Objective To investigate the clinical effects of repairing massive bone defects in limbs by using vascularized free fibular autograft compoundingmassive bone allografts. Methods From January 2001 to December 2003, large bone defects in 19 patients (11 men and 8 women, aging from 6 to 35 years) were repaired by vascularized free fibular transplant with a monitoringflap compounding massive deep frozen bone allografts. The length of bone defects were 12 to 25 cm (16.6 cm on average), of vascularized free fibular 15 to 28 cm (18.3 cm on average), and of massive bone allografts 11 to 24 cm (16.1 cm on average). Thelocation of massive bone defects were humerus in 1 case, femur in 9 cases and tibia in 9 cases. Results After followup of 5 to 36 onths (18.2 months on average), wounds of donor and recipient sites were healed at Ⅰstage, monitoringflaps were alive, no obvious eject reaction of massive bone allografts was observed and no complications occurred in donor limbs. The radiographic evidence showed union in 15 patients 3 months and 3 patients 8 months after operation. One case of malignant synovioma of left lower femur recurred and amputation was performed 2.5 months after surgery. Internal fixation was removed in 5 patients, and complete bone unions werefound 1 year postoperatively. No massive bone allografts was absorbed or collapsed. Conclusion With strict indication, vascularized free fibular autograft compounding massive bone allografts, as an excellent method of repairing massive bone defects in limbs, can not only accelerate bone union but also activate and changer the final results of massive bone allografts from failure.
ObjectiveTo compare the effectiveness of calcium phosphate cement (CPC) loaded with recombinant human bone morphogenetic protein 2 (rhBMP-2) combined with CPC loaded with antibiotic versus CPC loaded with antibiotic alone in one stage for chronic osteomyelitis with bone defect.MethodsA single-blind prospective randomized controlled clinical trial was conducted. Between April 2018 and April 2019, 80 patients of chronic osteomyelitis with bone defect in accordance with the random number table were randomly divided into two groups, 40 in the trial group (CPC loaded with rhBMP-2 combined with CPC loaded with antibiotic) and 40 in the control group (CPC loaded with antibiotic). There was no significant difference in gender, age, disease duration, lesion, and preoperative white blood cells (WBC) count, platelet count, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) between the two groups (P>0.05). All patients were implanted the corresponding CPC and external fixator after lesion clearance in the two groups. The postoperative WBC count, platelet count, ESR, CRP, hospital stay, cure rate of osteomyelitis, repaired bone defect volume, the time of external fixator removal, and the time of full weight-bearing of the affected limb were compared between the two groups.ResultsAll patients were followed up 12-24 months, with an average of 18.4 months. There was no significant difference in WBC count, platelet count, ESR, and CRP between the two groups at 4 weeks after operation (P>0.05). There were significant differences in WBC count, platelet count, and CRP in the two groups between 1 week before operation and 4 weeks after operation (P<0.05). And the ESR showed no significant difference between pre- and post-operation in the two groups (P>0.05). In the trial group, the anaphylactic exudate occurred in 1 patient with tibial osteomyelitis and the incision healed after oral administration of loratadine. The incisions of other patients healed by first intention in the two groups. One case of distal tibial osteomyelitis recurred in each group, and 1 case of humeral osteomyelitis recurred in the control group. The cure rates of osteomyelitis were 97.5% (39/40) in the trial group and 95% (38/40) in the control group, showing no significant difference between the two groups (χ2=0.000, P=1.000). There was no significant difference in the repaired bone defect volume and hospital stay between the two groups (P>0.05). X-ray film and CT showed that the bone defects were repaired in the two groups. The time of external fixator removal and the time of full weight-bearing of the affected limb were significantly shorter in the trial group than in the control group (P<0.05).ConclusionApplication of CPC loaded with rhBMP-2 and antibiotic in one stage is effective for the chronic osteomyelitis with bone defect, which can accelerate the bone regeneration in situ to repair bone defect, reduce the trauma, shorten the course of treatment, and obtain good function of the affected limb.
ObjectiveTo investigate the effectiveness of Masquelet technique combined with flap transplantation in treatment of infectious bone and soft tissue defects of the lower leg.MethodsBetween January 2013 and January 2017, 35 cases of infectious bone and soft tissue defects of lower leg were treated with Masquelet technique combined with flap transplantation. There were 21 males and 14 females, with an average of 31.5 years (mean, 25-55 years). All patients were tibial fractures caused by trauma and the infections occurred after debridement or internal fixation. The time from injury to admission was 1 to 6 months, with an average of 3.2 months. Defect located at the proximal leg in 11 cases, the middle leg in 11 cases, and the distal leg in 13 cases. The length of tibia defect after debridement ranged from 5.6 to 11.2 cm, with an average of 7.1 cm. The size of soft tissue defect ranged from 14.2 cm×6.9 cm to 17.3 cm×8.7 cm. Bacterial culture of purulent secretion of wound was positive in 18 cases. After debridement, the bone cement was used to fill the bone defect and the flap transplantation was used to repair the wound. The bone cement was taken out at 8 to 12 weeks after the one-stage operation, and the bone defect was repaired with autogenous iliac bone or combined with artificial bone.ResultsThree cases had necrosis at the distal edge of the flap after one-stage operation, and survived after dressing change. The other flaps survived successfully, and the wounds healed by first intention. All incisions healed by first intention after two-stage operation. All patients were followed up 24-32 months, with an average of 27 months. The color of the flap was similar to that of the surrounding normal tissue, and its texture was good. X-ray reexamination showed that all bone defects healed after 6-8 months, with an average of 6.7 months. At 9 months after two-stage operation, according to the revised Edwards tibial fracture evaluation standard, 19 cases were excellent, 14 cases were good, and 2 cases were poor, the excellent and good rate was 94.3%. The American Orthopedic Ankle Association (AOFAS) score was 60-98, with an average of 81.3. And 21 cases were excellent, 11 were good, and 3 were fair, with an excellent and good rate of 91.4%.ConclusionMasquelet technique combined with flap transplantation is an effective treatment for infectious bone and soft tissue defects of lower leg.
Objective To review research advances of revision surgery after primary total hip arthroplasty (THA) for patients with Crowe type Ⅳ developmental dysplasia of the hip (DDH). Methods The recent literature on revision surgery after primary THA in patients with Crowe type Ⅳ DDH was reviewed. The reasons for revision surgery were analyzed and the difficulties of revision surgery, the management methods, and the related prosthesis choices were summarized. Results Patients with Crowe type Ⅳ DDH have small anteroposterior diameter of the acetabulum, large variation in acetabular and femoral anteversion angles, severe soft tissue contractures, which make both THA and revision surgery more difficult. There are many reasons for patients undergoing revision surgery after primary THA, mainly due to aseptic loosening of the prosthesis. Therefore, it is necessary to restore anatomical structures in primary THA, as much as possible and reduce the generation of wear particles to avoid postoperative loosening of the prosthesis. Due to the anatomical characteristics of Crowe type Ⅳ DDH, the patients have acetabular and femoral bone defects, and the repair and reconstruction of bone defects become the key to revision surgery. The acetabular side is usually reconstructed with the appropriate acetabular cup or combined metal block, Cage, or custom component depending on the extent of the bone defect, while the femoral side is preferred to the S-ROM prosthesis. In addition, the prosthetic interface should be ceramic-ceramic or ceramic-highly cross-linked polyethylene wherever possible. Conclusion The reasons leading to revision surgery after primary THA in patients with Crowe type Ⅳ DDH and the surgical difficulties have been clarified, and a large number of clinical studies have proposed corresponding revision modalities based on which good early- and mid-term outcomes have been obtained, but further follow-up is needed to clarify the long-term outcomes. With technological advances and the development of new materials, personalized prostheses for these patients are expected to become a reality.
In recent years, 3D printing technology, as a new material processing technology, can precisely control the macroscopic and microstructure of biological scaffolds and has advantages that traditional manufacturing methods cannot match in the manufacture of complex bone repair scaffolds. Magnesium ion is one of the important trace elements of the human body. It participates in many physiological activities of the body and plays a very important role in maintaining the normal physiological function of the organism. In addition, magnesium ions also have the characteristics of promoting the secretion of osteogenic proteins by osteoblasts and osteogenic differentiation of mesenchymal stem cells. By combining with 3D printing technology, more and more personalized magnesium-based biological scaffolds have been produced and used in bone regeneration research in vivo and in vitro. Therefore, this article reviews the application and research progress of 3D printing magnesium-based biomaterials in the field of bone regeneration and repair.
Objective To investigate the feasibility of MRI three-dimensional (3D) reconstruction model in quantifying glenoid bone defect by comparing with CT 3D reconstruction model measurement. Methods Forty patients with shoulder anterior dislocation who met the selection criteria between December 2021 and December 2022 were admitted as study participants. There were 34 males and 6 females with an average age of 24.8 years (range, 19-32 years). The injury caused by sports injury in 29 cases and collision injury in 6 cases, and 5 cases had no obvious inducement. The time from injury to admission ranged from 4 to 72 months (mean, 28.5 months). CT and MRI were performed on the patients’ shoulder joints, and a semi-automatic segmentation of the images was done with 3D slicer software to construct a glenoid model. The length of the glenoid bone defect was measured on the models by 2 physicians. The intra-group correlation coefficient (ICC) was used to evaluate the consistency between the 2 physicians, and Bland-Altman plots were constructed to evaluate the consistency between the 2 methods. Results The length of the glenoid bone defects measured on MRI 3D reconstruction model was (3.83±1.36) mm/4.00 (0.58, 6.13) mm for physician 1 and (3.91±1.20) mm/3.86 (1.39, 5.96) mm for physician 2. The length of the glenoid bone defects measured on CT 3D reconstruction model was (3.81±1.38) mm/3.80 (0.60, 6.02) mm for physician 1 and (3.99±1.19) mm/4.00 (1.68, 6.38) mm for physician 2. ICC and Bland-Altman plot analysis showed good consistency. The ICC between the 2 physicians based on MRI and CT 3D reconstruction model measurements were 0.73 [95%CI (0.54, 0.85)] and 0.80 [95%CI (0.65, 0.89)], respectively. The 95%CI of the difference between the two measurements of physicians 1 and 2 were (–0.46, 0.49) and (–0.68, 0.53), respectively. Conclusion The measurement of glenoid bone defect based on MRI 3D reconstruction model is consistent with that based on CT 3D reconstruction model. MRI can be used instead of CT to measure glenoid bone defects in clinic, and the soft tissue of shoulder joint can be observed comprehensively while reducing radiation.
Objective To investigate the expression levels and significance of vascular endothel ial growth factor (VEGF) and microvessel density (MVD) in rabbit radius defects repaired with allogeneic and autogenic bone. Methods Forty adult New Zealand rabbits were chosen, and 10 mm bone defect model was created in the bilateral radii of 28 experimental rabbits. The other 12 rabbits provided allogeneic bone under the standard of American Association of Tissue Bank. In the left side, allogeneic bone were used to repair bone defect (experimental group), equal capacity autogenous il iac bone was used in the right side (control group). Animals were sacrificed at 2, 4, 8, and 12 weeks postoperatively. Immunohistochemical method was used to determine the expression of VEGF, CD34 protein and MVD counting. Bone histomorphometric parameters, including percent trabecular area (BV/TV), trabecular number (Tb.N), trabecular thickness (Tb.Th), and trabecular separation (Tb.Sp) were measured by von Kossa staining undecalcified sl ices. The relation was analyzed between VEGF and MVD, histomorphometric parameters. Results The positive signals of VEGF protein were detected in cytoplasm of vascular endothel ial cells, chondrocytes, osteoblasts, fibroblasts and osteoclasts. At 2 weeks, there was no significant difference in VEGF protein expression between experimental group and control group (P gt; 0.05); at 4 and 8 weeks, the expression of VEGF in control group was significantly higher than that in experimental group (P lt; 0.05); and at 12 weeks, there was no significant difference between two groups (P gt; 0.05). There was a positive correlation (P lt; 0.01) between VEGF expression and MVD value in two groups at 2, 4, 8, and 12 weeks postoperatively. There was no significant difference in bone histomorphometric parameters (BV/TV, Tb.Th, Tb.N, Tb.Sp) between two groups at 12 weeks postoperatively (P gt; 0.05), but there was a positive correlation between VEGF expression and parameters of BV/TV, Tb.Th, and Tb.N (P lt; 0.01); and a negative correlation between VEGF and Tb.Sp (P lt; 0.01). Conclusion VEGF can express diversity at different time and positions, and the different expressions indicated various biology significances in the process of the bone heal ing. It can coordinate growth of cartilage and bone and profit vascular reconstruction of allogeneic bone. VEGF may participate in promoting osteogenesis in the course of allogeneic bone transplantation.
With the developing of three-dimensional (3D) printing technology, it is widely used in the treatment of bone tumors in the clinical orthopedics. Because of the great individual differences in the location of bone tumor, resection and reconstruction are difficult. Based on 3D printing technology, the 3D models can be prepared to show the anatomical part of the disease, so that the surgeons can create a patient-specific operational plans based on better understand the local conditions. At the same time, preoperative simulation can also be carried out for complex operations and patient-specific prostheses can be further designed and prepared according to the location and size of tumor, which may have more advantages in adaptability. In this paper, the domestic and international research progress of 3D printing technology in the treatment of limb bone tumors in recent years were reviewed and summarized.
Objective To investigate the effectiveness of tissue transplantation combined with bone transmission in treatment of large defects of tibial bone and soft tissue. Methods Between February 2006 and February 2011, 15 cases of traumatic tibia bone and soft tissue defects were treated. There were 12 males and 3 females, aged from 16 to 54 years (mean, 32 years). After internal and external fixations of fracture, 11 patients with open fracture (Gustilo type III) had skin necrosis, bone exposure, and infection; after open reduction and internal fixation, 2 patients with closed fracture had skin necrosis and infection; and after limb replantation, 2 patients had skin necrosis and bone exposure. The area of soft tissue defect ranged from 5 cm × 5 cm to 22 cm × 17 cm. Eight cases had limb shortening with an average of 3.5 cm (range, 2-5 cm) and angular deformity. The lenghth of bone defect ranged from 4 to 18 cm (mean, 8 cm). The flap transplantation and skin graft were used in 9 and 6 cases, respectively; bone transmission and limb lengthening orthomorphia were performed in all cases at 3 months after wound healing; of them, 2 cases received double osteotomy bone transmission, and 14 cases received autologous bone graft and reset after apposition of fracture ends. Results All flaps and skin grafts survived; the wound healed at 3.5 months on average (range, 3 weeks-18 months). The length of bone lengthening was 6-22 cm (mean, 8 cm). The time of bone healing and removal of external fixation was 9.5-39.0 months (mean, 15 months). The healing index was 40-65 days/cm (mean, 55 days/cm). All patients were followed up 1-5 years (mean, 4 years). The wounds of all the cases healed well without infection or ulceration. The functions of weight-bearing and walking were recovered; 6 cases had normal gait and 9 cases had claudication. The knee range of motion was 0° in extention, 120-160° in flexion (mean, 150°). According to the American Orthopaedic Foot and Ankle Society (AOFAS) scoring system for ankle function, the results were excellent in 7 cases, good in 4 cases, and fair in 4 cases, with an excellent and good rate of 73.3%. Conclusion Tissue transplantation combined with bone transmission is an effective method to treat large defects of soft tissue and tibial bone, which can increase strength of bone connection and reduce damage to the donor site.
Objective To analyze the effectiveness of free vascularized fibula grafts (FVFG) for extensive bone defects after resection of lower limb malignant bone tumors. Methods Between November 2015 and July 2018, 15 cases of lower limb malignant bone tumors were treated. There were 12 males and 3 females with an average age of 12.3 years (range, 9-21 years). There were 11 cases of osteosarcoma and 4 cases of Ewing’s sarcoma. The tumor located at middle femur in 8 cases, lower femur in 4 cases, and middle tibia in 3 cases. The disease duration was 2-6 months (mean, 3.2 months). The tumor was completely removed, and the length of the bone defect was 8-23 cm (mean, 17.7 cm). The bone defect was repaired by FVFG, and combined inactivated tumor bone was used in 8 cases of femoral bone defect. Results The average operation time was 280 minutes (range, 180-390 minutes). The average blood loss was 310 mL (range, 200-480 mL). All incisions healed by first intention. All patients were followed up 2-24 months with an average of 14.5 months. Bone healing achieved in all patients at 9-18 months (mean, 12.3 months) after operation except 1 patient which was followed up only 2 months. The fibula grafts had active metabolism and the average bone metabolism score was 184 (range, 111-257) in effected side and 193 (range, 127-259) in contralateral side. There was no difference between bilateral sides. The average Enneking score was 24.6 (range, 20-30) at last follow-up. No ankle instability or paralysis of common peroneal nerve occurred. Conclusion FVFG appeared very efficient in repair of extensive bone defect after resection of lower limb malignant bone tumor.