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Vascularized Periosteal Flaps Accelerate Osteointegration and Revascularization of Allografts in Rats

Gallardo-Calero, Irene, MD, PhD; Barrera-Ochoa, Sergi, MD, PhD; Manzanares, Maria Cristina, MD, PhD; Sallent, Andrea, MD; Vicente, Matias, MD; López-Fernández, Alba, MSc; De Albert, Matias, MD; Aguirre, Marius, MD, PhD; Soldado, Francisco, MD, PhD; Vélez, Roberto, MD, PhD

Clinical Orthopaedics and Related Research®: April 2019 - Volume 477 - Issue 4 - p 741–755
doi: 10.1097/CORR.0000000000000400

Background Surgical reconstruction of large bone defects with structural bone allografts can restore bone stock but is associated with complications such as nonunion, fracture, and infection. Vascularized reconstructive techniques may provide an alternative in the repair of critical bone defects; however, no studies specifically addressing the role of vascularized periosteal flaps in stimulating bone allograft revascularization and osseointegration have been reported.

Questions/purposes (1) Does a vascularized periosteal flap increase the likelihood of union at the allograft-host junction in a critical-size defect femoral model in rats? (2) Does a vascularized periosteal flap promote revascularization of a critical-size defect structural bone allograft in a rat model? (3) What type of ossification occurs in connection with a vascularized periosteal flap?

Methods Sixty-four rats were assigned to two equal groups. In both the control and experimental groups, a 5-cm critical size femoral defect was created in the left femur and then reconstructed with a cryopreserved structural bone allograft and intramedullary nail. In the experimental group, a vascularized periosteal flap from the medial femoral condyle, with a pedicle based on the descending genicular vessels, was associated with the allograft. The 32 rats of each group were divided into subgroups of 4-week (eight rats), 6-week (eight rats), and 10-week (16 rats) followup. At the end of their assigned followup periods, the animals were euthanized and their femurs were harvested for semiquantitative and quantitative analysis using micro-CT (all followup groups), quantitative biomechanical evaluation (eight rats from each 10-week followup group), qualitative confocal microscopic, backscattered electron microscopic, and histology analysis (4-week and 6-week groups and eight rats from each 10-week followup group). When making their analyses, all the examiners were blinded to the treatment groups from which the samples came.

Results There was an improvement in allograft-host bone union in the 10-week experimental group (odds ratio [OR], 19.29 [3.63–184.50], p < 0.05). In contrast to control specimens, greater bone neoformation in the allograft segment was observed in the experimental group (OR [4-week] 63.3 [39.6–87.0], p < 0.05; OR [6-week] 43.4 [20.5–66.3], p < 0.05; OR [10-week] 62.9 [40.1–85.7], p < 0.05). In our biomechanical testing, control samples were not evaluable as a result of premature breakage during the embedding and assembly processes. Therefore, experimental samples were compared with untreated contralateral femurs. No difference in torsion resistance pattern was observed between both groups. Both backscattered electron microscopy and histology showed newly formed bone tissue and osteoclast lacunae, indicating a regulated process of bone regeneration of the initial allograft in evaluated samples from the experimental group. They also showed intramembranous ossification produced by the vascularized periosteal flap in evaluated samples from the experimental group, whereas samples from the control group showed an attempted endochondral ossification in the allograft-host bone junctions.

Conclusions A vascularized periosteal flap promotes and accelerates allograft-host bone union and revascularization of cryopreserved structural bone allografts through intramembranous ossification in a preclinical rat model.

Clinical Relevance If large-animal models substantiate the findings made here, this approach might be used in allograft reconstructions for critical defects using fibular or tibial periosteal flaps as previously described.

I. Gallardo-Calero, A. Sallent, M. Vicente, M. Aguirre, R. Vélez, Orthopedic Surgery Department, Hospital Universitari Vall d’Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain

S. Barrera-Ochoa, F. Soldado, Hand Surgery and Microsurgery Unit, Hospital Sant Joan de Déu, Universitat de Barcelona, Barcelona, Spain

S. Barrera-Ochoa, Hand and Microsurgery Unit, Hospital Universitari Quiron-Dexeus, ICATME, Barcelona, Spain

M.C. Manzanares, Human Anatomy and Embryology Unit, Dpt Experimental Pathology and Therapeutics, Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Spain

I. Gallardo-Calero, S. Barrera-Ochoa, A. Sallent, M. Vicente, A. López-Fernández, M. Aguirre, R. Vélez, Vall d'Hebron Research Institute, Musculoskeletal Tissue Engineering Group, Universitat Autònoma de Barcelona, Barcelona, Spain

M. De Albert, Radiology Department, Hospital Universitari Vall d’Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain

I. Gallardo-Calero, Hospital Universitari Vall d’Hebron, Orthopedic Surgery Department, Universitat Autònoma de Barcelona, Passeig de la Vall d’Hebron 119-129, 08035, Barcelona, Spain, email:

One of the authors certifies that he (MA) has received payments or benefits, during the study period, an amount of USD 10,000 to 100,000 from Societat Catalana de Cirurgia Ortopedica i Traumatologia (Barcelona, Spain).

All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request.

Clinical Orthopaedics and Related Research® neither advocates nor endorses the use of any treatment, drug, or device. Readers are encouraged to always seek additional information, including FDA approval status, of any drug or device before clinical use.

Each author certifies that his or her institution approved the animal protocol for this investigation and that all investigations were conducted in conformity with ethical principles of research.

This work was performed at Vall d'Hebron Institut de Recerca, Barcelona, Spain.

Received November 20, 2017

Accepted June 18, 2018

© 2019 Lippincott Williams & Wilkins LWW
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