgical delivery, stable graft fixation, and timely restoration of biomechanical integrity without excessive biotherapeutics remains challenging. Here, we engineered hydration-induced swelling/stiffening and thermal-responsive shape-memory properties into scalable, three-dimensional–printed amphiphilic degradable polymer-osteoconductive mineral composites as macroporous, non–load-bearing, resorbable synthetic grafts. The distinct physical properties of the grafts enabled straightforward surgical insertion into critical-size rat femoral segmental defects. Grafts rapidly recovered their precompressed shape, stiffening and swelling upon warm saline rinse to result in 100% stable graft fixation. The osteoconductive macroporous grafts guided bone formation throughout the defect as early as 4 weeks after implantation; new bone remodeling correlated with rates of scaffold composition-dependent degradation. A single dose of 400-ng recombinant human bone morphogenetic protein-2/7 heterodimer delivered via the graft accelerated bone regeneration bridging throughout the entire defect by 4 weeks after delivery. Full restoration of torsional integrity and complete scaffold resorption were achieved by 12 to 16 weeks after surgery. This biomaterial platform enables personalized bone regeneration with improved surgical handling, in vivo efficacy and safety.
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26
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Meng ZL, Wu ZQ, Shen BX, Li HB, Bian YY, Zeng DL, Fu J, Peng L. Reconstruction of large segmental bone defects in rabbit using the Masquelet technique with α-calcium sulfate hemihydrate. J Orthop Surg Res 2019; 14:192. [PMID: 31242906 PMCID: PMC6595676 DOI: 10.1186/s13018-019-1235-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Accepted: 06/11/2019] [Indexed: 12/17/2022] Open
Abstract
Background Large segmental bone defects can be repaired using the Masquelet technique in conjunction with autologous cancellous bone (ACB). However, ACB harvesting is severely restricted. α-calcium sulfate hemihydrate (α-CSH) is an outstanding bone substitute due to its easy availability, excellent biocompatibility, biodegradability, and osteoconductivity. However, the resorption rate of α-CSH is too fast to match the rate of new bone formation. The objective of this study was to investigate the bone repair capacity of the Masquelet technique in conjunction with isolated α-CSH or an α-CSH/ACB mix in a rabbit critical-sized defect model. Methods The rabbits (n = 28) were randomized into four groups: sham, isolated α-CSH, α-CSH/ACB mix, and isolated ACB group. A 15-mm critical-sized defect was established in the left radius, followed by filling with polymethyl methacrylate spacer. Six weeks after the first operation, the spacers were removed and the membranous tubes were grafted with isolated α-CSH, isolated ACB, α-CSH/ACB mix, or none. Twelve weeks later, the outcomes were evaluated by manual assessment, radiography, and spiral-CT. The histopathological and morphological changes were examined by H&E staining. The levels of alkaline phosphatase and osteocalcin were analyzed by immunohistochemistry and immunofluorescence staining. Results Our results suggest that the bone repair capacity of the α-CSH/ACB mix group was similar to the isolated ACB group, while the isolated α-CSH group was significantly decreased compared to the isolated ACB group. Conclusion These results highlighted a promising strategy in the healing of large segmental bone defect with the Masquelet technique in conjunction with an α-CSH/ACB mix (1:1, w/w) as they possessed the combined effects of sufficient supply and low resorption.
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Affiliation(s)
- Zhu Long Meng
- Municipal Hospital Affiliated to Medical School of Taizhou University, Taizhou, China.,Department of Trauma Center, The First Affiliated Hospital of Hainan Medical University, Haikou, China
| | - Zi Quan Wu
- Department of Trauma Center, The First Affiliated Hospital of Hainan Medical University, Haikou, China
| | - Bi Xin Shen
- School of Pharmaceutical Sciences, Wenzhou Medical University, Wenzhou, China
| | - Hong Bo Li
- Department of Trauma Center, The First Affiliated Hospital of Hainan Medical University, Haikou, China
| | - Yang Yang Bian
- Department of Trauma Center, The First Affiliated Hospital of Hainan Medical University, Haikou, China
| | - De Lu Zeng
- Department of Trauma Center, The First Affiliated Hospital of Hainan Medical University, Haikou, China
| | - Jian Fu
- Department of Trauma Center, The First Affiliated Hospital of Hainan Medical University, Haikou, China
| | - Lei Peng
- Department of Trauma Center, The First Affiliated Hospital of Hainan Medical University, Haikou, China.
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27
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Masquelet A, Kanakaris NK, Obert L, Stafford P, Giannoudis PV. Bone Repair Using the Masquelet Technique. J Bone Joint Surg Am 2019; 101:1024-1036. [PMID: 31169581 DOI: 10.2106/jbjs.18.00842] [Citation(s) in RCA: 142] [Impact Index Per Article: 28.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Alain Masquelet
- Department of Orthopaedic Surgery, Avicenne Hospital, Bobiny, France
| | - Nikolaos K Kanakaris
- Major Trauma Centre, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom.,NIHR Leeds Biomedical Research Center, Chapel Allerton Hospital, Leeds, United Kingdom
| | - Laurent Obert
- Traumatology, Reconstructive, and Plastic Surgery Unit, CHU Jean Minjoz, Besançon, France
| | - Paul Stafford
- Orthopedic Trauma Surgery of Oklahoma, Tulsa, Oklahoma
| | - Peter V Giannoudis
- Major Trauma Centre, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom.,NIHR Leeds Biomedical Research Center, Chapel Allerton Hospital, Leeds, United Kingdom.,Department of Trauma & Orthopaedics, School of Medicine, University of Leeds, Leeds, United Kingdom
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28
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Gathen M, Norris G, Kay S, Giannoudis PV. Recalcitrant distal humeral non-union following previous Leiomyosarcoma excision treated with retainment of a radiated non-angiogenic segment augmented with 20 cm free fibula composite graft: A case report. World J Orthop 2019; 10:212-218. [PMID: 31041163 PMCID: PMC6475814 DOI: 10.5312/wjo.v10.i4.212] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 02/27/2019] [Accepted: 03/12/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Leiomyosacromas in the Extremities are rare malignant smooth muscle tumors. Adjuvant radiation therapy, in combination with wide surgical excision allows the best chance of treatment. During the follow up pathological fractures are common complications that can be accompanied by Implant failure and defect situations that are most challenging in their management.
CASE SUMMARY We present a case of a 52-year-old female suffering from a pathological fracture of the humeral shaft 10 yr after resection of a Leiomyosarcoma and postoperative radiotherapy. She developed implant failure after retrograde nailing and another failure after revision to double plate fixation. In a two-stage revision, the implants were removed and the huge segmental defect created after debridement was bridged by a compound osteosynthesis with nancy nails and bone cement for formation of the induced membrane. Due to the previous radiotherapy treatment, 20 cm of the humeral shaft were declared devascularized but were left in situ as a scaffold. In the second stage, a vascularized fibula graft was used in combination with a double plate fixation and autologous spongiosa grafts for final reconstruction.
CONCLUSION This combinatory treatment approach led to a successful clinical outcome and can be considered in similar challenging cases.
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Affiliation(s)
- Martin Gathen
- Department of Orthopedics and Trauma Surgery, University Hospital of Bonn, Bonn 53129, Germany
| | - Grayson Norris
- Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, Leeds LS3 3EX, United Kingdom
| | - Simon Kay
- Plastic and Reconstructive Surgery, School of Medicine, University of Leeds, Leeds LS3 3EX, United Kingdom
| | - Peter V Giannoudis
- Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, Leeds LS3 3EX, United Kingdom
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29
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DeBaun MR, Stahl AM, Daoud AI, Pan CC, Bishop JA, Gardner MJ, Yang YP. Preclinical induced membrane model to evaluate synthetic implants for healing critical bone defects without autograft. J Orthop Res 2019; 37:60-68. [PMID: 30273977 DOI: 10.1002/jor.24153] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Accepted: 09/12/2018] [Indexed: 02/04/2023]
Abstract
Critical bone defects pose a formidable orthopaedic problem in patients with bone loss. We developed a preclinical model based on the induced membrane technique using a synthetic graft to replace autograft for healing critical bone defects. Additionally, we used a novel osteoconductive scaffold coupled with a synthetic membrane to evaluate the potential for single-stage bone regeneration. Three experimental conditions were investigated in critical femoral defects in rats. Group A underwent a two-stage procedure with insertion of a polymethylmethacrylate (PMMA) spacer followed by replacement with a 3D printed polycaprolactone(PCL)/β-tricalcium phosphate (β-TCP) osteoconductive scaffold after 4 weeks. Group B received a single-stage PCL/β-TCP scaffold wrapped in a PCL-based microporous polymer film creating a synthetic membrane. Group C received a single-stage bare PCL/β-TCP scaffold. All groups were examined by serial radiographs for callus formation. After 12 weeks, the femurs were explanted and analyzed with micro-CT and histology. Mean callus scores tended to be higher in Group A. Group A showed statistically significant greater bone formation on micro-CT compared with other groups, although bone volume fraction was similar between groups. Histology results suggested extensive bone ingrowth and new bone formation within the macroporous scaffolds in all groups and cell infiltration into the microporous synthetic membrane. This study supports the use of a critical size femoral defect in rats as a suitable model for investigating modifications to the induced membrane technique without autograft harvest. Future investigations should focus on bioactive synthetic membranes coupled with growth factors for single-stage bone healing. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res.
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Affiliation(s)
- Malcolm R DeBaun
- Departiment of Orthopaedic Surgery, Stanford University, Stanford, California
| | - Alexander M Stahl
- Departiment of Orthopaedic Surgery, Stanford University, Stanford, California.,Departiment of Chemistry, Stanford University, Stanford, California
| | - Adam I Daoud
- School of Medicine, Stanford University, Stanford, California
| | - Chi-Chun Pan
- Departiment of Orthopaedic Surgery, Stanford University, Stanford, California.,Departiment of Mechanical Engineering, Stanford University, Stanford, California
| | - Julius A Bishop
- Departiment of Orthopaedic Surgery, Stanford University, Stanford, California
| | - Michael J Gardner
- Departiment of Orthopaedic Surgery, Stanford University, Stanford, California
| | - Yunzhi P Yang
- Departiment of Orthopaedic Surgery, Stanford University, Stanford, California.,Material Science and Engineering, Stanford University, Stanford, California.,Departiment of Bioengineering, Stanford University, Stanford, California
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30
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Haubruck P, Tanner MC, Vlachopoulos W, Hagelskamp S, Miska M, Ober J, Fischer C, Schmidmaier G. Comparison of the clinical effectiveness of Bone Morphogenic Protein (BMP) -2 and -7 in the adjunct treatment of lower limb nonunions. Orthop Traumatol Surg Res 2018; 104:1241-1248. [PMID: 30293748 DOI: 10.1016/j.otsr.2018.08.008] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 08/10/2018] [Accepted: 08/24/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Substantial evidence exists demonstrating the individual effectiveness of both rhBMP-2 and -7 in the treatment of nonunions, data comparing the clinical effectiveness of adjunct rhBMP-2 and -7 remains scarce. Therefore, we examined our large single-center case series to compare the clinical effectiveness of both rhBMP-2 and -7 in non-union therapy aiming to answer: - Does a certain type of BMP have an advantageous effect on radiological outcome of applied lower limb non-union therapy? - Does application of a certain type of BMP have an advantageous effect on radiological outcome of infected lower limb nonunions? - Are there any additional risk factors associated with inferior outcome in context with an adjunct BMP treatment? HYPOTHESIS Both BMPs have the same effect on the radiological outcome of surgically treated lower limb nonunions. PATIENTS AND METHODS Single-center retrospective database analysis of a case series of patients with lower limb long bone nonunions receiving either a one- or two-stage (Masquelet-) procedure based on the "diamond concept" with application of rhBMP-2 or -7. The "diamond concept" summarizes core factors that need to be present to achieve bone healing. In particular, these factors relate to the optimization of the mechanical (stability) and biological environment (sufficient osteogenic and angiogenic cells, osteoconductive scaffolds and growth factors). All medical data from patients that received surgical treatment between 01/01/2010 and 31/12/2016 were assessed. In total, 356 patients were treated with BMPs and 156 patients 18 years or older with non-union of their tibia or femur having a follow-up of at least 1 year were included. Consolidation in context with type of rhBMP was compared and the influence of relevant risk factors assessed. RESULTS Consolidation rate was significantly higher in patients treated with rhBMP-2 (rhBMP-2: 42/46 (91%) vs. rhBMP-7: 64/110 (58%); p<0.001). In particular, application of rhBMP-2 increased the likelihood of consolidation for tibial nonunions (OR 32.744; 95%CI: 2.909-368.544; p=0.005) and when used in two-stage therapy (OR 12.095; 95% CI: 2.744-53.314; p=0.001). Furthermore, regression modeling revealed a higher correlation between application of rhBMP-2 and osseous consolidation in infected nonunions (OR 61.062; 95% CI: 2.208-1688.475; p=0.015) than in aseptic nonunions (OR 4.787; 95% CI: 1.321-17.351; p=0.017). Risk factors negatively influencing the outcome of non-union treatment in context with rhBMPs were identified as active smoking (OR 0.357; 95% CI: 0.138-0.927; p=0.024), atrophic nonunion (OR 0.23; 95% CI: 0.061-0.869; p=0.030), higher BMI (OR 0.919; 95% CI: 0.846-0.998; p=0.046) and a larger defect size (OR 0.877; 95% CI: 0.784-0.98; p=0.021). DISCUSSION Patients who received rhBMP-2 for the treatment of tibial nonunions and as part of the two-stage treatment had a significantly higher rate of healing compared to patients treated with rhBMP-7 regardless of infection. LEVEL OF EVIDENCE III, retrospective case-control study.
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Affiliation(s)
- Patrick Haubruck
- HTRG, Heidelberg Trauma Research Group, Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Trauma and Reconstructive Surgery, Heidelberg University Hospital, Schlierbacher Landstrasse 200a, 69118 Heidelberg, Germany.
| | - Michael C Tanner
- HTRG, Heidelberg Trauma Research Group, Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Trauma and Reconstructive Surgery, Heidelberg University Hospital, Schlierbacher Landstrasse 200a, 69118 Heidelberg, Germany
| | - Wasilios Vlachopoulos
- HTRG, Heidelberg Trauma Research Group, Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Trauma and Reconstructive Surgery, Heidelberg University Hospital, Schlierbacher Landstrasse 200a, 69118 Heidelberg, Germany
| | - Saskia Hagelskamp
- HTRG, Heidelberg Trauma Research Group, Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Trauma and Reconstructive Surgery, Heidelberg University Hospital, Schlierbacher Landstrasse 200a, 69118 Heidelberg, Germany
| | - Matthias Miska
- HTRG, Heidelberg Trauma Research Group, Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Trauma and Reconstructive Surgery, Heidelberg University Hospital, Schlierbacher Landstrasse 200a, 69118 Heidelberg, Germany
| | - Julian Ober
- HTRG, Heidelberg Trauma Research Group, Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Trauma and Reconstructive Surgery, Heidelberg University Hospital, Schlierbacher Landstrasse 200a, 69118 Heidelberg, Germany
| | - Christian Fischer
- HTRG, Heidelberg Trauma Research Group, Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Trauma and Reconstructive Surgery, Heidelberg University Hospital, Schlierbacher Landstrasse 200a, 69118 Heidelberg, Germany
| | - Gerhard Schmidmaier
- HTRG, Heidelberg Trauma Research Group, Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Trauma and Reconstructive Surgery, Heidelberg University Hospital, Schlierbacher Landstrasse 200a, 69118 Heidelberg, Germany
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McEwan JK, Tribe HC, Jacobs N, Hancock N, Qureshi AA, Dunlop DG, Oreffo RO. Regenerative medicine in lower limb reconstruction. Regen Med 2018; 13:477-490. [PMID: 29985779 DOI: 10.2217/rme-2018-0011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Bone is a highly specialized connective tissue and has a rare quality as one of the few tissues that can repair without a scar to regain pre-injury structure and function. Despite the excellent healing capacity of bone, tumor, infection, trauma and surgery can lead to significant bone loss requiring skeletal augmentation. Bone loss in the lower limb poses a complex clinical problem, requiring reconstructive techniques to restore form and function. In the past, amputation may have been the only option; however, there is now an array of reconstructive possibilities and cellular therapies available to salvage a limb. In this review, we will evaluate current applications of bone tissue engineering techniques in limb reconstruction and identify potential strategies for future work.
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Affiliation(s)
- Josephine K McEwan
- Bone & Joint Research Group, Centre for Human Development, Stem Cell & Regeneration, Institute of Developmental Sciences, University of Southampton, Tremona Road, Southampton SO16 6YD, UK
| | - Howard C Tribe
- Bone & Joint Research Group, Centre for Human Development, Stem Cell & Regeneration, Institute of Developmental Sciences, University of Southampton, Tremona Road, Southampton SO16 6YD, UK
| | - Neal Jacobs
- Salisbury NHS Foundation Trust, Salisbury, Wiltshire, UK
| | - Nicholas Hancock
- Trauma & Orthopaedic Department, University Hospital Southampton, Southampton, UK
| | - Amir A Qureshi
- Trauma & Orthopaedic Department, University Hospital Southampton, Southampton, UK
| | - Douglas G Dunlop
- Trauma & Orthopaedic Department, University Hospital Southampton, Southampton, UK
| | - Richard Oc Oreffo
- Bone & Joint Research Group, Centre for Human Development, Stem Cell & Regeneration, Institute of Developmental Sciences, University of Southampton, Tremona Road, Southampton SO16 6YD, UK
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Haubruck P, Solte A, Heller R, Daniel V, Tanner M, Moghaddam A, Schmidmaier G, Fischer C. Chemokine analysis as a novel diagnostic modality in the early prediction of the outcome of non-union therapy: a matched pair analysis. J Orthop Surg Res 2018; 13:249. [PMID: 30305140 PMCID: PMC6180511 DOI: 10.1186/s13018-018-0961-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Accepted: 09/28/2018] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Despite the regenerative capability of skeletal tissue fracture, non-union is common. Treatment of non-unions remains challenging, and early determination of the outcome is impossible. Chemokines play an important role in promoting the formation of new bone and remodeling existing bone. Despite their importance regarding the regulation of bone biology, the potential of chemokines as biological markers reflecting osseous regeneration is unknown. The purpose of this study was to determine (1) if serum chemokine expression levels correlate with the outcome of non-union surgery and (2) if chemokine expression analysis can be used to identify patients at risk for treatment failure. METHODS Non-union patients receiving surgical therapy in our institution between March 2012 and March 2014 were prospectively enrolled in a clinical observer study. Regular clinical and radiological follow-up was conducted for 12 months including collection of blood during the first 12 weeks. Based on the outcome, patients were declared as responders or non-responders to the therapy. To minimize biases, patients were matched (age, sex, body mass index (BMI)) and two groups of patients could be formed: responders (R, n = 10) and non-responders (NR, n = 10). Serum chemokine expression (CCL-2, CCL-3, CCL-4, CXCL-10, CCL-11, and interferon gamma (IFN-γ)) was analyzed using Luminex assays. Data was compared and correlated to the outcome. RESULTS CCL-3 expression in NR was significantly higher during the course of the study compared to R (p = 0.002), and the expression pattern of CCL-4 correlated with CCL-3 in both groups (NR: p < 0.001 and r = 0.63). IFN-γ expression in NR was continuously higher than in R (p < 0.001), and utilization of CCL-3 and IFN-γ serum expression levels 2 weeks after the treatment resulted in a predictive model that had an AUC of 0.92 (CI 0.74-1.00). CONCLUSION Serum chemokine expression analysis over time is a valid and promising diagnostic tool. The chemokine expression pattern correlates with the outcome of the Masquelet therapy of lower limb non-unions. Utilization of the serum analysis of CCL-3 and IFN-γ 2 weeks after the treatment resulted in an early predictive value regarding the differentiation between patients that are likely to heal and those that are prone to high risk of treatment failure.
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Affiliation(s)
- Patrick Haubruck
- HTRG—Heidelberg Trauma Research Group, Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Trauma and Reconstructive Surgery, Heidelberg University Hospital, Schlierbacher Landstrasse 200a, 69118 Heidelberg, Germany
- Raymond Purves Bone and Joint Research Laboratories, Kolling Institute of Medical Research, Institute of Bone and Joint Research, University of Sydney, St Leonards, New South Wales 2065 Australia
| | - Anja Solte
- HTRG—Heidelberg Trauma Research Group, Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Trauma and Reconstructive Surgery, Heidelberg University Hospital, Schlierbacher Landstrasse 200a, 69118 Heidelberg, Germany
| | - Raban Heller
- HTRG—Heidelberg Trauma Research Group, Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Trauma and Reconstructive Surgery, Heidelberg University Hospital, Schlierbacher Landstrasse 200a, 69118 Heidelberg, Germany
| | - Volker Daniel
- Department of Transplantation Immunology, Institute of Immunology, University of Heidelberg, Im Neuenheimer Feld 305, 69120 Heidelberg, Germany
| | - Michael Tanner
- HTRG—Heidelberg Trauma Research Group, Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Trauma and Reconstructive Surgery, Heidelberg University Hospital, Schlierbacher Landstrasse 200a, 69118 Heidelberg, Germany
| | - Arash Moghaddam
- HTRG—Heidelberg Trauma Research Group, Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Trauma and Reconstructive Surgery, Heidelberg University Hospital, Schlierbacher Landstrasse 200a, 69118 Heidelberg, Germany
- ATORG—Aschaffenburg Trauma and Orthopedic Research Group, Center for Trauma Surgery, Orthopedics and Sports Medicine, Am Hasenkopf 1, 63739 Aschaffenburg, Germany
| | - Gerhard Schmidmaier
- HTRG—Heidelberg Trauma Research Group, Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Trauma and Reconstructive Surgery, Heidelberg University Hospital, Schlierbacher Landstrasse 200a, 69118 Heidelberg, Germany
| | - Christian Fischer
- HTRG—Heidelberg Trauma Research Group, Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Trauma and Reconstructive Surgery, Heidelberg University Hospital, Schlierbacher Landstrasse 200a, 69118 Heidelberg, Germany
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Haubruck P, Heller R, Apitz P, Kammerer A, Alamouti A, Daniel V, Schmidmaier G, Moghaddam A. Evaluation of matrix metalloproteases as early biomarkers for bone regeneration during the applied Masquelet therapy for non-unions. Injury 2018; 49:1732-1738. [PMID: 30072031 DOI: 10.1016/j.injury.2018.07.015] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Accepted: 07/23/2018] [Indexed: 02/02/2023]
Abstract
INTRODUCTION In the current study, we sought to determine if serum concentrations of MMPs correlate with bone regeneration occurring during the course of the Masquelet-therapy and to identify if MMPs may serve as early biomarkers reflecting successful bone regeneration and tissue remodeling. MATERIAL AND METHODS This study was designed as a prospective clinical observer study. We compared serum samples over the time of treatment, as a matched-pair analysis, from 10 patients who were treated successfully with the Masquelet-therapy (Responder) with 10 patients who did not respond to the Masquelet-therapy (Non-Responder). The quantitative measurement was performed with Luminex Performance Human High Sensitivity Assays according to manufacturer's instructions. The lab technician performing the Luminex assays was blinded to both patient data and clinical outcome. RESULTS Analysis of the expression pattern of MMP-2, -8 and -9 showed significant differences between groups. Two days after the first step of the Masquelet therapy Responder showed peak values of MMP-8 and MMP-9 that where significantly higher (p = 0.003 and p = 0.042, respectively) than in Non-Responder. In contrast serum levels of MMP-2 were lower after the first step of the Masquelet therapy in the Non-Responder group. The ratio of MMP-9 and MMP-2 was significantly higher in the Responder group two days after step I (p = 0.031) as well as 4 weeks after step II (p = 0.030). CONCLUSION The findings of the current study emphasize the potential role of MMPs as biomarkers in bone remodeling. In particular, a distinct expression of MMP-2 correlates with successful bone regeneration, whereas initial overexpression of MMP-2 serum levels might identify patients that have a higher risk for a poor outcome of the Masquelet-therapy. Furthermore, we were able to introduce the serum analysis of the ratio of MMP-9 and MMP-2 as promising novel modality for early prediction of the outcome of the Masquelet therapy. Further analysis of this ratio over time subsequent to the second step might serve as an early indicator of a favorable response to the induced membrane technique.
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Affiliation(s)
- P Haubruck
- Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Trauma and Reconstructive Surgery, Heidelberg University Hospital, Schlierbacher Landstrasse 200a, D-69118 Heidelberg, Germany.
| | - R Heller
- Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Trauma and Reconstructive Surgery, Heidelberg University Hospital, Schlierbacher Landstrasse 200a, D-69118 Heidelberg, Germany
| | - P Apitz
- Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Trauma and Reconstructive Surgery, Heidelberg University Hospital, Schlierbacher Landstrasse 200a, D-69118 Heidelberg, Germany
| | - A Kammerer
- Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Trauma and Reconstructive Surgery, Heidelberg University Hospital, Schlierbacher Landstrasse 200a, D-69118 Heidelberg, Germany
| | - A Alamouti
- Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Trauma and Reconstructive Surgery, Heidelberg University Hospital, Schlierbacher Landstrasse 200a, D-69118 Heidelberg, Germany
| | - V Daniel
- Department of Transplantation Immunology, Institute of Immunology, University of Heidelberg, Im Neuenheimer Feld 305, D-69120 Heidelberg, Germany
| | - G Schmidmaier
- Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Trauma and Reconstructive Surgery, Heidelberg University Hospital, Schlierbacher Landstrasse 200a, D-69118 Heidelberg, Germany
| | - A Moghaddam
- Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Trauma and Reconstructive Surgery, Heidelberg University Hospital, Schlierbacher Landstrasse 200a, D-69118 Heidelberg, Germany; Center for Trauma Surgery, Orthopedics and Sports Medicine, Am Hasenkopf 1, D-63739 Aschaffenburg, Germany
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Björkenheim R, Strömberg G, Ainola M, Uppstu P, Aalto-Setälä L, Hupa L, Pajarinen J, Lindfors NC. Bone morphogenic protein expression and bone formation are induced by bioactive glass S53P4 scaffolds in vivo. J Biomed Mater Res B Appl Biomater 2018; 107:847-857. [DOI: 10.1002/jbm.b.34181] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 05/16/2018] [Accepted: 05/28/2018] [Indexed: 01/15/2023]
Affiliation(s)
- Robert Björkenheim
- Department of Musculoskeletal and Plastic Surgery; University of Helsinki and Helsinki University Hospital; Helsinki Finland
| | - Gustav Strömberg
- Department of Musculoskeletal and Plastic Surgery; University of Helsinki and Helsinki University Hospital; Helsinki Finland
- Department of Surgery; Päijät-Häme Central Hospital; Lahti Finland
| | - Mari Ainola
- Department of Medicine, Clinicum; University of Helsinki and Helsinki University Central Hospital; Helsinki Finland
| | - Peter Uppstu
- Laboratory of Polymer Technology, Centre of Excellence in Functional Materials at Biological Interfaces; Åbo Akademi University; Turku Finland
| | - Laura Aalto-Setälä
- Johan Gadolin Process Chemistry Centre; Åbo Akademi University; Turku Finland
| | - Leena Hupa
- Johan Gadolin Process Chemistry Centre; Åbo Akademi University; Turku Finland
| | - Jukka Pajarinen
- Department of Musculoskeletal and Plastic Surgery; University of Helsinki and Helsinki University Hospital; Helsinki Finland
| | - Nina C. Lindfors
- Department of Musculoskeletal and Plastic Surgery; University of Helsinki and Helsinki University Hospital; Helsinki Finland
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Haubruck P, Heller R, Tanner MC, Daniel V, Schmidmaier G, Bolourchi F, Moghaddam A, Fischer C. A Preliminary Study of Contrast-Enhanced Ultrasound (CEUS) and Cytokine Expression Analysis (CEA) as Early Predictors for the Outcome of Tibial Non-Union Therapy. Diagnostics (Basel) 2018; 8:diagnostics8030055. [PMID: 30149501 PMCID: PMC6164610 DOI: 10.3390/diagnostics8030055] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 08/19/2018] [Accepted: 08/22/2018] [Indexed: 01/09/2023] Open
Abstract
The current study investigates if contrast-enhanced ultrasound (CEUS) or cytokine expression analysis (CEA) evaluating vascularization are capable of predicting the outcome of non-union therapy. Patients with tibial non-unions were surgically treated and participated in our follow-up program including perioperative collection of blood as well as CEUS analysis. Two groups were formed: Responders in group 1 (G1, N = 8) and Non-Responders in group 2 (G2, N = 5). Serum cytokine expression and local microperfusion were compared and correlated to the radiologic outcome. Evaluation of TNF-α expression revealed significantly lower values prior to first surgery in G1 (G1: 9.66 ± 0.96 pg/mL versus G2: 12.63 ± 1.2 pg/mL; p = 0.045); whereas after treatment both CEA and CEUS indicated a higher potential for angiogenesis in Responders. Logistic regression modelling revealed the highest predictive power regarding eventual osseous consolidation for the combination of both CEUS and serum CEA. The results provide first evidence regarding a link between changes in the serum expression of distinct pro-angiogenic cytokines and alterations in the local microperfusion assessed via both non-invasive and radiation-free diagnostic modalities. In addition, a combination of CEUS and CEA is a promising novel tool in early prediction of the outcome of non-union therapy.
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Affiliation(s)
- Patrick Haubruck
- HTRG-Heidelberg Trauma Research Group, Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Trauma and Reconstructive Surgery, Heidelberg University Hospital, Schlierbacher Landstrasse 200a, 69118 Heidelberg, Germany.
- Raymond Purves Bone and Joint Research Laboratories, Kolling Institute of Medical Research, Institute of Bone and Joint Research, University of Sydney, St. Leonards, New South Wales 2065, Australia.
| | - Raban Heller
- HTRG-Heidelberg Trauma Research Group, Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Trauma and Reconstructive Surgery, Heidelberg University Hospital, Schlierbacher Landstrasse 200a, 69118 Heidelberg, Germany.
| | - Michael C Tanner
- HTRG-Heidelberg Trauma Research Group, Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Trauma and Reconstructive Surgery, Heidelberg University Hospital, Schlierbacher Landstrasse 200a, 69118 Heidelberg, Germany.
| | - Volker Daniel
- Department of Transplantation Immunology, Institute of Immunology, University of Heidelberg, Im Neuenheimer Feld 305, 69120 Heidelberg, Germany.
| | - Gerhard Schmidmaier
- HTRG-Heidelberg Trauma Research Group, Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Trauma and Reconstructive Surgery, Heidelberg University Hospital, Schlierbacher Landstrasse 200a, 69118 Heidelberg, Germany.
| | - Farhoud Bolourchi
- HTRG-Heidelberg Trauma Research Group, Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Trauma and Reconstructive Surgery, Heidelberg University Hospital, Schlierbacher Landstrasse 200a, 69118 Heidelberg, Germany.
| | - Arash Moghaddam
- HTRG-Heidelberg Trauma Research Group, Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Trauma and Reconstructive Surgery, Heidelberg University Hospital, Schlierbacher Landstrasse 200a, 69118 Heidelberg, Germany.
- ATORG-Aschaffenburg Trauma and Orthopedic Research Group, Center for Trauma Surgery, Orthopedics and Sports Medicine, Am Hasenkopf 1, 63739 Aschaffenburg, Germany.
| | - Christian Fischer
- HTRG-Heidelberg Trauma Research Group, Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Trauma and Reconstructive Surgery, Heidelberg University Hospital, Schlierbacher Landstrasse 200a, 69118 Heidelberg, Germany.
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Clinical Applications of Bone Tissue Engineering in Orthopedic Trauma. CURRENT PATHOBIOLOGY REPORTS 2018; 6:99-108. [PMID: 36506709 PMCID: PMC9733044 DOI: 10.1007/s40139-018-0166-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Purpose of Review Orthopaedic trauma is a major cause of morbidity and mortality worldwide. Although many fractures tend to heal if treated appropriately either by nonoperative or operative methods, delayed or failed healing, as well as infections, can lead to devastating complications. Tissue engineering is an exciting, emerging field with much scientific and clinical relevance in potentially overcoming the current limitations in the treatment of orthopaedic injuries. Recent Findings While direct translation of bone tissue engineering technologies to clinical use remains challenging, considerable research has been done in studying how cells, scaffolds, and signals may be used to enhance acute fracture healing and to address the problematic scenarios of nonunion and critical-sized bone defects. Taken together, the research findings suggest that tissue engineering may be considered to stimulate angiogenesis and osteogenesis, to modulate the immune response to fractures, to improve the biocompatibility of implants, to prevent or combat infection, and to fill large gaps created by traumatic bone loss. The abundance of preclinical data supports the high potential of bone tissue engineering for clinical application, although a number of barriers to translation must first be overcome. Summary This review focuses on the current and potential applications of bone tissue engineering approaches in orthopaedic trauma with specific attention paid to acute fracture healing, nonunion, and critical-sized bone defects.
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Tanner MC, Heller R, Westhauser F, Miska M, Ferbert T, Fischer C, Gantz S, Schmidmaier G, Haubruck P. Evaluation of the clinical effectiveness of bioactive glass (S53P4) in the treatment of non-unions of the tibia and femur: study protocol of a randomized controlled non-inferiority trial. Trials 2018; 19:299. [PMID: 29843766 PMCID: PMC5975373 DOI: 10.1186/s13063-018-2681-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Accepted: 05/10/2018] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Treatment of non-union remains challenging and often necessitates augmentation of the resulting defect with an autologous bone graft (ABG). ABG is limited in quantity and its harvesting incurs an additional surgical intervention leaving the risk for associated complications and morbidities. Therefore, artificial bone graft substitutes that might replace autologous bone are needed. S53P4-type bioactive glass (BaG) is a promising material which might be used as bone graft substitute due to its osteostimulative, conductive and antimicrobial properties. In this study, we plan to examine the clinical effectiveness of BaG as a bone graft substitute in Masquelet therapy in comparison with present standard Masquelet therapy using an ABG with tricalciumphosphate to fill the bone defect. METHODS/DESIGN This randomized controlled, clinical non-inferiority trial will be carried out at the Department of Orthopedics and Traumatology at Heidelberg University. Patients who suffer from tibial or femoral non-unions with a segmental bone defect of 2-5 cm and who are receiving Masquelet treatment will be included in the study. The resulting bone defect will either be filled with autologous bone and tricalciumphosphate (control group, N = 25) or BaG (S53P4) (study group, N = 25). Subsequent to operative therapy, all patients will receive the same standardized follow-up procedures. The primary endpoint of the study is union achieved 1year after surgery. DISCUSSION The results from the current study will help evaluate the clinical effectiveness of this promising biomaterial in non-union therapy. In addition, this randomized trial will help to identify potential benefits and limitations regarding the use of BaG in Masquelet therapy. Data from the study will increase the knowledge about BaG as a bone graft substitute as well as identify patients possibly benefiting from Masquelet therapy using BaG and those who are more likely to fail, thereby improving the quality of non-union treatment. TRIAL REGISTRATION German Clinical Trials Register (DRKS), ID: DRKS00013882 . Registered on 22 January 2018.
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Affiliation(s)
- Michael C. Tanner
- HTRG – Heidelberg Trauma Research Group, Centre for Orthopaedics, Trauma Surgery and Spinal Cord Injury, Trauma and Reconstructive Surgery, Heidelberg University Hospital, Schlierbacher Landstrasse 200a, 69118 Heidelberg, Germany
| | - Raban Heller
- HTRG – Heidelberg Trauma Research Group, Centre for Orthopaedics, Trauma Surgery and Spinal Cord Injury, Trauma and Reconstructive Surgery, Heidelberg University Hospital, Schlierbacher Landstrasse 200a, 69118 Heidelberg, Germany
| | - Fabian Westhauser
- HTRG – Heidelberg Trauma Research Group, Centre for Orthopaedics, Trauma Surgery and Spinal Cord Injury, Trauma and Reconstructive Surgery, Heidelberg University Hospital, Schlierbacher Landstrasse 200a, 69118 Heidelberg, Germany
| | - Matthias Miska
- HTRG – Heidelberg Trauma Research Group, Centre for Orthopaedics, Trauma Surgery and Spinal Cord Injury, Trauma and Reconstructive Surgery, Heidelberg University Hospital, Schlierbacher Landstrasse 200a, 69118 Heidelberg, Germany
| | - Thomas Ferbert
- HTRG – Heidelberg Trauma Research Group, Centre for Orthopaedics, Trauma Surgery and Spinal Cord Injury, Trauma and Reconstructive Surgery, Heidelberg University Hospital, Schlierbacher Landstrasse 200a, 69118 Heidelberg, Germany
| | - Christian Fischer
- HTRG – Heidelberg Trauma Research Group, Centre for Orthopaedics, Trauma Surgery and Spinal Cord Injury, Trauma and Reconstructive Surgery, Heidelberg University Hospital, Schlierbacher Landstrasse 200a, 69118 Heidelberg, Germany
| | - Simone Gantz
- HTRG – Heidelberg Trauma Research Group, Centre for Orthopaedics, Trauma Surgery and Spinal Cord Injury, Trauma and Reconstructive Surgery, Heidelberg University Hospital, Schlierbacher Landstrasse 200a, 69118 Heidelberg, Germany
| | - Gerhard Schmidmaier
- HTRG – Heidelberg Trauma Research Group, Centre for Orthopaedics, Trauma Surgery and Spinal Cord Injury, Trauma and Reconstructive Surgery, Heidelberg University Hospital, Schlierbacher Landstrasse 200a, 69118 Heidelberg, Germany
| | - Patrick Haubruck
- HTRG – Heidelberg Trauma Research Group, Centre for Orthopaedics, Trauma Surgery and Spinal Cord Injury, Trauma and Reconstructive Surgery, Heidelberg University Hospital, Schlierbacher Landstrasse 200a, 69118 Heidelberg, Germany
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Gaio N, Martino A, Toth Z, Watson JT, Nicolaou D, McBride-Gagyi S. Masquelet technique: The effect of altering implant material and topography on membrane matrix composition, mechanical and barrier properties in a rat defect model. J Biomech 2018; 72:53-62. [PMID: 29510858 PMCID: PMC5895482 DOI: 10.1016/j.jbiomech.2018.02.026] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Revised: 02/12/2018] [Accepted: 02/18/2018] [Indexed: 12/26/2022]
Abstract
The Masquelet technique is a surgical procedure to regenerate segmental bone defects. The two-phase treatment relies on the production of a vascularized foreign-body membrane to support bone grafts over three times larger than the traditional maximum. Historically, the procedure has always utilized a bone cement spacer to evoke membrane production. However, membrane formation can easily be effected by implant surface properties such as material and topology. This study sought to determine if the membrane's mechanical or barrier properties are affected by changing the spacer material to titanium or roughening the surface finish. Ten-week-old, male Sprague Dawley rats were given an externally stabilized, 6 mm femur defect which was filled with a pre-made spacer of bone cement (PMMA) or titanium (TI) with a smooth (∼1 μm) or roughened (∼8 μm) finish. After 4 weeks of implantation, the membranes were harvested, and the matrix composition, tensile mechanics, shrinkage, and barrier function was assessed. Roughening the spacers resulted in significantly more compliant membranes. TI spacers created membranes that inhibited solute transport more. There were no differences between groups in collagen or elastin distribution. This suggests that different membrane characteristics can be created by altering the spacer surface properties. Surgeons may unknowingly effecting membrane formation via bone cement preparation techniques.
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Affiliation(s)
- Natalie Gaio
- Department of Orthopaedic Surgery, Saint Louis University School of Medicine, 1402 S. Grand Blvd, Schwitalla Hall M176, St. Louis, MO 63132, USA
| | - Alice Martino
- Department of Orthopaedic Surgery, Saint Louis University School of Medicine, 1402 S. Grand Blvd, Schwitalla Hall M176, St. Louis, MO 63132, USA
| | - Zacharie Toth
- Department of Orthopaedic Surgery, Saint Louis University School of Medicine, 1402 S. Grand Blvd, Schwitalla Hall M176, St. Louis, MO 63132, USA
| | - J Tracy Watson
- Department of Orthopaedic Surgery, Saint Louis University School of Medicine, 1402 S. Grand Blvd, Schwitalla Hall M176, St. Louis, MO 63132, USA
| | - Daemeon Nicolaou
- Department of Orthopaedic Surgery, Saint Louis University School of Medicine, 1402 S. Grand Blvd, Schwitalla Hall M176, St. Louis, MO 63132, USA
| | - Sarah McBride-Gagyi
- Department of Orthopaedic Surgery, Saint Louis University School of Medicine, 1402 S. Grand Blvd, Schwitalla Hall M176, St. Louis, MO 63132, USA.
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Inhibition of Dll4/Notch1 pathway promotes angiogenesis of Masquelet's induced membrane in rats. Exp Mol Med 2018; 50:1-15. [PMID: 29674611 PMCID: PMC5938037 DOI: 10.1038/s12276-018-0062-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2017] [Revised: 12/30/2017] [Accepted: 01/08/2018] [Indexed: 11/18/2022] Open
Abstract
The Masquelet’s induced membrane technique for repairing bone defects has been demonstrated to be a promising treatment strategy. Previous studies have shown that the vessel density of induced membrane is decreased in the late stage of membrane formation, which consequently disrupts the bone healing process. However, relatively little is known about certain mechanisms of vessel degeneration in the induced membrane tissue and whether promotion of angiogenesis in induced membranes can improve bone regeneration. Here, we showed that the Delta-like ligand 4/ Notch homolog 1 (Dll4/Notch1) pathway was relatively activated in the late stage of induced membrane, especially at the subcutaneous site. Then, DAPT, a classical γ-secretase inhibitor, was applied to specifically inhibit Notch1 activation, followed by up-regulation of vascular endothelial growth factor receptor 2 (VEGFR2) and CD31 expression. DAPT-modified induced membranes were further confirmed to contribute to bone regeneration after autogenous bone grafting. Finally, in vitro experiments revealed that knocking down Notch1 contributed to the functional improvement of endothelial progenitor cells (EPCs) and that DAPT-treated induced membrane tissue was more favorable for angiogenesis of EPCs compared with the vehicle group. In conclusion, the present findings demonstrate that Dll4/Notch1 signaling is negatively associated with the vessel density of induced membrane. Pharmacological inhibition of Notch1 attenuated the vessel degeneration of induced membrane both in vitro and in vivo, which consequently improved bone formation at the bone defect site and graft resorption at the subcutaneous site. Repairs to serious bone injuries may be improved by blocking a signaling pathway that causes newly forming membranes to fail. Masquelet’s technique involves placing acrylic spacers in areas of bone damage, inducing the formation of vascularised membranes which encourage the body to accept bone grafts. However, sometimes Masquelet’s membranes do not form correctly, leading to weaknesses in bone repairs and potential graft rejection. In experiments on rats, Qian Tang from Wenzhou Medical University, China, and coworkers found that a particular signaling pathway, D114/Notch1, was upregulated around 6 weeks post-operation, reducing blood vessel density and limiting new vessel growth, weakening the membranes. The team inhibited this pathway using an existing therapy that prevents blood clots. This treatment improved bone repairs by promoting the formation and function of blood vessels in membranes.
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Schindeler A, Mills RJ, Bobyn JD, Little DG. Preclinical models for orthopedic research and bone tissue engineering. J Orthop Res 2018; 36:832-840. [PMID: 29205478 DOI: 10.1002/jor.23824] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Accepted: 11/27/2017] [Indexed: 02/04/2023]
Abstract
In this review, we broadly define and discuss the preclinical rodent models that are used for orthopedics and bone tissue engineering. These range from implantation models typically used for biocompatibility testing and high-throughput drug screening, through to fracture and critical defect models used to model bone healing and severe orthopedic injuries. As well as highlighting the key methods papers describing these techniques, we provide additional commentary based on our substantive practical experience with animal surgery and in vivo experimental design. This review also briefly touches upon the descriptive and functional outcome measures and power calculations that are necessary for an informative study. Obtaining informative and relevant research outcomes can be very dependent on the model used, and we hope this evaluation of common models will serve as a primer for new researchers looking to undertake preclinical bone studies. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:832-840, 2018.
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Affiliation(s)
- Aaron Schindeler
- Orthopedic Research and Biotechnology Unit, The Children's Hospital at Westmead, Locked Bag 4001, Westmead, Sydney, New South Wales, 2145, Australia.,Discipline of Pediatrics and Child Health, Faculty of Medicine, University of Sydney, Sydney, Australia
| | - Rebecca J Mills
- Orthopedic Research and Biotechnology Unit, The Children's Hospital at Westmead, Locked Bag 4001, Westmead, Sydney, New South Wales, 2145, Australia
| | - Justin D Bobyn
- Orthopedic Research and Biotechnology Unit, The Children's Hospital at Westmead, Locked Bag 4001, Westmead, Sydney, New South Wales, 2145, Australia.,Discipline of Pediatrics and Child Health, Faculty of Medicine, University of Sydney, Sydney, Australia
| | - David G Little
- Orthopedic Research and Biotechnology Unit, The Children's Hospital at Westmead, Locked Bag 4001, Westmead, Sydney, New South Wales, 2145, Australia.,Discipline of Pediatrics and Child Health, Faculty of Medicine, University of Sydney, Sydney, Australia
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McBride-Gagyi S, Toth Z, Kim D, Ip V, Evans E, Watson JT, Nicolaou D. Altering spacer material affects bone regeneration in the Masquelet technique in a rat femoral defect. J Orthop Res 2018; 36:10.1002/jor.23866. [PMID: 29424019 PMCID: PMC6785358 DOI: 10.1002/jor.23866] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2017] [Accepted: 01/30/2018] [Indexed: 02/04/2023]
Abstract
The Masquelet technique depends on pre-development of a foreign-body membrane to support bone regeneration with grafts over three times larger than the traditional maximum. To date, the procedure has always used spacers made of bone cement, which is the polymer polymethyl methacrylate (PMMA), to induce the foreign-body membrane. This study sought to compare (i) morphology, factor expression, and cellularity in membranes formed by PMMA, titanium, and polyvinyl alcohol sponge (PVA) spacers in the Masquelet milieu and (ii) subsequent bone regeneration in the same groups. Ten-week-old, male Sprague-Dawley rats were given an externally stabilized, 6 mm femur defect, and a pre-made spacer of PMMA, titanium, or PVA was implanted. All animals were given 4 weeks to form a membrane, and those receiving an isograft were given 10 weeks post-implantation to union. All samples were scanned with microCT to measure phase 1 and phase 2 bone formation. Membrane samples were processed for histology to measure membrane morphology, cellularity, and expression of the factors BMP2, TGFβ, VEGF, and IL6. PMMA and titanium spacers created almost identical membranes and phase 1 bone. PVA spacers were uniformly infiltrated with tissue and cells and did not form a distinct membrane. There were no quantitative differences in phase 2 bone formation. However, PMMA induced membranes supported functional union in 6 of 7 samples while a majority of titanium and PVA groups failed to achieve the same. Spacer material can alter the membrane enough to disrupt phase 2 bone formation. The membrane's role in bone regeneration is likely more than just as a physical barrier. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res.
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Affiliation(s)
- Sarah McBride-Gagyi
- Department of Orthopaedic Surgery, Saint Louis University School of Medicine, St. Louis, MO
| | - Zacharie Toth
- Department of Orthopaedic Surgery, Saint Louis University School of Medicine, St. Louis, MO
| | - Daniel Kim
- Department of Orthopaedic Surgery, Saint Louis University School of Medicine, St. Louis, MO
| | - Victoria Ip
- Department of Orthopaedic Surgery, Saint Louis University School of Medicine, St. Louis, MO
| | - Emily Evans
- Department of Orthopaedic Surgery, Saint Louis University School of Medicine, St. Louis, MO
| | - J Tracy Watson
- Department of Orthopaedic Surgery, Saint Louis University School of Medicine, St. Louis, MO
| | - Daemeon Nicolaou
- Department of Orthopaedic Surgery, Saint Louis University School of Medicine, St. Louis, MO
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Horstmann PF, Raina DB, Isaksson H, Hettwer W, Lidgren L, Petersen MM, Tägil M. Composite Biomaterial as a Carrier for Bone-Active Substances for Metaphyseal Tibial Bone Defect Reconstruction in Rats. Tissue Eng Part A 2017; 23:1403-1412. [DOI: 10.1089/ten.tea.2017.0040] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Affiliation(s)
- Peter Frederik Horstmann
- Department of Orthopedics, Clinical Sciences, Lund University, Lund University Hospital, Lund, Sweden
- Department of Orthopedics, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Deepak Bushan Raina
- Department of Orthopedics, Clinical Sciences, Lund University, Lund University Hospital, Lund, Sweden
| | - Hanna Isaksson
- Department of Orthopedics, Clinical Sciences, Lund University, Lund University Hospital, Lund, Sweden
- Department of Biomedical Engineering, Lund University, Lund, Sweden
| | - Werner Hettwer
- Department of Orthopedics, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Lars Lidgren
- Department of Orthopedics, Clinical Sciences, Lund University, Lund University Hospital, Lund, Sweden
| | - Michael Mørk Petersen
- Department of Orthopedics, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Magnus Tägil
- Department of Orthopedics, Clinical Sciences, Lund University, Lund University Hospital, Lund, Sweden
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Zoller SD, Cao LA, Smith RA, Sheppard W, Lord EL, Hamad CD, Ghodasra JH, Lee C, Jeffcoat D. Staged reconstruction of diaphyseal fractures with segmental defects: Surgical and patient-reported outcomes. Injury 2017; 48:2248-2252. [PMID: 28712488 DOI: 10.1016/j.injury.2017.06.018] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Revised: 05/26/2017] [Accepted: 06/20/2017] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Two-stage limb reconstruction is an option for patients with critical size segmental bone defects following acute trauma or non-union. Reconstruction is technically demanding and associated with a high complication rate. Current protocols for limb reconstruction have well-documented challenges, and no study has reported on patient outcomes using a validated questionnaire. In this study, we aimed to examine the clinical and patient-centered outcomes following our surgical protocol for two-stage limb reconstruction following critical size segmental defects. PATIENTS AND METHODS A single surgeon performed reconstruction of long bone defects using antibiotic impregnated cement spacers and intramedullary cancellous bone autograft. A retrospective chart review was performed. Three reviewers independently measured time to union based on radiographs. The Lower Extremity Functional Scale (LEFS) survey was administered to patients after most recent follow-up. RESULTS Ten limbs representing nine patients were included. All patients sustained a lower extremity injury, and one patient had bilateral lower extremity injuries. Average clinical follow-up was 18.3 months (range 7-33) from final surgical intervention, and follow-up to questionnaire administration was 28 months (range 24-37). The mean time between stages was 3.1 months. Average time to unrestricted weight-bearing was 7.9 months from Stage 1 (range 3.4-15.9) and 4.5 months from Stage 2 (range 1.1-11.6). Average time to full union was 16.7 months from Stage 1 (range 6.4-28.6) and 13.5 months from Stage 2 (range 1.8-27). Eight patients (nine limbs) participated in the LEFS survey, the average score was 53.1 (range 30-67), equating to 66% of full functionality (range 38%-84%). Complications included 5 infections, 3 non-unions, and one amputation. There was a moderate positive correlation between infection at any time point and non-union (R=0.65, p=0.03). DISCUSSION AND CONCLUSIONS Outcomes in this small patient cohort were good despite risks of complication. There is an association between infection and non-union. Further studies addressing clinical and functional outcomes will help to guide expectations for future surgeons and patients.
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Affiliation(s)
- S D Zoller
- Department of Orthopaedic Surgery, University of California, Los Angeles (UCLA), 1250 16th St. Suite 2100, Santa Monica CA 90404, United States
| | - L A Cao
- Department of Orthopaedic Surgery, University of Southern California (USC), 1975 Zonal Ave., Los Angeles, CA 90033, United States
| | - R A Smith
- Department of Orthopaedic Surgery, University of California, Los Angeles (UCLA), 1250 16th St. Suite 2100, Santa Monica CA 90404, United States
| | - W Sheppard
- Department of Orthopaedic Surgery, University of California, Los Angeles (UCLA), 1250 16th St. Suite 2100, Santa Monica CA 90404, United States
| | - E L Lord
- Department of Orthopaedic Surgery, University of California, Los Angeles (UCLA), 1250 16th St. Suite 2100, Santa Monica CA 90404, United States
| | - C D Hamad
- Department of Orthopaedic Surgery, University of California, Los Angeles (UCLA), 1250 16th St. Suite 2100, Santa Monica CA 90404, United States
| | - J H Ghodasra
- Department of Orthopaedic Surgery, University of California, Los Angeles (UCLA), 1250 16th St. Suite 2100, Santa Monica CA 90404, United States
| | - C Lee
- Department of Orthopaedic Surgery, University of California, Los Angeles (UCLA), 1250 16th St. Suite 2100, Santa Monica CA 90404, United States
| | - D Jeffcoat
- Department of Orthopaedic Surgery, University of California, Los Angeles (UCLA), 1250 16th St. Suite 2100, Santa Monica CA 90404, United States.
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Scientific Understanding of the Induced Membrane Technique: Current Status and Future Directions. J Orthop Trauma 2017; 31 Suppl 5:S3-S8. [PMID: 28938383 DOI: 10.1097/bot.0000000000000981] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To review the most recent basic science advances made in relation to the induced membrane technique and how those relate to clinical practice, applications, and future research directions. DESIGN Review of the literature. SETTING Any trauma center which might encounter large segmental bone defects. ARTICLES REVIEWED Basic science articles that looked at characteristics of the induced membrane published in the past 30 years. INTERVENTION None.
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Cho JW, Kim J, Cho WT, Kim JK, Song JH, Kim HJ, Masquelet AC, Oh JK. Circumferential bone grafting around an absorbable gelatin sponge core reduced the amount of grafted bone in the induced membrane technique for critical-size defects of long bones. Injury 2017; 48:2292-2305. [PMID: 28802745 DOI: 10.1016/j.injury.2017.08.012] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Accepted: 08/05/2017] [Indexed: 02/02/2023]
Abstract
OBJECTIVES The objectives of the study were to introduce a circumferential bone graft around an absorbable gelatin sponge core using an induced membrane technique, to assess its ability to reduce the required amount of graft and to maintain the bone graft, and to evaluate the clinical outcomes in the management of critical-size bone defects. PATIENTS AND METHODS Circumferential bone grafting using a staged induced membrane technique for managing critical-size bone defects was performed in 21 patients. Postoperative computed tomography scans were performed 7days after Hemovac drain removal and 3 months after bone grafting. Volumetric measurements of the defect size, gelatin sponge proportion, and amount of grafted bone were performed by two independent observers using three-dimensional (3D) software. RESULTS The critical-size defects were located at the metadiaphyseal area of 11 tibias, eight femurs, and two humeri. The average defect size was 8.9cm in length and 65.2cm3 in volume. The absorbable gelatin sponge core replaced 21.4% (average) of the defect volume. There was no significant deterioration in the shape of the grafted bone among the serial 3D models. Eighteen patients (86%) were healed radiographically at 9.1 months (average). CONCLUSION Our study suggests that circumferential bone grafting in association with the induced membrane technique could reduce the required amount of bone graft and adequately maintain graft position and shape, with favourable clinical outcomes.
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Affiliation(s)
- Jae-Woo Cho
- Department of Orthopedic Surgery, Korea University Medical Center, 148 Gurodong-ro, Guro-gu, Seoul, Republic of Korea
| | - Jinil Kim
- Department of Orthopedic Surgery, Korea University Medical Center, 148 Gurodong-ro, Guro-gu, Seoul, Republic of Korea
| | - Won-Tae Cho
- Department of Orthopedic Surgery, Korea University Medical Center, 148 Gurodong-ro, Guro-gu, Seoul, Republic of Korea
| | - Jin-Kak Kim
- Department of Orthopedic Surgery, Korea University Medical Center, 148 Gurodong-ro, Guro-gu, Seoul, Republic of Korea
| | - Jong Hoon Song
- Department of Orthopedic Surgery, Hanyang University Medical Center, 153, Kyoungchun-ro, Guri-si, Gyeonggi-do, Republic of Korea
| | - Hyung-Jin Kim
- Department of Orthopedic Surgery, Dongtan Sacred Heart Hospital, Hallym University College of Medicine, 7, Keunjaebong-gil, Hwaseong-si, Gyeonggi-do, Republic of Korea
| | - Alain C Masquelet
- Reconstructive & Hand Surgery Unit, Orthopaedic Department, Hopital Saint-Antoine, 184, rue du Faubourg, Saint Antoine, Paris, France
| | - Jong-Keon Oh
- Department of Orthopedic Surgery, Korea University Medical Center, 148 Gurodong-ro, Guro-gu, Seoul, Republic of Korea.
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Induced membrane technique: Advances in the management of bone defects. Int J Surg 2017; 42:110-116. [DOI: 10.1016/j.ijsu.2017.04.064] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Revised: 04/19/2017] [Accepted: 04/30/2017] [Indexed: 12/31/2022]
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de Oliveira LSDS, de Araújo AA, de Araújo Júnior RF, Barboza CAG, Borges BCD, da Silva JSP. Low-level laser therapy (780 nm) combined with collagen sponge scaffold promotes repair of rat cranial critical-size defects and increases TGF-β, FGF-2, OPG/RANK and osteocalcin expression. Int J Exp Pathol 2017; 98:75-85. [PMID: 28556971 DOI: 10.1111/iep.12226] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Accepted: 02/09/2017] [Indexed: 12/15/2022] Open
Abstract
The aim of this study was to evaluate the effect of collagen sponge scaffold (CSS) implantation associated with low-level laser therapy (LLLT) on repairing bone defects. A single 5-mm cranial defect was surgically created in forty Wistar rats, which then received one of the following four interventions (n = 10 per group): no treatment (G0); bone defect implanted with collagen sponge scaffold (CSS) alone (G1); defect treated with low-level laser therapy (LLLT) (wavelength 780 nm; total energy density 120 J/cm2 ; power 50 mW) alone (G2); and CSS associated with LLLT treatment (G3). After surgery, animals in each group were euthanized at 21 days and 30 days (n = 5 per euthanasia time group). Bone formation was monitored by X-ray imaging analysis. Biopsies were collected and processed for histological analysis and immunohistochemical evaluation of transforming growth factor-beta (TGF-β), fibroblast growth factor-2 (FGF-2), osteoprotegerin (OPG) and receptor activator of nuclear factor ƙ (RANK). Osteocalcin (OCN) was detected by immunofluorescence analysis. Compared to the G0 group, defects in the 30-day G3 group exhibited increased bone formation, both by increase in radiopaque areas (P < 0.01) and by histomorphometric analysis (P < 0.001). The histopathological analysis showed a decreased number of inflammatory cells (P < 0.001). The combined CCS + LLLT (G3) treatment also resulted in the most intense immunostaining for OPG, RANK, FGF-2 and TGF-β, and the most intense and diffuse OCN immunofluorescent labelling at 30 days postsurgery (G3 vs. G0 group, P < 0.05). Therefore, the use of CCS associated with LLLT could offer a synergistic advantage in improving the healing of bone fractures.
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Affiliation(s)
| | - Aurigena Antunes de Araújo
- Department of Biophysics and Pharmacology, Post Graduation Program in Public Health/Post Graduation Program in Pharmaceutical Science, Federal University of Rio Grande do Norte, Natal, RN, Brazil
| | - Raimundo Fernandes de Araújo Júnior
- Department of Morphology, Post Graduation Program in Health Science/Post Graduation Program in Functional and Structural Biology, Federal University of Rio Grande do Norte, Natal, RN, Brazil
| | - Carlos Augusto Galvão Barboza
- Department of Morphology, Post-Graduation Program in Oral Pathology, Federal University of Rio Grande do Norte, Natal, RN, Brazil
| | - Boniek Castillo Dutra Borges
- Department of Dentistry, Post-Graduation Program in Public Health, Federal University of Rio Grande do Norte, Natal, RN, Brazil
| | - José Sandro Pereira da Silva
- Department of Dentistry, Post-Graduation Program in Public Health, Federal University of Rio Grande do Norte, Natal, RN, Brazil
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Meyers N, Sukopp M, Jäger R, Steiner M, Matthys R, Lapatki B, Ignatius A, Claes L. Characterization of interfragmentary motion associated with common osteosynthesis devices for rat fracture healing studies. PLoS One 2017; 12:e0176735. [PMID: 28453556 PMCID: PMC5409164 DOI: 10.1371/journal.pone.0176735] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Accepted: 04/14/2017] [Indexed: 01/21/2023] Open
Abstract
Rat models are widely used in preclinical studies investigating fracture healing. The interfragmentary movement at a fracture site is critical to the course of healing and therefore demands definition in order to aptly interpret the experimental results. Estimation of this movement requires knowledge of the fixation stiffness and loading. The characteristic loading for the rat femur has been estimated, but the stiffness of fixation used in rat studies has yet to be fully described. This study aimed to determine the 6 degree of freedom stiffness of four commonly used implants, two external fixators (RatExFix and UlmExFix), a locking plate, and a locking intramedullary nail, in all degrees of freedom and estimate the interfragmentary movement under specific physiological loads. The external fixator systems allow the greatest movement. Mounted 45° anterolateral on the femur, the RatExFix allows an average of 0.88 mm of motion in each anatomic direction while the stiffer UlmExFix allows about 0.6 mm of motion. The nail is far stiffer than the other implants investigated while the plate allows movement of an intermediate magnitude. Both the nail and plate demonstrate higher axial than shear stiffness. The relatively large standard deviations in external fixator shear motion imply strong dependence on bone axis alignment across the gap and the precise orientation of the specimen relative to the loading. The smaller standard deviation associated with the nail and plate results from improved alignment and minimization of the influence of rotational positioning of the specimen due to the reduced implant eccentricity relative to the specimen axis. These results show that the interfragmentary movement is complex and varies significantly between fixation devices but establishes a baseline for the evaluation of the results of different studies.
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Affiliation(s)
- Nicholaus Meyers
- Institute of Orthopedic Research and Biomechanics, Center of Musculoskeletal Research Ulm, University Hospital Ulm, Ulm, Baden-Württemberg, Germany
- * E-mail:
| | - Matthias Sukopp
- Institute of Orthopedic Research and Biomechanics, Center of Musculoskeletal Research Ulm, University Hospital Ulm, Ulm, Baden-Württemberg, Germany
| | - Rudolf Jäger
- Department of Orthodontics, University Hospital Ulm, Ulm, Baden-Württemberg, Germany
| | - Malte Steiner
- Institute of Orthopedic Research and Biomechanics, Center of Musculoskeletal Research Ulm, University Hospital Ulm, Ulm, Baden-Württemberg, Germany
| | | | - Bernd Lapatki
- Department of Orthodontics, University Hospital Ulm, Ulm, Baden-Württemberg, Germany
| | - Anita Ignatius
- Institute of Orthopedic Research and Biomechanics, Center of Musculoskeletal Research Ulm, University Hospital Ulm, Ulm, Baden-Württemberg, Germany
| | - Lutz Claes
- Institute of Orthopedic Research and Biomechanics, Center of Musculoskeletal Research Ulm, University Hospital Ulm, Ulm, Baden-Württemberg, Germany
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Guerado E, Caso E. Challenges of bone tissue engineering in orthopaedic patients. World J Orthop 2017; 8:87-98. [PMID: 28251059 PMCID: PMC5314152 DOI: 10.5312/wjo.v8.i2.87] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Revised: 10/23/2016] [Accepted: 11/22/2016] [Indexed: 02/06/2023] Open
Abstract
Bone defects may impede normal biomechanics and the structural stability of bone as an organ. In many cases, the correction of bone defects requires extensive surgical intervention involving the use of bone-grafting techniques and other procedures in which healing is slow, there is a high risk of infection and considerable pain is provoked - with no guarantee of complete correction of the defect. Therefore, the search for surgical alternatives continues to present a major challenge in orthopaedic traumatology. The reamer-irrigator-aspirator (RIA) system, which was devised to avoid the problems that can arise with autograft harvesting from the iliac crest, consists of collecting the product of the femoral canal after reaming. The RIA technique improves osteogenic differentiation of mesenchymal stem cells, compared to bone marrow aspiration or cancellous bone harvesting from the iliac crest using a spoon. Another approach, the Masquelet technique, consists of reconstructing a long bone defect by means of an induced membrane grown onto an acrylic cement rod inserted to fill the defect; in a second surgical step, once the membrane is constituted, the cement rod is removed and cancellous autograft is used to fill the defect. Both in RIA and in the Masquelet technique, osteosynthesis is usually needed. Bone transportation by compression-distraction lengthening principles is commonly implemented for the treatment of large bone loss. However, complications are frequently encountered with these techniques. Among new techniques that have been proposed to address the problem of large bone loss, the application of stem cells in conjunction with tissue engineering techniques is very promising, as is the creation of personalised medicine (or precision medicine), in which molecular profiling technologies are used to tailor the therapeutic strategy, to ensure the right method is applied for the right person at the right time, after determining the predisposition to disease among the general population. All of the above techniques for addressing bone defects are discussed in this paper.
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