Masquelet technique using an allogeneic cortical bone graft for a large bone defect:A case report

BACKGROUND The induced-membrane technique was initially described by Masquelet as an effective treatment for large bone defects,especially those caused by infection.Here,we report a case of chronic osteomyelitis of the radius associated with a 9 cm bone defect,which was filled with a large allogeneic cortical bone graft from a bone bank.Complete bony union was achieved after 14 months of follow-up.Previous studies have used autogenous bone as the primary bone source for the Masquelet technique;in our case,the exclusive use of allografts is as successful as the use of autologous bone grafts.With the advent of bone banks,it is possible to obtain an unlimited amount of allograft,and the Masquelet technique may be further improved based on this new way of bone grafting.CASE SUMMARY In this study,we reported a case of repair of a long bone defect in a 40-year-old male patient,which was characterized by the utilization of allograft cortical bone combined with the Masquelet technique for the treatment of the patient's long bone defect in the forearm.The patient's results of functional recovery of the forearm were surprising,which further deepens the scope of application of Masquelet technique and helps to strengthen the efficacy of Masquelet technique in the treatment of long bones indeed.CONCLUSION Allograft cortical bone combined with the Masquelet technique provides a new method of treatment to large bone defect.

Investigating the mechanical properties of cortical bone under dynamic torsional loading

Bone is a multi-phase,non-homogeneous material that exhibits strain rate sensitivity,and it may fail under compression,tension,torsion,or a combination of these loading.The mechanical properties of cortical bone with strain rate effect under compression and tension have been obtained through the application of the split Hopkinson pressure/tension bar technique,but no such studies have been reported for determining the strain rate behavior properties of bony materials under torsion.In this study,the shear stress-strain curves with the rate-dependent cortical bone subjected to dynamic torsional loading were first obtained using a torsional split Hopkinson bar system.Based on the experiments,an improved mathematical model consisting of elastic,viscoelastic,and viscoplastic components was used to identify the material parameters of the cortical bone.Detailed material properties are derived through constitutive relations.The results may assist researchers in developing more accurate models of cortical bone behavior under different load conditions.

In vivo evidence of IGF-I–estrogen crosstalk in mediating the cortical bone response to mechanical strain

Although insulin-like growth factor-I （IGF-I） and estrogen signaling pathways have been shown to be involved in mediating the bone anabolic response to mechanical loading, it is not known whether these two signaling pathways crosstalk with each other in producing a skeletal response to mechanical loading. To test this, at 5 weeks of age, partial ovariectomy （pOVX） or a sham operation was performed on heterozygous IGF-I conditional knockout （H IGF-I KO） and control mice generated using a Cre-loxP approach. At 10 weeks of age, a 10 N axial load was applied on the right tibia of these mice for a period of 2 weeks and the left tibia was used as an internal non-non-loaded control. At the cortical site, partial estrogen loss reduced total volumetric bone mineral density （BMD） by 5% in control pOVX mice （P=0.05, one-way ANOVA）, but not in the H IGF-I KO pOVX mice. At the trabecular site, bone volume/total volume （BV/TV） was reduced by 5%-6% in both control pOVX （P〈0.05） and H IGF-I KO pOVX （P=0.05） mice. Two weeks of mechanical loading caused a 7 %-8% and an 11%-13% （P〈0.05 vs. non-loaded bones） increase in cortical BMD and cortical thickness （Ct.Th）, respectively, in the control sham, control pOVX and H IGF-I KO sham groups. By contrast, the magnitude of cortical BMD （4%, P=0.13） and Ct.Th （6%, P〈0.05） responses were reduced by 50% in the H IGF-I KO pOVX mice compared to the other three groups. The interaction between genotype and estrogen deficiency on the mechanical loading-induced cortical bone response was significant （P〈0.05） by two-way ANOVA. Two weeks of axial loading caused similar increases in trabecular BV/TV （13%-17%） and thickness （17%-23%） in all four groups of mice. In conclusion, partial loss of both estrogen and IGF-I significantly reduced cortical but not the trabecular bone response to mechanical loading, providing in vivo evidence of the above crosstalk in mediating the bone response to loading.

Measurement of Cortical Bone Thickness in Adults by Cone-beam Computerized Tomography for Orthodontic Miniscrews Placement

The purpose of this study was to investigate the cortical bone thickness of the inter-dental area of both jaws for orthodontic miniscrew placement. The cone-beam computerized tomography images of 32 non-orthodontic adults with normal occlusion were taken to measure the cortical bone thick- ness in both.jaws. One-way analysis of variance （ANOVA） was used to analyze the differences in cortical bone thickness. Buccal cortical bone in the mandible was thicker than that in the maxilla. In the maxilla, cortical bone thickness was thicker in the buccal side than in the palatal side. Buccal cortical bone thickness in the mandible was thickest at the site distal to the first molar, and in the maxilla it was thickest at the site mesial to the first molar, while in the palatal side of maxilla it was thickest at the site mesial to the second premolar. The changing pattern of cortical bone thickness varies at different sites. In the buccal side of maxilla, the thinnest cortical bone thickness was lbund to be at 4 mm level from the alveolar crest, while the thickest was at 10 mm level （except for the site mesial to the first premolar）. The buccal cortical bone thickness at the sites mesial or distal to the first molar in the mandible and palatal cortical bone thickness of maxilla tended to increase with increasing distance from the alveolar bone.

A mathematical model of cortical bone remodeling at cellular level under mechanical stimulus

A bone cell population dynamics model for cor- tical bone remodeling under mechanical stimulus is devel- oped in this paper. The external experiments extracted from the literature which have not been used in the creation of the model are used to test the validity of the model. Not only can the model compare reasonably well with these ex- perimental results such as the increase percentage of final values of bone mineral content （BMC） and bone fracture en- ergy （BFE） among different loading schemes （which proves the validity of the model）, but also predict the realtime devel- opment pattern of BMC and BFE, as well as the dynamics of osteoblasts （OBA）, osteoclasts （OCA）, nitric oxide （NO） and prostaglandin E2 （PGE2） for each loading scheme, which can hardly be monitored through experiment. In conclusion, the model is the first of its kind that is able to provide an in- sight into the quantitative mechanism of bone remodeling at cellular level by which bone cells are activated by mechan- ical stimulus in order to start resorption/formation of bone mass. More importantly, this model has laid a solid foun- dation based on which future work such as systemic control theory analysis of bone remodeling under mechanical stimu- lus can be investigated. The to-be identified control mecha- nism will help to develop effective drugs and combined non- pharmacological therapies to combat bone loss pathologies. Also this deeper understanding of how mechanical forces quantitatively interact with skeletal tissue is essential for the generation of bone tissue for tissue replacement purposes in tissue engineering.

Comparison of Clinical Outcomes of Cortical Bone Trajectory and Traditional Pedicle Screw Fixation in Posterior Lumbar Interbody Fusion

Posterior lumbar interbody fusion (PLIF) is a common surgical procedure and widely used in the treatment of lumbar degenerative disc disorders. Traditionally, posterior lumbar interbody fusion is done by using the traditional pedicle screw (PS) which offers great advantages, but at the same time it has some disadvantages which include the risk of superior facet joint violation and muscle damage. Recently, an alternative method of screw insertion via cortical bone trajectory (CBT) has been invented which has less invasive process and can be placed without the drawbacks associated with the traditional pedicle screw. However, it has to remain an interest whether CBT will provide similar or greater clinical outcomes compared to PS in PLIF. So the main aim of this review is to compare the clinical outcomes of cortical bone trajectory and traditional pedicle screw fixation in posterior lumbar interbody fusion based on the articles published on this topic. Compared to the traditional pedicle screw fixation, PLIF with CBT has similar clinical outcome based on pain intensity, ODI status and JOA score, as well as similar fusion rate and radiological evaluated complication such as loosening of screw. In addition PLIF with CBT has advantages of less facet joint violation, less blood loss, less intraoperative muscle damage and perioperative pain. On the basis of this study, we can suggest that PLIF with CBT can be considered as a reasonable alternative to PS in PLIF.

Application of the cortical bone trajectory technique in posterior lumbar fixation

The cortical bone trajectory(CBT) is a novel technique in lumbar fixation and fusion.The unique caudocephalad and medial-lateral screw trajectories endow it with excellent screw purchase for vertebral fixation via a minimally invasive method.The combined use of CBT screws with transforaminal or posterior lumbar interbody fusion can treat a variety of lumbar diseases,including spondylolisthesis or stenosis,and can also be used as a remedy for revision surgery when the pedicle screw fails.CBT has obvious advantages in terms of surgical trauma,postoperative recovery,prevention and treatment of adjacent vertebral disease,and the surgical treatment of obese and osteoporosis patients.However,the concept of CBT internal fixation technology appeared relatively recently;consequently,there are few relevant clinical studies,and the long-term clinical efficacy and related complications have not been reported.Therefore,large sample and prospective studies are needed to further reveal the long-term complications and fusion rate.As a supplement to the traditional pedicle trajectory fixation technique,the CBT technique is a good choice for the treatment of lumbar diseases with accurate screw placement and strict indications and is thus deserving of clinical recommendation.

On a Constitutive Material Model to Capture Time Dependent Behavior of Cortical Bone

It is commonly known that cortical bone exhibits viscoelastic-viscoplastic behavior which affects the biomechanical response when an implant is subjected to an external load. In addition, long term effects such as creep, relaxation and remodeling affect the success of the implant over time. Constitutive material models are commonly derived from data obtained in in vitro experiments. However during function, remodeling of bone greatly affects the bone material over time. Hence it is essential to include long term in vivo effects in a constitutive model of bone. This paper proposes a constitutive material model for cortical bone incorporating viscoelasticity, viscoplasticity, creep and remodeling to predict stress-strain at various strain rates as well as the behavior of bone over time in vivo. The rheological model and its parameters explain the behavior of bone subjected to longitudinal loading. By a proper set of model parameters, for a specific cortical bone, the present model can be used for prediction of the behavior of this bone under specific loading conditions. In addition simulation with the proposed model demonstrates excellent agreement to in vitro and in vivo experimental results in the literature.

Experimental Investigation of Material Removal in Elliptical Vibration Cutting of Cortical Bone

To benefit tissue removal and postoperative rehabilitation,increased efficiency and accuracy and reduced operating force are strongly required in the osteotomy.A novel elliptical vibration cutting(EVC)has been introduced for bone cutting compared with conventional cutting(CC)in this paper.With the assistance of high-speed microscope imaging and the dynamometer,the material removals of cortical bone and their cutting forces from two cutting regimes were recorded and analysed comprehensively,which clearly demonstrated the chip morphology improvement and the average cutting force reduction in the EVC process.It also revealed that the elliptical vibration of the cutting tool could promote fracture propagation along the shear direction.These new findings will be of important theoretical and practical values to apply the innovative EVC process to the surgical procedures of the osteotomy.

EFFECT OF INTERNAL FIXATION PLATES ON MICROCIRCULATION IN UNDER-PLATE CORTICAL BONES MICROANGIOGRAPHY AND SCANNING ELECTRONMICROSCOPY

To elucidate the effect of the internal fixation plates on the local bone blood sapply, we used microangiography and scanning electron microscopy to observe the morphological changes of microcirculation in the cortical bones obtained from intact rabbit tibiae on which plates of two different stiffness had been fixed for comparison. The results indicated that both rigid stainless steel plate and less rigid methyl methacrylate plate could induce the bone microcirculation under the plate to undergo a process from early depression to late reactive recruitment. The features of the microcircuiation recruitment such as vascular number, arrangement and dilatation varied with plates of different stiffness and were more obvious in the cortex fixed by rigid stainless steel plate.

Quantitative Histological Study on Changes of the Cortical Bones after Internal Fixation with Plates of Different Rigidity

In an effect to explore the potemtial role of bone microcirculation causing plate-induced reginal osteoporosis

Lumbar pedicle cortical bone trajectory screw

Objective The purpose of this study was to demonstrate the lumbar pedicle cortical bone trajectory （CBT） screw fixation technique,a new fixation technique for lumbar surgery.Data sources The data analyzed in this review are mainly from articles reported in PubMed published from 1994 to 2014.Study selection Original articles and critical reviews relevant to CBT technique and lumbar pedicle fixation were selected.Results CBT technique was firstly introduced as a new fixation method for lumbar pedicle surgery in 2009.The concepts,morphometric study,biomechanical characteristics and clinical applications of CBT technique were reviewed.The insertional point of CBT screw is located at the lateral point of the pars interarticularis,and its trajectory follows a caudocephalad path sagittally and a laterally directed path in the transverse plane.CBT technique can be used for posterior fixation during lumbar fusion procedures.This technique is a minimally invasive surgery,which affords better biomechanical stability,fixation strength and surgical safety.Therefore,CBT technique has the greatest benefit in lumbar pedicle surgery for patients with osteoporosis and obesity.Conclusion CBT technique is a better alternative option of lumbar pedicle fixation,especially for patients with osteoporosis and obesity.

Cortical bone trajectory screws in the treatment of lumbar degenerative disc disease in patients with osteoporosis

Lumbar degenerative disc disease(DDD)in the elderly population remains a global health problem,especially in patients with osteoporosis.Osteoporosis in the elderly can cause failure of internal fixation.Cortical bone trajectory(CBT)is an effective,safe and minimally invasive technique for the treatment of lumbar DDD in patients with osteoporosis.In this review,we analyzed the anatomy,biomechanics,and advantages of the CBT technique in lumbar DDD and revision surgery.Additionally,the clinical trials and case reports,indications,advancements and limitations of this technique were further discussed and reviewed.Finally,we concluded that the CBT technique can be a practical,effective and safe alternative to traditional pedicle screw fixation,especially in DDD patients with osteoporosis.

A cortical bone milling force model based on orthogonal cutting distribution method

In orthopedic surgery,the bone milling force has attracted attention owing to its significant influence on bone cracks and the breaking of tools.It is necessary to build a milling force model to improve the process of bone milling.This paper proposes a cortical bone milling force model based on the orthogonal cutting distribution method(OCDM),explaining the effect of anisotropic bone materials on milling force.According to the model,the bone milling force could be represented by the equivalent effect of a transient cutting force in a rotating period,and the transient milling force could be calculated by the transient milling force coefficients,cutting thickness,and cutting width.Based on the OCDM,the change in transient cutting force coefficients during slotting can be described by using a quadratic polynomial.Subsequently,the force model is updated for robotic bone milling,considering the low stiffness of the robot arm.Next,an experimental platform for robotic bone milling is built to simulate the milling process in clinical operation,and the machining signal is employed to calculate the milling force.Finally,according to the experimental result,the rationality of the force model is verified by the contrast between the measured and predicted forces.The milling force model can satisfy the accuracy requirement for predicting the milling force in the different processing directions,and it could promote the development of force control in orthopedic surgery.

Comparative Study on Inorganic Composition and Crystallographic Properties of Cortical and Cancellous Bone

Objective To comparatively investigate the inorganic composition and crystallographic properties of cortical and cancellous bone via thermal treatment under 700 ℃. Methods Thermogravimetric measurement, infrared spectrometer, X-ray diffraction, chemical analysis and X-ray photo-electron spectrometer were used to test the physical and chemical properties of cortical and cancellous bone at room temperature 250 ℃, 450 ℃, and 650 ℃, respectively. Results The process of heat treatment induced an extension in the a-lattice parameter and changes of the c-lattice parameter, and an increase in the crystallinity reflecting lattice rearrangement after release of lattice carbonate and possible lattice water. The mineral content in cortical and cancellous bone was 73.2wt% and 71.5wt%, respectively. For cortical bone, the weight loss was 6.7% at the temperature from 60 ℃ to 250℃, 17.4% from 250 ℃ to 450 ℃, and 2.7% from 450 ℃ to 700 ℃. While the weight loss for the cancellous bone was 5.8%, 19.9%, and 2.8 % at each temperature range, the Ca/P ratio of cortical bone was 1.69 which is higher than the 1.67 of stoichiometric HA due to the B-type CO32- substitution in apatite lattice. The CaJP ratio of cancellous bone was lower than 1.67, suggesting the presence of more calcium deficient apatite. Conclusion The collagen fibers of cortical bone were arrayed more orderly than those of cancellous bone, while their mineralized fibers ollkded similar. The minerals in both cortical and cancellous bone are composed of poorly crystallized nano-size apatite crystals with lattice carbonate and possible lattice water. The process of heat treatment induces a change of the lattice parameter, resulting in lattice rearrangement after the release of lattice carbonate and lattice water and causing an increase in crystal size and crystallinity. This finding is helpful for future biomaterial design, preparation and application.

Fatigue behavior of cortical bone:a review

Fatigue is a common cause of bone failure.As the main load-bearing tissue,cortical bone carries a considerable share of load in the whole bone.Under cyclic loading condition,microdamage may generates and accumulates in cortical bone,which further triggers the fracture of bone.It is crucial to explore the fatigue properties of cortical bone and the influential factors for both clinical diagnosis and establishment of models that can predict fatigue failure of human cortical bone.In this review,the fatigue behavior of cortical bone was investigated.Through the complex hierarchical structure and self-repairing process,the risk of catastrophic fracture is reduced.Based on these understandings,the multiple influential factors of cortical bone fatigue properties were analyzed,which were considered to be a combination of internal and external factors.The internal factors include material properties of bone composition(i.e.,mineral,organic material,and water)and bone structure.External factors refer to loading condition such as frequency,amplitude and direction of load.Besides,age,disease,radiation exposure and other factors affect the fatigue behavior of bone by altering one or more factors mentioned above.

Assessment of cortical bone microdamage following insertion of microimplants using optical coherence tomography: a preliminary study

Objectives： The study was done to evaluate the efficacy of optical coherence tomography （OCT）, to detect and analyze the microdamage occurring around the microimplant immediately following its placement, and to compare the findings with micro-computed tomography （IJCT） images of the samples to validate the result of the present study. Methods： Microimplants were inserted into bovine bone samples. Images of the samples were obtained using OCT and μCT. Visual comparisons of the images were made to evaluate whether anatomical details and microdamage induced by microimplant insertion were accurately revealed by OCT. Results： The surface of the cortical bone with its anatomical variations is visualized on the OCT images. Microdamage occurring on the surface of the cortical bone around the microimplant can be appreciated in OCT images. The resulting OCT images were compared with the μCT images. A high correlation regarding the visualization of individual microcracks was observed. The depth penetration of OCT is limited when compared to μCT. Conclusions： OCT in the present study was able to generate high-resolution images of the microdamage occurring around the microimplant. Image quality at the surface of the cortical bone is above par when compared with μCT imaging, because of the inherent high contrast and high-resolution quality of OCT systems. Improvements in the imaging depth and development of intraoral sensors are vital for developing a real-time imaging system and integrating the system into orthodontic practice.

Material and regenerative properties of an osteon-mimetic cortical bone-like scaffold

The objective of this work was to fabricate a rigid,resorbable and osteoconductive scaffold by mimicking the hierarchical structure of the cortical bone.Aligned peptide-functionalize nanofiber microsheets were generated with calcium phosphate(CaP)content similar to that of the natural cortical bone.Next,the CaP-rich fibrous microsheets were wrapped around a microneedle to form a laminated microtube mimicking the structure of an osteon.Then,a set of the osteon-mimetic microtubes were assembled around a solid rod and the assembly was annealed to fuse the microtubes and form a shell.Next,an array of circular microholes were drilled on the outer surface of the shell to generate a cortical bone-like scaffold with an interconnected network of Haversian-and Volkmann-like microcanals.The CaP content,porosity and density of the bone-mimetic microsheets were 240 wt%,8%and 1.9 g/ml,respectively,which were close to that of natural cortical bone.The interconnected network of microcanals in the fused microtubes increased permeability of a model protein in the scaffold.The cortical scaffold induced osteogenesis and vasculogenesis in the absence of bone morphogenetic proteins upon seeding with human mesenchymal stem cells and endothelial colony-forming cells.The localized and timed-release of morphogenetic factors significantly increased the extent of osteogenic and vasculogenic differentiation of human mesenchymal stem cells and endothelial colony-forming cells in the cortical scaffold.The cortical bonemimetic nature of the cellular construct provided balanced rigidity,resorption rate,osteoconductivity and nutrient diffusivity to support vascularization and osteogenesis.

Elastic modulus and hardness of cortical and trabecular bovine bone measured by nanoindentation

The elastic modulus and hardness of several microstructure components of dry bovine vertebrae and tibia have been investigated in the longitude and transverse directions using nanoindentation. The elastic modulus for the osteons and the interstitial lamellae in the longitude direction were found to be (24.7±2.5) GPa and (30.1±2.4) GPa. As it's difficult to distinguish osteons from interstitial lamellae in the transverse direction, the average elastic modulus for cortical bovine bone in the transverse direction was (19.8±1.6) GPa. The elastic modulus for trabecular bone in the longitude and transverse direction were (20±2) GPa and (14.7±1.9) GPa respectively. The hardness also varied among the microstructure components in the range of 0.41-0.89 GPa. Analyses of variance show that the values are significantly different.

Indication and surgical approach for reconstruction with endoprosthesis in bone-associated soft tissue sarcomas:Appropriate case management is vital

It is important for surgeons performing sarcoma surgery to know that bone resection and tumor prosthesis applications in soft tissue sarcomas(STS)have unique features in terms of indication,surgical approach and follow-up,in terms of the management of these cases.Some STS are associated with bone and major neurovascular structures.Bone-associated STS are generally relatively large and relatively deep-seated.Additionally,the tendency for metastasis is high.In some cases,the decision about which structures to resect is difficult.These cases are often accompanied by poor oncological and surgical outcomes.Management of cases should be done by a multidisciplinary team in advanced centers specialized in this field.The surgical team must have sufficient knowledge and experience in the field of limb-sparing surgery.Preoperative evaluation and especially good planning of bone and soft tissue reconstruction are vital.