The Mechanism of Action of Induced Membranes in Bone Repair

Clinical Research Center (O.-M.A., P.L., S.L., and H.-V. L), Department of Clinical Chemistry, Institute of Diagnostics (J.R.), Division of Anatomy and Cell Biology, Department of Biomedicine (P.L, S.L., and H.-V. L), P.O. Box 8000, 90014, University of Oulu, Oulu, Finland. E-mail address for O.-M. Aho: . E-mail address for P. Lehenkari: . E-mail address for S. Lehtonen: . E-mail address for J. Risteli: . E-mail address for H.-V. Leskelä: .
The Journal of Bone and Joint Surgery (Impact Factor: 5.28). 04/2013; 95(7):597-604. DOI: 10.2106/JBJS.L.00310
Source: PubMed


Inducement of foreign-body granulation tissue is a relatively novel therapeutic modality in bone repair. A two-stage bone reconstruction method, known as the Masquelet technique, combines inducement of a granulation tissue membrane and subsequent bone autografting as a biphasic technique allowing reconstruction of large bone defects. In light of their already well-characterized osteogenesis-improving capabilities in animals, we performed this translational study to investigate these membranes in patients.

Fourteen patients with complicated fractures and bone defects were randomly selected for this study. Biopsy samples of foreign-body-induced membranes were collected at different time points during scheduled surgical procedures. The membranes were co-cultured with mesenchymal stromal cells, and differentiation into the osteoblastic lineage was assessed by measuring alkaline phosphatase activity, aminoterminal propeptide of type-I procollagen (PINP) production, and Ca2+ concentration. Histological characteristics were evaluated with image analysis. Quantitative reverse transcription polymerase chain reaction was used to measure vascular endothelial growth factor (VEGF), interleukin-6 (IL-6), and type-I collagen (Col-1) expression.

The induced membranes were characterized histologically by maturating vascularized fibrous tissue. The vascularization was greatest in one-month-old samples and decreased to <60% in three-month-old samples. One-month-old membrane samples had the highest expression of VEGF, IL-6, and Col-1, whereas two-month-old membranes expressed <40% of the levels of the one-month-old membranes. Specific alkaline phosphatase activity, PINP production, and Ca2+ concentration were increased in co-cultures when a membrane sample was present. In cultures of one-month-old membranes, PINP production was more than two times and Ca2+ deposition was four times higher than that in cultures of two-month-old membranes.

The induced membranes have osteogenesis-improving capabilities. These capabilities, however, appear to decrease over time. We speculate that the optimal time for performing second-stage surgery may be within a month after implantation of foreign material.

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    • "Induced membrane technique was first described by Masquelet et al. in 2000 and can be adapted to mandible or long bone reconstruction when more conventional procedures have failed to reconstruct the bone loss [1] [2] [3] [4] [5] [6] [7] caused by trauma or infection [8] [9] [10]. Induced membrane technique has been used for patients in need of cancer treatment with extensive loss of necrotic bone tissue [11] [12]. "
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    ABSTRACT: The induced membrane technique has been used for long bone defect reconstruction after traumatism. One of the mayor drawbacks of this method is the difficult removal of the polymethyl methacrylate spacer after membrane formation. We therefore replaced the stiff PMMA spacer with a semi-flexible medical grade silicone spacer. This study aimed to compare subcutaneously formed membranes, induced by PMMA and silicone, in the irradiated or not irradiated areas within 28 rats that received the spacers. Histological analysis was performed to evaluate the composition of the membrane and to quantify the amount of vessels. Histomorphometric measurements were used to evaluate the membranes' thickness, while fibrosis and inflammation were scored. The expression of VEGF and BMP-2 in lysates of the crushed membranes was determined by Western blotting. ALP expression was analysed in HBMSC cultures in contact with the same lysates. Non-irradiated membranes induced by the two spacer types were non-inflammatory, fibrous and organized in layers. Irradiation did not change the macroscopic properties of membranes that were induced by silicone, while PMMA induced membranes were sensitive to the radiotherapy, resulting in thicker, strongly inflammatory membranes. Irradiated membranes showed an overall reduced osteogenic potential. Medical grade silicone is safe for the use in radiotherapy and might therefore be of great advantage for patients in need of cancer treatment. Copyright © 2015. Published by Elsevier Ltd.
    Full-text · Article · Mar 2015 · Acta Biomaterialia
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    • "The mechanism of action of induced membranes in bone repair was studied recently by Aho and his colleagues [11]. They found that the one-month-old membrane has higher osteogenesis-improving capabilities compared to twomonth-old membrane; they concluded that optimal time for performing second-stage surgery may be within a month after implantation of foreign material [11]. In our series, the mean interval between the first and second surgeries is 43.5 days, which is comparable to other studies. "
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    ABSTRACT: Masquelet technique, which is the use of a temporary cement spacer followed by staged bone grafting, is a recent treatment strategy to manage a posttraumatic bone defect. This paper describes a series of 9 patients treated with this technique of staged bone grafting following placement of an antibiotic spacer to successfully manage osseous long bone defects. The injured limbs were stabilized and aligned at the time of initial spacer placement. In our series, osseous consolidation was successfully achieved in all cases. This technique gives promising result in the management of posttraumatic bone defects.
    Full-text · Article · Feb 2014 · The Scientific World Journal
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    ABSTRACT: Tissue engineered cell-seeded constructs with poly(3)hydroxybutyrate (PHB) induced ectopic bone formation after implantation into the back muscle of rats. The objective of our in vivo study was to evaluate the osteogenic potential of pure PHB patches in surgically created cranial defects. For this, PHB patches were analyzed after implantation in surgically created defects on the cranium of adult male rats. After healing periods of 4, 8 and 12 weeks, the bone tissue specimens containing PHB patches were processed and analyzed histologically as well as molecular-biologically. After 4 weeks, the PHB patches were completely embedded in connective tissue. Eight weeks after PHB insertion, bone regeneration proceeding from bearing bone was found in 50% of all treated animals, whereas all PHB treated cavities showed both bone formation and embedding of the patches in bone 12 weeks after surgery. Furthermore, all slices showed pronounced development of blood vessels. Histomorphometric analysis presented a regenerated bone mean value between 46.4 ± 16.1% and 54.2 ± 19.3% after 4 to 12 weeks of healing. Caveolin-1 staining in capillary-like structures showed a 1.16 to 1.38fold increased expression in PHB treated defects compared to controls. Real-time RT-PCR analyzes showed significantly lower expressions of Alpl, Col1a1 and VEGFA in cranium defects after treatment with PHB patches compared to untreated bony defects of the same cranium. Within the limits of the presented animal investigation, it could conclude that the tested PHB patches featured a good biocompatibility and an osteoconductive character.
    No preview · Article · May 2014 · Annals of Anatomy - Anatomischer Anzeiger
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