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Cerclage wiring of the humeral diaphysis entails particular danger to the radial nerve and the deep brachial artery. We sought to delineate safe zones for minimally invasive cerclage wiring of the humeral diaphysis, specifically in relation to the radial nerve and accompanying vasculature. Cerclage wires were percutaneously inserted into three groups of fresh-frozen cadaveric humeri. Group 1-proximal midshaft humerus at 30% of humeral height (n = 4); Group 2-midshaft spiral groove at 45% of humeral height (n = 4); and Group 3-distal midshaft humerus at 60% of humeral height (n = 4). Subsequently, an extensive surgical exploration of the arteries and nerves around the humerus was performed, noting any disturbance to the vessels or nerves and measuring the distance from the cerclage wire to the radial nerve. Neurovascular structures were injured in 75% of specimens when the cerclage wire was inserted at the level of the spiral groove. Both posterior structures, e.g. the radial nerve and the deep brachial artery, and medial structures, e.g., the median nerve and brachial artery, were incarcerated. Application of the cerclage at 30% or 60% of humeral height did not cause neurovascular injury. Minimally invasive application of the cerclage wire at the spiral groove, which is at 45% of humeral height, is likely to cause injury to neurovascular structures. Application of the cerclage at the proximal or distal midshaft humeral areas is associated with less risk of such injury. Clin. Anat. 33:552-557, 2020. © 2019 Wiley Periodicals, Inc., (© 2019 Wiley Periodicals, Inc.)

The nutrient arteries, located in the long bone diaphysis, are the major blood supply to long bones, especially during the early phases of growth and ossification. Their intersection with the central axis of the medullary area corresponds to the ossification center, and their opening on the outer bone surface to the nutrient foramen. Nutrient arteries/foramen have essentially been analyzed in humans, and only to a much lesser extent in a few mammals. Some studies have taken measurements of the nutrient foramen; others have investigated the shape and orientation of the nutrient canals, although only partially. No studies have analyzed the nutrient canal in three dimensions inside the bone and the relationships between nutrient foramen, nutrient canal, growth, and physiology require further investigation. The current study proposes to investigate in three dimensions the shape of the nutrient canal in stylopod bones of various mammals. Qualitative and quantitative parameters are defined to discuss the diversity in, for example, morphology, orientation, and diameter encountered, resorting to two different datasets to maximize differences within mammals and then analyze variation within morphologically and phylogenetically closer taxa. This study highlights a strong intraspecific variation for various parameters, with limited biological signal, but also shows trends. It notably provides evidence that canals are generally more numerous and relatively thinner in less elongated bones. Moreover, it shows that the growth center is located distally in the humerus and proximally in the femur, and that the canals are essentially oriented towards the faster growing end, so that the nutrient foramen does not indicate the location of the growth center. This result seems general in mammals but cannot be generalized outside of Mammalia. Further analyses of the features of nutrient arteries in reptiles are required to make comparisons with the trends observed in mammals., (© 2019 Anatomical Society.)

Quantitative assessment of functional perfusion capacity and vessel architecture is critical when validating biomaterials for regenerative medicine purposes and requires high-tech analytical methods. Here, combining two clinically relevant imaging techniques, (magnetic resonance imaging; MRI and microcomputed tomography; MicroCT) and using the chorioallantoic membrane (CAM) assay, we present and validate a novel functional and morphological three-dimensional (3D) analysis strategy to study neovascularization in biomaterials relevant for bone regeneration. Using our new pump-assisted approach, the two scaffolds, Optimaix (laminar structure mimicking entities of the diaphysis) and DegraPol (highly porous resembling spongy bone), were shown to directly affect the architecture of the ingrowing neovasculature. Perfusion capacity (MRI) and total vessel volume (MicroCT) strongly correlated for both biomaterials, suggesting that our approach allows for a comprehensive evaluation of the vascularization pattern and efficiency of biomaterials. Being compliant with the 3R-principles (replacement, reduction and refinement), the well-established and easy-to-handle CAM model offers many advantages such as low costs, immune-incompetence and short experimental times with high-grade read-outs when compared to conventional animal models. Therefore, combined with our imaging-guided approach it represents a powerful tool to study angiogenesis in biomaterials.

Background: Arteriovenous malformations (AVMs) are rare congenital vascular lesions associated with early quiescence, late expansion, and, ultimately, infiltration and destruction of local soft tissue and bone. The extremities are a common location. Incidence of bony involvement by AVM has been reported as high as 31%. However, there are few reports on management of pathologic fracture associated with AVM. Teriparatide is a recombinant parathyroid hormone (PTH) analogue consisting of the 1-34 fragment of PTH. Recently, some reports have shown the ability of teriparatide to improve fracture healing. Here, we present a case of pathologic femoral shaft fracture associated with large AVMs that was treated successfully by external fixation and teriparatide., Case Presentation: A 68-year-old Japanese woman, previously diagnosed as having large AVMs, sustained a right femoral shaft fracture due to a fall. At the time of admission, she presented with massive swelling and venous varicosities of the right thigh. Plain radiography of the right thigh revealed femoral shaft fracture with bony erosion and calcification of soft tissue. We planned closed reduction and intramedullary nailing with a unilateral external fixator following embolization of the feeding artery. However, closed reduction using the fracture table was difficult. When we attempted open reduction, massive bleeding (1000 mL) after incision of subcutaneous tissue occurred. Finally, we carefully applied a Taylor Spatial Frame. Fracture displacement was corrected successfully and bony union was obtained with administration of teriparatide 15 months after the initial surgery. The patient is able to walk using 1 cane., Conclusion: We present the first report of pathologic fracture associated with large AVMs that achieved bony union using a 3-dimensional external fixator and teriparatide.

Although bone defects after trauma appear in different locations and forms, many clinicians have adopted a single strategy to deal with any defect. In this overview, a distinction is made between metaphyseal, or cancellous defects, and diaphyseal, or cortical defects. The treatment goals and background of these two types of defects are discussed in order to describe the difference in strategy and hence the difference in treatment method., (Copyright © 2017. Published by Elsevier Ltd.)

Purpose: Neovascularization is essential for bone regeneration in fractures. This study aimed to investigate the microvascular morphology and distribution in the non-injured femur and the neovascularization of the metaphyseal critical size defect in a small animal model of osteoporosis., Materials and Methods: Female rats (n=7) were ovariectomized (OVX) and received a multideficiency diet. Three months after OVX, a 5mm wedge shaped critical size defect was cut at the distal femoral metaphysis and stabilized with a T-shaped mini-plate. After six weeks, the animals were euthanized, and femora were removed and decalcified for micro-CT measurement of fracture neovascularization., Results: No fracture healing was observed along the critical size defects. In the non-injured bone, micro-vessel distribution showed a specific pattern, thereby enabling a differentiation between epi-, meta- and diaphysis. Micro-CT based morphometry revealed a significant reduction of the vascular volume fraction as well as the vascular thickness (p<0.001) in the critical size defect compared to the intact contralateral femur. Blood volume related vascular surface (vascular surface/volume) increased significantly (p<0.001). Connectivity density and tissue volume related vascular surface (vascular surface density) did not change significantly., Conclusions: Micro-CT based vascular morphometry demonstrated differences between epi-, meta- and diaphysis in the non-injured bone as well as differences between the critical size defect and the non-injured metaphysis. As angiogenesis is a crucial prerequisite that precedes osteogenesis, our results may influence further evaluation of osteoconductive or osteogenic biomaterials in this small animal model of osteoporosis., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Objective: To study the diaphyseal Nutrient Foramina (NF) of dry Pakistani fibulae morphometrically and topographically., Study Design: Descriptive cross-sectional study., Place and Duration of Study: Anatomy Department, Allama Iqbal Medical College, Lahore, from December 2013 to April 2014., Methodology: The materials comprised 168 dried fibulae, 80 of left side and 88 of right side. Length of bone and distance of NF from the proximal end was calculated by placing bones on osteometric board. The Foramen Index (FI) was calculated by applying the Hughes formula, dividing the distance of the foramen from the proximal end (DNF) by the total length of the bone (TL) which was multiplied by hundred FI = (DNF/TL) x 100., Results: Eighty five bones (96.6%) of right side and 79 bones (98.8%) of left side had a single nutrient foramen. Mean length of left fibula was 34.690 ±2.353 cms and of right fibula 34.905 ±2.198 cms. Mean foramen index was 47.651 ±7.601 on the left side and 50.283 ±11.478 on the right side. In the right fibulae, type-1 foramen was present in one (1.13%) bone, type-2 was present in 77 (87.5%) bones and type-3 was found in 10 (11.36%) bones. In the left fibulae, type-1 foramen was not found in any bone, type-2 in 79 bones (98.75%) and type 3 in only 1 bone (1.25%)., Conclusion: This study provides important information on the topography of nutrient foramina of fibula in Pakistani population. As microvascular bone transfer is becoming more popular, such data regarding nutrient foramina will be of importance to orthopaedic surgeons.

Besides the use of autologous bone grafting several osteoconductive and osteoinductive methods have been reported to improve bone healing. However, persistent non-union occurs in a considerable number of cases and compromised angiogenesis is suspected to impede bone regeneration. Hyperbaric oxygen therapy (HBO) improves angiogenesis. This study evaluates the effects of HBO on bone defects treated with autologous bone grafting in a bone defect model in rabbits. Twenty-four New-Zealand White Rabbits were subjected to a unilateral critical sized diaphyseal radius bone defect and treated with autologous cancellous bone transplantation. The study groups were exposed to an additional HBO treatment regimen. Bone regeneration was evaluated radiologically and histologically at 3 and 6 weeks, angiogenesis was assessed by immunohistochemistry at three and six weeks. The additional administration of HBO resulted in a significantly increased new bone formation and angiogenesis compared to the sole treatment with autologous bone grafting. These results were apparent after three and six weeks of treatment. The addition of HBO therapy to autologous bone grafts leads to significantly improved bone regeneration. The increase in angiogenesis observed could play a crucial role for the results observed., (© 2015 Orthopaedic Research Society. Published by Wiley Periodicals, Inc.)

Transphyseal reinforcement of right intact tibia performed with thin steel rods in six mongrel dogs at the age of six months. Contralateral segment served as control. The leg growth and blood supply studied under the created conditions for the next six months. Radiographic, physiologic (surface thermometry, photoplethysmography), and statistical methods used for studying. The significant effect of transphyseally inserted rods on the leg longitudinal growth and blood supply has not been revealed. The changes in natural shape-formation oftibial proximal and distal meta-epiphyses observed influenced by the transphyseal rods in the experiment. In order to evaluate the tissue response and the degree of the functional activity of leg bone meta-epiphyseal zones the most informative areas considered to be the following: the area of medial malleolus in the early period of physiological growth completion, and the area of the tibial lateral condyle--at the late stage.

Bone fragility due to osteopenia, osteoporosis or debilitating focal skeletal dysplasias is a frequent observation in the Mendelian disease Neurofibromatosis type 1 (NF1). To determine the mechanisms underlying bone fragility in NF1 we analyzed two conditional mouse models, Nf1Prx1 (limb knock-out) and Nf1Col1 (osteoblast specific knock-out), as well as cortical bone samples from individuals with NF1. We examined mouse bone tissue with micro-computed tomography, qualitative and quantitative histology, mechanical tensile analysis, small-angle X-ray scattering (SAXS), energy dispersive X-ray spectroscopy (EDX), and scanning acoustic microscopy (SAM). In cortical bone of Nf1Prx1 mice we detected ectopic blood vessels that were associated with diaphyseal mineralization defects. Defective mineral binding in the proximity of blood vessels was most likely due to impaired bone collagen formation, as these areas were completely devoid of acidic matrix proteins and contained thin collagen fibers. Additionally, we found significantly reduced mechanical strength of the bone material, which was partially caused by increased osteocyte volume. Consistent with these observations, bone samples from individuals with NF1 and tibial dysplasia showed increased osteocyte lacuna volume. Reduced mechanical properties were associated with diminished matrix stiffness, as determined by SAM. In line with these observations, bone tissue from individuals with NF1 and tibial dysplasia showed heterogeneous mineralization and reduced collagen fiber thickness and packaging. Collectively, the data indicate that bone fragility in NF1 tibial dysplasia is partly due to an increased osteocyte-related micro-porosity, hypomineralization, a generalized defect of organic matrix formation, exacerbated in the regions of tensional and bending force integration, and finally persistence of ectopic blood vessels associated with localized macro-porotic bone lesions.

Despite clinical efforts to treat growth disturbances only little is known about the growth potential of the different zones of the growth plate. The aim of this study was to investigate the growth potential of different zones of the growth plate. A total of 20 New Zealand White rabbits were used for this experiment. The right and left ulna of each animal were used resulting in a total of 40 ulnae. Animals were assigned into five groups. In groups I and II resection of the metaphyseal (n = 12) or the epiphyseal (n = 6) segment of the growth plate was performed. In group III resection of the growth plate and re-implantation was performed (n = 6). In group IV the growth plate was resected and re-implanted after a 180° rotation (n = 6). Animals in group V served as controls. Histologic and radiologic examinations were performed to evaluate the growth process at 1, 2, 4, and 12 weeks following surgery. In group I, III, and IV temporary growth disturbance which was compensated within a short time was observed. Resection of the epiphyseal part resulted in growth arrest of the distal ulna in combination with normal growth of the radius which led to and valgus deformity of the limb. The results of this study indicate the importance of the reserve zone for the functioning of the growth plate., (Copyright © 2011 Orthopaedic Research Society.)

Laser-Doppler flowmetry (LDF) is an outstanding tool to monitor blood flow in a continuous and non-invasive way. In this work, we study LDF at large interoptode spacing applied to a human bone model (i.e. tibia diaphysis). To that aim, we first performed an extensive set of Monte Carlo (MC) simulations for 10 and 25 mm interoptode spacing. Second, we have assembled a dedicated LDF instrumentation based on an optimized industrial avalanche photo-detector. We performed LDF experimental measurements on human muscle using well-known physiological protocols, which confirmed the reliability of our instrumentation and the relevance of the LDF algorithms tested with the MC simulations. In a second set, we repeated the measurements on human tibia diaphysis. Again, the experiments corroborate the MC simulations and demonstrate the effectiveness of LDF to monitor blood perfusion in bone. The proposed technique has great potential for non-invasive neuro-vascular studies since it will certainly help to reveal the mechanisms underlying the interaction between bone/bone marrow, the circulatory system and the nervous system.

It is generally accepted that in tibial fractures the results of reamed intramedullary nailing are better than those of unreamed. However, it is not known whether the clinical effects of reaming are cumulative or if minimal reaming would induce the same beneficial effects as more extensive reaming. This international multicentre study has investigated the effects of different degrees of reaming. 100 patients with closed diaphyseal tibial fractures were prospectively randomised in two centres. Method of treatment was reamed nailing up to 12 mm inserting an 11 mm tibial nail (n: 50), and minimally reamed nailing up to 10 mm inserting a 9 mm tibial nail (n: 50). All patients included in the study had follow-up studies at 4,8,12,16,26 and 52 weeks after trauma. Sixty-six male and thirty-four female patients with an average age of 37.5 years were included in the study. Gender, age, and injury side were identical in both groups. There was no significant difference of complications in the two methods. The rate of deep wound infections was higher in the reamed group (n: 3) versus the minimally reamed group (n: 1). Union occurred earlier in the reamed group (17 wks) compared to patients with minimally reamed nailing (19 wks), and there were more patients with reamed nails in whom the fracture had healed by 16 weeks (57%) versus the minimally reamed group (43%), however, this was not statistically significant. Pain scales were similar for both groups from week 4 to week 52. A considerable number of outcome parameters including knee and ankle function, as well as the comparison of time intervals to restart certain activities, and return to work showed no significant statistical difference between the two groups. However, patients of the extensive reamed group returned earlier to running, training, and normal sports activities. This study found no significant evidence that more extensive reaming gave better results, however there seemed to be a tendency of more aggressive reaming to induce earlier fracture healing with a tendency of faster recovery times., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

The intracortical vessel system of the rabbit femur has been studied after perfusion of the vascular tree with a water solution of dye (China ink) with multiplanar analysis. This method utilizes the full depth of field of the microscope objectives focusing different planes of the thick cortex. The microscopic observation even if restricted to a limited volume of cortex allowed to differentiate true 3-D nodes (54.5%) from the superimposition of vessels lying on different planes. The network model with elongated meshes preferentially oriented along the longitudinal axis of the diaphysis in his static configuration is not very different from the vascular anatomy depicted in the 2-D traditional models; however, the semi-quantitative morphometric analysis applied to the former supported the notion of a multidirectional microvascular network allowing change of flow according to the functional requirements. Other peculiar aspects not previously reported were cutting cone loops, blind-end and short-radius-bent vessels, and button-holes figures. The network design and node distribution were consistent with the straight trajectory of the secondary remodeling, with the proximal-to-distal and distal-to-proximal advancement directions of the cutting cones and with two main modes of node formation, namely bifurcation of the cutting cone and interception with pre-existing canals. The general organization of the network and its uninterrupted transformation during bone modeling and remodeling suggested a substantial plasticity of the intracortical vascular system capable to adapt itself to the changeable haemodynamic conditions., (Copyright © 2010 Elsevier Inc. All rights reserved.)

Despite the important physiological role of periosteum in the pathogenesis and treatment of osteoporosis, little is known about the structural and cellular characteristics of periosteum in osteoporosis. To study the structural and cellular differences in both diaphyseal and metaphyseal periosteum of osteoporotic rats, samples from the right femur of osteoporotic and normal female Lewis rats were collected and tissue sections were stained with hematoxylin and eosin, antibodies or staining kit against tartrate resistant acid phosphatase (TRAP), alkaline phosphatase (ALP), vascular endothelial growth factor (VEGF), von Willebrand (vWF), tyrosine hydroxylase (TH) and calcitonin gene-related peptide (CGRP). The results showed that the osteoporotic rats had much thicker and more cellular cambial layer of metaphyseal periosteum compared with other periosteal areas and normal rats (P < 0.001). The number of TRAP(+) osteoclasts in bone resorption pits, VEGF(+) cells and the degree of vascularization were found to be greater in the cambial layer of metaphyseal periosteum of osteoporotic rats (P < 0.05), while no significant difference was detected in the number of ALP(+) cells between the two groups. Sympathetic nerve fibers identified by TH staining were predominantly located in the cambial layer of metaphyseal periosteum of osteoporotic rats. No obvious difference in the expression of CGRP between the two groups was found. In conclusion, periosteum may play an important role in the cortical bone resorption in osteoporotic rats and this pathological process may be regulated by the sympathetic nervous system.

The purpose of this study was to demonstrate that living bone allotransplants can incorporate, remodel, and maintain mechanical properties without long-term immunosuppression in a fashion comparable to living autotransplants. For this, viability is maintained by repair of nutrient vessels and neovascularization from implanted host-derived vasculature. Microsurgically revascularized femoral diaphysis allotransplants were transferred from young male New-Zealand-White (NZW) into 4 groups of male Dutch-Belted (DB) rabbits. Short-term immunosuppression by tacrolimus (IS, groups 4 and 5) and host-derived neovascularization (NV) from implanted fascial flaps was used to maintain viability (groups 3 and 5) as independent variables. Group 2 received neither IS nor NV. Vascularized pedicled autotransplants were orthotopically transplanted in group 1. After 16 weeks, transplants were evaluated using radiologic, histologic, biomechanical, and histomorphometric parameters. Vascularized bone allotransplants treated with both short-term IS and host-derived NV (group 5) healed in a fashion similar to pedicled autotransplants (group 1). Their radiographic scores were higher than other groups. Groups with patent fascial flaps (3 and 5) showed significantly greater neoangiogenesis than ligated controls (2 and 4). Tacrolimus administration did not affect neoangiogenesis. Elastic modulus and ultimate stress were significantly greater in autogenous bone than in allotransplanted femora. Biomechanical properties were not significantly different among allotransplants. Bone turnover was decreased with IS, but increased with NV by the implanted fascial flaps. Living allogeneic femoral allotransplants treated with short-term IS and host-derived neoangiogenesis can lead to stable transplant incorporation in this rabbit model. The combination of both factors optimizes bone healing. Transplant mineralization is improved with neoangiogenesis but diminished with IS., (Copyright 2008 Orthopaedic Research Society)

Purpose: The purpose of this study was to categorize and systematize the arterial supply of the metatarsal bones and furthermore the observation of arterial lesions after frequently performed forefoot surgeries., Materials and Methods: Twenty-two cadaver feet were analyzed by two plastination methods and the enzyme maceration method. Five forefoot surgeries were performed after arterial injections., Results: The bases of the metatarsal bones were primarily supplied by dorsal and plantar arteries. The arterial supply of the metatarsal diaphysis was given by a frequently observed nutrient artery. The first plantar metatarsal artery was the main supply of the first metatarsal head. The plantar and dorsal metatarsal arteries supplied the lesser metatarsals heads. The forefoot surgeries revealed lesions of arteries in all cases., Conclusions: The plastination methods were excellent methods to analyze the arterial supply. In addition arterial damage after forefoot surgeries could be analyzed with these methods.

Introduction: Transfer of proximal epiphysis and diaphysis of fibula is a treatment of bony defects in children. Although there are few reports of this procedure, different arteries or combination of arteries have been used as supplying pedicle and the reported success rates are different. This is an anatomical study to clarify the vascular anatomy of this region., Materials and Methods: A total of 16 fresh cadavers were enrolled. An incision was made in the popliteal fossa to find the popliteal artery, which was dissected distally and the lateral inferior genicular artery, anterior tibial artery, tibioperoneal trunk and its bifurcation were located. In eight subjects popliteal artery was cannulated above the level of femoral condyles and injected by latex. In the next eight cases the same material was injected in the anterior tibial artery. The next steps of dissection were done by 4.3-loupe magnification. Lateral inferior genicular artery was dissected from its origin to the fibular head and branches of anterior tibial artery were also dissected. In three specimens, the fibula and its supplying arteries were removed after dissection and put in diluted hydrochloric acid to be opened for studying the medullary vasculature., Results: This study confirms the existence of not only periosteal but also intramedullary anastomosis between artery of the neck and peroneal artery. Artery of the neck was usually a branch of anterior tibial artery and in 24% of the subjects a branch of popliteal artery. In the latter condition the pedicle would be too short to permit the surgeon to do this surgery. Therefore preoperative angiography is mandatory to identify the origin of the artery of the neck., Conclusion: According to these dissections, a classification system of arterial supply of proximal fibular epiphysis is introduced in this article.

The purpose of the study was to detect the relation between the formation of ossification nucleus in the epiphysis and the ingrowth of vessels into it, using laser radiation of femoral heads. The study was performed in 30 golden hamsters, 20 of them starting at 10 days after birth were exposed to daily irradiation of the right hip joint (during 3-80 days). The left joint was used as control. The radiation was performed with Agnis laser device (radiation power--2 mW, impulse frequency--2500 Hz, exposure duration--8 min, optical fiber diameter--4 mm). Femoral bones of experimental and control animals were histologically studied at days 13 till 90. Laser radiation was found could delay vessel growth from diaphysis into epiphysis for up to 13 days, and the beginning of ossification nucleus formation in the femoral head--for up to 5 days. This suggests the direct relation of the development of bone ossification nucleus in the epiphysis and growing of vessels into its cartilage, since no other factors retarding the vessel growth and formation of bone nucleus were used.

A new vascularized bone transplantation model is described, including the anatomy and surgical technique of isolating a rabbit femoral diaphyseal segment on its nutrient vascular pedicle. The histologic and biomechanical parameters of pedicled vascularized femoral autotransplants were studied following orthotopic reimplantation in the resulting mid-diaphyseal defect. Vascularized femur segments were isolated in 10 rabbits on their nutrient pedicle, and then replaced orthotopically with appropriate internal fixation. Postoperative weightbearing and mobility were unrestricted, and the contralateral femora served as no-treatment controls. After 16 weeks, the bone flaps were evaluated by x-ray (bone healing), mechanical testing (material properties), microangiography (quantification of intraosseous vasculature), histology (bone viability), and histomorphometry (bone remodeling). Bone healing occurred by 2 weeks, with further callus remodeling throughout the survival period. Eight transplants healed completely, while two had a distal pseudarthrosis. Microangiography demonstrated patent pedicles in all transplants. Intraosseous vessel densities were comparable to nonoperated (control) femora. We found ultimate strength and elastic modulus to be significantly reduced when compared to normal controls. Viable bone, increased mineral apposition rate, and bone turnover were demonstrated in all transplants. The method described, and the data provided will be of value for the further study of isolated segments of living bone, and in particular, for investigations of reconstruction of segmental bone loss in weight-bearing animal models. This study also provides important normative data on living autologous bone flap material properties, vascularity, and bone remodeling. We intend to use this method and data for comparison in subsequent studies of large bone vascularized allotransplantation., ((c) 2008 Wiley-Liss, Inc. Microsurgery, 2008)

The architecture of the diaphyseal bone is closely correlated with the cortical vessel network, whose pattern develops in the course of growth. Various methods have been applied to clarify the three-dimensional anatomy of the cortical canal system, but there is still disagreement about the geometry, blood supply, flux dynamics and factors controlling canal geometry during bone growth and remodeling. A modification of the currently employed dye-injection method was applied to study the vessel network of the whole hemi-shaft of the rabbit femur in mature bones (8-month-old rabbits) and growing bones (1.5-month-old rabbits). The cortical vascular tree of the hemi-shaft of the femur was injected with black China ink and observed in full-thickness specimens of the cortex. The same specimens were then processed for histology. A comparative study of the middle diaphysis (mid-shaft) with the distal extremity (distal shaft) was performed in both young and old rabbit femurs. The longitudinally oriented pattern of the vessel network was seen to develop in the diaphysis of mature femurs, while at the extremity of the shaft of the same specimen the network showed a reticular organization without a dominant polarization. The vessels were significantly higher in the mid-shaft than in the distal shaft of the old femurs (P < 0.0001), as was their diameter (P < 0.05). In the group of young rabbits at mid-shaft level the longitudinally oriented pattern of the vessel network was not yet completely developed, without their being significant differences in length and diameter between the mid-shaft and distal shaft. The differentiation of the mid-shaft from the distal shaft was confirmed histologically by the presence, in the latter, of longitudinal calcified cartilage septa between osteons. This pattern of structural organization and development of the intracortical vascular network has not been previously reported. The cells primarily involved in polarization of the remodeling process were the osteoclasts at the top of the cutting cones advancing from the proximal and distal metaphyses toward the mid-shaft. This suggests, first, a relationship with the longitudinally oriented structures already present in the cortex near the metaphysis (the calcified cartilage septa) and then with the columns of interosteonic breccia, which were formed as a secondary effect of the longitudinal polarization of the remodeling process. Our observations did not enable us to substantiate the model of two different systems, one of longitudinal vessels (Havers) and the other of connecting transversal vessels (Volkmann), but suggested instead that there is a network whose loops lengthen in the direction of the major bone axis in the course of growth and secondary modeling. The associated morphology supported the view that the type of structural organization of the tubular bone cortex is primarily determined by an inherited constitutional factor rather than by mechanical strains.

Changes in tibial hemodynamics have been studied experimentally after applying a clamp (n=41) and resection of superficial femoral artery (n=22) in 63 adult dogs. It has been revealed with the help ofrheovasography that, in case of blood flow disorders in the superficial femoral artery, anastomoses with deep femoral artery branches contribute to maintenance of blood circulation in tibia, and in this connection the parameters of tibial blood flow may significantly differe from those of circulation in the leg soft tissues. Preservation of intraosseous pressure all along tibial diaphyseal cavity demonstrates a possibility of using its driving force to compensate for the circulatory insufficiency in the leg soft tissues and, moreover, in that part of the bone the environment of which in ischemia is involved.

Purpose: Nonunion of the distal humerus after fracture or osteotomy is uncommon but can present an important clinical problem. Vascular insufficiency of bone may be an important contributing factor. The purpose of this study was to describe the intraosseous vascular anatomy of the distal humerus., Methods: Nine fresh-frozen upper extremity cadaver specimens were injected with India ink and Ward's blue latex solution. A modified Spalteholz technique was used to show the intraosseous vascular anatomy., Results: The distal humeral diaphysis was supplied by a single nutrient artery. The lateral column was supplied predominately by posterior segmental vessels, whereas the medial column was supplied by anterior and posterior segmental vessels. The trochlea, olecranon fossa, and coronoid fossa were watershed areas., Conclusions: Our study shows the intraosseous vascular anatomy of the distal humerus is relatively consistent. There also appears to be a consistent trochlear vessel medially and small anterior perforating vessels in the lateral column that have not previously been described.

In 25 dogs, it was revealed that the pressure in a long bone shaft cavity (IBP) pulsed at relatively high values. According to rheovasography data, the pulse changes of the vascular blood filling of a shaft cavity caused the IBP. The blood filling changes at pulsing IBP produced pulse changes in interstitial fluid amount, at non-pulsing IBP they provided for fluid coming into the interstitial space of the shaft cavity without pulsations. Tunnelization led to appearance of compact substance defect, at the size of which, coming to 2.4% of shaft area, IBP always decreased, remained decreased during 2 months and restored during the third month. The IBP decrease changed the bone hemodynamics.

This paper describes one of the mechanisms of the effect of bone tunneling on limb circulation. The study was carried out in 33 adult mongrel dogs with the leg length measuring 10 to 12 cm. The tunneling of tibial bone diaphysis was performed using 1.8-mm-diameter wire. Measurements were the made of the pressure in the bone diaphyseal cavity. Medullography was accomplished over time. It has been revealed that the growth in the size of the compact substance defect led to the lowering of the pressure in the bone diaphyseal cavity associated with its stabilization at a new level. After the healing of the bone defects the pressure was restored. Medullography performed over time has demonstrated that the substrate filling the compact substance defects prior to their healing is permeable for aqueous solutions. This allowed the conclusion that the cause of pressure lowering was translocation of the interstitial fluid from the diaphyseal cavity to the bone-surrounding tissue. To replenish the amount of the interstitial fluid, filtration from the vascular bed of the diaphyseal cavity was increased providing for pressure stabilization.

The application of technique for obtaining the tibial fragment (split) with a preserved vascular network of the nutrient artery and its branches, that participate in the blood supply of this bone area, permits to detect significant osteogenetic potential of both endosteum and undifferentiated bone marrow cells. Under these conditions it was possible to increase the bone thickness 2 to 3 times in short time. The regeneration process in this case is characterized by a rapid course and formation of large massive of cancellous bone. The results of this study suggest that an adequate blood supply, stable fixation of bone using Ilizarov apparatus and the chosen rate of split displacement create the favorable conditions for the active osteogenesis.

Epiphyseal transplants in children were introduced into clinical practice about 20 years ago. Among possible donor sites, the proximal fibula is definitely the most popular choice, and has been used mainly for reconstruction of the proximal humerus and distal radius. Provided that an adequate blood supply both to the physis and to the diaphysis must be restored in order to obtain acceptable axial growth of the transferred fibula and a bone fusion at the osteotomy site, the choice of feeding pedicle is still a controversial issue. Our contribution involves a homogeneous series of 24 patients under 11 years of age who had skeletal reconstruction in the upper limb by means of a vascularized transfer of the proximal fibula based on the anterior tibial artery. The aim of the present paper is to describe in detail the harvesting technique which has been partially modified and gradually refined in our 10-year experience., (Copyright 2005 Wiley-Liss, Inc.)

Objective: We sought to study the normal enhancement patterns seen on MRIs of the epiphysis, physis, and metaphysis and age-related vascular changes in piglets using gadoteridol, a nonionic gadolinium chelate., Materials and Methods: We quantitatively and qualitatively analyzed the normal changes on sequential T1-weighted images after the IV administration of gadoteridol. In an investigation approved by the research animal care committee at our hospital, we studied the proximal and distal femurs of 26 piglets 1-6 weeks old and correlated the enhanced images with findings on intermediate-weighted, T2-weighted, and gradient-recalled echo images and at histologic examination., Results: We observed early enhancement of the epiphyseal vascular canals, the main physis, the physis of the secondary ossification center, and a metaphyseal band adjacent to the physis. Enhancement of the epiphyseal and metaphyseal marrow and of the epiphyseal cartilage was slower. In the epiphyseal cartilage, we saw three phases of enhancement: vascular, canalicular, and cartilaginous. As the piglets matured, enhancement of the epiphyseal cartilage decreased, and the epiphyseal vascular canals were less conspicuous. Physeal enhancement was greatest during the first week of life, declined at 3 weeks, and subsequently increased again as the physis came to lie adjacent to a larger segment of the epiphyseal ossification center., Conclusion: Gadoteridol-enhanced MRIs showed multiple cartilaginous and vascular structures of the growing skeleton. With maturity and progressive epiphyseal ossification, epiphyseal cartilage enhancement decreased, and physeal cartilage enhancement increased.

The vascular factor in the unsuccessful healing of the osteotomised forearm bone is widely discussed in literature at the so-called "level operations" aiming at correcting the "ulna minus" variant in Kienböck's disease. The purpose of our study was to trace the nourishing vessels of the forearm bones from their source from which a. nutritia radii (ANR) and a. nutritia ulnae (ANU) is separated and to locate the foramen nutritium (FN) of the radial and ulnar bones diaphysis. The forearms of 70 upper extremities were dissected and 204 macerated radial bones and 134 macerated ulnar bones were investigated scopically and metrically. The results demonstrated that there is less variability of sources from which ANR was separated as compared to the variability of the sources from which ANU was separated. Foramen nutritium radii (FNR) and foramen nutritium ulnae (FNU) were located mainly along facies anterior and its edges margo anterior and margo interosseus and only in a few cases they were observed along facies posterior. The metrical investigations showed that FNR were located mainly in the second fourth along the bone length, between 30 and 40% from the radial bone length in the distal direction. FNU were located mainly in the second fourth along the bone length, between 30 and 50% from the ulnar bone length in the distal direction. The results for vascular anatomy of the forearm bones give grounds to assume that osteotomy with a subsequent shortening of the radius is more feasible than osteotomy with ulnar lengthening. The distal half of the radius, between the third and fourth quarter in particular, is also recommended as most suitable for surgical intervention.

In experiment on the animal's bones the various kinds of ischemia was simulated (obturational, compressive, traumatic) it was established that the central mechanism of the bone infarction pathogenesis is irreversible blockade of microcirculatory bed by cellular aggregates and microthrombi. The most extended and constant infarction occurs in embolization of the main nourishing artery and in osteotomy of diaphysis with the bone marrow intersection and the periosteum detachment on the ends of fragments.

Acute disturbances in diaphysial intraosseous circulation secondary to the major nutrient artery intersection are not fully compensated from the potential intraosseous collaterals early in their course, which fact leads to bone infarction, as evidenced by histological and angiomorphological investigations in the experiment in rats. Recovery of ischemic tissues occurs in different time periods, necrotized myelokaryocytes undergo lysis, the bone marrow ischemic necrosis focus gets revascularized, with the reduced blood supply foci being intact, immature hemocytes scanty; necrotized osseous tissue undergoes revascularization and revitalization during the course of long-continued reorganization.

This article has presented the preliminary results of three patients who received vascularized allogeneic femoral diaphyses and three patients having undergone vascularized transplantation of fresh and perfused total human knee joints. The large osseous defects in the femora followed osteomyelitis and chondrosarcoma. The three knee joints were lost due to various trauma mechanisms. All grafts were harvested within 25 hours from multiorgan donors perfused with 4 L of UW solution. All osteosyntheses were performed employing intramedullary nails. Vascular pedicles of the grafts were anastomosed end-to-side to the superficial femoral artery and vein in the adductorial canal of the recipient thigh. Immunosuppression was based mainly on two drugs: CyA and AZA. Perfusion of the grafts was demonstrated by DSA, and bone metabolism in the graft by SPECT scintigraphy. Six months after the operation all osteotomies demonstrated callus formation and osseous consolidation in conventional radiographs. Biopsies of the grafted bone revealed intact osteocytes, and arthroscopy of the transplanted knee joints demonstrated intact synovial, chondral, and ligamentous structures. From the surgical aspect, the vascularized transplantation of the femoral diaphyses and total knee joints is technically feasible. The main problems are immunologic. All transplantations were performed with respect to ABO compatibility, but with a large HLA mismatch. Therefore, acute and chronic rejection crises were observed. In total synovial joints, lifelong immunosuppression of graft recipients seems to be currently unavoidable.

The role of the periosteal and intraosseous blood supply to the femur and the proximal tibia was investigated to improve the operating technique for transplantation of allogenic vascularized femoral diaphyses and knee joints in humans. Altogether 48 limbs were injected with gelatin, red latex milk, or Revertex and macroscopically prepared; 41 limbs were studied for the variation and division of the truncus profundo-circumflexus. In 200 femurs and 200 tibias the location of the nutrient foramen was determined. The arteries supplying the periosteum of the distal femur and the proximal tibia have defined nutritive areas. The following technique should be followed: If the femoral artery alone is prepared as the vascular pedicle, the optimal section for resection of the femur in knee joint transplantations is 6 to 12 cm above the level of the femur condyles and 5 to 7 cm below the tibial plateau. For the transplantation of femoral diaphyses, the deep femoral artery can be used if the lateral femoral circumflex artery is protected. The Proximal line of resection is defined between the greater and lesser trochanter. For shorter grafts one must consider the number and location of nutrient foramens. For longer grafts the distal branches of the femoral artery must be respected as the intraosseous blood supply reaches distally down to the level of about 8 cm above the femoral condyles. In all these operations of the variation of the truncus profundo-circumflexus and the trifurcation of the popliteal artery must be considered.

The nutrient foramina in the human femoral diaphysis were counted in 109 cleaned and dried bones, ranging in age from 38 to 98 y. Although statistical analysis for univariate associations found that foramen number was not linked to age, sex (male/female) or side (R/L), multivariate logistic analysis revealed a significant interaction between the effects of sex and side (P < 0.01). Univariate analysis for sex and for side separately revealed a significant difference in for men number between the results for men and women for R bones 62% (18/29) vs 33% (8/24) (P < 0.04), but not for L bones 35% (9/26) vs 48% (13/27) (P < 0.28). One lower limb from 15 cadavers was perfused with a barium sulphate suspension to show the blood supply of the femoral diaphysis. Twelve were in the age group 59-88 y and considered to be senescent material. In addition, 3 more femora were perfused, 1 from a young male aged 21 y, another from a 42-y-old male considered to show early senescent changes, and a third from a man aged 56 y with a hip prosthesis in situ, to provide an example of a cortex deprived entirely of its medulla. All perfused femora were fixed and decalcified, and sections were then radiographed. Cross-sections through the middiaphysis showed that aged bone cortex is supplied predominantly from the periosteum in contrast to the medullary supply in young human and animal material. The change is attributed to increasingly severe medullary ischaemia with age, brought on by atherosclerosis of the marrow vessels. An examination of the findings reported by investigators of animal bone blood supply in the past 40 y shows a large measure of agreement. Long standing controversy seems to be based on a failure to recognise that marrow ischaemia accompanies natural senescence, affecting transcortical haemodynamics, and entraining an increasing periosteal supply for bone survival in old age. The change over from a medullary to a periosteal blood supply to bone cortex is the consequence of medullary ischaemia and reduced marrow arterial pressure, brought about by medullary atherosclerosis.

A new 3-D presentation of the whole vasculature of the epiphyseal growth plate clearly allows for a distinction between arterial and venous sections of the blood circulation. Histological investigations using these processing methods could neither prove the connection between epiphyseal and metaphyseal vessels through the growth plate in newborns nor the concept of an arterial epiphyseal blood supply of the growth plate presented by Trueta. It is rather a question of an arterial metaphyseal perfusion and an epiphyseal venous drainage system.

Six dogs each had one tibia filled with standard poly(methyl methacrylate) (PMMA) bone cement and the contralateral tibia filled with a new methyl methacrylate-n-decyl methacrylate-isobornyl methacrylate (MMA-DMA-IBMA) bone cement (Boneloc) with lowered polymerization heat and monomer leakage. An additional six dogs each had one tibia filled with MMA-DMA-IBMA and the contralateral tibia filled with bone wax. There was a higher diaphyseal blood flow, measured with a microsphere technique, in the legs filled with MMA-DMA-IBMA than in those filled with PMMA. The wax-filled bones presented higher blood perfusion than those with MMA-DMA-IBMA. We found a tendency towards higher 99mtechnetium-labelled methylene diphosphonate (99mTcMDP) uptake, and autoradiograms revealed a tendency towards larger subperiosteal apposition and more blackening, both at the subperiosteal apposition and the cortex, in the bones filled with new bone cement in the first series, but in wax-filled bone in the second series. It is concluded that the new bone cement, compared to standard acrylic bone cement, seems to inhibit the vascular response and bone remodelling activity less, making earlier remodelling possible. However, the new bone cement still seems to inhibit bone blood perfusion compared to bone wax.

The anatomy of the canine distal ulna was evaluated to determine its potential as a free vascularized bone graft. Twelve cadavers were studied by gross dissection and nonselective and selective angiography. The caudal interosseous artery consistently served as a source artery to the distal ulnar periosteal vasculature in all dogs. The diameters of the caudal interosseous artery and venae comitantes were large enough to permit microvascular anastomoses. Nonselective perfusions of the brachial artery demonstrated large barium-filled vessels within soft tissues surrounding the ulna with anastomotic connections between medullary and periosteal vasculature. Grafts selectively perfused through the caudal interosseous artery (periosteal circulation only) had barium-filled vessels within the muscular cuff, periosteum, cortical bone, and medullary canal of the ulna. A surgical approach to remove the distal ulna along with an intact musculoperiosteal cuff and its associated vasculature is described.