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Freischmidt H, Guehring T, Thomé P, Armbruster J, Reiter G, Grützner PA, Nolte PC. Treatment of Large Femoral and Tibial Bone Defects With Plate-Assisted Bone Segment Transport. J Orthop Trauma 2024; 38:285-290. [PMID: 38381977 PMCID: PMC11017834 DOI: 10.1097/bot.0000000000002784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Accepted: 02/06/2024] [Indexed: 02/23/2024]
Abstract
OBJECTIVES The purposes of this study were to assess clinical and radiographic outcomes following plate-assisted bone segment transport (PABST) in large bone defects of the lower extremities. METHODS DESIGN Retrospective study of prospectively collected data. SETTING Level-1 trauma center located in Germany. PATIENT SELECTION CRITERIA Patients who underwent PABST and were at least 1 year postoperatively were included. OUTCOME MEASURES AND COMPARISONS Demographic data were collected. Radiographic apparent bone gap (RABG), time to consolidation, time to full weight-bearing, and consolidation index were calculated. Numeric rating scale, lower extremity functional scale (LEFS), and complications were assessed. RESULTS Fifteen patients [13 male; mean age 51 years (range, 20-75)] underwent PABST and had follow-up at a mean of 29.1 months. The tibia was affected in 8 and the femur in 7 patients. Preoperative RABG was 60 mm [interquartile range (IQR): 40-125], and bone defects were caused by septic nonunions in 73% of patients. Fourteen patients (93%) demonstrated consolidated transport callus at 7.3 months [95% confidence interval (95% CI), 6-8.5], and 9 patients (60%) demonstrated complete consolidation of both docking site and transport callus at 11.5 months (95% CI, 7.3-15.3). Postoperative RABG was 0.1 mm (IQR: 0-0.8), and consolidation index was 1.9 months/cm (95% CI, 1.3-2.5). All patients achieved full weight-bearing at 8.7 months (IQR: 6.5-10.3). LEFS was 42 (95% CI, 34-50), and numeric rating scale was 3 (95% CI, 2-4). Patients treated for tibial defects had a significantly higher consolidation rate compared with patients treated for femoral defects ( P = 0.040). CONCLUSIONS PABST demonstrated high consolidation of transport callus with few complications. Although full weight-bearing was achieved in all patients, complete consolidation of the docking site was only present in 60% of cases. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Holger Freischmidt
- Department of Trauma and Orthopedic Surgery, BG Klinik Ludwigshafen, Ludwigshafen am Rhein, Germany; and
| | - Thorsten Guehring
- Department of Shoulder and Elbow Surgery, Sportsmedicine & Traumatology, Diakonie Clinic Paulinenhilfe, Stuttgart, Germany
| | - Patrick Thomé
- Department of Trauma and Orthopedic Surgery, BG Klinik Ludwigshafen, Ludwigshafen am Rhein, Germany; and
| | - Jonas Armbruster
- Department of Trauma and Orthopedic Surgery, BG Klinik Ludwigshafen, Ludwigshafen am Rhein, Germany; and
| | - Gregor Reiter
- Department of Trauma and Orthopedic Surgery, BG Klinik Ludwigshafen, Ludwigshafen am Rhein, Germany; and
| | - Paul Alfred Grützner
- Department of Trauma and Orthopedic Surgery, BG Klinik Ludwigshafen, Ludwigshafen am Rhein, Germany; and
| | - Philip-Christian Nolte
- Department of Trauma and Orthopedic Surgery, BG Klinik Ludwigshafen, Ludwigshafen am Rhein, Germany; and
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Marais LC, Zalavras CG, Moriarty FT, Kühl R, Metsemakers WJ, Morgenstern M. The surgical management of fracture-related infection. Surgical strategy selection and the need for early surgical intervention. J Orthop 2024; 50:36-41. [PMID: 38162257 PMCID: PMC10755499 DOI: 10.1016/j.jor.2023.11.033] [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: 06/26/2023] [Accepted: 11/14/2023] [Indexed: 01/03/2024] Open
Abstract
The aim of this narrative review is to describe the various surgical management strategies employed in fracture-related infection (FRI), to explore how they are selected and discuss the rationale for early surgical intervention. Surgical treatment options in patients with FRI include debridement, antibiotics and implant retention (DAIR), revision (exchange) or removal. In selecting a treatment strategy, a variety of factors need to be considered, including the condition of the bone, soft tissues, host and causative microorganism. Irrespective of the selected treatment strategy, prompt surgical intervention should be considered in order to confirm the diagnosis of an FRI, to identify the causative organism, remove necrotic or non-viable tissue that can serve as a nidus for ongoing infection, ensure a healthy soft tissue envelope and to prevent the vicious cycle of infection associated with skeletal and/or implant instability. Ultimately, the objective is to prevent the establishment of a persistent infection. Urgent surgery may be indicated in case of active, progressive disease with systemic deterioration, local progression of infection, deterioration of soft tissues, or progressive fracture instability. In case of static disease, the patient should be monitored closely and surgery can be performed on an elective basis, allowing adequate time for optimisation of the host through risk factor modification, optimisation of the soft tissues and careful planning of the surgery.
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Affiliation(s)
- Leonard C. Marais
- Department of Orthopaedics, School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Charalampos G. Zalavras
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, USA
| | - Fintan T. Moriarty
- AO Research Institute Davos, Davos, Switzerland
- Center for Musculoskeletal Infections, Department of Orthopaedics and Trauma Surgery, University Hospital Basel, Basel, Switzerland
| | - Richard Kühl
- Center for Musculoskeletal Infections, Department of Orthopaedics and Trauma Surgery, University Hospital Basel, Basel, Switzerland
- Department of Infectious Diseases and Hospital Hygiene, University Hospital Basel, Switzerland
| | - Willem-Jan Metsemakers
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Mario Morgenstern
- Center for Musculoskeletal Infections, Department of Orthopaedics and Trauma Surgery, University Hospital Basel, Basel, Switzerland
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Amouzadeh Omrani F, Sarzaeem MM, Noorbakhsh M, Baroutkoub M, Afzal S, Barati H, Panjeshahi A. The Outcomes of Distraction Osteogenesis over an Intramedullary Nail for the Treatment of Bone Defects in Infectious Nonunions. THE ARCHIVES OF BONE AND JOINT SURGERY 2024; 12:204-210. [PMID: 38577507 PMCID: PMC10989721 DOI: 10.22038/abjs.2023.73572.3407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 12/18/2023] [Indexed: 04/06/2024]
Abstract
Objectives The concurrent utilization of an external fixator and intramedullary nail (IMN) for segment transportation may potentially decrease the duration of external fixator implementation and reduce associated complications. This study aimed to report the outcomes of bone transport utilizing a combination of IMN and Ilizarov frame in a cohort of individuals who had tibia or femur critical-sized bone deficiency resulting from nonunion. Methods The present research used a single-arm clinical trial design to enroll a series of patients presenting with critical-sized bone defects resulting from infectious nonunion of the tibia or femur. The study was conducted during the period of 2017-2020 in a referral Orthopedic Surgery Center located in Tehran, Iran. The management of patients with infectious nonunion was carried out through two main stages, including infection eradication and bone transportation. The process of bone healing and segment transportation was evaluated by radiographic assessment throughout the follow-up period. Results A total of 39 patients with bone defects in the tibia (19 cases) or femur (20 cases) with a mean age of 31.44 (±11.95, range=18-60) were included in this study. Twenty-nine (74.3%) patients had open fractures. The bone defect exhibited an average size of 6.31 ± 1.95 cm. The mean of the consolidation index (CI) was 0.97 (range=0.51-1.32) mo/cm, and the mean of the external fixator index was 0.67 (range=0.41-1.10). Although the CI was longer in patients with open fracture compared to those with closed fracture, the difference was not statistically significant (P=0.353). After the end of the two-year follow-up, complete union was observed in 35 patients (89.7%). Conclusion Intercalary segmental bone transportation using the Ilizarov technique over an IMN, as well as preserving the advantages of the conventional callotasis method, reduces the complications of long-term use of the Ilizarov frame and increases patient adherence to treatment.
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Affiliation(s)
- Farzad Amouzadeh Omrani
- Department of Orthopedic Surgery, School of medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad Mahdi Sarzaeem
- Department of Orthopedic Surgery, School of medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohsen Noorbakhsh
- Cellular and Molecular Research Center, Shahrekord University of Medical Sciences, Shahrekord, Iran
| | - Mojtaba Baroutkoub
- Department of Orthopedic Surgery, School of medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Sina Afzal
- Department of Orthopedic Surgery, School of medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hasan Barati
- Department of Orthopedic Surgery, School of medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Ali Panjeshahi
- Department of Orthopedic Surgery, School of medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Rossi N, Sciancalepore F, Daolio PA, Verdoni F, Mangiavini L. Huntington procedure for the treatment of tibial nonunion in a 17-years old male: A case report. Int J Surg Case Rep 2023; 113:109084. [PMID: 37988988 PMCID: PMC10667759 DOI: 10.1016/j.ijscr.2023.109084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 11/16/2023] [Accepted: 11/17/2023] [Indexed: 11/23/2023] Open
Abstract
INTRODUCTION Bone is considered a tissue with good healing properties, and many bone defects can heal spontaneously under appropriate conditions. Extreme bone loss can hinder remodeling and regenerative processes, leading to bone nonunion. This condition negatively impacts the patient's quality of life with a severe socioeconomic burden. Many treatment options have been proposed, but none can be defined as a gold standard, mainly due to the variety of clinical presentation, bone loss, and quality. PRESENTATION OF CASE We present a 15-year-old case of tibial nonunion following multiple traumas. The patient was treated non-surgically at the beginning, but the external fixator positioning was required due to a delay in the healing process. Following further trauma, the patient showed progressive anterolateral angulation, severe lateral procurvation, and a progressive worsening of the pseudoarthrosis. The severe bone loss and poor quality of the bone surrounding the defect required a special technique called Huntington procedure that consists in a vascularized bone autograft from the ipsilateral fibula to achieve mechanical and biological healing of the pseudoarthrosis. The patient recovered well and returned to full weight bearing without a mobility aid. DISCUSSION We report this case of complex tibial nonunion and malalignment, developed after subsequent traumas. Due to the multiple complications, and the poor biology a Huntington procedure was required to provide mechanical stability and a biological boost to the bone defect. CONCLUSION This case report shows a complicated case requiring several surgeries and treatment options and confirms the potential benefit of the Huntington procedure for treating a tibial severe bone loss.
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Affiliation(s)
- Nicolò Rossi
- Residency Program in Orthopaedics and Traumatology, University of Milan, Milano, Italy.
| | | | | | - Fabio Verdoni
- IRCCS Ospedale Galeazzi Sant'Ambrogio, Milano, Italy
| | - Laura Mangiavini
- IRCCS Ospedale Galeazzi Sant'Ambrogio, Milano, Italy; Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
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Kunwar BB, Maheshwari V, Dhingra M, bhagat S, PV C, Vardhan S. Use of locked plates and mono-rail fixator in segmental tibial defects: A prospective interventional study. J Orthop 2023; 44:47-52. [PMID: 37664557 PMCID: PMC10471829 DOI: 10.1016/j.jor.2023.08.003] [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: 04/23/2023] [Revised: 07/05/2023] [Accepted: 08/13/2023] [Indexed: 09/05/2023] Open
Abstract
Introduction The management of gap non-union is a major challenge to both the clinician and the patient as it is technically difficult, time-intensive, and physically arduous for the patient along with an unpredictable result. Gap non-union can arise from extrusion of bony fragment at the time of trauma or after debridement of unhealthy bone later. Moreover, Tibia because of its subcutaneous anatomy can easily undergo bone-loss and segmental defect. Among various methods available for managing gap non-union of tibia distraction osteogenesis using either ilizarov fixator or mono-rail fixator is the most popular one. Here we present functional and bony outcomes of combined use of locking plate and Limb Reconstruction System (LRS) in tibial gap non-union and assess whether it decreases fixator time and related complications. Patients and methods A prospective intervention study constituting 10 patients with Paley's type B1 tibial gap non-union over a period of 22months. In first stage, debridement was done; tibial locking plate and mono-rail fixator were applied along with corticomy at proximal tibia. Distraction was started 7-14 days later. At the end of distraction phase, fixator was removed and transported segment was fixed with screws with or without bone grafting at docking site. Patients were followed up every 6 weeks for radiological and clinical assessment. Functional assessment using Application for the Study and Application of the Method of Ilizarov (ASAMI) functional score, and Musculoskeletal Tumour Society (MSTS) functional score while bone outcome was assessed with ASAMI bone score. Quality of regenerate was assessed by Fernandez-Esteve grading. Detailed scoring was done at the time of index surgery, at the time of LRS removal and at the time of consolidation phase. Results All the 10 patients were male with mean age of 33 years. The mean defect size was 4.94 cm after debridement. Minimum duration of follow up was 30 weeks after removal of LRS. Mean duration between trauma and inclusion in the study was 17.7 months. The median external fixator index was 15.63 days/cm. The complication rate was 1.3/patient. According to Paley's classification, there were eleven problems and two obstacles, and no true complications. Both ASAMI bone score and functional scores were excellent in three and good in six patients. The median MSTS composite score was 76.66%. Conclusion The integrated fixation is an effective and satisfactory method enabling early external fixator removal with low rate of complication. So, this technique can be recommended for the management of segmental tibial defects. Level of evidence II.
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Affiliation(s)
- Bom Bahadur Kunwar
- Department of Orthopedics, All India Institute of Medical Sciences, Rishikesh, India
| | - Vikas Maheshwari
- Department of Orthopedics, All India Institute of Medical Sciences, Rishikesh, India
| | - Mohit Dhingra
- Department of Orthopedics, All India Institute of Medical Sciences, Rishikesh, India
| | - Saroj bhagat
- Department of Orthopedics, All India Institute of Medical Sciences, Rishikesh, India
| | - Chanakya PV
- Department of Orthopedics, All India Institute of Medical Sciences, Rishikesh, India
| | - Sunit Vardhan
- Department of Orthopedics, All India Institute of Medical Sciences, Rishikesh, India
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Rossi N, Hadad H, Bejar-Chapa M, Peretti GM, Randolph MA, Redmond RW, Guastaldi FPS. Bone Marrow Stem Cells with Tissue-Engineered Scaffolds for Large Bone Segmental Defects: A Systematic Review. TISSUE ENGINEERING. PART B, REVIEWS 2023; 29:457-472. [PMID: 36905366 DOI: 10.1089/ten.teb.2022.0213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/12/2023]
Abstract
Critical-sized bone defects (CSBDs) represent a significant clinical challenge, stimulating researchers to seek new methods for successful bone reconstruction. The aim of this systematic review is to assess whether bone marrow stem cells (BMSCs) combined with tissue-engineered scaffolds have demonstrated improved bone regeneration in the treatment of CSBD in large preclinical animal models. A search of electronic databases (PubMed, Embase, Web of Science, and Cochrane Library) focused on in vivo large animal studies identified 10 articles according to the following inclusion criteria: (1) in vivo large animal models with segmental bone defects; (2) treatment with tissue-engineered scaffolds combined with BMSCs; (3) the presence of a control group; and (4) a minimum of a histological analysis outcome. Animal research: reporting of in Vivo Experiments guidelines were used for quality assessment, and Systematic Review Center for Laboratory animal Experimentation's risk of bias tool was used to define internal validity. The results demonstrated that tissue-engineered scaffolds, either from autografts or allografts, when combined with BMSCs provide improved bone mineralization and bone formation, including a critical role in the remodeling phase of bone healing. BMSC-seeded scaffolds showed improved biomechanical properties and microarchitecture properties of the regenerated bone when compared with untreated and scaffold-alone groups. This review highlights the efficacy of tissue engineering strategies for the repair of extensive bone defects in preclinical large-animal models. In particular, the use of mesenchymal stem cells, combined with bioscaffolds, seems to be a successful method in comparison to cell-free scaffolds.
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Affiliation(s)
- Nicolò Rossi
- Wellman Center for Photomedicine and Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Henrique Hadad
- Skeletal Biology Research Center, Department of Oral and Maxillofacial Surgery, Massachusetts General Hospital, Harvard School of Dental Medicine, Boston, Massachusetts, USA
| | - Maria Bejar-Chapa
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Giuseppe M Peretti
- Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
| | - Mark A Randolph
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Robert W Redmond
- Wellman Center for Photomedicine and Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Fernando P S Guastaldi
- Skeletal Biology Research Center, Department of Oral and Maxillofacial Surgery, Massachusetts General Hospital, Harvard School of Dental Medicine, Boston, Massachusetts, USA
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Voljc T, Schintler M, Vasilyeva A, Kamolz LP, Buerger H. Simultaneous Free Fibula and Anterolateral Thigh Flap in Lower Extremity Reconstruction Following Osteomyelitis in a Trauma Patient: A Case Report. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1206. [PMID: 37512018 PMCID: PMC10384821 DOI: 10.3390/medicina59071206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 06/12/2023] [Accepted: 06/21/2023] [Indexed: 07/30/2023]
Abstract
This case report focuses on a 17-year-old polytrauma patient who suffered a septic wound infection after an open reduction and internal fixation (ORIF) and soft tissue reconstruction with a pedicled flap, which led to a substantial bone and soft tissue defect of the lower leg. After thorough antibiotic treatment and after ensuring a non-septic wound, the defect was reconstructed using a contralateral free fibula flap designed as a flow through flap in a double loop manner to accommodate two fibular fragments and an ipsilateral ALT flap. Early weight bearing was initiated 11 days after the free flap transfer under external fixation, with full weight bearing achieved in 36 days with external fixation. After the removal of external fixation, full weight bearing was able to be reinitiated after 13 days, leading to the patient's return to normal activity 6 months after the bony reconstruction. This case presents an innovative approach to treating a complex defect, with the final decision on using two separate free flaps instead of a single osteofasciocutaneous free flap resulting in a good bony reconstruction and soft tissue coverage, and with the use of external fixation enabling early rehabilitation.
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Affiliation(s)
- Tadej Voljc
- Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, University Hospital Graz, 8036 Graz, Austria
| | - Michael Schintler
- Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, University Hospital Graz, 8036 Graz, Austria
| | - Anna Vasilyeva
- Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, University Hospital Graz, 8036 Graz, Austria
| | - Lars-Peter Kamolz
- Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, University Hospital Graz, 8036 Graz, Austria
| | - Heinz Buerger
- Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, University Hospital Graz, 8036 Graz, Austria
- Division of Hand and Microsurgery, Private Hospital Maria Hilf, 9020 Klagenfurt am Woerthersee, Austria
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Huang J, Lu J, Liu Z, Jin J, Xie C, Zheng Y, Wang Z, Yu L, Zhu Y, Fan G, Sun G, Xu Z, Zhou G. Covalent immobilization of VEGF on allogeneic bone through polydopamine coating to improve bone regeneration. Front Bioeng Biotechnol 2022; 10:1003677. [PMID: 36312529 PMCID: PMC9597090 DOI: 10.3389/fbioe.2022.1003677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 09/20/2022] [Indexed: 11/17/2022] Open
Abstract
Objective: Promoting bone regeneration and repairing in bone defects is of great significance in clinical work. Using a simple and effective surface treatment method to enhance the osteogenic ability of existing bone scaffold is a promising method. In this article, we study the application of catecholic amino acid 3,4-dihydroxyphenylalanine (DOPA) surface coating chelated with vascular endothelial growth factor (VEGF) on allogeneic bone. Method: Allogeneic bone is immersed in DOPA solution and DOPA form polydopamine (PDA) with good adhesion. Electron microscopy is used to characterize the surface characteristics of allogeneic bone. MC3T3-E1 cells were tested for biocompatibility and osteogenic signal expression. Finally, a 12-week rabbit bone defect model was established to evaluate bone regeneration capability. Results: We found that the surface microenvironment of DOPA bonded allogeneic bone was similar to the natural allogeneic bone. VEGF loaded allografts exhibited satisfying biocompatibility and promoted the expression of osteogenic related signals in vitro. The VEGF loaded allografts healed the bone defect after 12 weeks of implantation that continuous and intact bone cortex was observed. Conclusion: The PDA coating is a simple surface modification method and has mild properties and high adhesion. Meanwhile, the PDA coating can act on the surface modification of different materials. This study provides an efficient surface modification method for enhancing bone regeneration by PDA coating, which has a high potential for translational clinical applications.
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Affiliation(s)
- Jianhao Huang
- Department of Orthopedics, Jinling Hospital, The first School of Clinical Medicine, Southern Medical University, Nanjing, China
| | - Jingwei Lu
- Affiliated Jinling Hospital, School of Medicine, Nanjing University, Nanjing, China
| | - Ziying Liu
- Affiliated Jinling Hospital, School of Medicine, Nanjing University, Nanjing, China
| | - Jing Jin
- Nanjing Drum Tower Hospital, Nanjing, China
| | - Chunmei Xie
- Hangzhou Lancet Robotics Company Ltd, Hangzhou, China
| | - Yang Zheng
- Nanjing Yaho Dental Clinic, Nanjing, China
| | - Zhen Wang
- Affiliated Jinling Hospital, School of Medicine, Nanjing University, Nanjing, China
| | - Lingfeng Yu
- Affiliated Jinling Hospital, School of Medicine, Nanjing University, Nanjing, China
| | - Yan Zhu
- Affiliated Jinling Hospital, School of Medicine, Nanjing University, Nanjing, China
| | - Gentao Fan
- Affiliated Jinling Hospital, School of Medicine, Nanjing University, Nanjing, China
| | - Guojing Sun
- Affiliated Jinling Hospital, School of Medicine, Nanjing University, Nanjing, China
| | - Zhihong Xu
- Department of Orthopaedic Surgery, Nanjing Drum Tower Hospital, Nanjing, China
- *Correspondence: Zhihong Xu, ; Guangxin Zhou,
| | - Guangxin Zhou
- Department of Orthopedics, Jinling Hospital, The first School of Clinical Medicine, Southern Medical University, Nanjing, China
- Affiliated Jinling Hospital, School of Medicine, Nanjing University, Nanjing, China
- *Correspondence: Zhihong Xu, ; Guangxin Zhou,
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