Introduction: Atrophic nonunion is a well recognised complication of long bone fractures. Clinical trials show that BMP-2 accelerates healing and reduces nonunion in open tibial fractures. We are interested in a natural small molecule that has been previously demonstrated to stimulate angiogenesis in vivo. Our aim is to assess the two treatments in the prevention of nonunion. The small animal model we used is a non-critical size defect of the tibia deprived it of its blood supply by surgical stripping of the periosteum and curetting of the local endosteum thus closely reflecting the clinical situation. The outcomes were measured by radiographic assessment and histology. Methods: Wistar rats were treated with either the angiogenic molecule (0.1% or 0.003%), BMP-2 or vehicle alone (PBS) soaked in a type I collagen sponge. All animals underwent a 2mm osteotomy, stripping of the periosteum and endosteum proximally and distally for the length of the diameter of the tibia. Fluorescent markers were injected at 2 weekly intervals. The rats were sacrificed at 8 weeks. Both tibiae were disarticulated; fixator and soft tissues were removed and AP and lateral X-rays were taken. Subjective assessment of the healing on X-ray was carried out in two ways; using a radiographic scoring system and by grey scale analysis. The samples were embedded, sectioned and stained for new bone formation. Results: Bridging or potential to bridge was seen in a number of animals on x-ray. Bridging or potential to bridge was judged to be present in 72.22% of the BMP-2 group and 66.67% of the high dose group compared to 22.22% of the control group. Histological analysis is being performed to confirm these findings. Discussion: Atrophic nonunion is a serious clinical complication, unfortunately BMP-2 is a highly costly treatment option and therefore alternative molecular therapies are much sought after. We describe here an angiogenic molecule has some potential in preventing formation of nonunion.
The vascularization of developing cartilage rudiments is temporally and spatially defined. By using an in vivo angiogenesis model, the chorioallantoic membrane (CAM) of the chick embryo and chick embryo cartilage rudiments, we conclude that the factors controlling the vascular invasion of cartilage rudiments are intrinsic. Intact rudiments, separate hypertrophic zones and separate rounded cell zones, when grafted onto the CAM, become vascularized in the same temporal and spatial manner as occurs in ovo . When grown as organ cultures prior to CAM grafting, rudiments still become vascularized in the same temporal and spatial manner. The integrity of the extracellular matrix and the presence of the periosteum are two physical factors regulating the control of vascularization. Removal of the periosteum from hypertrophic regions caused a cessation of the invasion. Insults to the matrix via brief enzymatic degradation of extracellular matrix components resulted in invasion and erosion of rounded cell zones at an earlier time than is ordinarily seen both in ovo and on the CAM.
PICTURE Cerebral venous thrombosis in Behçet's diseaseA 22 year old man presented acutely with blurred vision and headache.He had recurrent oral (top left) and genital ulcers (top middle), erythema nodosum (top right), and a positive pathergy test, fulfilling the criteria for Behçet's disease.There was bilateral papilloedema, and a CSF pressure of 45 cm H 2 O. Plain head CT showed a dense triangle (arrow, bottom left) and an empty delta sign after contrast (arrow, bottom middle), suggestive of a superior sagittal sinus thrombosis.Magnetic resonance venography showed a flow void consistent with thrombosis within the superior sagittal and left lateral sinuses (arrowheads and arrow respectively, bottom right).
Abstract We present the initial evaluation of bone burring under local anaesthesia (LA) for skin cancers involving periosteum at the time of Mohs extirpation. Bone burring under LA enables patients to have their procedure on the same day. Including the bone burring as part of the Mohs process is logical as we can most accurately assess the location of the involved periosteal tissue. Our evaluation highlights the evolution of our service, our technique, the cost savings and an assessment of patient tolerability with qualitative data. We use a pneumatic De Soutter microdrill with a rose head drill tip. We have evolved to use a crosshatch pass technique with burring to enable the treated field to have two passes bidirectionally. Bone fragments are gathered and sent for histological and immunohistochemical analysis. Local anaesthesia bone burring is rapid, taking < 5 min. At the time of submission, three patients (aged 78–83 years) with skin cancers were offered the option of bone burring under LA. In each case, the bone appeared clinically normal. All tumours were histologically confirmed infiltrative squamous cell carcinomas on the frontal scalp, nasal dorsum and chin, ranging in size from 30 × 22 to 42 × 30 mm. Mohs stages ranged from two to four, all with periosteal involvement confirmed in the Mohs layer with frozen sectioning. At least a week after the procedure, all patients were asked to rate the pain from the bone burring procedure (0 being no discomfort and 10 being intolerable). The patients all reported a value of 0 (no discomfort). All patients confirmed that they would not have chosen differently between having the procedure done under LA vs. GA. The implementation of LA bone burring not only offers greater convenience to often elderly or frail patients, but also confers a considerable cost-saving. Initial outlay with equipment and maintenance costs are minimal, and staffing costs are modest compared with the general anaesthesia approach, when considering the avoided appointments, dermatology theatre staffing and procedure speed. Bone burring under LA represents an effective, safe, well-tolerated and cost-effective method of achieving clear deep margins in cases of tumour periosteal/bone involvement. Bone burring can be undertaken as part of the Mohs process so that the patient can still have the benefit of a definitive surgical reconstruction on the same day.
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