Segmental Diaphyseal Bone Research Articles

Surgical outcomes of segmental diaphyseal forearm fractures in adults: a small case series on plate osteosynthesis, intramedullary nailing, and other surgical methods

BackgroundSegmental fractures often result from high-energy or indirect trauma that causes bending or torsional forces with axial loading. We evaluated surgical outcomes of patients with forearm segmental diaphyseal fractures.MethodsWe retrospectively analyzed data from patients with forearm segmental fractures for which they underwent surgery at the Pusan National University Trauma Center from March 2013 to March 2022. We also analyzed accompanying injuries, injury severity score (ISS), injury mechanism, occurrence of open fracture, surgical technique, and treatment results.ResultsFifteen patients were identified, one with bilateral segmental diaphyseal forearm bone fracture, for a total of 16 cases. Nine of the patients were male. The overall mean age was 50 years, and the mean follow-up period was 16.2 months. Six cases who underwent surgery using plate osteosynthesis achieved bone union without length deformity at final follow-up. Three of seven patients who underwent intramedullary nailing alone underwent reoperation due to nonunion. Six cases achieved bone union at final follow-up, three of which showed length deformity. Three patients underwent surgery using a hybrid method of IM nailing, plates, and mini cables. One patient who underwent surgery with a plate and one patient who underwent surgery with IM nailing alone showed nonunion and were lost to follow-up.ConclusionPlate osteosynthesis is considered the gold standard for treatment of adult forearm diaphyseal segmental fractures. In this study, IM nailing was associated with high rates of non-union and length deformity. However, the combination of IM nailing and a plate-cable system may be an acceptable alternative in segmental diaphyseal forearm fracture, achieving a union rate similar to that provided by plate fixation.

Surgical repair of large segmental bone loss with the induced membrane technique: patient reported outcomes are comparable to nonunions without bone loss.

To compare the outcomes of patients with segmental bone loss who underwent repair with the induced membrane technique (IMT) with a matched cohort of nonunion fractures without bone loss. Retrospective analysis on prospectively collected data. Academic medical center. Two cohorts of patients, those with upper and lower extremity diaphyseal large segmental bone loss and those with ununited fractures, were enrolled prospectively between 2013 and 2020. Sixteen patients who underwent repair of 17 extremities with segmental diaphyseal or meta-diaphyseal bone defects treated with the induced membrane technique were identified, and matched with 17 patients who were treated for 17 fracture nonunions treated without an induced membrane. Sixteen of the bone defects treated with the induced membrane technique were due to acute bone loss, and the other was a chronic aseptic nonunion. Healing rate, time to union, functional outcome scores using the Short Musculoskeletal Functional Assessment (SMFA) and pain assessed by the Visual Analog Scale (VAS). The initial average defect size for patients treated with the induced membrane technique was 8.85cm. Mean follow-up times were similar with 17.06 ± 10.13months for patients treated with the IMT, and 20.35 ± 16.68. months for patients treated without the technique. Complete union was achieved in 15/17 (88.2%) of segmental bone loss cases treated with the IMT and 17/17 (100%) of cases repaired without the technique at the latest follow up visit. The average time to union for patients treated with the induced membrane technique was 13.0 ± 8.4months and 9.64 ± 4.7months for the matched cohort. There were no significant differences in reported outcomes measured by the SMFA or VAS. Patients treated with the induced membrane technique required more revision surgeries than those not treated with an induced membrane. Outcomes following treatment of acute bone loss from the diaphysis of long bones with the induced membrane technique produces clinical and radiographic outcomes similar to those of long bone fracture nonunions without bone loss that go on to heal. III.

Bone Morphogenetic Protein-2 Rapidly Heals Two Distinct Critical Sized Segmental Diaphyseal Bone Defects in a Porcine Model.

Segmental bone defects (SBDs) are devastating injuries sustained by warfighters and are difficult to heal. Preclinical models that accurately simulate human conditions are necessary to investigate therapies to treat SBDs. We have developed two novel porcine SBD models that take advantage of similarities in bone healing and immunologic response to injury between pigs and humans. The purpose of this study was to investigate the efficacy of Bone Morphogenetic Protein-2 (BMP-2) to heal a critical sized defect (CSD) in two novel porcine SBD models. Two CSDs were performed in Yucatan Minipigs including a 25.0-mm SBD treated with intramedullary nailing (IMN) and a 40.0-mm SBD treated with dual plating (ORIF). In control animals, the defect was filled with a custom spacer and a bovine collagen sponge impregnated with saline (IMN25 Cont, n = 8; ORIF40 Cont, n = 4). In experimental animals, the SBD was filled with a custom spacer and a bovine collage sponge impregnated with human recombinant BMP-2 (IMN25 BMP, n = 8; ORIF40 BMP, n = 4). Healing was quantified using monthly modified Radiographic Union Score for Tibia Fractures (mRUST) scores, postmortem CT scanning, and torsion testing. BMP-2 restored bone healing in all eight IMN25 BMP specimens and three of four ORIF40 BMP specimens. None of the IMN25 Cont or ORIF40 Cont specimens healed. mRUST scores at the time of sacrifice increased from 9.2 (±2.4) in IMN25 Cont to 15.1 (±1.0) in IMN25 BMP specimens (P < .0001). mRUST scores increased from 8.2 (±1.1) in ORIF40 Cont to 14.3 (±1.0) in ORIF40 BMP specimens (P < .01). CT scans confirmed all BMP-2 specimens had healed and none of the control specimens had healed in both IMN and ORIF groups. BMP-2 restored 114% and 93% of intact torsional stiffness in IMN25 BMP and ORIF40 BMP specimens. We have developed two porcine CSD models, including fixation with IMN and with dual-plate fixation. Porcine models are particularly relevant for SBD research as the porcine immunologic response to injury closely mimics the human response. BMP-2 restored healing in both CSD models, and the effects were evident within the first month after injury. These findings support the use of both porcine CSD models to investigate new therapies to heal SBDs.

Adding a Fibular Strut Allograft to Intramedullary Nail and Cancellous Autograft During Stage II of the Masquelet Technique for Segmental Femur Defects: A Technique Tip.

Reconstruction of segmental diaphyseal bone defects has been a major challenge in limb salvage surgery. Staged reconstruction as first described by Masquelet is a common strategy to deal with this problem in limb salvage surgery. One consequence of this technique is a time period of prolonged limited weightbearing while the segmental defect heals. The purpose of this study was to describe an adjunctive technique for stage II of the Masquelet procedure and retrospectively analyze the outcome and weight bearing progression of 3 patients who sustained femur fractures with significant bone loss and underwent this technique. A retrospective chart review was performed. The patients (2 males, 1 female with an average age of 36.6 years) all sustained segmental femur fractures which resulted in significant bone loss. Induced membrane technique with adjunct use of a fibular strut allograft was performed after initial stabilization and PMMA spacer placement. All three patients went on to union and full weight bearing after being treated by the described technique. All the patients were allowed toe-touch weight bearing immediately after surgery and all progressed to weight bearing as tolerated at an average of 3.6 months. Using a fibular strut allograft as an adjunct to the induced membrane technique serves as a biologic and mechanical scaffold and may allow earlier weightbearing.

Systematic Approach to the Management of Post-traumatic Segmental Diaphyseal Long Bone Defects: Treatment Algorithm and Comprehensive Classification System.

Bone defects remain challenging to manage. The wide array of treatment options is a testament no single strategy works in every patient. This is more complex if consideration is given to the status of the host and the soft tissues. The choice of treatment should be based on specific patient requirements after taking all variables into account. We present a comprehensive classification system and treatment algorithm to assist with decision-making in management. All potential treatment modalities including amputation are discussed with their relevant pearls and pitfalls. The proposed classification system may potentially assists with communication, enable patient stratification for assigning the most appropriate treatment modality and guide reporting of treatment outcomes. Ferreira N, Tanwar YS. Systematic Approach to the Management of Post-traumatic Segmental Diaphyseal Long Bone Defects: Treatment Algorithm and Comprehensive Classification System. Strategies Trauma Limb Reconstr 2020;15(2):106-116.

The presence of periosteum is essential for the healing of large diaphyseal segmental bone defects reconstructed with trabecular metal: A study in the femur of goats

Large segmental diaphyseal bone defects can be reconstructed with massive structural allografts, but this technique is associated with high complication rates. Tantalum tabecular metal implants have been successfully used to restore bone defects associated with revision total knee or hip arthroplasties. The aim of this study was to investigate if tantalum cylinders could be used to reconstruct large load bearing segmental diaphyseal bone defects in the presence or absence of a periosteum coverage. Segmental bone defects were reconstructed with tantalum cylinders with or without preservation of the periosteum and stabilized by an intramedullary nail. Radiological analysis was performed postop and at 26 weeks follow-up. New bone was labeled with fluorochromes at 13 and 26 weeks follow-up. Reconstructions were tested mechanically and subsequently investigated histologically. Contra-lateral femurs were used as controls. Clinically all goats returned to normal functional loading after 2 weeks allowing unlimited weight bearing. Radiologically, all tantalum cylinders with periosteum coverage united with the host bone. Reconstructions with cylinders without periosteum coverage lead to radiological nonunion in five out of six cases. The strengths of the reconstruction with and without periosteum preservation were respectively 102.1% and 24.5% compared to controls. In the periosteum covered implants, bone contact was found at all levels of the tantalum cylinder and more and deeper bone ingrowth was found in this group. Tantalum cylinders seem a safe and reliable alternative for a massive cortical graft to reconstruct large diaphyseal bone defects in a goat model if healthy periosteum is present.

The stability of impacted morsellized bone grafts in a metal cage under dynamic loaded conditions: an in vitro reconstruction of a segmental diaphyseal bone defect

Reconstructions of segmental diaphyseal bone defects with massive allografts are related to complications like nonunion and fractures. A reconstruction of these defects with a cage filled with an impacted morsellized bone graft could be an alternative. The bone graft in these cages should ideally be loaded to prevent resorption. Loading of morsellized bone grafts however can cause instability. The goal of this study was to assess the stability of an impacted morsellized bone graft in a cage under dynamic loaded conditions in an in vitro reconstruction of a segmental diaphyseal bone defect. The second goal was to assess the influence of cage type, washing of the graft and bone-cage fit. Two different cage types were filled with impacted morsellized bone graft. The grafts were used washed and unwashed and in variable bone-cage fit conditions. We recorded the bone graft deformation in the cage under dynamic loaded conditions. Stability appeared to be not very sensitive to the cage type and whether the bone chips were washed or not. However, quality of the fit of the cage with the bone segment was an important parameter and should be optimized during surgery. Morsellized impacted bone graft in a cage is stable in dynamic loaded conditions in an in vitro reconstruction of a segmental diaphyseal bone defect. We believe that this method of reconstruction is a promising alternative for the reconstruction of large diaphyseal bone defects and should be tested relative to its biological merits in animal experiments.

New Approaches in the Treatment of Critical‐Size Segmental Defects in Long Bones

AbstractSummary: The treatment of large segmental diaphyseal bone deficiencies presents a formidable challenge. The standard treatment modalities such as cancellous bone grafting, cortical allografts, vascularized bone transfer, or distraction osteogenesis exhibit extremely high complication rates, and can culminate in limb amputation or major functional deficits. Recent efforts to develop new treatment modalities for segmental bone loss have resulted in designing new biodegradable polymeric and metallic mesh implants that can incorporate novel osteogenic, osteoinductive, and/or osteoconductive bone healing augmentation materials. These biologic implant composites are capable of further enhancing the efficacy of the treatment applied. This paper briefly reviews the limitations of the currently applied standard treatment modalities for segmental critical size bone defects, provides insight into the specific treatment challenges, and presents the animal and initial clinical results of new alterative treatment approaches that involve the application of cylindrical mesh implants consisting of biodegradable polylactide membranes or titanium cages as a means of potentiating the efficacy of bone graft.

Induction of a Barrier Membrane to Facilitate Reconstruction of Massive Segmental Diaphyseal Bone Defects: An Ovine Model

To report an ovine model that can be used to evaluate the efficacy of bone substitutes for repair of segmental diaphyseal bone defects. Experimental study. Eleven 2-year-old Pré-Alpes Sheep. Mid-diaphyseal metatarsal bone defects (25 mm long) were stabilized by a dynamic compression plate over a polymethylmethacrylate (PMMA) cement spacer, and by external coaptation. The PMMA spacer was removed at 6 weeks by incising the encapsulating membrane. The defect remained unfilled (Group 1; n=5) or was filled with morselized autologous corticocancellous graft (Group 2; n=6), the membrane sutured closed, and external coaptation applied for 6 months, when healing was evaluated. Radiographic, computed tomographic, and histologic examinations at 6 months after the 2nd surgery revealed non-union in ungrafted defects whereas grafted defects showed bone healing. The induced membrane had blood vessels, CBFA1+ cells, and very few macrophages entrapped in a collagenous tissue positive for type I collagen. This ovine metatarsal defect model resulted in a critical-size defect (non-union) that healed when grafted. The PMMA-induced membrane constrained the graft, was well vascularized, and may have osteogenic properties. This model may be useful to evaluate new strategies in bone tissue engineering because the PMMA-induced membrane may help confine bone morphogenetic proteins, skeletal stem cells, or other agents to the defect cavity where they could be useful to enhance bone formation.

Polylactide membranes and sponges in the treatment of segmental defects in rabbit radii

Long segmental diaphyseal bone loss exceeding the size of a critical defect and resulting from various conditions is currently treated by complicated methods such as distraction osteogenesis or vascularized bone graft. These methods have significant complications and the supply of implants is limited so there is a demand for bone substitutes of unlimited supply. In the present study, segmental defects exceeding a critical size defect in rabbit radii were successfully treated with polylactide membranes and sponges. Resorbable polymers solely or in combination with osteogenic agents or angiogenic agents have great potential to become bone substitutes suitable for the treatment of long segmental defects in humans.

Primary resective shortening followed by distraction osteogenesis for limb reconstruction: a comparison with simple lengthening.

Resective distraction osteogenesis is a new approach to treat segmental diaphyseal bone defects by primary limb shortening and secondary distraction osteogenesis from the same site. A rabbit model was introduced to compare the bone-regeneration characteristics of this technique with those of simple lengthening procedures. Twenty-four skeletally mature New Zealand White rabbits were divided into two equal groups. In the test group, limbs were lengthened after a 10-mm segmental diaphyseal bone resection and limb shortening. In the control group, a simple subperiosteal osteotomy for limb lengthening was performed without resection. New bone formation was evaluated mechanically, radiologically, histomorphometrically, and densitometrically. Bone bridging occurred in all animals. Normalized mechanical values for the newly reconstructed tibiae demonstrated similar torsional stiffness (71+/-3.3 compared with 71+/-8.2%; p = 0.95) and strength (64+/-5.3 compared with 68+/-7.3%; p = 0.66) in the two groups. The average normalized callus diameter was significantly greater in the test group than in the control group (p < 0.01). The remodeling index calculated from densitometry, however, showed a significantly less progressed stage of remodeling in the test group (p < 0.05). Histomorphometric analysis of the callus center supported this finding, showing significantly lower values for trabecular thickness (p < 0.05) and total bone volume (p < 0.01) in the test group. The results demonstrated the possibility of new bone formation after resection and monofocal shortening. This suggests a new therapeutic option to treat diaphyseal segmental bone defects.

Regeneration of Diaphyseal Bone Defects Using Resorbable Poly(L/DL-Lactide) and Poly(D-Lactide) Membranes in the Yucatan Pig Model

To determine the effects of tubular resorbable polymer membranes on the healing of a segmental diaphyseal bone defect. A randomized prospective study using the minipig model. Animals were evaluated with in vivo roentgenograms on a biweekly basis until explanted at twelve weeks. After surgery, animals were allowed unrestricted activity and weight bearing between twenty-four and forty-eight hours. Fifteen yearling Yucatan minipigs. A 2.5- to 3.0-centimeter mid-diaphyseal defect was created in the middle third of the radius. Animals were assigned in groups of three to receive the following implants: (a) poly(L/DL-lactide), (b) poly(L/DL-lactide)-CaCO3, (c) poly(D-lactide), (d) poly(D-lactide)-CaCO3, and (e) an untreated defect. No adjunctive internal or external fixation was used as the ulna was left intact. The limbs were studied with in vivo anterior-posterior and lateral radiographs at biweekly intervals for the presence and pattern of bone formation. All limbs were explanted at twelve weeks postimplantation for methyl-methacrylate embedding and histologic and microradiographic study. The bone defects covered with membranes were completely reconstituted by six to eight weeks. Untreated defects healed with less bone formation and in a more disorganized pattern. Histologic evaluation of the implants demonstrated that the entire lumen of the implant was filled with bone, with some periosteal bone formation occurring on the outer surface of the membrane. There was direct apposition of bone onto the membrane surface or minimal fibrous tissue interposition between membrane and new bone. There was no foreign body or adverse reaction to the membrane. Untreated defects showed woven bone formation with clefts and irregularly shaped margins occupied by fibrous tissues or surrounding muscle tissues. This study supports the concept that a membrane enhances bone defect healing by excluding nonosseous tissues from a defect and providing structural scaffolding for periosteal and endosteal bone regeneration.

Multistaged Surgical Management of Posttraumatic Segmental Tibial Bone Loss

Fracture nonunions associated with segmental diaphyseal bone loss challenge present methods of sustaining bone length and securing bony union. In the tibia, single-stage grafting procedures to accomplish this reconstruction requires major tissue sacrifice from adjacent areas and often results in amputation. A series of nine patients with tibial segmental diaphyseal bone loss were treated with multistaged surgical reconstruction. All nine were patients with severe trauma, with soft-tissue loss and local sepsis, who were candidates for amputation. The follow-up period averaged 5.5 years. All of the patients achieved healed, stable legs. All but one were fully ambulatory without a brace eight to 15 months after the first stage of bone grafting. There were several minor complications, which were satisfactorily treated. Multistaged bone graft operations were relatively low-risk, with a high incidence of success for treatment of major tibial segmental bone loss.

Revascularized segmental diaphyseal bone transfers in the canine. An analysis of viability.

The biologic behavior of free revascularized bone segments was investigated using a unique canine model. Conventional methods to assess bone kinetics included the histologic osteocyte count, tetracycline uptake, appositional bone formation rate, and quantitative microradiography. The percentage of viable osteocytes in the revascularized segment was 52.4%, compared with 66.8% in the normal controls and 28.5% in the nonrevascularized segment. These differences were statistically significant. Both qualitative and quantitative differences were noted regarding deposition of tetracycline. On the basis of this study, we conclude that an apparently successful vascularized bone transfer retains a degree of viability greater than a conventional bone graft but less than that of normal undisturbed bone.