The effect of surgical dissections on blood flow to the tibial tubercle
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Abstract:
Tibial tubercle transfer is often used for the treatment of patella maltracking. Because the periosteum of both sides of the tibia is stripped off along the tibial tubercle and then the bilateral cortices are transferred, this procedure may disturb the blood supply to the tibial tubercle. However, the blood supply to the tibial tubercle has not yet been clearly elucidated. The purpose of this study is to investigate the effect of surgical dissection on blood flow to the tibial tubercle in an animal model using a hydrogen washout technique. Eleven knees of nine mongrel dogs weighing from 7.0 to 19.1 kg were utilized. The blood flow was measured using a hydrogen washout technique. Before performing the surgical procedures, the control blood flow rate of the tibial tubercle averaged 19.6 ml/min per 100 g of tissue. The blood flow rate did not significantly decrease after transecting the periosteum on the lateral side of the tibia alone (P > 0.05). After completing the tibial tubercle osteotomy, the blood flow rate averaged 11.5 ml/min per 100 g of tissue, which is a 25.3% decrease as compared with the value after transecting the periosteum on the lateral side of the tibia alone (P < 0.05). The blood flow rate significantly decreased to 3.4 ml/min per 100 g of tissue after the distal periosteal transection and osteotomy of the distal cortex of the tibial tubercle (P < 0.05). The addition of a medial periosteal transection caused a complete arrest of the blood flow in 10 out of 11 knees, or a 91.2% decrease as compared with the value after a distal periosteal transection and osteotomy of the distal cortex of the tibial tubercle (P < 0.05).Keywords:
Tubercle
Periosteum
Objective
To investigate the clinical effect of irradiated-host bone ends' union after transplantation of pedicled vascularized fibular periosteum in the treatment of Children's tibia sarcoma.
Methods
From June, 2016 to December, 2016, there were 5 children of tibia sarcoma, which were 2 boys and 3 girls, aged of 9-15 years(mean, 12 years). They were treated by the re-transplantation of extracorporal irradiated segmental autograft, and used ipsilateral pedicled vascularized fibular periosteum cover the ends of irradiated-host bone to shorten the bone union time of irradiated tibia autograft and prevent nonunion. Patients were 3 cases of osteosarcoma, 1 of Ewing's sarcoma, and 1 of relapse of Langerhans's cell histocytosis in tibia. The length of resect bone was 14.0-20.0 cm (mean, 17.2 cm), constitute of 2 osteoarticular resections and 3 intercalary resections. The method of inactivation of bone segment was intraoperative extracorporal irradiation. Regular followed-up were done postoperative. The X-ray and CT were applied to observe the function of affect limb. The bone union time and complication were record.
Results
All patients were followed-up of 12-18 months (mean, 14.2 months). Eight ends of irradiated-host bone in 5 patients healed completely in 7.8(6-10) months postoperative. The region of ends were covered by periosteum and showed excellent osteogenic power. There was no leg length discrepancy occurred in patients who received intercalary inactivation because of the preservation of growth plate. But the other 2 osteoarticular inactivated patients suffered leg length discrepancy of 1.0 cm and 1.5 cm respectively because of the inactivation of growth plate. At the follow-up of 12 months post-operation, the mean MTSS of affect limb was 25.8(22-28), and the mean of MTSS% was 86%(73%-93%).
Conclusion
Transplantation of pedicled vascularized fibular periosteum can promote effectively healing of irradiated tibia bone after replantation in Children, with simple operation and less complications.
Key words:
Pedicled vascularized fibular periosteum; Transplantation of periosteum; Inactivated tibia section; Bone union; Children
Periosteum
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The mode of action of the periosteum in the growth of the long bones was investigated by comparing the activity of the growth plate after hemicircumferential and longitudinal periosteal incisions. Twenty-eight rabbits were divided into three groups. A longitudinal periosteum incision was made on the medial upper tibia in rabbits of Group A, and a hemicircumferential periosteum incision was made in Group B. An incision of the skin and superficial tissue only, similar to the skin incision of Groups A and B, was performed on rabbits in Group C. Certain differences in the development of the right tibia compared to the control side were observed in rabbits of Group B: (1) valgus deformity, 5 degrees-10 degrees; (2) overgrowth, 1-2 mm; (3) an S-shaped tibia deformity. The dynamics of the deformity support the mechanical theory because the direction of periosteum division was an important factor in the appearance of growth disturbances.
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SUMMARY The longitudinal endosteal blood supply is interrupted by fractures while the transverse blood supply conveyed by the periosteum sustains viability on both sides of the fracture site. The intact periosteum seals the fracture gap and the periosteal vessels revascularize the distal fragment. The integrity of the periosteum is of vital importance in determining the rate of healing of a fractured tibia.
Periosteum
Blood supply
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The periosteum is a rich source of osteoprogenitor cells and periosteal grafts can be used as an alternative method to replace bone grafts. The low-intensity pulsed ultrasound (LIPUS) has often been used as a noninvasive method to stimulate osteogenesis and reduce the fracture healing time. The aim of this study was to evaluate the effects of the ultrasound exposure on the rat tibia periosteum. Group I (7 animals) received LIPUS therapy on the left tibia for 7 days and group II (7 animals) on the left tibia for 14 days. After euthanasia, the tibias were processed. Number of periosteal cells and vessels and thickness of the periosteum were analyzed. The number of periosteal cells was higher in stimulated periosteum compared to controls at 7 and 14 days, but the number of vessels and the thickness only were higher in the group stimulated at 14 days. Furthermore, the ultrasound treatment for 14 days was more effective than 7 days. The ultrasound stimulation of the periosteum prior to grafting procedure can be advantageous, since it increases periosteal activity, and LIPUS may be an alternative method for stimulating the periosteum when the use of periosteal grafts in bone repair is needed.
Periosteum
Low-intensity pulsed ultrasound
Tibia Fracture
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Hemicircumferential division of the periosteum was performed on the upper tibia of the rabbit. Division of the medial side regularly caused a valgus angulation, but other injuries about the upper tibia had no effect. The cause of deformity after periosteal damage is discussed.
Periosteum
Rabbit (cipher)
Valgus deformity
Distal tibia
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In previous experiments it was shown that a great difference exists in the osteogenic power of the periosteum of the rib and tibia of the same animal. Periosteum from only the mid-portions of these bones was tested. In the present experiments, specimens of periosteum of various portions of the tibia were compared with each other in this respect. Rabbits, 6 to 12 months old, and adult dogs were used, in 3 groups. In each animal, equal strips of bone-free periosteum were aseptically removed from different parts of the bone's antero-medial aspect and laid upon the fascia of the corresponding tibialis anticus muscle. After 5 1/2 to 10 weeks, the specimens were removed and examined for the extent of osteogenesis. Group 1, 4 rabbits. The specimens were from the upper and lower thirds of the shaft of the tibia. New bone formed in both, but it was about 5 times more abundant in the specimen from the upper third. In each case, the end of the graft originally nearer the epiphysis had more bone than the other. Group 2, one rabbit and 2 dogs. The specimens were from the upper, middle, and lower thirds of the bone. Those from the middle third developed no bone; and the others behaved as in group 1. Group 3, 2 dogs and 2 rabbits. The grafts were from the upper third and from the junction of the middle and lower thirds of the shaft of tibia. The positions of the transplantations were reversed (in order to control the factor of possible differences in vascularity of different parts of the tibialis anticus muscle fascia). The transplants from the upper third of the shaft showed solid sheets of bone, while those from the junction of the middle and lower thirds of the shaft showed only a very slight amount of osteogenesis—slightly less than that formed in the grafts taken from the lower one-third of the shaft as in groups 1 and 2.
Periosteum
Epiphysis
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To investigate the effect of the fibula on growth of the tibia in the rat, (1) a sleeve of periosteum was removed from the middle third of the tibia, (2) a length of the fibula was excised, or (3) a sleeve of periosteum was removed from the middle third of the tibia and a length of fibula was also excised. Over a 14 wk experimental period subsequent tibial bone growth was measured on radiographs and compared with unoperated contralateral control tibiae. Procedure (1) had no effect on growth, (2) resulted in 4.2% overgrowth and (3) produced 19.7% overgrowth compared with control tibiae. The failure of overgrowth after periosteal resection from the middle third of the rat tibia argues against the vascular response theory in relation to bone overgrowth. The longitudinal overgrowth after procedure (2) and its further accentuation by procedure (3) suggests that the fibula influences tibial bone growth by exerting a mechanical restraint on it, which is reciprocal to the restraining influence of the tibial periosteum. Overgrowth appears to be facilitated by decompression of the cartilage growth plate of the rat tibia when a sleeve of the periosteum is removed from it, and this suggests a mechanical relationship between the fibrous periosteum and the cartilage growth plate of the tibia. It is concluded that the fibula plays a reciprocal role in regulating tibial bone growth in the rat.
Periosteum
Long bone
Bone Growth
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A study was undertaken to determine which arteries supply the periosteum of the normal adult canine tibia. The vessels were found to arise from locations distinct from the muscular vascularization. The venous drainage of the tibial periosteum had a satellite relationship with the arteries. On the surface of the periosteum, the vessels formed rectangular patterns. All surfaces of the distal end of the tibia seemed to have less distinct anastomoses of the transverse periosteal twigs, compared with the proximal end of the tibia.
Periosteum
Blood supply
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Tibia Fracture
Animal model
Tibial fracture
Callus
High tibial osteotomy
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