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Testing of a New One-Stage Bone-Transport Surgical Procedure Exploiting the Periosteum for the Repair of Long-Bone Defects
Melissa L. Knothe Tate, PhD1; Todd F. Ritzman, MD2; Erich Schneider, PhD3; Ulf R. Knothe, MD, DSc2
1 Departments of Biomedical Engineering and Mechanical and Aerospace Engineering, Case Western Reserve University, Wickenden 309, 10900 Euclid Avenue, Cleveland, OH 44106
2 Department of Orthopaedic Surgery (T.F.R. and U.R.K.) and Orthopaedic Research Center (T.F.R. and U.R.K.), A41, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195. E-mail address for U.R. Knothe: knotheu@ccf.org
3 AO Research Institute, Clavadelerstrasse 8, CH-7270 Davos Platz, Switzerland
View Disclosures and Other Information
Disclosure: In support of their research for or preparation of this work, one or more of the authors received, in any one year, outside funding or grants in excess of $10,000 from the AO Research Foundation and the Cleveland Clinic Research Program Council. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.
Investigation performed at the Department of Orthopaedic Surgery, Cleveland Clinic, and the Departments of Biomedical Engineering and Mechanical and Aerospace Engineering, Case Western Reserve University, Cleveland, Ohio, and the AO Research Institute, Davos Platz, Switzerland

The Journal of Bone and Joint Surgery, Incorporated
J Bone Joint Surg Am, 2007 Feb 01;89(2):307-316. doi: 10.2106/JBJS.E.00512
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Abstract

Background: A recently proposed one-stage bone-transport surgical procedure exploits the intrinsic osteogenic potential of the periosteum while providing mechanical stability through intramedullary nailing. The objective of this study was to assess the efficacy of this technique to bridge massive long-bone defects in a single stage.

Methods: With use of an ovine femoral model, an in situ periosteal sleeve was elevated circumferentially from healthy diaphyseal bone, which was osteotomized and transported over an intramedullary nail into a 2.54-cm (1-in) critical-sized diaphyseal defect. The defect-bridging and bone-regenerating capacity of the procedure were tested in five groups of seven animals each, which were defined by the absence (Group 1; control) or presence of the periosteal sleeve alone (Group 2), bone graft within the periosteal sleeve (Groups 3 and 5), as well as retention of adherent, vascularized cortical bone chips on the periosteal sleeve with or without bone graft (Groups 4 and 5). The efficacy of the procedure was assessed qualitatively and quantitatively.

Results: At sixteen weeks, osseous bridging of the defect was observed in all twenty-eight experimental sheep in which the periosteal sleeve was retained; the defect persisted in the remaining seven control sheep. Among the experimental groups 2 through 5, significant differences were observed in the density of the regenerated bone tissue; the two groups in which vascularized bone chips adhered to the inner surface of the periosteal sleeve (Groups 4 and 5) showed a higher mean bone density in the defect zone (p < 0.02) than did the other groups. In these two groups with the highest bone density, the addition of bone graft was associated with a significantly lower callus density than that observed without bone graft (p < 0.05). The volume of regenerate bone (p < 0.02) was significantly greater in the groups in which the periosteal sleeve was retained than it was in the control group. Among the experimental groups (groups 2 through 5), however, with the numbers studied, no significant differences in the volume of regenerate bone could be attributed to the inclusion of bone graft within the sleeve or to vascularized bone chips remaining adherent to the periosteum.

Conclusions: The novel surgical procedure was shown to be effective in bridging a critical-sized defect in an ovine femoral model. Vascularized bone chips adherent to the inner surface of the periosteal sleeve, without the addition of morselized cancellous bone graft within the sleeve, provide not only a comparable volume of regenerate bone and composite tissue (callus and bone) but also a superior density of regenerate bone compared with that after the addition of bone graft.

Clinical Relevance: These in vivo studies show, for the first time, the efficacy of the procedure and present a potential new way to regenerate bone in defects, such as those arising from tumor resection, débridement after infection, nonunion, or trauma, with use of a single-stage procedure.

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    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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