You-Shui Gao

Free vascularised fibular grafting combined with a locking plate for massive bone defects in the lower limbs: a retrospective analysis of fibular hypertrophy in 18 cases.

OBJECTIVE Free vascularised fibular grafting (FVFG) could be a good option for the restoration of massive bone defects in lower limbs when combined with use of a locking plate. The progress of fibular hypertrophy is closely related to regain of function, as well as to prevention of stress fractures. Multiple variables affecting fibular hypertrophy were investigated in the current study to elucidate correlative factors. METHODS Eighteen patients with a massive bone defect in a lower limb reconstructed by FVFG combined with a locking plate were retrospectively enrolled in the current study. The degree of fibular hypertrophy was calculated based on the measurements from anteroposterior imaging at regular intervals of 3 months, 6 months, 1, 2 and 3 years postoperatively. Repeated measures analysis of variance was employed to evaluate and compare correlative factors including gender (male vs. female), age distribution (<30 years vs. >30 years), site (femur vs. tibia) and length of bone defect (6-10 cm vs. >10 cm), previous number of operations (once vs. more than twice) and concomitant infection (detected vs. non-detected). RESULTS All defects could be successfully repaired by FVFG and bone union was achieved uneventfully. The degree of fibular hypertrophy was 0.14%, 11.27%, 31.53%, 58.14% and 71.81% retrospectively at the five follow-up time points. Statistical analysis revealed that the above-mentioned factors did not affect the progress of fibular hypertrophy. CONCLUSIONS FVFG could be a good choice for the reconstruction of massive bone defects when combined with a locking plate. Factors including gender, age distribution, site and length of bone defects, number of previous operations and infection do not impact the progress of fibular hypertrophy, which implies that intrinsic factors might play an important role in restoration.

Chronic calcaneal osteomyelitis associated with soft-tissue defect could be successfully treated with platelet-rich plasma: a case report

Chronic osteomyelitis associated with soft‐tissue defect following surgical management is a severe complication for orthopaedic surgeons. Traditionally, the treatment protocol for the notorious complication involved thorough debridement, bone grafting, long‐term antibiotic use and flap surgery. Alternatively, platelet‐rich plasma (PRP), a high concentration of platelets collected via centrifugation, has been successfully used as an adjuvant treatment for bone and soft‐tissue infection in medical practices. PRP has numerous significant advantages, including stypsis, inflammation remission and reducing the amount of infected fluid. It increases bone and soft‐tissue healing and allows fewer opportunities for transplant rejection. Through many years of studies showing the advantages of PRP, it has become preferred organic product for the clinical treatment of infections, especially for chronic osteomyelitis associated with soft‐tissue defect. To promote the clinical use of this simple and efficacious technique in trauma, we report the case of a patient with chronic calcaneal osteomyelitis associated with soft‐tissue defect that healed uneventfully with PRP.

Surgical approach for high-energy posterior tibial plateau fractures.

Background: High-energy fractures of posterior tibial plateau always need surgical treatment. Generally, posterior fragments of these fractures could not be exposed and reduced well in conventional anterior approaches. Although a posterolateral/posteromedial approach to manage posterior tibial plateau fractures can achieve satisfactory results, there are few presentations concerning the treatment of these high-energy injuries based on posterior approaches combined with anterior approach if necessary. Materials and Methods: Ten cases of posterior tibial plateau fractures from high-energy injuries were retrospectively reviewed and followed up for mean 26.5 months (range 14–45 months). A posterolateral/posteromedial approach was adopted primarily to fix main fragment in posterior tibial plateau, and intraoperative assessment of the stability of knee was done. An anterior approach was added if required. Results: Posterolateral approach was employed in seven cases, posteromedial in three, and additional anteromedial in three, and anterolateral in two cases. The average time to union of all 10 fractures was 3.7 months (range 3–5.5 months). Nine patients had satisfactory articular reduction. The range of motion of the knee averaged 2° of extension to 110.5° of flexion. No patient complained of knee instability. The average postoperative HSS score at the final followup was 92.70. Conclusions: High-energy fractures of posterior tibial plateau could be well treated based on posterior approaches combined with necessary anterior approach if required.

Unilateral Free Vascularized Fibula Shared for the Treatment of Bilateral Osteonecrosis of the Femoral Head

Between June 2007 and May 2008, 21 patients with bilateral osteonecrosis of the femoral head were surgically treated with implantation of free vascularized fibula obtained from the unilateral donor site. All patients were followed up clinically and radiographically for an average of 3.5 years. The evaluation included operative duration, blood loss, Harris hip score, incidence of complications, and radiological examinations. The time for fibular harvesting was 20min on average. Total operative duration was 100-240min, with an average of 150min. Blood loss averaged 300ml. All transplanted fibula integrated well to the femoral head 3.5years postoperatively with no severe complications observed. The results revealed that unilateral free vascularized fibula is effective for the treatment of bilateral osteonecrosis of the femoral head.

Revision hip arthroplasty as a treatment of Vancouver B3 periprosthetic femoral fractures without bone grafting

Background: It is conventionally considered that bone grafting is mandatory for Vancouver B3 periprosthetic femoral fractures (PFF) although few clinical studies have challenged the concept previously. The aim of the current study was to investigate the radiographic and functional results of Vancouver B3 PFF treated by revision total hip or hemiarthroplasty (HA) in combination with appropriate internal fixation without bone grafting. Materials and Methods: 12 patients with Vancouver B3 PFF were treated by revision THA/HA without bone grafting between March 2004 and May 2008. There were nine females and three males, with an average age of 76 years. PFFs were following primary THA/HA in nine patients and following revision THA/HA in three. Postoperative followup was 5.5 years on average (range, 3.5-6.5 years). At the final followup, radiographic results were evaluated with Beals and Towers criteria and functional outcomes were evaluated using the Merle d’Aubigné scoring system. Results: All fractures healed within an average of 20 weeks (range, 12-28 weeks). There was no significant deformity and shortening of the affected limb and the implant was stable. The average Merle d’Aubigné score was 15.8. Walking ability was regained in 10 patients without additional assistance, while 2 patients had to use crutches. There were 2 patients with numbness of lateral thigh, possibly due to injury to the lateral femoral cutaneous nerve. There were no implant failures, dislocation and refractures. Conclusions: Revision THA/HA in combination with appropriate internal fixation without bone grafting is a good option for treatment of Vancouver B3 periprosthetic femoral fractures in the elderly.

Primary tumorectomy promotes angiogenesis and pulmonary metastasis in osteosarcoma-bearing nude mice

PURPOSE To investigate the effect of primary tumorectomy on angiogenesis and pulmonary metastasis in osteosarcoma-bearing nude mice. METHODS Osteosarcoma was introduced to nude mice via subcutaneous injection of MG-63 cells. One hundred and eighty osteosarcoma-bearing mice were used equally in 3 parallel experiments. The effect of tumorectomy (TR) on the expression of vascular endothelial growth factor (VEGF) and endostatin was investigated by ELISA. Meanwhile, the effect on angiogenesis was evaluated by Matrigel plug assay, and pulmonary metastasis assessed by calculating the metastatic foci. Sham-operation (SO) and untreated (UT) groups served as controls. RESULTS The VEGF (TR: 79.55 ± 7.82 pg/mL vs. SO: 110.01 ± 5.69 pg/mL, UT: 123.50 ± 10.41 pg/mL; p < 0.01) and endostatin (TR: 47.09 ± 6.22 ng/mL vs. SO: 117.64 ± 7.39 ng/mL, UT: 126.73 ± 6.55 ng/mL; p<0.01) were down-regulated significantly after tumorectomy, and angiogenesis was significantly promoted simultaneously. The incidence of pulmonary metastatic foci was 80.0% in the TR group, 40.0% in the SO group and 35.0% in the UT group. CONCLUSION Primary tumorectomy can down-regulate the expression of VEGF and endostatin and promote angiogenesis which leads to the acceleration of pulmonary metastasis. These findings imply that anti-angiogenic treatment can be considered after primary tumorectomy.

Free vascularised fibular graft for neglected femoral neck fractures in young adults

Neglected femoral neck fractures in young adults pose a great challenge to orthopedic surgeons because of the high risks of nonunion and osteonecrosis. We attempted to determine whether free vascularised fibular grafting through an anterior approach could enhance bone union, improve hip function and reduce complications in the treatment of such fractures. Thirteen patients with neglected femoral neck fractures were treated with a free vascularised fibular graft through an anterior approach between 2004 and 2008. The mean age was 30.9 years (range, 17–47 years). The average delay between injury and operation was 6.7 months (range, 1.5–22 months). All 13 cases had ununited fractures but without osteonecrosis of the femoral head on plain radiographs before coming under our care. The average follow-up was 51.2 months (range, 36–75 months). All patients had fracture union within an average of 4.8 months (range, 3–9 months). Postoperatively, 9 patients had coxa vara of 10 to 20 degrees and leg discrepancy between 0.5 to 1.5 cm. One patient had coxa vara deformity of 25 degrees and 2-cm leg discrepancy. No patients developed osteonecrosis of the femoral head or donor-site morbidity. The mean Harris hip score improved from 55.5 points preoperatively to 84.8 points postoperatively (p<0.01). This procedure may be useful and safe in the treatment of neglected femoral neck fractures in young adults, but further studies with a large number of patients are needed.

An animal model of femoral head osteonecrosis induced by a single injection of absolute alcohol: An experimental study

Summary Background The lack of an experimental animal model that can reliably mimic all stages of osteonecrosis of the femoral head has hindered progress toward the successful prevention and treatment of the disease. Material/Methods A goat model of osteonecrosis of the femoral head (ONFH) was established and observed from the early to the intermediate-to-late stage of mechanical failure. Absolute alcohol was injected slowly into the center of bilateral femoral heads in 12 adult Small Tail Han goats. Postoperatively, the femoral heads were harvested and examined using macrostructural and histological analyses and radiographic and MRI examinations at weeks 4, 8, 12, and 25. Results Macrostructural and radiographic examinations revealed that the contour of both femoral heads was deformed slightly at 12 weeks, but a contour deformation with joint space narrowing was observed at 25 weeks. Histologically, a strong concordance with the natural history of ONFH in humans was found. The present model demonstrated bone trabeculae, marrow necrosis, a reconstruction deficiency and destruction of the microcirculation. Conclusions Among quadrupedal models, the goat model of ONFH, which is induced by a single injection of absolute alcohol, may be suitable and valuable for the evaluation of various therapeutics and side effects in the treatment of ONFH.

Why we choose free vascularized fibular grafting for osteonecrosis of the femoral head

We read the review article authored by Korompilias et al. with great interest. As authors described, the current treatment protocols for preservation of the femoral head with osteonecrosis consist of free vascularized fibular grafting (FVFG), local transposition of vascularized grafting, nonvascularized bone grafting, core decompression, implantation of porous metal, and various osteotomies. It has been found that FVFG could provide mechanical support for the loading architecture, and restore local circulation via vascular anastomosis, by which, various precursors and cytokines in peripheral circulation could be transferred to the necrotic area for reparation. Korompilias et al. have accumulated great experience in management of the osteonecrosis of femoral head (ONFH) with FVFG in past decades. However, the anterolateral approach to hip and the method for harvest of the free vascularized fibula graft as they described are more technically demanding. With their techniques, cooperation of two surgical teams is necessary to complete the entire procedure. Previously we had modified the technique for harvesting FVFG and approaching the hip, which could significantly shorten the operative time, reduce intraoperative difficulties, and only needs a single team. With our technique of the lateral approach for harvesting the fibula graft, via the natural space between posterior and anterior musculatures, damage to muscles could be decreased. Osteotomy first could facilitate dissecting the vascular pedicle and trimming the muscle cuff around the fibula graft. The anterior approach to hip joint is also easy to perform. Anatomically, the location of lateral femoral circumflex vessels is constant, which could provide a long pedicle with suitable diameter for anastomosis to the peroneal vessels. All dissections can be performed via the natural space of musculatures. When capsulotomy along femoral-neck axis is done, a matched bone tunnel could be made. Removal of the necrotic bony tissue, spongy bone and vascularized fibula grafting, fixation of graft can be maneuvered under direct version. This approach only needs a shorter fibular pedicle for vascular anastomosis, which is beneficial for less donor site morbidity. The shortcoming of this approach is that capsulotomy may result in restricted hip-joint motion after surgery. Early postoperative rehabilitation is encouraged for prevention of possible joint adhesion according to our experience. This modified technique of FVFG for treatment of ONFH has been employed for more than 1,500 patients in our institute. A recent analysis of 342 hips with follow-up longer than 3 years (unpublished data) showed that Harris Hip Score could be improved from 66.0 to 88.1 after surgery, and 85.9% of joint contour with precollapsed ONFH could be maintained, as well as improvement of joint motion and pain relief. However, only 59.5% of postcollapsed ONFH could achieve the similar results. Although various factors may affect the prognosis of femoral head after receiving FVFG, we believe that this technique is effective for the majority of patients under the indications. When compared with the Ioannina’s report, similar results could be expected in our *Correspondence to: Chang-Qing Zhang, Ph.D., M.D., Department of Orthopedic Surgery, Shanghai Sixth People’s Hospital, Shanghai Jiao Tong University, Shanghai 200233, China. E-mail: changqing_1914@yahoo.cn

Injury-to-surgery interval does not affect the occurrence of osteonecrosis of the femoral head: a prospective study in a canine model of femoral neck fractures.

Summary Background It is controversial whether an early reduction and internal fixation can reduce the occurrence of femoral neck fracture-induced osteonecrosis of the femoral head (ONFH). This prospective study was designed to reflect the relationship between injury-to-surgery interval (ISI) and traumatic ONFH based on a canine model of femoral neck fractures. Material/Methods Twenty-four dogs were equally divided randomly into 3 groups. A lateral L-shape approach centered left great trochanter was used for exposure of the femoral neck. A low-speed drill was used for making displaced fractures in the narrow femoral neck, with the femoral head kept in situ with ligamentum teres intact. In Group A, the fracture was immediately reduced and fixed with 3 parallel pins; while the operation was done 3 days later in Group B, and 3 weeks later in Group C. Another 2 dogs had their fractures untreated. Postoperatively, all dogs were fed separately and received regular x-ray examination. Left femoral heads were harvested for histological examination with a postoperative follow-up of 3.5 months. Results The canine model of femoral neck fractures could be achieved successfully. Radiological signs of post-fracture ONFH could not be detected at intervals of 2 weeks, 4 weeks, 1 month and 2 months. Histologically, there were 2 cases with ONFH in Group A, 1 case in Group B, and 2 cases in Group C. The difference had no statistical significance. For untreated fractures, obvious ONFH could be found radiologically. Conclusions A shorter ISI may not reduce the incidence of fracture-induced ONFH, which suggests that intrinsic factors play an important role in the occurrence of ONFH.