Clinical outcomes of autogenous cancellous bone grafts obtained through the portal for tibial nailing

Department of Orthopaedic Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea.
Injury (Impact Factor: 2.14). 03/2012; 43(7):1118-23. DOI: 10.1016/j.injury.2012.02.021
Source: PubMed
ABSTRACT
The purpose of this study is to introduce and review the clinical outcomes of a new technique for harvesting autogenous cancellous bone grafts in association with tibial intramedullary (IM) nailing.
We retrospectively reviewed 21 patients who received autogenous cancellous bone grafts obtained from the entry portal of a tibial IM nail for fracture gaps, malalignment or nonunion in the lower extremities. All patients were scheduled to receive IM nailing or had already received IM nailing for the fixation of an ipsilateral tibia shaft fracture. A total of 33 patients who received only tibial IM nailing were selected as a control group. Through the follow-up, postoperative complications related to the bone harvest were monitored. Further by taking serial X-rays, radiographic changes of the donor site and the knee joint were closely observed. Knee pain (visual analogue scale (VAS)) and function (Lysholm knee score) were compared between the study group and the control group.
At the last follow-up, the average VAS in the study group was 1.28 (0-5), which was not significantly different from the control group (VAS: 1.36, range 0-7) (P=0.985). The range of motion of the knee joint was similar in both groups, averaging 130.23° (range: 115-135°) and 131.36° (range: 115-135°), respectively. There was no significant difference in the Lysholm knee score between the study and control groups (P=0.610). All patients exhibited complete fracture healing at an average of 6 months and no complications associated with the bone donor site were observed.
By using the new technique, autogenous cancellous bone grafting can be performed conveniently and safely to treat fracture gaps, malalignment or nonunion in the lower extremities without additional morbidity at the donor site.

Full-text

Available from: Moses Lee, Oct 29, 2015
Clinical
outcomes
of
autogenous
cancellous
bone
grafts
obtained
through
the
portal
for
tibial
nailing
Moses
Lee,
Hyung-Keun
Song,
Kyu-Hyun
Yang
*
Department
of
Orthopaedic
Surgery,
Yonsei
University
College
of
Medicine,
Seoul,
Republic
of
Korea
Although
several
bone
substitutes
have
been
introduced
and
commercialised,
autogenous
bone
grafting
is
still
preferred
due
to
its
effectiveness.
1–6
Autogenous
cancellous
bone
grafting
is
a
particu-
larly
useful
treatment
for
bone
defects
or
nonunions
after
lower
extremity
fractures,
including
tibial
shaft
fractures.
Even
though
the
iliac
crest
is
the
most
popular
donor
site,
it
is
cumbersome
to
prepare
a
separate
operation
site.
Further,
approaching
and
closing
the
second
wound
is
time
consuming.
Moreover,
such
operations
incur
many
possible
complications
and
postoperative
morbidities.
For
these
reasons,
the
search
for
alternate
donor
sites
has
continued.
7–12
Besides
the
iliac
crest,
the
distal
femur,
proximal
tibia,
distal
tibia,
fibula
and
calcaneus
are
possible
lower
extremity
bone
graft
donor
sites.
13–15
Several
studies
have
reported
the
use
of
the
proximal
tibia
as
a
bone
graft
donor
site.
7–9,11,12
However,
all
of
these
prior
studies
used
a
separate
incision
to
approach
the
proximal
metaphysis
of
the
tibia.
8,9,11,12
Unlike
previous
methods,
we
harvested
autogenous
cancellous
bone
from
the
proximal
tibia
through
the
entry
portal
of
the
intramedullary
(IM)
nail.
Postoperative
outcomes
were
retrospectively
reviewed,
and
knee
pain
and
function
were
compared
with
those
of
patients
who
received
tibial
nailing
alone
without
bone
harvesting.
Patients
and
methods
Patients
This
study
was
approved
by
our
institutional
review
board.
From
August
1998
to
January
2009,
patients
who
met
the
following
conditions
were
selected
to
receive
autogenous
bone
grafts
using
the
new
technique:
(1)
a
patient
who
was
scheduled
to
receive
tibial
IM
nailing,
(2)
a
patient
who
had
already
received
IM
nailing
for
the
fixation
of
an
ipsilateral
tibia
shaft
fracture
and
was
scheduled
to
remove
or
exchange
the
nail,
Injury,
Int.
J.
Care
Injured
43
(2012)
1118–1123
A
R
T
I
C
L
E
I
N
F
O
Article
history:
Accepted
28
February
2012
Keywords:
Cancellous
bone
graft
Tibia
Intramedullary
nail
A
B
S
T
R
A
C
T
Background:
The
purpose
of
this
study
is
to
introduce
and
review
the
clinical
outcomes
of
a
new
technique
for
harvesting
autogenous
cancellous
bone
grafts
in
association
with
tibial
intramedullary
(IM)
nailing.
Materials
and
methods:
We
retrospectively
reviewed
21
patients
who
received
autogenous
cancellous
bone
grafts
obtained
from
the
entry
portal
of
a
tibial
IM
nail
for
fracture
gaps,
malalignment
or
nonunion
in
the
lower
extremities.
All
patients
were
scheduled
to
receive
IM
nailing
or
had
already
received
IM
nailing
for
the
fixation
of
an
ipsilateral
tibia
shaft
fracture.
A
total
of
33
patients
who
received
only
tibial
IM
nailing
were
selected
as
a
control
group.
Through
the
follow-up,
postoperative
complications
related
to
the
bone
harvest
were
monitored.
Further
by
taking
serial
X-rays,
radiographic
changes
of
the
donor
site
and
the
knee
joint
were
closely
observed.
Knee
pain
(visual
analogue
scale
(VAS))
and
function
(Lysholm
knee
score)
were
compared
between
the
study
group
and
the
control
group.
Results:
At
the
last
follow-up,
the
average
VAS
in
the
study
group
was
1.28
(0–5),
which
was
not
significantly
different
from
the
control
group
(VAS:
1.36,
range
0–7)
(P
=
0.985).
The
range
of
motion
of
the
knee
joint
was
similar
in
both
groups,
averaging
130.238
(range:
115–1358)
and
131.368
(range:
115–1358),
respectively.
There
was
no
significant
difference
in
the
Lysholm
knee
score
between
the
study
and
control
groups
(P
=
0.610).
All
patients
exhibited
complete
fracture
healing
at
an
average
of
6
months
and
no
complications
associated
with
the
bone
donor
site
were
observed.
Conclusions:
By
using
the
new
technique,
autogenous
cancellous
bone
grafting
can
be
performed
conveniently
and
safely
to
treat
fracture
gaps,
malalignment
or
nonunion
in
the
lower
extremities
without
additional
morbidity
at
the
donor
site.
ß
2012
Elsevier
Ltd.
All
rights
reserved.
*
Corresponding
author
at:
Department
of
Orthopaedic
Surgery,
Yonsei
University
College
of
Medicine,
Gangnam
Severance
Hospital,
Dogok-dong,
Gangnam-gu,
Seoul
135-720,
Republic
of
Korea.
Tel.:
+82
2
2019
3414;
fax:
+82
2
573
5393.
E-mail
addresses:
kyang@yuhs.ac,
kyang@yumc.yonsei.ac.kr
(K.-H.
Yang).
Contents
lists
available
at
SciVerse
ScienceDirect
Injury
jo
ur
n
al
ho
m
epag
e:
ww
w.els
evier
.c
om
/lo
cat
e/inju
r
y
0020–1383/$
see
front
matter
ß
2012
Elsevier
Ltd.
All
rights
reserved.
doi:10.1016/j.injury.2012.02.021
Page 1
(3)
accompanying
concomitant
problems
at
the
same
leg,
which
needed
a
cancellous
bone
graft
and
(4)
normal
proximal
tibial
anatomy
with
intact
knee
joint,
which
was
confirmed
by
preoperative
X-rays.
Further,
the
exclusion
criteria
were
specified
as
follows:
(1)
patients
who
had
any
joint
lesions
due
to
systemic
disease
(rheumatoid
arthritis,
gout
or
other
connective
tissue
disease),
(2)
a
history
of
a
fracture
at
the
same
leg
or
previous
operation
involving
the
knee
joint
(menisectomy,
anterior
cruciate
ligament
(ACL)
reconstruction
or
other
soft-tissue
surgeries)
and
(3)
patients
who
needed
structural
bone
graft.
Twenty-one
patients
met
the
inclusion
criteria
and
were
eligible
for
the
study
group.
Using
the
patients’
medical
records,
we
reviewed
age
at
time
of
presentation,
gender,
history
of
trauma,
initial
symptoms
and
durations,
as
well
as
the
number
of
previous
operations.
All
the
patients
underwent
autogenous
bone
grafting
from
the
proximal
tibial
metaphysis
due
to
a
bone
defect
after
fracture
or
its
complications,
such
as
malalignment
or
nonunion,
Fig.
1.
(A)
Initial
radiograph
of
a
36-year-old
female
presenting
nonunion
of
the
tibia
after
lengthening
osteotomy
to
correct
leg
length
discrepancy
(11
months
after
first
operation).
Arrows
indicate
the
nonunion
site.
(B)
Post-operative
radiographs;
the
previous
IM
nail
was
converted
to
plate
fixation
with
the
new
tibial
bone
graft
technique
(C)
Intra-operative
photograph
demonstrating
the
nonunion
site
before
and
after
bone
grafting.
(D)
Radiograph
after
six
months;
presenting
complete
union
(arrows).
M.
Lee
et
al.
/
Injury,
Int.
J.
Care
Injured
43
(2012)
1118–1123
1119
Page 2
all
of
which
occurred
in
the
tibia,
fibula
or
foot
on
the
same
limb.
The
patients
consisted
of
16
men
and
five
women
with
an
average
age
of
40
years
(range:
18–67
years).
There
were
nine
cases
of
motorcycle
accidents,
two
cases
of
motor
vehicle
accidents,
two
cases
of
pedestrian
traffic
accidents,
two
cases
of
sports
injuries,
two
cases
of
a
fall
from
height,
three
cases
of
industrial
accidents
and
one
case
of
tibial
osteotomy
to
treat
a
leg
length
discrepancy.
Postoperative
complications
at
the
donor
site,
time
to
union
and
functional
outcomes
were
reviewed
based
on
the
medical
record
and
interviews
with
patients.
A
total
of
eight
cases
of
nonunion
were
treated
with
proximal
tibia
bone
grafting
(tibia:
five
and
distal
fibula:
three).
If
bone
union
was
not
achieved
within
9
months
after
internal
fixation
and
no
progress
was
observed
during
the
last
3
months
of
follow-up,
the
patient
was
diagnosed
as
having
nonunion.
From
the
initial
operation
to
the
last
autogenous
tibial
bone
grafting,
the
average
time
was
12.8
months
(tibia:
11.8
months
and
fibula:
14.6
months).
All
five
cases
of
tibial
nonunion
were
referred
from
outside
hospitals
after
receiving
IM
nailing.
Following
the
removal
of
the
previous
IM
nail,
the
cancellous
bone
was
harvested
from
the
tibia
using
the
IM
nail
insertion
site
as
a
portal.
Then,
internal
fixation
was
performed
using
the
adequate
size
of
the
IM
nail
or
plate.
The
harvested
bone
was
grafted
into
the
nonunion
site
(Fig.
1).
Concomitant
ipsilateral
tibia
shaft
fractures
were
initially
treated
with
IM
nailing
in
all
three
cases
of
fibular
nonunion.
Later,
sufficient
bony
union
was
achieved
at
the
tibia
in
all
cases
except
for
fibula
fractures.
When
the
IM
nail
was
removed,
the
autogenous
bone
was
harvested
and
grafted
to
the
fibular
nonunion
site.
Re-
plating
of
the
nonunion
sites
of
distal
fibular
fractures
was
also
performed
for
stability.
In
four
cases,
malalignment
of
more
than
10
8
of
angular
deformity
was
identified
after
the
initial
IM
nailing.
These
cases
were
presented
to
our
hospital
with
valgus
malalignment
and
delayed
union
from
1
to
10
months
after
the
initial
surgery.
The
previously
inserted
IM
nail
was
removed
and
then
bone
harvest
was
performed
at
the
IM
nail
entry
site.
The
IM
nail
was
exchanged
for
another
nail
of
adequate
size.
Finally,
the
harvested
bone
was
grafted
at
the
fracture
gap.
Among
these,
one
case
received
plate
fixation
instead
of
exchange
IM
nailing.
Four
patients
received
temporary
external
fixators
for
open
tibial
fractures
that
were
later
converted
into
IM
nailing
(Fig.
2).
Autogenous
bone
grafting
at
the
fracture
site
was
also
performed
after
IM
nailing.
The
average
interval
from
external
fixation
to
nail
conversion
was
3.2
months
from
initial
trauma
(range:
1–
5
months).
Four
cases
presented
moderate
bone
defects
over
1
cm
due
to
fracture
comminution
following
accidents,
one
in
the
shaft
of
the
tibia
and
three
in
the
distal
fibula.
In
all
cases,
prior
to
inserting
the
tibia
IM
nail,
autogenous
cancellous
bone
was
obtained
from
both
condyles
of
the
tibia
and
grafted
to
the
tibia
or
fibula.
Fixation
of
the
distal
fibular
or
lateral
malleolus
was
performed
to
aid
in
the
reduction
of
unstable
distal
tibial
fractures
during
tibial
nailing.
Fig.
2.
(A)
Initial
radiograph
of
an
18-year-old
male
who
was
initially
treated
with
closed
reduction
and
temporary
external
fixation
for
an
open
tibia
fracture.
(B)
Post-
operative
radiographs;
after
one
month,
nail
conversion
was
performed
with
the
new
tibial
bone
graft
technique.
Arrows
indicate
the
bone
donor
site
(short
arrows)
and
grafted
site
(long
arrows).
(C)
Intra-operative
photograph
demonstrating
the
fracture
gap
before
and
after
bone
grafting.
(D)
Radiograph
after
six
months;
presenting
complete
union
at
the
main
fracture
site
(long
arrow)
and
no
interval
change
at
donor
site
(short
arrow).
M.
Lee
et
al.
/
Injury,
Int.
J.
Care
Injured
43
(2012)
1118–1123
1120
Page 3
One
patient
sustained
tibial
fractures
and
fracture
dislocation
of
the
ipsilateral
Lisfranc
joint.
Both
fractures
were
treated
with
IM
nailing
and
multiple
pinning
after
reduction.
After
16
months,
bony
union
was
achieved
in
the
tibia
but
post-traumatic
osteoarthritis
occurred
at
the
Lisfranc
joint.
When
the
tibial
IM
nail
was
removed,
Lisfranc
joint
fusion
was
concurrently
performed
using
autogenous
bone
obtained
from
the
proximal
tibia,
as
in
the
other
cases.
A
total
of
33
patients
(men:
25
and
women:
8)
were
selected
for
the
control
group.
The
control
group
exhibited
the
same
inclusion
and
exclusion
criteria
as
the
study
group,
except
that
they
only
had
tibia
shaft
fracture
without
concomitant
injuries.
The
average
age
of
the
control
group
was
39
years
(range:
21–71
years).
All
controls
underwent
tibial
nailing
only
for
tibial
shaft
fractures
during
the
same
time
period.
Operative
technique
Each
patient
was
placed
on
an
ordinary
operating
table
in
the
supine
position
with
a
tourniquet
at
the
proximal
thigh.
An
image
intensifier
was
placed
on
the
contralateral
side
of
the
operation
field.
For
the
13
patients
who
already
had
an
IM
nail
from
the
initial
operation,
a
skin
incision
was
made
along
the
previous
operation
scar.
All
prior
scars
were
located
on
the
anterior
aspect
of
the
patella
tendon.
For
the
eight
patients
who
were
planned
to
receive
IM
nailing,
a
midline
skin
incision
was
also
made
on
the
anterior
aspect
of
the
patella
tendon
starting
at
the
inferior
pole
of
the
patella
and
extending
3
cm
distally.
After
careful
soft-tissue
dissection,
the
patella
tendon
was
exposed
and
split.
An
entry
portal
was
created
at
the
junction
between
the
anterior
plateau
margin
and
anterior
tibial
cortex
using
an
awl.
Setting
the
entry
Fig.
3.
(A)
The
proximal
tibial
portal
for
bone
harvesting
after
removing
the
IM
nail;
an
arrow
indicates
the
tibial
portal
(long
arrow)
and
nonunion
site
(short
arrow).
(B)
Illustration
of
the
new
tibial
bone
graft
technique.
(C)
Harvested
cancellous
bone
from
the
proximal
tibia.
M.
Lee
et
al.
/
Injury,
Int.
J.
Care
Injured
43
(2012)
1118–1123
1121
Page 4
site
of
the
nail
as
a
reference
point,
both
the
medial
and
lateral
condyles
were
used
as
bone-harvesting
sites
using
conventional
curette
and
osteotomes
(Fig.
3).
For
patients
who
already
had
IM
nails
in
place,
bone
harvesting
was
performed
after
removing
the
nails.
After
removing
the
previous
nail,
removal
of
the
fibrous
lining
was
performed
to
collect
pure
cancellous
bone.
If
the
nail
needed
to
be
replaced,
this
was
accomplished
after
completing
the
harvest.
The
full-flexed
position
was
preferred
for
better
visuali-
sation
and
prevention
of
upward
bone
harvesting.
Prior
to
bone
harvesting,
an
image
intensifier
was
used
to
confirm
the
direction
of
the
curette
and
the
distance
from
the
joint
line.
The
harvest
was
carefully
performed
with
curettes
facing
downward
from
the
entry
portal
to
protect
the
subchondral
bone.
Assessment
Postoperative
follow-up
was
performed
on
a
regular
basis
at
1
month,
2
months,
3
months
and
every
6
months
thereafter.
Including
the
knee
joint,
extended
entire
tibia
X-rays
were
routinely
obtained
to
check
the
donor
site
and
the
operation
sites.
Any
radiographic
changes
such
as
joint
space
narrowing
and
subchondral
sclerosis
at
the
donor
site
were
closely
observed.
Complications
at
the
donor
site,
pain
measured
by
the
visual
analogue
scale
(VAS),
range
of
motion
and
the
union
status
of
the
main
operation
site
were
determined.
At
the
last
follow-up
after
surgery,
functional
clinical
outcomes
were
assessed
using
the
Lysholm
knee
score.
Statistical
methods
Two-sample
nonparametric
Mann–Whitney
tests
were
used
to
compare
VAS,
range
of
motion
and
Lysholm
knee
scores
between
the
study
and
control
groups
using
SAS
software
version
9.1
(SAS
Inc.,
Cary,
NC,
USA).
To
determine
potential
age
and
gender
differences
between
the
two
groups,
t-tests
and
chi-
square
tests
were
used.
P-values
<
0.05
were
considered
statistically
significant.
Results
In
total,
21
cases
of
the
study
group
were
followed
up
for
more
than
2
years.
The
mean
follow-up
was
62.7
months
(range:
24–
148
months).
There
were
no
differences
between
the
study
group
and
the
control
group
regarding
age
and
gender
(P
=
0.769
and
P
=
0.971,
respectively).
At
the
last
follow-up,
the
average
knee
pain
score
of
patients
who
underwent
proximal
tibial
bone
harvesting
was
1.28
(range:
0–5),
while
the
average
score
of
the
control
group
was
1.36
(range:
0–7);
this
was
not
significantly
different
(P
=
0.985).
The
knee
joint
range
of
motion
was
similar
in
both
the
study
and
the
control
groups,
averaging
130.238
(range:
115–1358)
and
131.368
(range:
115–1358),
respectively
(P
=
0.266).
At
the
final
follow-up,
knee
function
was
assessed
with
the
Lysholm
knee
score.
No
significant
differences
were
found
between
the
two
groups
(study
group:
89.71
and
control
group:
91.15,
P
=
0.610).
Each
patient’s
serial
X-rays
were
reviewed
by
three
authors.
There
were
no
significant
changes
such
as
knee
joint
space
narrowing,
subchondral
sclerosis,
subchondral
cyst
formation,
newly
developed
fracture
line,
depression
around
tibial
plateau
or
alteration
of
radio
opacity
at
the
donor
site.
There
were
no
infections,
dysesthesias,
fractures
or
haemato-
mas
around
the
donor
sites,
or
other
specific
complications
immediately
after
the
operation
or
during
the
follow-up
period.
Complete
bony
union
was
achieved
at
the
grafted
site
after
a
mean
duration
of
5.7
months
(range:
3–9
months).
Discussion
The
first
autogenous
cancellous
bone
graft
was
documented
by
van
Meekeren
16
in
1668.
Since
then,
it
has
become
a
very
popular
procedure
for
the
treatment
of
bone
defects
and
nonunion
and
reconstructive
surgery
in
orthopaedics,
and
is
performed
over
200
000
times
annually
in
the
United
States.
17
Several
bones
are
used
as
potential
donor
sites,
including
the
ilium,
rib,
distal
radius,
distal
femur,
proximal
and
distal
tibia,
fibula
and
calcaneus.
9,13–15
Among
these,
the
ilium
is
the
most
commonly
used
site.
Although
the
iliac
crest
can
be
easily
accessed
and
provides
a
sufficient
amount
of
bone,
many
studies
pointed
out
that
it
was
short
of
being
the
optimal
site
for
harvesting
bones
due
to
many
complications.
13–15,18–23
Reported
complications
include
haema-
toma,
fractures,
wound
complications,
chronic
pain,
neural
damage
(affecting
the
lateral
femoral
cutaneous
nerve,
cluneal
nerve
and
ilioinguinal
nerve)
and
herniation
of
abdominal
contents.
13–15,22–24
In
a
recent
systematic
review
by
Dimitriou
et
al.,
25
the
overall
complication
rate
after
iliac
crest
bone
harvesting
was
19.37%
(1249
complications
in
6449
patients).
In
addition,
500
patients
(7.75%)
had
chronic
donor
site
pain,
which
persisted
for
more
than
6
months.
To
address
those
problems,
attempts
to
use
other
sites
such
as
the
olecranon,
proximal
tibia
and
even
the
IM
canal
using
the
reamer/irrigator/aspirator
(RIA)
system
have
been
reported.
7–12,18–21
Including
the
largest
study
(230
patients)
by
O’Keeffe
et
al.,
11
the
average
complication
rate
after
using
proximal
metaphysis
of
the
tibia
as
a
bone
graft
donor
site
ranged
from
1.4%
to
2.7%.
8,9,12
Moreover,
two
studies
that
directly
compared
the
proximal
tibia
to
the
iliac
crest
presented
less
postoperative
pain.
19,20
These
reports
favourably
compared
the
proximal
tibia
to
the
ilium
as
a
bone
donor
site
in
terms
of
safety
and
low
morbidity.
Furthermore,
according
to
findings
from
other
studies,
concerns
for
the
amount
of
harvestable
bone
available
at
the
proximal
tibia
are
unfounded,
as
there
are
no
volumetric
differences
between
the
proximal
tibia
and
the
ilium
in
the
amount
of
harvestable
bone.
19,26,27
Clinically,
all
prior
studies
that
used
the
proximal
tibia
as
a
donor
site
obtained
a
sufficient
amount
of
bone.
8,9,11,12,27,28
In
addition,
harvesting
bone
from
the
proximal
tibial
metaphysis
did
not
increased
the
risk
of
fractures.
7,19,20
The
current
study
confirms
these
prior
reports,
as
it
found
no
complications
related
to
the
donor
site
and
knee
function.
Despite
all
of
the
advantages,
harvesting
bone
from
the
proximal
tibia
using
the
previous
technique
bears
sensory-related
complications,
likely,
due
to
injury
to
the
infrapatellar
branch
of
the
saphenous
nerve
or
the
lateral
sural
cutaneous
nerve
from
the
common
peroneal
nerve.
Gerdy’s
tubercle
was
used
as
an
anatomic
landmark,
and
a
separate
incision
was
made
around
the
antero-lateral
aspect
of
the
proximal
tibia.
8,9,11,12
To
our
knowledge,
no
study
has
used
the
entry
of
the
IM
nail
as
an
approach
for
harvesting
autogen ous
cancellous
bone
from
the
proximal
tibia.
Using
the
entry
of
the
IM
nail
as
an
access
point
for
harvesting
bone
has
numerous
advantages.
Unlike
the
ilium,
a
tourniquet
can
be
applied
proximal
to
the
operation
field,
which
can
lessen
unnecessary
bleeding.
Surgeons
also
have
more
options
for
anaesthesia;
this
may
prevent
inadequate
anaesthesia.
9
Further,
the
proximal
tibia
is
in
the
same
operation
field,
which
makes
the
surgery
more
convenient
in
terms
of
positioning
and
draping.
12
This
may
lessen
the
chance
of
contamination.
Since
this
technique
recycles
the
scar
from
the
previous
operation,
there
is
no
need
to
make
another
incision;
this
shortens
the
operation
time
and
minimises
cosmetic
complications.
In
addition,
if
the
patient
has
a
history
of
prior
bone
graft
surgeries
such
as
a
spinal
fusion,
the
proximal
tibia
can
be
a
convenient
alternative
for
the
bone
graft
donor
site.
M.
Lee
et
al.
/
Injury,
Int.
J.
Care
Injured
43
(2012)
1118–1123
1122
Page 5
The
limitations
of
the
current
study
include
the
small
patient
sample
and
its
retrospective
nature.
In
addition,
since
the
bone
was
harvested
only
in
the
needed
amounts,
it
was
difficult
to
assess
the
maximum
amount
of
grafted
bone
in
clinical
situation.
Despite
these
limitations,
the
current
study
suggests
that
it
is
possible
to
obtain
a
sufficient
amount
bone
for
grafting
using
the
entry
site
of
the
tibial
nail,
without
complications
at
the
donor
site.
This
technique
was
especially
useful
for
nail
conversion
from
external
fixation
and
exchange
IM
nailing
with
a
persistent
fracture
gap.
During
the
follow-up
period,
knee
function
and
pain
in
the
experimental
group
did
not
differ
from
those
of
the
control
group.
These
findings
demonstrate
that
this
technique
is
a
potentially
useful
approach
for
bone
harvesting,
at
least
in
similar
contexts.
Conflict
of
interest
statement
The
authors
confirm
that
no
benefits
in
any
form
have
been
received
or
will
be
received
from
other
people
or
a
commercial
party
related
directly
or
indirectly
to
the
subject
of
this
article.
Acknowledgements
The
authors
thank
D.S.
Jang
for
his
excellent
support
with
medical
illustrations.
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  • Source
    • "Bone morphogenetic protein-2 (BMP-2) is a potent osteoinductive cytokine that plays a critical role during bone regeneration and repair. In the extracellular environment , sulfated polysaccharides anchored covalently to glycoproteins such as syndecan and also non-covalently to fibronectin fibers have been shown to bind to BMP-2 through a heparin-binding domain and regulate its bio- activity [37]. The supramolecular peptide amphiphile nanofibers, which integrate the biological role of syndecan and fibronectin, have been controlled and designed to form as a network within the pores of an absorbable collagen scaffold. "
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  • [Show abstract] [Hide abstract] ABSTRACT: Critical failures associated with current engineered bone grafts involve insufficient induction of osteogenesis of the implanted cells and lack of vascular integration between graft scaffold and host tissue. This study investigated the combined effects of surface microtextures and biochemical supplements to achieve osteogenic differentiation of human mesenchymal stem cells (hMSCs) and revascularization of the implants in vivo. Cells were cultured on 10μm micropost-textured polydimethylsiloxane (PDMS) substrates in either proliferative basal medium (BM) or osteogenic medium (OM). In vitro data revealed that cells on microtextured substrates in OM had dense coverage of extracellular matrix, whereas cells in BM displayed more cell spreading and branching. Cells on microtextured substrates in OM demonstrated a higher gene expression of osteoblast-specific markers, namely collagen I, alkaline phosphatase, bone Sialoprotein, and Osteocalcin, accompanied by substantial amount of bone matrix formation and mineralization. To further investigate the osteogenic capacity, hMSCs on microtextured substrates under different biochemical stimuli were implanted into subcutaneous pockets on the dorsal aspect of immunocompromised mice to study capacity for ectopic bone formation. In vivo data revealed greater expression of osteoblast-specific markers coupled with increased vascular invasion on microtextured substrates with hMSCs cultured in OM. Together, these data represent a novel regenerative strategy that incorporates defined surface microtextures and biochemical stimuli to direct combined osteogenesis and re-vascularization of engineered bone scaffolds for musculoskeletal repair and relevant bone tissue engineering applications. Copyright © 2015. Published by Elsevier Ltd.
    No preview · Article · Feb 2015 · Acta Biomaterialia
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    [Show abstract] [Hide abstract] ABSTRACT: Introduction: Nonunion is a challenging problem that may occur after certain bone fractures. The treatment of nonunion is closely related to its type. To develop an effective treatment strategy for each type of nonunion, biological analysis of nonunion tissue is essential. Pseudoarthrosis is a distinct pathologic entity of nonunion. To understand the pathology of pseudoarthrosis, we investigated the cellular properties of pseudoarthrosis tissue-derived cells (PCs) in vitro. Patients and methods: PCs were isolated from four patients with pseudoarthrosis and cultured. Cells were evaluated for cell-surface protein expression by using flow cytometry. Osteogenic differentiation capacity was assessed by using Alizarin Red S staining, alkaline phosphatase (ALP) activity assay, and reverse transcription polymerase chain reaction (RT-PCR) after osteogenic induction. Chondrogenic differentiation capacity was assessed via Safranin O staining and RT-PCR after chondrogenic induction. Results: PCs were consistently positive for the mesenchymal stem cell-related markers CD29, CD44, CD105, and CD166, but were negative for the haematopoietic-lineage markers CD31, CD34, CD45, and CD133. Alizarin Red S staining revealed that PCs formed a mineralised matrix that was rich in calcium deposits after osteogenic induction. ALP activity under osteogenic conditions was significantly higher than that under control conditions. Gene expression of ALP, Runx2, osterix, osteocalcin, and bone sialoprotein was observed in PCs cultured under osteogenic conditions. Induced pellets were negatively stained by Safranin O staining. Gene expression of aggrecan, collagen II, collagen X, SOX5, and SOX9 was not observed. Conclusion: We have shown for the first time the properties of cells in patients with pseudoarthrosis. Our results indicated that osteogenic cells existed in the pseudoarthrosis tissue. This study might provide insights into understanding the pathology of pseudoarthrosis and improving the treatment for pseudoarthrosis.
    Preview · Article · Mar 2016 · Injury