This paper presents an idea with no experience. In my opinion, the concept is only applicable in children. Children have a thick periosteum with substantial regenerative capacity. The technique may also be applicable only in areas with a very good blood supply such as the femur—I would recommend caution in other areas.
In patients with traumatic defects, the quality of the adjacent bone, periosteum and muscle envelope may limit the applicability of this technique. Adult patients have very thin periosteum for which this technique is questionable at best.
An additional comment would be that the fibula is not the same as the tibia and femur and one should not generalize the regenerative capacity at the fibula to other bones.
Competing interests
None
Efficacy of the procedure proved in an ovine model
Ulf Knothe, The Cleveland Clinic, Department of Orthopaedic Surgery
25 February 2005
Thank you for your interest in my research. I am pleased to share with you that I carried out a study using an in vivo ovine model (n=35) in which I was able to prove efficacy of this novel procedure in critical size defects of the sheep femur. Please refer to the Orthopaedic Research Society website to download the abstract (www.ors.org) which is summarized below; the reference for the abstract is Ritzman TF, Knothe Tate ML, Wieling R, Schneider E, Knothe UR. Novel Surgical Procedure Shown to be Efficacious for Regeneration of Bone in Massive, Diaphyseal Bone Defects, 2005. Trans ORS, 1739.
The goals of the study were to assess efficacy of the procedure described in my original article and to determine the relative roles of the periosteal sleeve alone, bone graft within the periosteal sleeve, and retention of adherent, vascularized cortical bone chips on the periosteal sleeve in facilitating regeneration of bone within the defect. It was hypothesized that the inclusion of cortical bone chips adherent to the periosteal sleeve as well as the inclusion of cancellous bone graft within the sleeve would augment in situ regeneration of bone compared to the presence of the periosteal sleeve alone. An ovine femur model was implemented with a critical size (2.6 cm) diaphyseal defect in skeletally mature, female sheep. The periosteum was elevated circumferentially off the proximal femoral diaphysis adjacent to the defect. The healthy “donor” bone was then osteotomized and transported distally over a retrograde IM nail to fill the defect thereby creating a new defect around which the healthy periosteum was sutured to form a sleeve (according to Fig. 1 in my World Journal of Surgical Oncology manuscript). Five groups of seven sheep were investigated. In the 1st (control) group, no periosteal sleeve enveloped the defect. The sleeve alone enveloped the defect in a 2nd group. Autogenous cancellous bone graft was placed within the sleeve of the 3rd group. Vascularized bone chips were left adhering to the periosteum in the 4th group. Bone graft and adherent bone chips were included in the 5th group.
Based on clinical assessment of radiographs, regenerate bone bridged the defect site in all sheep with a retained periosteal sleeve (28 sheep; Groups 2-5 – referred to as "experimental" groups) at the 16 week post-operative (post-op) interval. Without the periosteal sleeve the defect persisted (7 animals - Group 1, referred to as "control"). The docking site of the transported bone healed uniformly in all 35 sheep. Quantitative analysis of digitized radiographs showed that all experimental sheep displayed greater bone regeneration than did controls at each time interval studied (p<0.0001). Quantitative measures of high resolution micro-CT data showed that all of the experimental groups exhibited significantly greater volume of regenerate bone than the control group. Furthermore, the density of regenerate bone in each of the groups containing a periosteal flap approached 90 per cent of the density of the contralateral control femora at the final 16 week post operative period.
Hence, this novel surgical procedure was shown to be efficacious in bridging a critical size defect in an ovine femoral model. The presence of the periosteal sleeve had a dominant effect on bridging of the critical size defect; without the periosteum, the defect persisted. The experimental groups containing a periosteal sleeve all consistently displayed significant increases in regenerate bone density, volume, and area over the control group through all radiographic parameters evaluated. However, no statistically significant inter-group differences were observed in the radiographic parameters between these four experimental groups. Thus, the addition of cancellous bone graft did not improve bone regeneration. Due to the similar results of groups 2 and 4, we recommend utilizing the periosteal sleeve elevated with a chisel (leaving adherent cortical chips) for cases with thin periosteum, which may be difficult to elevate; otherwise, use of the periosteum alone may be sufficient.
Nice idea, but...
9 February 2005
This paper presents an idea with no experience. In my opinion, the concept is only applicable in children. Children have a thick periosteum with substantial regenerative capacity. The technique may also be applicable only in areas with a very good blood supply such as the femur—I would recommend caution in other areas.
In patients with traumatic defects, the quality of the adjacent bone, periosteum and muscle envelope may limit the applicability of this technique. Adult patients have very thin periosteum for which this technique is questionable at best.
An additional comment would be that the fibula is not the same as the tibia and femur and one should not generalize the regenerative capacity at the fibula to other bones.
Competing interests
None
Efficacy of the procedure proved in an ovine model
25 February 2005
Thank you for your interest in my research. I am pleased to share with you that I carried out a study using an in vivo ovine model (n=35) in which I was able to prove efficacy of this novel procedure in critical size defects of the sheep femur. Please refer to the Orthopaedic Research Society website to download the abstract (www.ors.org) which is summarized below; the reference for the abstract is Ritzman TF, Knothe Tate ML, Wieling R, Schneider E, Knothe UR. Novel Surgical Procedure Shown to be Efficacious for Regeneration of Bone in Massive, Diaphyseal Bone Defects, 2005. Trans ORS, 1739.
The goals of the study were to assess efficacy of the procedure described in my original article and to determine the relative roles of the periosteal sleeve alone, bone graft within the periosteal sleeve, and retention of adherent, vascularized cortical bone chips on the periosteal sleeve in facilitating regeneration of bone within the defect. It was hypothesized that the inclusion of cortical bone chips adherent to the periosteal sleeve as well as the inclusion of cancellous bone graft within the sleeve would augment in situ regeneration of bone compared to the presence of the periosteal sleeve alone. An ovine femur model was implemented with a critical size (2.6 cm) diaphyseal defect in skeletally mature, female sheep. The periosteum was elevated circumferentially off the proximal femoral diaphysis adjacent to the defect. The healthy “donor” bone was then osteotomized and transported distally over a retrograde IM nail to fill the defect thereby creating a new defect around which the healthy periosteum was sutured to form a sleeve (according to Fig. 1 in my World Journal of Surgical Oncology manuscript). Five groups of seven sheep were investigated. In the 1st (control) group, no periosteal sleeve enveloped the defect. The sleeve alone enveloped the defect in a 2nd group. Autogenous cancellous bone graft was placed within the sleeve of the 3rd group. Vascularized bone chips were left adhering to the periosteum in the 4th group. Bone graft and adherent bone chips were included in the 5th group.
Based on clinical assessment of radiographs, regenerate bone bridged the defect site in all sheep with a retained periosteal sleeve (28 sheep; Groups 2-5 – referred to as "experimental" groups) at the 16 week post-operative (post-op) interval. Without the periosteal sleeve the defect persisted (7 animals - Group 1, referred to as "control"). The docking site of the transported bone healed uniformly in all 35 sheep. Quantitative analysis of digitized radiographs showed that all experimental sheep displayed greater bone regeneration than did controls at each time interval studied (p<0.0001). Quantitative measures of high resolution micro-CT data showed that all of the experimental groups exhibited significantly greater volume of regenerate bone than the control group. Furthermore, the density of regenerate bone in each of the groups containing a periosteal flap approached 90 per cent of the density of the contralateral control femora at the final 16 week post operative period.
Hence, this novel surgical procedure was shown to be efficacious in bridging a critical size defect in an ovine femoral model. The presence of the periosteal sleeve had a dominant effect on bridging of the critical size defect; without the periosteum, the defect persisted. The experimental groups containing a periosteal sleeve all consistently displayed significant increases in regenerate bone density, volume, and area over the control group through all radiographic parameters evaluated. However, no statistically significant inter-group differences were observed in the radiographic parameters between these four experimental groups. Thus, the addition of cancellous bone graft did not improve bone regeneration. Due to the similar results of groups 2 and 4, we recommend utilizing the periosteal sleeve elevated with a chisel (leaving adherent cortical chips) for cases with thin periosteum, which may be difficult to elevate; otherwise, use of the periosteum alone may be sufficient.
Competing interests
none