Plastic repair using the demineralized matrix of flat allogeneic bone in an operation for ventral hernia

Investigations were performed in experiments on 36 dogs. Clinico-morphological results of plasty of artificial defects of the anterior abdominal wall by demineralized matrix of a flat allogeneic bone have shown good taking by tissues. In clinic the demineralized matrix of flat allogeneic bone (scapula, skull fornix) was used in ventral hernias in 36 patients. No recurrent hernias were noted in these patients within 20 months after operation.     

Use of demineralized allogeneic bone implants for the correction of maxillocraniofacial deformities.

Two major problems in maxillocraniofacial surgery are the limited amount of fresh autogenous bone, the standard material for bone grafting, and the resorption of the grafted bone. Experimental studies with demineralized, devitalized bone matrix have shown induction of endochondral ossification. Fifty-five demineralized allogeneic implants have been used in 44 patients over the past two years for a variety of congenital (n = 37) and acquired (n = 7) defects. The allogeneic bone was obtained from cadavers, prepared as powders, chips or blocks, and was demineralized. After having been sterilized by irradiation, they were used to augment contour, fill defects, or construct bone within soft tissue. Of implanted sites that could be evaluated by physical examination, 31 of 31 were solid by three months. By radiographic examination three of 19 were healed by three months, and an additional 11 were positive by six months. Induced bone was seen in four of four biopsy specimens. Infection occurred in four of 44 patients (9%), comparable with conventional grafts. Implant resorption occurred in four instances. Allogeneic demineralized implants offer several advantages over conventional bone grafting, such as avoidance of a harvesting operation, ease of manipulation, and potentially unlimited material in banked form. In addition, healing by induced osteogenesis may bypass the resorption seen with healing of mineral-containing grafts.     

A study of 23 unicameral bone cysts of the calcaneus: open chip allogeneic bone graft versus percutaneous injection of bone powder with autogenous bone marrow

BACKGROUND: The treatment of unicameral bone cyst varies from percutaneous needle biopsy, aspiration and local injection of steroid, autologous bone marrow, or demineralized bone matrix to curettage and open bone-grafting. The purpose of this study was to compare the results of open chip allogeneic bone graft versus percutaneous injection of demineralized bone powder with autogenous bone marrow in management of calcaneal cysts. MATERIALS AND METHODS: Twenty-three calcaneal unicameral cysts in 20 patients were treated. Lyophilized irradiated chip allogeneic bone (CAB) and autogenous bone marrow were used for treatment of 13 cysts in 11 patients, and 10 cysts in 9 patients were treated with percutaneous injection of irradiated allogeneic demineralized bone powder (DBP) and autogenous bone marrow. There were 11 males and 9 female patients with mean age of 17 years. RESULTS: The patients were followed for an average of 49.4 months. Complete healing was achieved in 9 cysts treated with chip allogeneic bone and in 5 cysts treated with powdered bone. Four cysts treated with CAB and 3 cysts treated with DBP healed with a defect. Two cysts treated with powdered bone and autogenous bone marrow were classified as persistent. No infections or pathological fractures were observed during the followup period. CONCLUSION: Percutaneous injection of a mixture of allogeneic bone powder with autogenous bone marrow is a minimal invasive method and could be an effective alternative in the treatment of unicameral calcaneal bone cysts. The postoperative morbidity was low, the hospital stay was brief, and patient's comfort for unrestricted activity was enhanced.     

Hand reconstruction with allograft demineralized bone: twenty-six implants in twelve patients.

A long-term study of 26 phalangeal or metacarpal defects that were reconstructed with allogeneic demineralized bone implants demonstrates healing comparable to that which follows autogenous bone grafting. Average follow-up was 54 months. Five patients had multiple enchondromas (Ollier's syndrome), five children had congenital hand deformities, and all of these had previously had bone grafts harvested for associated craniofacial reconstructions. With the use of demineralized bone implants, tourniquet and operative times were significantly reduced and potential donor site morbidity was eliminated. Further, regional anesthesia was used more frequently and hospitalization time was reduced. There were no postoperative complications. Demineralized bone implants have been particularly useful in patients who previously had refused bone grafting.     

Treatment of active unicameral bone cysts with percutaneous injection of demineralized bone matrix and autogenous bone marrow

BACKGROUND: The treatment of unicameral bone cysts varies from open bone-grafting procedures to percutaneous injection of corticosteroids or bone marrow. The purpose of this study was to evaluate the feasibility and effectiveness of percutaneous injection of a mixture of demineralized bone matrix and autogenous bone marrow for the treatment of simple bone cysts. METHODS: Twenty-three patients with an active unicameral bone cyst were treated with trephination and injection of allogeneic demineralized bone matrix and autogenous bone marrow. The patients were followed for an average of fifty months (range, thirty to eighty-one months), at which time pain, function, and radiographic signs of resolution of the cyst were assessed. RESULTS: The average time until the patients had pain relief was five weeks, and the average time until the patients returned to full, unrestricted activities was six weeks. Bone-healing at the site of the injection was first seen radiographically at three to six months. No patient had a pathologic fracture during this early bone-healing stage. Cortical remodeling was seen radiographically by six to nine months, and after one year the response was usually complete, changing very little from then on. Five patients required a second injection because of recurrence of the cyst, and all five had a clinically and radiographically quiescent cyst after an average of thirty-six additional months of follow-up. Seven of the twenty-three patients had incomplete healing manifested by small, persistent radiolucent areas within the original cyst. None of these cysts increased in size or resulted in pain or fracture. CONCLUSIONS: Percutaneous injection of allogeneic demineralized bone matrix and autogenous bone marrow is an effective treatment for unicameral bone cysts.     

Evaluation with three-dimensional computed tomography after anterior skull base reconstruction using two musculopericranial flaps and a grafted bone

Postoperative evaluation by three-dimensional (3D) computed tomography (CT) was performed in 15 patients who underwent anterior skull base reconstruction using two musculopericranial flaps and a grafted bone sandwiched between the two flaps. Especially in the case of large bone grafts (4 x 4 cm or more), the graft was positioned with the convex side facing upward into the cranial cavity to avoid creating an intracranial dead space. The extent of the absorption and changes in the contour of the grafted bone were evaluated. Imaging was done at a CT level of 150 using a Proceed 3-D CT scanner (Yokogawa Medical Co., Tokyo, Japan). Donor bone for grafting to the skull base was harvested the cranium in 10 patients and the ilium in 5 others. Patients ranged in age from 7 to 76 years (mean, 47); there were 10 men and 5 women. The grafted bone ranged in size from 1 x 2 cm to 5 x 8 cm (1 x 2 cm to about 4 x 3 cm: 10 patients; 4 x 4 to about 5 x 8 cm: 5 patients).No marked absorption of grafted bone was seen in these 15 patients, and no brain hernia occurred. In patients with large bone grafts (4 x 4 cm to about 5 x 8 cm), a graft that had been positioned with the convex side facing upward into cranial cavity at the time of transplant was subsequently observed to be transformed into a downward convex contour of normal skull base. Fostoperative infection did not occur because of the dead space nor were there any symptom of pressure on the brain because of the upward convexity of the grafted bone.The present reconstructive method is not only a minimum invasive but also a safe and reliable method for anterior skull base surgery.     

Clinical experience in cranial and facial reconstruction with demineralized bone

While autogenous bone is the preferred building material for skull and facial bone reconstruction, it has definite disadvantages that make the continued use of alloplastic materials inviting. Studies in the past few years have generated considerable publicity about demineralized bone as a possible substitute for autogenous bone. A clinical study using commercially available, demineralized bone in 25 patients with a follow-up period of 6 to 18 months was completed. Results indicated that where there was a functional need or the environment (tissue envelope) was satisfactory, the demineralized bone induced osteogenesis; otherwise, there was considerable resorption of the implant. This implies that, for filling bony defects or reconstructing posttraumatic deformities, the implant generally worked fairly well, while attempts to augment bony contours, especially large areas such as the forehead, were generally not satisfactory. Even where there was a functional need for bone, a significant degree of unpredictable resorption of the demineralized implant occurred.     

A comparison of four particulate bone derivatives

Samples of four types of particulate bone matrix derivatives were prepared and surgically inserted into standardized critical-sized defects in calvariae of Long-Evans rats. Implantation of demineralized bone matrix (DBM), bone regenerative matrix, and two types of particulate chemosterilized, antigen-extracted, autolyzed, allogeneic (AAA) bone from endochondral (eAAA) and intramembranous (iAAA) sources will result in the regeneration of bone in orthotopic skull defects. The four preparations were tested in orthotopic, 8-mm calvarial wounds to compare the quantity of new bone that formed 28 days postimplantation. Quantitative computer imaging was used to measure roentgenographic gray levels and bone volume of new trabeculae (calcified plus osteoid). All experimental bone matrix derivatives produced more bone volume than the nontreated control wounds. Bone volume regenerated from iAAA was significantly less than eAAA and DBM-regenerated bone.     

自体骨髓基质干细胞组织工程骨修复颅骨缺损的临床研究

目的探讨人骨髓基质干细胞(hBMSCs)作为种子细胞的组织工程骨修复外伤后颅骨缺损的可行性。方法自2006年6月至2007年2月,共4例外伤后颅骨缺损患者,抽取患者骨髓,分离得到hBMSCs,体外扩增和成骨诱导后,将hBMSCs与部分脱钙骨复合,体外共培养1周后,手术植入颅骨缺损区。分别于术后1周和3个月、6个月进行临床和三维CT检查随访。结果术后1周,三维CT均显示骨缺损区被所植入的组织工程骨充填;术后3～6个月,CT显示组织工程骨形成并修复骨缺损,新生骨与骨缺损断端融合。高龄患者及骨缺损面积过大患者,组织工程骨体内成活率较差。结论通过选择适宜的病例,以自体hBMSCs作为种子细胞,运用组织工程技术可以在人体内形成稳定的组织工程骨并可用于修复颅骨缺损。     

A radiographical and biomechanical study of demineralized bone matrix implanted into a bone defect of rat femurs with and without bone marrow

Repair of large bone defects represents a challenge to orthopedic surgery since autogenous graft is not available in large amounts. Demineralized bone matrix (DBM) which contains bone morphogenic protein, a potent osteoinductive glycoprotein, and collagen, an osteoconductive matrix, may be an effective substitute for these graft materials. Bone marrow which contains osteoprogenitor cells could potentiate the osteoinductive and osteoconductive properties of demineralized bone matrix. This study tested the ability of demineralized bone matrix with and without bone marrow to bridge large segmental defects, and evaluated the results both radiographically and biomechanically as compared to autogenous (isogeneic) cancellous bone graft. Demineralized bone-matrix segments implanted into a plated femoral segmental defect in rats resulted in firm union in most animals. Bone marrow significantly enhanced bone formation of demineralized bone-matrix implants at an early stage but with time, differences between bone marrow-augmented and bone marrow-deprived demineralized bone implants were no longer demonstrable radiographically and biomechanically. Newly formed bone had about 50% of the strength of the contralateral control bones. Femurs implanted with cancellous bone isografts had similar evidence of absolute union rate, radiographic and mechanical properties as DBM-implanted femurs.     

Reconstruction of post-traumatic frontal-bone depression using hydroxyapatite cement

The safety and efficacy of hydroxyapatite cement (Bone Source, Howmedica, Leibinger, Inc. Dallas, TX) use for the augmentation of post-traumatic frontal-bone depression was evaluated in a study of 20 consecutive oriental patients between June 1998 and July 2000 inclusively. The size of the depressed frontal bone ranged from 5 x 5 cm to 8 x 5 cm. The cement was placed in contact with the frontal sinus for 12 patients, none of whom revealed a history of paranasal sinus mucoperiosteal disease. Follow-up averaged 28 months for all 20 patients. Postimplantation evaluations included serial photographs, repeated physical examination, and 3-dimensional computed tomography for all patients. The cement paste allowed for precise and easy contouring of the bony depression's restoration. Meticulous hemostasis is essential to ensure a dry surgical field and successful application of the cement. No infection of the surgical site or extrusion of the cement was noted for any of our patients, and the contour of the reconstructed frontal bone was acceptable esthetically without any secondary depression noted during the follow-up period. Three-dimensional computed tomographic scans taken 2 years subsequent to implantation revealed good preservation of the cement restoration material. Small areas of cement loss due to cement absorption into the ambient fluid were noted for 2 patients, but such resorption did not appear to esthetically influence the final results. The results from this clinical study indicated that hydroxyapatite cement is a biocompatible, alloplastic material useful for augmentation of post-traumatic frontal-bone depression with stable volume maintenance over time. Judicious use of the hydroxyapatite cement offers an alternative to autogenous bone grafts or the use of methyl methacrylate for augmentation of the craniofacial skeleton among oriental patients.     

Extended pericranial flap and bone graft reconstruction in anterior skull base surgery.

OBJECTIVES: The objectives of this study was to establish a rationale for repairing large anterior skull base defects with an extended pericranial flap and split calvarial bone graft; to define large anterior skull base defects as those spanning the anterior cranial measuring at least 3.0 x 4.0 cm; and to describe the surgical technique and compare it with alternative strategies.Study design Thirty-four patients underwent anterior craniofacial resection of anterior skull-based tumors of varying histology with reconstruction using an extended pericranial flap and split calvarial bone graft. RESULTS: The survival of the pericranial flap and bone graft was maintained in 33 of 34 patients. There was 1 episode of postoperative cerebrospinal fluid leak, 1 episode of osteomyelitis of the bone graft and an epidural abscess, and 1 episode of asymptomatic pneumocephalus. CONCLUSION: Split calvarial bone graft with an extended pericranial flap is an effective technique for reconstructing large anterior skull base defects.     

利用计算机辅助设计／计算机辅助制造技术制造的钛合金补片修复颅骨大面积缺损

目的探索应用计算机辅助设计／计算机辅助制造（CAD／CAM）技术制造的钛合金补片修复大面积颅骨缺损的方法。方法2006年4月至、2008年6月期间,收治因肿瘤和外伤所致颅骨大面积缺损患者7例,采集电子计算机断层扫描（CT）数字化图像数据,利用快速成型技术制作患者的颅骨树脂模型,应用铸造技术制备修复颅骨缺损的钛合金。结果制造出个性化的颅骨树脂模型和精密的钛合金补片,置入体内,紧密覆盖颅骨缺损区。术后7例患者伤口均I期愈合,随访6个月至1年,缺损区颅骨外形恢复满意。结论利用CAD／CAM技术加工出的钛合金补片可以修复颅骨的大面积缺损,获得理想的修复效果。该方法操作简单,修复精确,很高的临床应用价值。     

New-bone formation by osteogenic protein-1 and autogenic bone marrow in a critical tibial defect model in sheep

AIM: Osteogenic Protein-1 (OP-1) is known to be a very potent osteoinductive growth factor. However, experimental studies using critical-size defect models in the weight-bearing lower extremity show non-uniform results. Therefore, we studied the osteoinductivity of OP-1 in a tibial worst-case defect model in sheep. Potential improvement of OP-1 induced new bone formation using a composite graft with autogenous bone marrow was to be investigated. METHOD: In 19 sheep a 5 cm segmental defect of the tibial diaphysis was treated by intramedullary nailing and filled with the following implants: 5 mg OP-1 + inactivated demineralized bone matrix (group 1; n = 6); 5 mg OP-1 + inactivated demineralized bone matrix + 5 ml autogenous bone marrow (group 2; n = 5); autogenous cancellous bone (group 3; n = 4), or inactivated demineralized bone matrix + 5 ml autogenous bone marrow (group 4; n = 4). RESULTS: In total, 3 out of 10 defect sites treated with OP-1 were completely bridged radiographically by 12 weeks. Initially, x-rays showed accelerated new bone formation by use of the composite grafts containing OP-1 and autogenous bone marrow. However, 12 weeks post surgery 3D-CT-volumetry could not detect significant differences of new bone formation within the defect sites treated by OP-1 with or without bone marrow, while new bone formation by autogenous cancellous bone was better than by OP-1. CONCLUSION: In our worst case defect model, the osteoinductive potential of OP-1 is initially accelerated but 12 weeks post surgery not increased when combined with autogenous bone marrow transplantation. So far, critical segmental bone defects of the weight-bearing lower extremity can not be bridged regularly in our model by use of OP-1. Therefore, for the treatment of such critical defects with rotational instability the examined application device of OP-1 can not yet be recommended.     

Endoscopic glabellar approach to the anterior skull base: a technical note.

OBJECT: An endoscopic glabellar transethmoidal approach via a small nasional incision to the anterior skull base is reported as a minimally invasive neurosurgical technique. SURGICAL TECHNIQUE: A frontonasal craniotomy (2 x 2 cm in size) between the medial orbits is made via a nasional skin incision approximately 3-cm in length. An ethmoidectomy is performed in order to expose the skull base at the anterior cranial fossa. Anterior and posterior ethmoidal arteries, which provide blood-supply to the tumor, are interrupted during the ethmoidectomy. The tumor located at the anterior cranial fossa is removed under an endoscope. A rod-lens endoscope, which is 4-mm in diameter and 18-cm in length, is used. The dura mater is reconstructed with dural graft placement. The skull-base bone at the anterior cranial fossa is reconstructed with autogenous bone or a piece of titanium mesh. The ethmoidectomy site is filled with abdominal fat graft material. The craniotomy bone flap is secured with titanium microplates and screws. Two demonstrative patients are reported. The benefits of the minimally invasiveness of this surgical technique have been observed in patient recovery. CONCLUSION: An endoscopic glabellar transethmoidal approach to the anterior cranial fossa via a small nasional incision is reported with two patients with olfactory groove meningiomas.     

Repair of mandible defect with tissue engineering bone in rabbits

BACKGROUND: The aim of the present study was to investigate the effect of tissue engineering bone composed of bone marrow-derived osteoblasts and demineralized bone in repairing mandible defect. METHODS: Bone marrow-derived osteoblasts of 20 rabbits were cultured and seeded into scaffold of allogeneic demineralized bone to construct tissue engineering bone graft in vitro, which was used to repair the 10 x 5-mm bone defect made in the same rabbit mandible edge. Implant of demineralized bone alone was as the control. Rabbits were killed according to the schedule: five after 2 weeks, five after 4 weeks, five after 8 weeks, five after 12 weeks, and the implants were harvested for gross, radiographic, and histological observation. RESULTS: New bone formation at the margin region of defect and osteogenesis at the centre were observed in the implant of tissue engineering bone, and the bone formation pattern included osteogenesis, osteoconduction, and osteoinduction. In the implant of demineralized bone alone, the major bone formation pattern was 'creeping substitute'. CONCLUSIONS: The tissue engineering bone graft constructed by autogenous bone marrow-derived osteoblasts and allogeneic demineralized bone was better than demineralized bone alone in bone formation capability, which might be an ideal graft for bone defect repair.     

Bone regeneration after enucleation of mandibular cysts: comparing autogenous grafts from tissue-engineered bone and iliac bone.

OBJECTIVE: The aim of this study was to compare bone regeneration after grafting enucleated mandibular cyst cavities using either autogenous osteoblasts cultured on a biomaterial or autogenous spongiose iliac bone. STUDY DESIGN: Twenty patients with 22 mandibular cysts were assessed. Eleven cysts were filled in with tissue-engineered bone (autogenous osteblasts cultured on demineralized bone matrix Osteovit) and 11 with spongiose iliac bone as controls. Panoramic radiographs were taken preoperatively, immediately postoperatively, and 3, 6, and 12 months after surgery. Radiolucency was computer analyzed using gray-level histograms. RESULTS: In both groups bone regeneration took place in a similar fashion. After 3 and 6 months there were few differences in bone density between the groups. However, in radiographic controls after 12 months ossification was considerably stronger in cysts grafted with tissue-engineered bone. CONCLUSION: These results advocate for the clinical application of tissue-engineered bone as an alternative viable filling material for cysts.     

Hydroxylapatite: an adjunct to cranial bone grafting

Hydroxylapatite is a dense pure ceramic material which has been used extensively in the reconstruction of atrophic maxillary and mandibular ridges. The authors describe a technique for the use of hydroxylapatite in combination with grafting of bone, either autogenous or from the bone bank, to restore contour to cranial defects. The use of hydroxylapatite in combination with bone grafting for contour restoration is recommended, as attempts to place the material directly on dura were not successful.     

三维重建仿真模型及计算机辅助设计个性化假体在下颌骨缺损修复中的应用

目的探讨三维重建仿真模型及计算机辅助设计个性化假体在修复下颌骨缺损中应用的可行性,并分析其临床疗效。方法 2002年7月-2009年11月,收治9例下颌骨缺损患者。男4例,女5例;年龄19～55岁。均为下颌骨病变截除术后遗留大面积下颌骨缺损;其中颌骨良性病变8例,下颌牙龈癌1例。缺损部位:缺损跨越中线2例,包括髁状突缺损4例,局限于一侧且未累及颞下颌关节缺损3例。缺损范围为9.0 cm×2.5 cm～17.0 cm×2.5 cm。术前行螺旋CT扫描后三维重建数字化颌骨模型,通过快速成型技术制备个性化假体。一期手术植入假体修复颌骨缺损,6个月后行二期手术种植义齿。结果一期手术中个性化假体就位顺利,耗时10～23 min;延伸板与骨面贴合良好。术后切口Ⅰ期愈合,面部外形满意,咬关系良好,张口时下颌偏斜纠正。二期手术时见种植体牢固无松动,基台穿龈后与对颌牙位置关系良好,达到术前设计理想位置。患者一期术后均获随访,随访时间1～9年。末次随访时复查X线片以及头颅后前位、颅基位、全口曲面断层X线片显示,个性化假体固定良好无松脱,外形对称。结论三维重建仿真模型及计算机辅助设计个性化假体应用于下颌骨缺损修复中能提高手术精度,节省手术时间。     

PRP modulates expression of bone matrix proteins in vivo without long-term effects on bone formation

This experimental study (domestic pig) examined the bone formation after filling defined defects of the frontal skull with autogenous bone or a deproteinized bovine bone matrix (DBBM) in combination with platelet-rich plasma (PRP). Six groups, both materials with and without PRP in two different concentrations (4.1x and 6.5x referring to untreated whole blood) were evaluated at 2, 4, 12, and 26 weeks by means of immunohistochemical staining for different bone matrix proteins, microradiography, light microscopy and polychromatic fluorescence labeling. The sequential expression of bone matrix proteins reflected the specific roles these proteins fulfil in the mineralization of hard tissue. Collagen I expression at 2 weeks was enhanced in all autogenous bone groups. No specific modification of the collagen I expression was found after use of DBBM with or without PRP. Osteopontin and especially osteonectin showed a remarkable enhancement at 4 weeks in nearly all autogenous bone and DBBM groups. These increased levels closely resembled the mineralization content evaluated by microradiography at that time. For the three autogenous bone groups, an expression peak for osteocalcin was demonstrated at 12 weeks, further reflecting the way of de novo bone formation. The microradiographic evaluation demonstrated a statistically significant enhancement in bone regeneration by PRP only after use of autogenous bone plus PRP at 2 weeks (P = 0.002). After 4 weeks, mineralization values after use of autogenous bone were significantly lower if PRP was added to the autogenous bone (P = 0.002). No long-term effects of the PRP administration were found in the mineralization process. In all DBBM groups, bone formation remained unchanged, confirming the lack of any osteoinductive capacity of PRP. PRP modulated the expression of bone matrix proteins in this experimental setting. However, an enhancement of bone formation was demonstrated only at 2 weeks after application of the higher PRP concentration in combination with autogenous bone. In conjunction with an anorganic bovine bone no effects of PRP on defect mineralization were discovered, demonstrating the lack of osteoinductive capacity in PRP as well as in DBBM.