Cortical bone microperfusion: response to ischemia and changes in major arterial blood flow

Labral Reconstruction via Capsular Augmentation Maintains Perfusion to the Acetabular Labrum and Locally Transferred Autograft: An in Vivo Laser Doppler Flowmetry Analysis

Background

The purpose of the present study was to examine the effects of arthroscopic labral repair with capsular augmentation on blood flow in vivo with use of laser Doppler flowmetry (LDF) to measure microvascular perfusion of the labrum and autograft tissue.

Methods

The present prospective case series included patients ≥18 years old who underwent arthroscopic acetabular labral repair with capsular augmentation; all procedures were performed by a single surgeon between 2018 and 2022. The LDF probe measured microvascular blood flow flux within 1 mm3 of the surrounding labral and capsular tissue of interest. Mean baseline measurements of flux were compared with readings immediately following capsular elevation and after completing labral augmentation. Blood flux changes were expressed as the percent change from the baseline measurements.

Results

The present study included 41 patients (24 men [58.5%] and 17 women [41.5%]) with a mean age (and standard deviation) of 31.3 ± 8.4 years, a mean BMI of 24.6 ± 3.4 kg/m2, a mean lateral center-edge of angle 35.3° ± 4.9°, a mean Tönnis angle of 5.8° ± 5.8°, and a mean arterial pressure of 93.7 ± 10.9 mm Hg. Following capsular elevation, the mean percent change in capsular blood flow flux was significantly different from baseline (-9.24% [95% confidence interval (CI), -18.1% to -0.04%]; p < 0.001). Following labral augmentation, the mean percent change in labral blood flow flux was significantly different from baseline both medially (-22.3% [95% CI, -32.7% to -11.9%]; p < 0.001) and laterally (-32.5% [95% CI, -41.5% to -23.6%]; p = 0.041). There was no significant difference between the changes in medial and lateral perfusion following repair (p = 0.136).

Conclusions

Labral repair with capsular augmentation sustains a reduced blood flow to the native labrum and capsular tissue at the time of fixation. The biological importance of this reduction is unknown, but these findings may serve as a benchmark for other labral preservation techniques and support future correlations with clinical outcomes.

Level of Evidence

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Laser doppler flow imaging of open lower leg fractures in an animal experimental model

PURPOSE

Open lower leg fractures are frequently associated with severe soft tissue damage, followed by osteomyelitis. Using an animal experimental model, we investigated the effect of timing of coverage of a tibial fracture with a local muscle flap.

METHODS

80 rabbits had a tibial fracture induced in a standardised fashion, which was stabilised by screw osteosynthesis. After 3 (group A; n=40) and 7 days (group B; n=40), respectively, the tissue defect was covered by a local gastrocnemius flap. In increasing intervals from 1 to 2, 4, 8, and 16 weeks, the rabbits from each group were killed and the bone fracture was analysed histomorphologically. Cortical microcirculation was measured by 2-channel laser doppler flowmetry.

RESULTS

Muscle flaps after 3 days improved perfusion significantly as compared with 7 days (24 Flux [standard error, 5 Flux] versus 10 Flux [3 Flux]; baseline, 1.4 Flux). Group A animals also displayed a lower rate of necrosis (0 versus 38). The incidence of osteomyelitis was higher in group B than in group A (24% versus 0%).

CONCLUSION

Laser doppler flowmetry was proven to be a reliable, minimally invasive means for identifying avital tissue, leading to reduction in the loss of vital bone tissue in experimental settings.

Approaches to study of ischemia in bone

Ischemic osteonecrosis is a complication of certain traumatic and a number of idiopathic conditions. The course of the disease may result in collapse of the convex member of a joint and osteoarthritis, often requiring arthroplasty. Increasing incidence in young adults poses a challenge for development of long-term joint prostheses. Current status of research into the disease is discussed and three new models using intravital microscopy described. The first, an arterial occlusion (AO) model, creates ischemia by occluding the common iliac artery exclusively, avoiding direct trauma on other tissues in the limb. The second, a total occlusion (TO) model utilizes classical tourniquet occlusion of the thigh vessels. The third, a venous occlusion (VO) model, is also a tourniquet procedure but it blocks occlusion of the femoral artery with a protective sheath. Preliminary results from AO and TO studies are reported which show that reperfusion injury is detectible after ischemia doses as short as 4 h. This complication was confirmed by observation of leukocyte adherence, secondary ischemia, and abnormal vessel leakage. Also, a new quantitation of osteonecrosis is introduced whereby fluorescently-tagged dead osteocytes and computer-based image processing provide values for an "osteonecrosis index." Viewing of all vascular events is made possible by intravital microscopy through a bone chamber window implanted in rabbit tibias. It is proposed that such chronic visual techniques allow quantitation of events leading to osteonecrosis as well as the revascularization, resorption and bone apposition of creeping substitution which characterizes postischemia recovery.

Dynamic measurement of bone blood perfusion with modified laser Doppler imaging

Although the mechanisms are not clearly defined, blood flow may play an important role in moderating skeletal adaptation. Most techniques currently available to measure blood flow in bone are time-consuming and require destruction of the tissue, but laser Doppler technology offers a less invasive method. The present study assessed whether laser Doppler perfusion imaging could detect changes in perfusion in cortical bone. By use of modified laser Doppler perfusion imaging with an adjustable, incorporated, near infrared-laser gain photodetection system, perfusion of blood in the mid-diaphyseal tibial cortex of New Zealand White rabbits (n = 5) was measured before, during, and after occlusion of the femoral artery. During occlusion, perfusion decreased 69% compared with control levels; removal of the arterial clip caused flux values to return to near normal. Laser Doppler perfusion imaging provides a two-dimensional image related to blood flow, and the results of this pilot study suggest that it may be an effective technique for imaging in vivo dynamic changes in perfusion in cortical bone.

Muscle perfusion after intramedullary nailing of the canine tibia

BACKGROUND

Intramedullary nailing with and without reaming leads to a reduction in cortical bone blood flow. The repair of the devascularized bone is mediated principally by the surrounding soft-tissue envelope. The objective of this study was to determine the effect on muscle blood flow of reamed and unreamed intramedullary nailing techniques.

METHODS

Midshaft tibial osteotomies to create a 2.5-cm segment of devascularized tibial cortex were performed in 19 adult canines. The tibia was stabilized with a locked intramedullary nail without reaming in 9 animals and with intramedullary reaming in 10 animals. In the unreamed group, the tibia was stabilized with a loosely fitting (n = 4) or a tightly fitting (n = 5) locked nail. In the reamed group, limited reaming (n = 5) or standard reaming (n = 5) was performed. Muscle perfusion was measured in the anterior compartment musculature of the hind-limb using laser Doppler flowmetry.

RESULTS

Overall muscle perfusion was greater in the reamed group than in the unreamed group at the conclusion of the nailing procedure (p = 0.0001) and at 5 weeks (p = 0.0008) and 11 weeks after nailing (p = 0.001). The degree of canal fit of the intramedullary nails and the extent of reaming before nail insertion did not further influence muscle circulation.

CONCLUSION

The results of this study demonstrate that in the presence of an intact soft-tissue envelope, intramedullary reaming of the canine tibia has a major effect on increasing the circulation to the surrounding muscles. The increased extraosseous circulation may have implications for fracture healing.

Effect of limited and standard reaming on cortical bone blood flow and early strength of union following segmental fracture

OBJECTIVE

To quantitatively determine the extent to which limited and standard intramedullary reaming disrupts cortical circulation and to evaluate the effect on the biomechanical properties of the united fracture.

DESIGN

Midshaft tibial osteotomies to create a 2.5-centimeter segment of diaphyseal bone were performed in ten adult dogs. Before insertion of a locked intramedullary nail, the tibia was reamed to either 7.0 millimeters (n = 5) or 9.0 millimeters (n = 5). Blood flow was measured using laser Doppler flowmetry during the nailing procedure and at eleven weeks postnailing. Bending stiffness and load to failure were determined for each healed tibia.

RESULTS

Tibial blood flow was reduced for the limited and the standard ream groups by 63 percent (p = 0.002) and 83 percent (p = 0.0008), respectively. After canal reaming, perfusion was reduced to a greater extent in the standard ream group (p = 0.009). At eleven weeks postnailing, tibial perfusion increased to the same levels in both groups (p = 0.43) and returned to base-line values. Bending stiffness and load to failure were reduced after limited reaming (p = 0.002, p = 0.003) and standard reaming (p = 0.01, p = 0.002) were performed. Stiffness and load to failure were reduced to the same extent in both groups (p = 0.12, p = 0.25).

CONCLUSIONS

Both limited reaming and standard reaming negatively affect diaphyseal cortical circulation. Limited reaming spares cortical perfusion compared with standard reaming at the time of nail insertion. No long-term advantage for limited reaming was demonstrated. Limited reaming may be advantageous acutely for the stabilization of tibial fractures in which the circulation is already compromised.

Cortical bone blood flow in loose and tight fitting locked unreamed intramedullary nailing: a canine segmental tibia fracture model

OBJECTIVES

To quantitatively determine the extent to which loose and tight fitting unreamed, locked intramedullary nails devascularize cortical bone and to determine their effect on early strength of union.

DESIGN

A 2.5-centimeter segment of devascularized diaphyseal bone was created in the tibiae of twelve skeletally mature mongrel dogs by means of two standardized transverse osteotomies. Stabilization of the tibia was achieved with either a 5.0-millimeter (n = 6) or a 6.5-millimeter (n = 6) unreamed, locked intramedullary nail. Bone blood flow was assessed using laser Doppler flowmetry. Bending stiffness and load to failure were determined for each healed tibia.

RESULTS

At the conclusion of the nailing procedure, the overall tibial blood flow was reduced by 58 percent and 72 percent for the 5.0-millimeter and 6.5-millimeter nail groups, respectively (p = 0.001, p = 0.00004). Perfusion was reduced to a greater extent in the tightly fitting nail group (p = 0.017). At eleven weeks postnailing, cortical perfusion increased in both the 5.0-millimeter and the 6.5-millimeter nail groups (p = 0.005, p = 0.002, respectively). Perfusion increased to a higher level in the loosely fitting nail group (p = 0.007). Biomechanical properties of the healed tibiae, including bending stiffness in two planes and load to failure, were similar in the two experimental groups (p = 0.42, p = 0.09, p = 0.34).

DISCUSSION

Our results demonstrate that a loose fitting nail spared cortical perfusion at the time of nail insertion more than did a canal filling nail and allowed more complete cortical reperfusion at eleven weeks postnailing. The results of this study have implications for the treatment of severe tibial shaft fractures in which the blood supply is significantly compromised.

Effect of brief intrusive force on human pulpal blood flow

The purpose of this study was to evaluate the effect of a 4-minute application of intrusive orthodontic force on human pulpal blood flow (PBF) with laser-Doppler flowmetry. Eight subjects had an intrusive force applied to a maxillary central incisor through a lever system. A cast chrome-cobalt coping was fabricated to fit over the incisor of each subject, and thus provided a reproducible point of force application as well as stabilization for the laser-Doppler flowmetry probe. Each subject participated in five testing sessions. During each session, PBF was measured during a 4-minute baseline period, then during the 4-minute force application, and then for a 12-minute period after removal of the force. Weights of 0, 5, 50, or 500 gm were attached to the end of the lever to produce intrusive forces ranging from 75 to 4498 gm. During the fifth testing session, local anesthetic with vasoconstrictor (epinephrine 1:100,000) was administered in place of the force application to determine the ability of this experimental paradigm to detect reductions in PBF. Baseline PBF values did not differ among sessions. Force levels had no statistically significant effect on PBF. However, PBF did drop significantly after administration of the vasoconstrictor. These results suggest that PBF is not altered during the application of a brief intrusive orthodontic force.

Cortical bone perfusion in plated fractured sheep tibiae

The limited contact dynamic compression plate and partial contact plate were designed to decrease contact with cortical bone in an attempt to decrease cortical ischemia, remodeling, and eventual porosis under the plate after use of standard dynamic compression plates. This study quantified cortical bone blood flow beneath the plate with these three different designs in a sheep tibia fracture model. In 18 skeletally immature sheep, the right tibia was fractured and then was internally fixed with an interfragmentary screw and a dynamic compression plate, limited contact dynamic compression plate, or partial contact plate. At 12 weeks, cortical bone perfusion was assessed with laser Doppler flowmetry in nine areas beneath the plate. The baseline (before fracture) cortical bone cell flux averaged 100 +/- 60 mV. After fracture, this decreased to 60 +/- 48 mV (p < 0.0003); immediately after plating, the perfusion averaged 29 +/- 25 mV (p < 0.01). Cortical bone perfusion then increased to 106 +/- 52, 165 +/- 71, and 163 +/- 71 mV at 2, 6, and 12 weeks after fracture (p < 0.001 for all when compared with values after plating). No significant differences in cortical perfusion were seen between the types of plate. Cortical porosity under the plate was assessed with digital density analysis of microradiographs of this region. No significant difference was seen between the types of plate in this analysis or in biomechanical and disulphine blue perfusion analysis. Thus, no significant advantage was seen for the new plate designs used in this model. This lack of advantage may be a result of the immature animals used in the study, the protocol for blood flow measurement, the invasive periosteal stripping employed to create the fracture, or all three. However, as advantages with the new plate designs have been seen in other studies, this area warrants further investigation.

Comparison of the effect of reamed and unreamed locked intramedullary nailing on blood flow in the callus and strength of union following fracture of the sheep tibia

This study was performed to compare the effects of reamed and unreamed locked intramedullary nailing on blood flow in the callus and early strength of union in a fractured sheep tibia model. After the creation of a standardized short spiral fracture by three-point bending with torsion, each tibia was stabilized by the insertion of a locked intramedullary nail. Ten animals were allocated randomly into two groups: one that had reaming prior to nail insertion and one that did not. Blood flow was measured in real time with use of laser Doppler flowmetry. Endosteal perfusion was determined at the fracture site before and after nail insertion. Perfusion of the callus was measured at three locations (proximal diaphysis, fracture site, and distal diaphysis) and at three time intervals (2, 6, and 12 week follow-up). All animals were killed 12 weeks postoperatively, and the tibiae were tested to failure in four-point bending. Nailing with reaming resulted in a larger decrease in overall endosteal perfusion than nailing without reaming (p < 0.015). The presence or absence of reaming did not affect blood flow within fracture callus. Perfusion of callus was greatest at 6 weeks of follow-up. Bending strength and stiffness were the same in both groups at 12 weeks. The study demonstrated that perfusion of callus and early strength of union are similar following intramedullary nailing with or without reaming.

Evaluation of a laser Doppler flowmetry implantable fiber system for determination of threshold thickness for flow detection in bone

Laser Doppler flowmetry (LDF) with the use of a standard metal shafted probe, has been successfully used to study bone blood flow in a wide variety of settings. The use of the standard probe is limited by the requirement that the probe be replaced onto the bone surface or driven into the bone with a trocar. In response to this, a system of implantable, detachable fibers was developed. This system allows repeated measurement over time without repeated surgical manipulation of the area of interest. This study was performed to evaluate the implantable fiber system by determining threshold thickness for flow detection in bone. A flow chamber with perpendicular and end-on flow was designed to collect results under controlled conditions for flow detection. Threshold thickness for bovine cortical and cancellous bone samples was determined after sequentially grinding the specimens and placing them in the flow chamber. A 2% solution of latex circulated in the chamber and each specimen was exposed to both flow directions and both types of probe. The laser Doppler probe was able to detect flow by resting on top of the sample, with the latex on the other side of the sample. The results showed a significantly greater threshold thickness for the standard probes than for the implantable probes, and a significantly greater threshold thickness for trabecular bone than for cortical bone. Despite the reduced threshold thickness with the implantable fiber, this new system was able to consistently detect depth of perfusion of 80-90% of the values for the standard probe.(ABSTRACT TRUNCATED AT 250 WORDS)