Periosteal Vascularization Research Articles

The effect of injectable platelet-rich fibrin in combination with autogenous bone grafts on bone healing in an ovariectomized osteoporotic rat model with critical-sized defects.

To assess the impact of autogenous graft materials, including autogenous bone graft (ABG) and injectable platelet-rich fibrin (I-PRF) clots, on bone defect regeneration in ovariectomized osteoporotic rats. Wistar rats (6-8 weeks old) were ovariectomized, and surgery began after 8 weeks. A 5-mm defect was created bilaterally in the parietal bones of 16 rats, which were divided into 4 groups. Group A (blank) had untreated defects; group B had defects filled with 0.1 ml of I-PRF, group C had defects filled with 0.1 ml of ABG, and group D had defects filled with a combination of 0.1 ml each of I-PRF and ABG. Four weeks post-surgery, the rats were euthanized. Bone regeneration was evaluated through histopathologic analysis and microcomputed tomography (micro-CT). In ovariectomized rats treated with ABG or I-PRF, bone regeneration was enhanced, with increased periosteal activity, osteoblast count, and new bone volume, as determined histologically. The ABG+I-PRF group had the highest periosteal vascularity, but the difference compared to the ABG group was not statistically significant (p>0.05). Osteoblast numbers were significantly higher in the ABG+I-PRF group than in the blank group (p<0.05). Micro-CT showed the highest mean new bone volume ratio in the ABG+I-PRF group, followed by the ABG group. The combined use of ABG and I-PRF enhances bone formation in osteoporotic rats following ovariectomy.

PLATE OSTEOSYNTHESIS FOR THE TREATMENT OF A COMPLEX METACARPAL FRACTURE IN A SAND GAZELLE (Gazella leptoceros)

A 5-month-old female gazelle (Gazella leptoceros) from Algeria was presented for consultation at the clinic, following a trauma that occurred when the gazelle was trapped in a wire mesh forelimb. The radiographic examination revealed a complex fracture displaced at the level of the left metacarpus, a surgical treatment by osteosynthesis was carried out, after approach and incision of the fracture site, a reduction and fixation of the bone was practiced using a screwed plate in steel and seven cortical bone screws, a suture by separate stitches was performed to close the skin, and a modified Robert Jones bondage was performed. X-rays performed 7, 15 and 21 days postoperative revealed very limited osteogenic activity and delayed healing despite bone alignment. This may be due to a defect in the periosteal vascularization linked to the direct surgical approach to the fracture.

Islanded facial artery osteomyomucosal/osseous flap in head and neck reconstruction

A local pedicled vascularized bone flap can prevent the morbidity and cost of free bone flap surgery in small segmental bone defects or long cartilaginous defects of the head and neck. Such flaps can also be useful in patients who are high risk for surgery. The periosteal vascularity of the mandible can be used to design islanded facial artery-based bone flaps, which can be utilized to that extent. Two patients with a small segmental mandibulectomy defect and one patient with a long cricotracheal resection defect underwent reconstruction using three different designs of islanded facial artery osteomyomucosal/osseous flap (iFOMM). The patients had a minimum follow-up period of 18 months. All flaps were successful, with satisfactory healing and without any functional deficit or disease at last follow-up.

Treatment of diaphyseal clavicular nonunion with special emphasis on microsurgery

Diaphyseal fractures of the clavicle had until recently the reputation to always heal with abundant callus formation, except if operated, due to a reported high rate of nonunion after plate fixation by older series. The reason would be that the bone has only periosteal vascularization, easily destroyed by periosteal stripping for implant apposition. Bone autograft and external fixation has been reported as the best technique to heal a nonunited clavicle nonunion. Are these classical considerations still valid nowadays? The purposes of this article focusing only on diaphyseal clavicular fractures are to review the vascularization of the bone, the rate of nonunion after nonoperative treatment, the indications and techniques of osteosynthesis, and the treatment possibilities of an established nonunion. This article will not deal with the specific problems of the lateral clavicular fractures, which are equivalent to acromio-clavicular fracture-dislocations, nor of medial fractures, close to the sterno-clavicular joint.

Fracture repair requires TrkA signaling by skeletal sensory nerves.

Bone is richly innervated by nerve growth factor-responsive (NGF-responsive) tropomyosin receptor kinase A-expressing (TrKa-expressing) sensory nerve fibers, which are required for osteochondral progenitor expansion during mammalian skeletal development. Aside from pain sensation, little is known regarding the role of sensory innervation in bone repair. Here, we characterized the reinnervation of tissue following experimental ulnar stress fracture and assessed the impact of loss of TrkA signaling in this process. Sequential histological data obtained in reporter mice subjected to fracture demonstrated a marked upregulation of NGF expression in periosteal stromal progenitors and fracture-associated macrophages. Sprouting and arborization of CGRP+TrkA+ sensory nerve fibers within the reactive periosteum in NGF-enriched cellular domains were evident at time points preceding periosteal vascularization, ossification, and mineralization. Temporal inhibition of TrkA catalytic activity by administration of 1NMPP1 to TrkAF592A mice significantly reduced the numbers of sensory fibers, blunted revascularization, and delayed ossification of the fracture callus. We observed similar deficiencies in nerve regrowth and fracture healing in a mouse model of peripheral neuropathy induced by paclitaxel treatment. Together, our studies demonstrate an essential role of TrkA signaling for stress fracture repair and implicate skeletal sensory nerves as an important upstream mediator of this repair process.

Anatomical Study of Periosteal Vascularization of the Forearm: Design of Vascularized Periosteal Flaps

Introduction Vascularized periosteal flaps (VPFs) have proven to be a useful technique for the treatment of unfavorable biological situations in children, with excellent results due to their osteogenic potential. The objective of this work is to present a detailed anatomical description of the periosteal vascularization of the radius and ulna, as well as the design of the forearm VPFs. Methods Anatomical study with 10 fresh-frozen specimens with antegrade injection of green colored latex. Periosteal branches of the radius and ulna, septocutaneous branches, and muscular branches were dissected. The size of the pre and postdissection flaps was measured, as well as the length of the vascular pedicles. Results The four vascular axes studied were the anterior interosseous vascular axis (AIA), radial axis (RA), ulnar axis (UA), and posterior interosseous vascular axis (PIA). The AIA (volar-radial VPF): an average of 16.2 periosteal branches were obtained, with a mean distance of 6.6 mm between them. The mean size of the VPF was 41.3 cm2 pre-dissection and 32.4 cm2 post-dissection. The average pedicle length was 16.1 cm. Vascular RA (radial VPF): an average of 20.8 branches was found, with a mean VPF size of 54.8 cm2predissection, and 39.3 cm2 post-dissection. The average pedicle length was 20.2 cm. Vascular PIA (dorsal-ulnar VPF): an average of 12.8 periosteal branches were obtained, with the mean VPF size being 26.2 cm2 pre-dissection and 20.4 cm2 post-dissection. The average pedicle length 12.6 cm. Vascular UA (ulnar VPF): an average of 10.2 periosteal branches were obtained with a mean VPF size of 37.5 cm2 pre-dissection and 28.2 cm2 post-dissection. of the average pedicle length was 14.8 cm. Conclusions We have described four new VPFs, with the most useful and versatile being the dorsal-ulnar VPF, based on the PIA, and the volar-radial, based on the AIA. The main advantages of these flaps with respect to microsurgical techniques are the simplicity and speed of the technique, its elasticity and adaptability to the recipient bed, as well as its versatility.

Can Ultrasound Differentiate Acute Erosive Arthritis Associated with Osteomyelitis, Rheumatoid Arthritis, or Gouty Arthritis?

AIM The study intended to determine the specific ultrasonographic features of acute arthritis with periarticular bone erosions caused by acute osteomyelitis (OM), rheumatoid arthritis (RA) and gouty arthritis (GA). METHOD We included 33 patients (seven with acute OM, 18 with RA flares, and eight with GA attacks) having acute monoarthritis or oligoarthritis, and receiving ultrasound (US) examinations in the acute stage. The US images were rated by three rheumatologists blinded to the diagnosis. The median scores of their evaluation of the subcutaneous tissue, periosteum, and synovium were compared. Interrater reliability was calculated using Cronbach's alpha. RESULTS The highest mean grade of subcutaneous edema appeared in patients with acute OM, and grade 2 edema was more frequent than patients with RA and GA (P = .003 and P = .026, respectively; α = .869). The prevalence of subcutaneous power Doppler signal was also higher in patients with acute OM than in those with RA and GA (P < .001 and P = .041, respectively; α = .756). Periosteal vascularity presented more frequently in acute OM (P = .003 compared with RA; P = .041 compared with GA), but the interrater reliability was poor (α = .518). The tophaceous material in GA was distinctive from OM and RA (P = .010 and P < .001, respectively; α = .774). CONCLUSION The most discriminative US features in this study were the subcutaneous tissue changes in addition to the periosteal findings. US could contribute to the differential diagnosis of acute erosive arthritis.

Periosteal vascularization of the distal femur in relation to distal femoral osteotomies: a cadaveric study.

BackgroundThe purpose of this study was to investigate periosteal vessels location as intra-operative landmarks in distal femoral osteotomies and focused on the branching pattern of the vascular supply of the medial and lateral femoral condyle, its constancy, and the relationship to the height of distal femoral osteotomies. Anastomoses of relevant vessels were studied to analyze the risk of vascular insufficiency after transection of landmark vessels.MethodsA human cadaver dissection study on the vascular supply of the medial and lateral side of the distal femur was conducted. Surgical dissection was performed in eight knees in total. Distances between the vascular supply and bony landmarks were calculated. Relation of the vascular structures to the transverse bone cuts of distal femoral osteotomies was described, as well as anastomoses of relevant vessels.ResultsOn the medial side of the distal femur the periosteum was primarily supplied by the descending genicular artery (DGA) in 87.5 % of the specimens. In the absence of the DGA, the superior medial genicular artery was the supplier. Vascularization took place through two constant branches, the upper transverse artery (UTA) and the central longitudinal artery. The UTA originated at a mean distance of 6.9 cm (range 5.9–7.9 cm) above the knee joint line. On the lateral side of the distal femur the superior lateral genicular artery was the main vessel. In all dissected knees it gave off the lateral transverse artery (LTA). The LTA originated at a mean distance of 6.9 cm (range 5.8–7.6 cm) above the knee joint line. Anastomoses between the UTA, LTA and the longitudinal arch of the femoral shaft were found that could prevent vascular insufficiencies after transection of the UTA and LTA.ConclusionsThe vascular supply of the medial and lateral aspects of the femoral condyle is highly constant. Both the UTA, on the medial side, and the LTA, on the lateral side, can serve as a landmark for orthopedic surgeons in determining the height of the osteotomy cuts in distal femoral osteotomies. Transection of these landmark vessels during the osteotomy will not result in vascular insufficiency because of a collateral supply.

Vascularization of the long process of the malleus: surgical implications.

Knowledge of the vascularization of the malleus may help to better understand some unwanted effects occurred in those surgical techniques using the handle as an attachment site of ossicle-replacement prostheses. Our hypothesis is that vascular damage occurred in the long process of the malleus during tympanic membrane detachment before fastening a malleovestibulopexy (MVP) prosthesis promotes the lysis of this ossicle at the attachment site. To confirm this premise, we carried out an evolutive and descriptive study of ten MVP procedures as well as a morphological analysis of ten cadaveric mallei using both light and scanning electron microscopies. The arterial supply of the manubrium comes from two main sources: vascular branches that reach this ossicle from the site of insertion of the tensor tympani tendon and small perforating branches which penetrate the bone from arteries of the tympanic membrane that, following the periosteum/perichondrium, they arrange parallel to the bone. The detachment of the tympanic membrane to fasten a MVP prosthesis causes a damage in the periosteal/perichondral vascular supply of the handle as well as micro-trauma on it, which can promote bone resorption at the point of anchorage by osteoclast stimulation. Respect periosteal vascularization of the manubrium may be important to prevent damage in this ossicle caused by some middle ear reconstruction prostheses.

Il trattamento con placche e viti delle fratture del terzo distale di femore

Distal femur fractures can result from high-energy trauma in men under 30 years of age or from low-energy trauma in women over 75. Surgical fixation of distal femoral fractures has evolved to the point that non-operative treatment entails a higher risk of complications, which makes surgical intervention the treatment of choice in most of these fractures. The lateral approach to the distal femur allows for visualization, reduction and fixation of simple articular fractures. More complex fractures are better exposed with a lateral parapatellar approach (Krettek’s approach). Plate osteosynthesis is indicated in fractures of the distal femur Type 33-A, in particular in high comminution subgroups, and in case of Type 33-C according to the AO classification system. Evolving materials and design have enhanced plates reliability. Nevertheless, the surgical technique is extremely demanding, and even a mild inaccuracy may lead to an high rate of complications, down to complete synthesis failure. If articular involvement is identified at imaging, adequate surgical exposure and accurate reconstruction of the articular surface must be performed. Mininvasive techniques with biological saving of periosteal vascularization and lower soft tissue damage may promote bone consolidation and must be considered by the surgeon.

Assessment &amp; Evaluation of the Outcome for Closed and Open Method in Treatment of Segmental Tibial Fracture

Segmental tibial fractures are considered to be a special type of injury associated with high complication rates and are defined by the presence of two or more distinct fracture lines with completely isolating an intermediary segment і.е interruption of bone integrity at two levels(majority) or moreand are usually caused by a high-energy direct trauma with important soft tissue damage effect the both intramedullary and periosteal vascularization, which are predisposed to slow healing with creation of unsuitable biological conditions for fracture union. The aim of our study was to evaluate and assess the outcome of our policy on dealing with closed segmental fracture of the tibia treated by (closed or open) application of external tubular device fixator (AO group of ASIF) .Within the period between October 1, 1998 and September 30, 2010 in Al Nasiriya military hospital, AL Amara military hospital and Al Husain teaching hospital, we collect 38 patients with displaced and minimally displaced closed segmental tibial fractures. We exclude the multiply injured patients died after surgical treatment in the course of further management, open fractures, and all the patients lost for follow up. The minimally or undisplaced fractures were treated by closed application of the external device, while those with significantly displaced fractures, firstly managed by calcaneal continuous traction for a few days as an attempt for reduction, some of them were reduced to minimally displaced or acceptable position which were treated also by closed method, and some are remain significantly displaced, treated by open reposition and external fixation with the help of X-ray control for all cases. A range of motion exercise of ankle and knee joints post operatively were encouraged. The mean age was 38.81 years. We collect and study 38 closed segmental tibial fractures i.e. (two fractures focuses for one bone), so we are dealing with 76 fractures in 38 patients. All the patients were treated by AO unilateral external fixator arranged in multiplanartechnique for more rigid fixation and regarded as a definitive procedure for holding the fractures until clinical& radiological union.Once a considerable callus seen, a loosening of the distal clamps and a very graduated weight bearing started, with the help of the crutches to permit an axial compression on the fractures sites until a secure union of the bone. Then the external fixation was removed and a partial weight bearing was continued with the help of the crutches until consolidation. Healing of the bone occurred in 52 fracture focuses (68.42%) patients, and 24 fractures (31.57%) patients reported significant complications in the course of treatment that required further surgical management, 18 of them delayed union (23.68%) patients and 6 of the fracture focuses(7.89)patients go to nonunion.The delayed union treated simply by dianamyzation with chips bone graft and sometimes rearrangement of the external fixator particularly the loose pines, all of them healed completely, while the nonunited were treated by (Revision procedure):(revision of the external fixator with wider pins and extensive refreshment of the fracture ends and added a considerable amount of bone graft), so all of them were united successfully. We conclude that the external fixation is a suitable method for the treatment of segmental tibial fractures with an acceptable rate of

Rush nail and management of fracture both bone forearm

Background: The failure of the conventional nailing of both bone of the forearm poses a potential problem of nail migration and rotational instability, despite the best reduction. Objectives: Rush nail is a very handy, low cost easily available implant. In the present study, we have tried to find out its applicability if used in the closed manner under C-arm control without injurying soft tissues and preserving the periosteal vascularity. Materials and Methods: This prospective study was conducted on thirty adult subjects. Skeletally mature subjects with Gustilo type 1 open and closed fractures without the neurovascular deficit were included. Stainless steel rush nails were used for all patients for both radius and ulnar repair. Patients were followed-up for a minimum of 4 months and maximum of 1.5 years. Results: The mean age of study participants was 37.43 years. Mean time of the union was 14.32 weeks. Average operative time was 67.16 min. No intraoperative complication occurred nor was any nailing converted to some other form of fixation, except in three cases radial nail was introduced by open method through anterior Henry's approach. Cast support was maintained for a mean of 7.43 weeks, after that forearm brace was applied for a mean period of 6.26 weeks and continued until radiographic union was seen. Three patients showed non-union of radius mostly distal third. They were treated with open reduction and internal fixation with locking plate and bone grafting. One patient had extensor tendon injury. Two patients have superficial infection which cured with antibiotics. One case had delayed union of radius which required bone grafting. Two patients had gross restrictions of wrist movements and pronation-supination movement. Using Anderson criteria 22 patients had satisfactory results (71.33%), three patients had excellent result. Three patients had non-unions (10%). Implant removal was performed in two cases about 14 months post-operatively and no refracture has been reported until date (after 4 months). Conclusion: Use of rush nail continues to have predictable and good results. Complication rates are lower when compared to plate osteosynthesis and even in locked intramedullary nails although application of above elbow cast after nailing is a downside of this procedure. The rush nail has still a future in repair of forearm fractures considering its low complications rates, cost and acceptable results in a developing country where financial matters are to be considered.

The Procurement of Allotransplants for Ballistic Trauma: A Preclinical Study and a Report of Two Clinical Cases

Maxillofacial trauma caused by severe ballistic injuries requires many steps of reconstruction and is often associated with disappointing results. The authors report on two clinical cases of facial allografting. After a preclinical anatomical study of 10 fresh cadavers, the authors performed allotransplantation of the lower two-thirds of the face in two patients in March and August of 2009. The grafts included all perioral muscles, facial nerves, parotid glands, the anterior region of the maxilla, and part of the mandible. The mandibular osteotomy included only the chin in one case, and the mandibular arch from one angle to the other in the second case. The cadaveric study confirmed that relying only on the anastomoses between the facial and the maxillary artery for vascularization of the posterior part of the maxilla was unsafe. Periosteal vascularization seemed essential. The clinical results confirmed that complete revascularization from a single facial pedicle was possible: the first end-to-end arterial anastomosis to the left external carotid artery was sufficient for full perioperative revascularization of the flap and immediate reestablishment of bilateral venous flow. The facial appearance of both recipients improved gradually, with the development of changes in expression and the appearance of nasolabial folds. Preoperatively placed gastrostomies and tracheostomies were able to be removed in both patients within 6 weeks postoperatively. The procurement part of the operation was performed in 7 hours. Partial facial composite tissue allotransplantation of the lower two-thirds of the face along with parts of the maxilla and mandible (chin or entire-toothed mandible) is technically feasible, with a good cosmetic and functional outcome in typical cases of attempted suicide with rifles.

The effect of multifilaments and monofilaments on cementless femoral revision hip components: An experimental study

Background Cerclage wires are widely used in revision hip surgery to reattach the lid of a femoral osteotomy. The present study compared the influence of multifilaments and monofilaments on primary stability of revision hip stems with different fixation principles. Methods A standardized extended proximal femoral osteotomy was performed in the anterior cortex of 6 synthetic femora. We used a high-resolution measuring device to explore spatial micromovements of a diaphyseal and a metaphyseal fixating revision stem. Both of these were implanted in 3 femora. The specimens were measured again after consecutive restabilization of osteotomies with multifilaments and monofilaments. The movement graphs generated defined relative micromovements between stems and bones and the stabilizing effect of the two wire systems compared. Findings Both multifilaments and monofilaments effected a major reduction of relative micromovements for both fixation principles. There were no differences in relative movements between the multifilament and monofilament treatments for the diaphyseal fixating stem. Yet for the metaphyseal fixating stem a significantly better restabilization was observed with multifilaments. Interpretation Both multifilaments and monofilaments can support the revision hip stem in bridging the extended proximal femoral osteotomy. Yet, which wiring system should be chosen depends on the fixation principle of the revision stem. Multifilaments seem to be advantageous when used with metaphyseal fixating stems. However, the use of multifilaments with diaphyseal fixating components should be reconsidered as this might constrict the periosteal vascularity.

Transposição do enxerto vascularizado da fíbula pro fêmur diafisário sem microanastomoses

OBJETIVO: O estudo descreve uma maneira nova e simples de transplantar o enxerto ósseo vascularizado da fíbula pro fêmur diafisário sem necessidade de microcirurgia, demonstra o caso clínico operado com bom resultado quanto a vascularização e consolidação óssea e, por último, especula sobre possíveis outras aplicações dentro da cirurgia reconstrutiva. MÉTODOS: A fíbula vascularizada é transportada até o fêmur sem necessidade de microcirurgia, alcançando até sua metáfise proximal através das comunicações das perfurantes do músculo gêmeo lateral com as septais fibulares via retalho de pele póstero-lateral da perna que intersecciona os dois sistemas. RESULTADOS: O paciente operado evoluiu sem infecção. Cintilografia esquelética precoce demonstrou vascularização óssea. CONCLUSÃO: O retalho gêmeo fibular é nova arma no arsenal do cirurgião. Sua técnica é factível, reprodutível, seu tempo cirúrgico reduzido e o princípio de construção com ponte através de ilhas de pele e perfurantes poderá ser aplicado na construção de novos retalhos.

Surgical Management of Proximal Fourth Metatarsal Stress Fracture Nonunion: Debridement and Locking Plate Stabilization

Although fractures of the proximal fourth metatarsal are rare, when they occur they may be associated with prolonged healing and increased rates of nonunion. We report a case of fourth metatarsal nonunion and describe the technique of debridement of the nonunion site and locking plate stabilization. This technique allows fracture stabilization and optimizes periosteal vascularization of the fracture site, thus promoting healing. We recommend this technique for the debridement and stabilization of marginal proximal metatarsal fractures with established nonunion.

Survival of the Fibula Osteoseptocutaneous Flap with Thrombosis of Peroneal Veins on Harvesting-Case Report

Management of bone loss that occurs after severe trauma of open lower extremity fractures remains a challenge to reconstructive surgeons. For patients with lower limb trauma, an osteocutaneous flap may be required when there are simultaneous defects of bone and soft tissue. We present a case where thrombosis in the peroneal veins of the fibula osteoseptocutaneous flap was encountered during the harvest. The mistake happened as the injury to the donor leg was inconspicuous and angiography was not routinely performed before harvesting. Here we describe a clinical situation in which bone marrow was used for drainage of venous blood in a free fibula osteoseptocutaneous flap. There were two important factors accounting for the survival of this large fibula osteoseptocutaneous flap. (1) In this flap, the arterial circuit was designed so that the two ends of the peroneal artery in the fibula flap were anastomosed to the anterior tibial artery and a branch of the great saphenous vein, to establish the flow-through mechanism. This constituted an uninterrupted arterial circulation. (2) The major venous drainage was through bone marrow. Although there was initial venous congestion and necrosis of the skin paddle, bone and most of the soft tissue survived. Roentgenogram and periosteal abundant vascularity demonstrated bone survival and gradual healing. After rehabilitation, the patient can stand up and walk with the traumatic leg tolerating partial weight bearing after 9 months.

Gray-scale and color Doppler ultrasonographic evaluation of reactivated post-traumatic/postoperative chronic osteomyelitis

We aimed to carry out a systematic assessment of gray-scale and color Doppler ultrasonography (CDUS) findings of reactivated post-traumatic/postoperative chronic osteomyelitis (COM) in adults. Gray-scale and color Doppler ultrasonography were performed on 40 consecutive patients with a history of long-standing post-traumatic/post-operative chronic osteomyelitis and clinical suggestion of reactivation, in a 32-month-period. All patients had metallic implants: 16 internal fixations, nine external fixations, 11 hip arthroplasties and four knee arthroplasties. The final diagnosis of reactivated COM was based upon biopsy findings, with microbiological and histological examination (n = 27), or a combination of laboratory, clinical and magnetic resonance (MR) findings (n = 13). The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of sonographic signs, including fistulous tracts, periosteal thickening, cortical discontinuity, soft tissue abscess and cellulitis, juxtacortical fluid, distension of the pseudocapsule in arthroplasties, and periosteal vascularity, were estimated. Statistically significant differences between patients with and without reactivated COM were found for fistulous tracts (P < 0.0001), juxtacortical fluid collections (P < 0.001) periosteal thickening (P < 0.01), distension of pseudocapsule (P < 0.05), and periosteal vascularity (P < 0.0001). Low-resistance arterial flow of periosteal vessels presented the highest sensitivity (92%), specificity, and PPV (100%), yielding only two false negative results in two obese patients. Among gray-scale findings, the presence of a fistulous tract yielded the highest specificity and PPV (100%), whereas periosteal thickening was the most sensitive (92%), though not specific, finding (specificity 50%). A constellation of gray-scale and CDUS findings can be highly indicative of reactivated bone infection in patients with long-standing chronic post-traumatic/post-operative osteomyelitis.

Vascular anatomical basis of clavicular non-union

The middle third of the clavicle is commonly involved in any injury and account for 5-10% of all fractures in adults. Although non-unions are rare, their treatment has not been well defined yet. This report describes the arterial supply of the clavicle to clarify the pathological mechanism and the surgical procedure of non-unions. This study was based on delineation of the thoraco-acromial and suprascapular arteries with colored latex on 17 specimens (ten cadavers). Observations were made after macroscopic dissection and maceration. The main blood supply to the middle third of the clavicle was the periosteal. This supply came from the two branches of the thoraco-acromial trunk that penetrated the pectoralis major muscle and the deltoid muscle. In 13 cases, these two periosteal branches were anastomosed between these two muscle attachments. Periosteal vascularization was always seen on the superior surface and the anterior border of the bone, but never on the inferior surface or the posterior border. The suprascapular artery contributed to supply the middle third of the clavicle by several periosteal branches and also by an independent branch. This branch was born proximally near the internal, middle thirds union and passed along the posterior face of the subclavius muscle and pierced the bone through the nutria foramina located near the external, middle thirds union. Nevertheless, intraosseous arteries were noted only in four cases. In these cases, they were never more than 2cm long. Our results showed that the periosteal blood supply located between the muscles insertions and the arterial supply from the suprascapular artery could be twice compromised in case of important displacement or severe fracture. If treatments of clavicular fractures or non-unions cannot preserve the periosteal blood supply, bone grafting should be indicated.

Damaging fatigue loading stimulates increases in periosteal vascularity at sites of bone formation in the rat ulna.

Bone formation in a variety of contexts depends on angiogenesis; however, there are few reports of the vascular response to osteogenic skeletal loading. We used the rat forelimb compression model to characterize vascular changes after fatigue loading. The right forelimbs of 72 adult rats were loaded cyclically in vivo to one of four displacement levels, to produce four discrete levels of ulnar damage. Rats were killed 3-14 days after loading, and their vasculature was perfused with silicone rubber. Transverse histological sections were cut along the ulnar diaphysis. We quantified vessel number, average vessel area, total vessel area, and bone area. On day 3, we observed a dramatic periosteal expansion near the ulnar midshaft, with significant increases in periosteal vascularity; total vessel area was increased 250-450% (P < 0.001). Vascularity remained elevated on days 7 and 14. Vessel number and average vessel area were not correlated (P = 0.09) and contributed independently to total vascular increases. Bone area was not increased on day 3 but on days 7 and 14 was increased significantly in all displacement groups (P < 0.01) due to periosteal woven bone formation. Vascular and bone changes depended on longitudinal location (P < 0.001), with peak increases 2 mm distal to the midshaft. Vascular and bone changes also depended on displacement level (P < 0.005), with greater increases at higher levels of fatigue displacement. We conclude that skeletal fatigue loading induces a rapid increase in periosteal vascularity, followed by an increase in bone area. The angiogenic-osteogenic response is spatially coordinated and scaled to the level of the mechanical stimulus.