Anatomical effects of periosteal elevation

From Free Tissue Transfer to Hydrogels: A Brief Review of the Application of the Periosteum in Bone Regeneration

The periosteum is a thin layer of connective tissue covering bone. It is an essential component for bone development and fracture healing. There has been considerable research exploring the application of the periosteum in bone regeneration since the 19th century. An increasing number of studies are focusing on periosteal progenitor cells found within the periosteum and the use of hydrogels as scaffold materials for periosteum engineering and guided bone development. Here, we provide an overview of the research investigating the use of the periosteum for bone repair, with consideration given to the anatomy and function of the periosteum, the importance of the cambium layer, the culture of periosteal progenitor cells, periosteum-induced ossification, periosteal perfusion, periosteum engineering, scaffold vascularization, and hydrogel-based synthetic periostea.

Traumatized periosteum: Its histology, viability, and clinical significance

The periosteum covers the surface of long bone except at the joints. During fracture fixation, we found the periosteum is ragged and damaged. Our objective is to determine the microscopic picture of traumatized periosteum in terms of the degree of damage, cell type, stromal tissue, and vascularity. Periosteum of 1cm*1cm is harvested at 1cm, 3cm, and 5cm proximal and distal to fracture site following fracture of a long bone in 20 humans. Ragged and damaged periosteum mainly consists of an outer fibrous layer with many hemorrhagic tissue and neovascularization. Osteoprogenitor cells were seen only in 12 out of 97 samples, mostly harvested 5 cm from the fracture site. The innermost layer of the periosteum remains attached to the bone surface after separating the fibrous layer following a fracture. The use of a periosteal elevator on the bone surface further damages the inner layer of the periosteum. Using a scalpel to separate the periosteum or merely pulling it away from the bone surface will decrease damage to the inner cambium layer. Fracture reduction can be achieved by indirect means at least 5 cm away from the fracture site.

Mouse Periosteal Cell Culture, in vitro Differentiation, and in vivo Transplantationin Tibial Fractures

The periosteum covering the outer surface of bone contains skeletal stem/progenitor cells that can efficiently form cartilage and bone during bone repair. Several methods have been described to isolate periosteal cells based on bone scraping and/or enzymatic digestion. Here, we describe an explant culture method to isolate periosteum-derived stem/progenitor cells for subsequent in vitro and in vivo analyses. Periosteal cells (PCs) isolated using this protocol express mesenchymal markers, can be expanded in vitro, and exhibit high regenerative potential after in vivo transplantation at a fracture site, suggesting that this protocol can be employed for PC production to use in new cell-based therapies.

Effects of low-intensity pulsed ultrasound exposure on rats tibia periosteum

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.

Colony Formation, Migratory, and Differentiation Characteristics of Multipotential Stromal Cells (MSCs) from "Clinically Accessible" Human Periosteum Compared to Donor-Matched Bone Marrow MSCs

Periosteum is vital for fracture healing, as a highly vascular and multipotential stromal cell- (MSC-) rich tissue. During surgical bone reconstruction, small fragments of periosteum can be “clinically accessible,” yet periosteum is currently not ultilised, unlike autologous bone marrow (BM) aspirate. This study is aimed at comparing human periosteum and donor-matched iliac crest BM MSC content and characterising MSCs in terms of colony formation, growth kinetics, phenotype, cell migration patterns, and trilineage differentiation capacity. “Clinically accessible” periosteum had an intact outer fibrous layer, containing CD271+ candidate MSCs located perivasculary; the inner cambium was rarely present. Following enzymatic release of cells, periosteum formed significantly smaller fibroblastic colonies compared to BM (6.1 mm² vs. 15.5 mm², n = 4, P = 0.0006). Periosteal colonies were more homogenous in size (range 2-30 mm² vs. 2-54 mm²) and on average 2500-fold more frequent (2.0% vs. 0.0008%, n = 10, P = 0.004) relative to total viable cells. When expanded in vitro, similar growth rates up to passage 0 (P0) were seen (1.8 population doublings (PDs) per day (periosteum), 1.6 PDs per day (BM)); however, subsequently BM MSCs proliferated significantly slower by P4 (4.3 PDs per day (periosteum) vs. 9.3 PDs per day (BM), n = 9, P = 0.02). In early culture, periosteum cells were less migratory at slower speeds than BM cells. Both MSC types exhibited MSC phenotype and trilineage differentiation capacity; however, periosteum MSCs showed significantly lower (2.7-fold) adipogenic potential based on Nile red : DAPI ratios with reduced expression of adipogenesis-related transcripts PPAR-γ. Altogether, these data revealed that “clinically accessible” periosteal samples represent a consistently rich source of highly proliferative MSCs compared to donor-matched BM, which importantly show similar osteochondral capacity and lower adipogenic potential. Live cell tracking allowed determination of unique morphological and migration characteristics of periosteal MSCs that can be used for the development of novel bone graft substitutes to be preferentially repopulated by these cells.

Bone Tissue Engineering Using Human Cells: A Comprehensive Review on Recent Trends, Current Prospects, and Recommendations

The use of proper cells for bone tissue engineering remains a major challenge worldwide. Cells play a pivotal role in the repair and regeneration of the bone tissue in vitro and in vivo. Currently, a large number of differentiated (somatic) and undifferentiated (stem) cells have been used for bone reconstruction alone or in combination with different biomaterials and constructs (e.g., scaffolds). Although the results of the cell transplantation without any supporting or adjuvant material have been very effective with regard to bone healing. Recent advances in bone scaffolding are now becoming new players affecting the osteogenic potential of cells. In the present study, we have critically reviewed all the currently used cell sources for bone reconstruction and discussed the new horizons that are opening up in the context of cell-based bone tissue engineering strategies.

Concise review: the periosteum: tapping into a reservoir of clinically useful progenitor cells

Elucidation of the periosteum and its regenerative potential has become a hot topic in orthopedics. Yet few review articles address the unique features of periosteum-derived cells, particularly in light of translational therapies and engineering solutions inspired by the periosteum's remarkable regenerative capacity. This review strives to define periosteum-derived cells in light of cumulative research in the field; in addition, it addresses clinical translation of current insights, hurdles to advancement, and open questions in the field. First, we examine the periosteal niche and its inhabitant cells and the key characteristics of these cells in the context of mesenchymal stem cells and their relevance for clinical translation. We compare periosteum-derived cells with those derived from the marrow niche in in vivo studies, addressing commonalities as well as features unique to periosteum cells that make them potentially ideal candidates for clinical application. Thereafter, we review the differentiation and tissue-building properties of periosteum cells in vitro, evaluating their efficacy in comparison with marrow-derived cells. Finally, we address a new concept of banking periosteum and periosteum-derived cells as a novel alternative to currently available autogenic umbilical blood and perinatal tissue sources of stem cells for today's population of aging adults who were "born too early" to bank their own perinatal tissues. Elucidating similarities and differences inherent to multipotent cells from distinct tissue niches and their differentiation and tissue regeneration capacities will facilitate the use of such cells and their translation to regenerative medicine.

Breast cancer-induced bone remodeling, skeletal pain, and sprouting of sensory nerve fibers

Breast cancer metastasis to bone is frequently accompanied by pain. What remains unclear is why this pain tends to become more severe and difficult to control with disease progression. Here we test the hypothesis that with disease progression, sensory nerve fibers that innervate the breast cancer bearing bone undergo a pathological sprouting and reorganization, which in other nonmalignant pathologies has been shown to generate and maintain chronic pain. Injection of human breast cancer cells (MDA-MB-231-BO) into the femoral intramedullary space of female athymic nude mice induces sprouting of calcitonin gene-related peptide (CGRP(+)) sensory nerve fibers. Nearly all CGRP(+) nerve fibers that undergo sprouting also coexpress tropomyosin receptor kinase A (TrkA(+)) and growth-associated protein-43 (GAP43(+)). This ectopic sprouting occurs in periosteal sensory nerve fibers that are in close proximity to breast cancer cells, tumor-associated stromal cells, and remodeled cortical bone. Therapeutic treatment with an antibody that sequesters nerve growth factor (NGF), administered when the pain and bone remodeling were first observed, blocks this ectopic sprouting and attenuates cancer pain. The present data suggest that the breast cancer cells and tumor-associated stromal cells express and release NGF, which drives bone pain and the pathological reorganization of nearby CGRP(+)/TrkA(+)/GAP43(+) sensory nerve fibers.

PERSPECTIVE

Therapies that block breast cancer pain by reducing the tumor-induced pathological sprouting and reorganization of sensory nerve fibers may provide insight into the evolving mechanisms that drive breast cancer pain and lead to more effective therapies for attenuating this chronic pain state.

The majority of myelinated and unmyelinated sensory nerve fibers that innervate bone express the tropomyosin receptor kinase A

Although skeletal pain is a leading cause of chronic pain and disability, relatively little is known about the specific populations of nerve fibers that innervate the skeleton. Recent studies have reported that therapies blocking nerve growth factor (NGF) or its cognate receptor, tropomyosin receptor kinase A (TrkA) are efficacious in attenuating skeletal pain. A potential factor to consider when assessing the analgesic efficacy of targeting NGF-TrkA signaling in a pain state is the fraction of NGF-responsive TrkA+ nociceptors that innervate the tissue from which the pain is arising, as this innervation and the analgesic efficacy of targeting NGF-TrkA signaling may vary considerably from tissue to tissue. To explore this in the skeleton, tissue slices and whole mount preparations of the normal, adult mouse femur were analyzed using immunohistochemistry and confocal microscopy. Analysis of these preparations revealed that 80% of the unmyelinated/thinly myelinated sensory nerve fibers that express calcitonin gene-related peptide (CGRP) and innervate the periosteum, mineralized bone and bone marrow also express TrkA. Similarly, the majority of myelinated sensory nerve fibers that express neurofilament 200 kDa (NF200) which innervate the periosteum, mineralized bone and bone marrow also co-express TrkA. In the normal femur, the relative density of CGRP+, NF200+ and TrkA+ sensory nerve fibers per unit volume is: periosteum>bone marrow>mineralized bone>cartilage with the respective relative densities being 100:2:0.1:0. The observation that the majority of sensory nerve fibers innervating the skeleton express TrkA+, may in part explain why therapies that block NGF/TrkA pathway are highly efficacious in attenuating skeletal pain.

Vascularized bone grafts for upper limb reconstruction: defects at the distal radius, wrist, and hand

Vascularized bone grafts have been successfully applied for the reconstruction of bone defects at the forearm, distal radius, carpus, and hand. Vascularized bone grafts are most commonly used in revision cases in which other approaches have failed. Vascularized bone grafts can be obtained from a variety of donor sites, including the fibula, the iliac crest, the distal radius (corticocancellous segments and vascularized periosteum), the metacarpals and metatarsals, and the medial femoral condyle (corticoperiosteal flaps). Their vascularity is preserved as either pedicled autografts or free flaps to carry the optimum biological potential to enhance union. The grafts can also be transferred as composite tissue flaps to reconstruct compound tissue defects. Selection of the most appropriate donor flap site is multifactorial. Considerations include size matching between donor and defect, the structural characteristics of the graft, the mechanical demands of the defect, proximity to the donor area, the need for an anastomosis, the duration of the procedure, and the donor site morbidity. This article focuses on defects of the distal radius, the wrist, and the hand.

Blockade of nerve sprouting and neuroma formation markedly attenuates the development of late stage cancer pain

For many patients, pain is the first sign of cancer and, while pain can be present at any time, the frequency and intensity of pain tend to increase with advancing stages of the disease. Thus, between 75 and 90% of patients with metastatic or advanced-stage cancer will experience significant cancer-induced pain. One major unanswered question is why cancer pain increases and frequently becomes more difficult to fully control with disease progression. To gain insight into this question we used a mouse model of bone cancer pain to demonstrate that as tumor growth progresses within bone, tropomyosin receptor kinase A (TrkA)-expressing sensory and sympathetic nerve fibers undergo profuse sprouting and form neuroma-like structures. To address what is driving the pathological nerve reorganization we administered an antibody to nerve growth factor (anti-NGF). Early sustained administration of anti-NGF, whose cognate receptor is TrkA, blocks the pathological sprouting of sensory and sympathetic nerve fibers, the formation of neuroma-like structures, and inhibits the development of cancer pain. These results suggest that cancer cells and their associated stromal cells release nerve growth factor (NGF), which induces a pathological remodeling of sensory and sympathetic nerve fibers. This pathological remodeling of the peripheral nervous system then participates in driving cancer pain. Similar to therapies that target the cancer itself, the data presented here suggest that, the earlier therapies blocking this pathological nerve remodeling are initiated, the more effective the control of cancer pain.

A phenotypically restricted set of primary afferent nerve fibers innervate the bone versus skin: therapeutic opportunity for treating skeletal pain

Although musculoskeletal pain is one of the most common causes of chronic pain and physical disability in both developing and developed countries, relatively little is known about the nerve fibers and mechanisms that drive skeletal pain. Small diameter sensory nerve fibers, most of which are C-fiber nociceptors, can be separated into two broad populations: the peptide-rich and peptide-poor nerve fibers. Peptide-rich nerve fibers express substance P (SP) and calcitonin gene-related peptide (CGRP). In contrast, the peptide-poor nerve fibers bind to isolectin B4 (IB(4)) and express the purinergic receptor P(2)X(3) and Mas-related G protein-coupled receptor member d (Mrgprd). In the present report, we used mice in which the Mrgprd(+) nerve fibers express genetically encoded axonal tracers to determine the peptide-rich and peptide-poor sensory nerve fibers that innervate the glabrous skin of the hindpaw as compared to the bone marrow, mineralized bone and periosteum of the femur. Whereas the skin is richly innervated by CGRP(+), SP(+), P(2)X(3)(+) and Mrgprd(+) sensory nerve fibers, the bone marrow, mineralized bone and periosteum receive a significant innervation by SP(+) and CGRP(+), but not Mrgprd(+) and P(2)X(3)(+) nerve fibers. This lack of redundancy in the populations of C-fibers that innervate the bone may present a unique therapeutic opportunity for targeting skeletal pain as the peptide-rich and peptide-poor sensory nerve fibers generally express a different repertoire of receptors and channels to detect noxious stimuli. Thus, therapies that target the specific types of C-nerve fibers that innervate the bone may be uniquely effective in attenuating skeletal pain as compared to skin pain.

Capsaicin-sensitive sensory nerve fibers contribute to the generation and maintenance of skeletal fracture pain

Although skeletal pain can have a marked impact on a patient's functional status and quality of life, relatively little is known about the specific populations of peripheral nerve fibers that drive non-malignant bone pain. In the present report, neonatal male Sprague-Dawley rats were treated with capsaicin or vehicle and femoral fracture was produced when the animals were young adults (15-16 weeks old). Capsaicin treatment, but not vehicle, resulted in a significant (>70%) depletion in the density of calcitonin-gene related peptide positive (CGRP(+)) sensory nerve fibers, but not 200 kDa neurofilament H positive (NF200(+)) sensory nerve fibers in the periosteum. The periosteum is a thin, cellular and fibrous tissue that tightly adheres to the outer surface of all but the articulated surface of bone and appears to play a pivotal role in driving fracture pain. In animals treated with capsaicin, but not vehicle, there was a 50% reduction in the severity, but no change in the time course, of fracture-induced skeletal pain-related behaviors as measured by spontaneous flinching, guarding and weight bearing. These results suggest that both capsaicin-sensitive (primarily CGRP(+) C-fibers) and capsaicin-insensitive (primarily NF200(+) A-delta fibers) sensory nerve fibers participate in driving skeletal fracture pain. Skeletal pain can be a significant impediment to functional recovery following trauma-induced fracture, osteoporosis-induced fracture and orthopedic surgery procedures such as knee and hip replacement. Understanding the specific populations of sensory nerve fibers that need to be targeted to inhibit the generation and maintenance of skeletal pain may allow the development of more specific mechanism-based therapies that can effectively attenuate acute and chronic skeletal pain.

Human periosteum-derived cells from elderly patients as a source for cartilage tissue engineering?

The aim of this study was to establish the potential of human periosteum-derived cells from elderly patients as a cell source for cartilage tissue engineering by optimizing culture conditions for both proliferation and differentiation. Periosteum was obtained from the tibiae of nine patients. Biopsies were prepared for routine histological examination. Periosteum-derived cells were allowed to grow out from the remaining tissue, and were expanded in minimum essential medium containing D-valine (MEM-DV). Fetal bovine serum (FBS) or substitutes, fibroblast growth factor-2 (FGF-2), insulin-like growth factor-1 (IGF-1) and non-essential amino acids were added to study proliferation. For differentiation of cells, serum-free medium was used supplemented with one or more isoforms of transforming growth factor-beta (TGFbeta) and/or IGF-1. Samples were analysed for expression of collagens type I, II and X by competitive RT-PCR, immunohistochemically, and histologically using Alcian blue staining. In all samples the cambium layer could hardly be detected. Periosteum-derived cells proliferated in serum-containing MEM-DV. Optimal proliferation was found when this medium was supplemented with 100 ng/ml FGF-2 and non-essential amino acids. Chondrogenesis was detected in 59% of micromasses that were cultured with TGFbeta isomers, and in 83% of the samples cultured in media to which two TGFbeta isoforms were added. Periosteum from elderly humans (mean age 66, range 41-76 years) has chondrogenic potential and remains an attractive cell source for cartilage tissue engineering. By expanding cells in MEM-DV, the selection of progenitor cells might be favoured, which would result in a higher cartilage yield for tissue engineering applications.

Human mastoid periosteum-derived stem cells: promising candidates for skeletal tissue engineering

Currently, mesenchymal stem cells (MSCs) are considered as the most eligible cells for skeletal tissue engineering. However, factors such as difficult stimulation and control of differentiation in vivo hamper their clinical use. In contrast, periosteum or periosteum-derived cells (PCs) are routinely clinically applied for bone and cartilage repair. PCs have often been named MSCs but, although cells of osteochondrogenic lineages arise from MSCs, it is unclear whether periosteum really contains MSCs. Our aim was to investigate the MSC-like character of PCs derived from the periosteum of mastoid bone. Harvesting of periosteum from mastoid bone is easy, so mastoid represents a good source for the isolation of PCs. Therefore, we analysed the MSC-like growth behaviour and the expression of embryonic, ectodermal, endodermal and mesodermal markers by microarray and FACS technology, and the multilineage developmental capacity of human PCs. Regarding clinical relevance, experiments were performed in human serum-supplemented medium. We show that PCs do not express early embryonic stem cell markers such as Oct4 and Nanog, or the marker of haematopoietic stem cells CD34, but express some other MSC markers. Osteogenesis resulted in the formation of calcified matrix, increased alkaline phosphatase activity, and induction of the osteogenic marker gene osteocalcin. Staining of proteoglycans and deposition of type II collagen documented chondrogenic development. As shown for the first time, adipogenic stimulation of mastoid-derived PCs resulted in the formation of lipid droplets and expression of the adipogenic marker genes aP2 and APM1. These results suggest MSC-like PCs from mastoid as candidates for therapy of complex skeletal defects.

Human periosteum-derived progenitor cells express distinct chemokine receptors and migrate upon stimulation with CCL2, CCL25, CXCL8, CXCL12, and CXCL13

For bone repair, transplantation of periosteal progenitor cells (PCs), which had been amplified within supportive scaffolds, is applied clinically. More innovative bone tissue engineering approaches focus on the in situ recruitment of stem and progenitor cells to defective sites and their subsequent use for guided tissue repair. Chemokines are known to induce the directed migration of bone marrow CD34(-) mesenchymal stem cells (MSCs). The aim of our study was to determine the chemokine receptor expression profile of human CD34(-) PCs and to demonstrate that these cells migrate upon stimulation with selected chemokines. PCs were isolated from periosteum of the mastoid bone and displayed a homogenous cell population presenting an MSC-related cell-surface antigen profile (ALCAM(+), SH2(+), SH3(+), CD14(-), CD34(-), CD44(+), CD45(-), CD90(+)). The expression profile of chemokine receptors was determined by real-time PCR and immunohistochemistry. Both methods consistently demonstrated that PCs express receptors of all four chemokine subfamilies CC, CXC, CX(3)C, and C. Migration of PCs and a dose-dependent migratory effect of the chemokines CCL2 (MCP1), CCL25 (TECK), CXCL8 (IL8), CXCL12 (SDF1alpha), and CXCL13 (BCA1), but not CCL22 (MDC) were demonstrated using a 96-multiwell chemotaxis assay. In conclusion, for the first time, here we report that human PCs express chemokine receptors, present their profile, and demonstrate a dose-dependent migratory effect of distinct chemokines on these cells. These results are promising towards in situ bone repair therapies based on guiding PCs to bone defects, and encourage further in vivo studies.

Inhibition of fracture healing

This paper reviews the current literature concerning the main clinical factors which can impair the healing of fractures and makes recommendations on avoiding or minimising these in order to optimise the outcome for patients. The clinical implications are described.

Biological Assessment of Porous-Implant Hydroxyapatite Combined With Periosteal Grafting in Maxillary Defects

PURPOSE

To investigate the use of porous hydroxyapatite (HA) combined with periosteal graft to repair an induced maxillary bone defect.

MATERIALS AND METHODS

A defect was produced in the premaxillary bone of rats. Four groups were used: 1) those treated with the mucoperiosteal graft from the premaxilla; 2) those treated with HA combined with mucoperiosteal graft from the premaxilla; 3) those treated with HA combined with periosteal graft from the femur; and 4) those treated with periosteal graft from the femur.

RESULTS

The radiographic aspects from all groups showed no signs of bone formation after 2 weeks. After 16 weeks, there was evidence of points of radiolucency inside the HA implants. Cell proliferation occurred from the periosteum covering the defect. Bone tissue grew from the defect margin to inside the defect in all cases. Mature bone was seen around the HA implants after 8 and 16 weeks.

CONCLUSION

The periosteal graft provides satisfactory support to the HA implant, allowing the growth of new bone.

Vascularised bone grafts for the management of non-union

Non-union of the long bones may have severe consequences, particularly when combined with other post-traumatic sequelae, such as tendon adhesions, reflex sympathetic dystrophy and infection, among others. In these cases, it is important to treat the delayed union or non-union first or at the same time with the other problems in order to achieve adequate function. Once the normal bony healing process has been slowed or stopped, it is necessary to provide both stability to the fracture site, as well as a biological stimulus for the fibrocartilagenous callus to finish the healing process. Vascularised grafts, such as the free fibula, offer not only structural support, but also promote bone healing. The later is achieved by trabecular bone formation, as well as vascular sprouting from pedicle vessels.

In Vivo Generation of Cartilage from Periosteum

Periosteum has chondrogenic and osteogenic potential and plays an important role in fracture healing. The purpose of this study was to evaluate the reactive tissue formed after damaging the periosteum. Damaging the periosteum may be a way to generate ectopic cartilage or bone, which may be useful for the repair of articular cartilage and bone defects. Periosteum was bilaterally dissected from the proximal medial tibia of New Zealand White rabbits. Reactive periosteal tissue was harvested 10, 20, and 40 days postsurgery and analyzed for expression of collagen types I, II, and X, aggrecan, osteopontin, and osteonectin (by reverse transcription-polymerase chain reaction) and collagen types I and II (by immunohistochemistry). Reactive tissue was present in 93% of cases. Histologically, this tissue consisted of hyaline cartilage at follow-up days 10 and 20. Expression of collagen type II and aggrecan was present at 10 and 20 days postsurgery. Highest expression was at 10 days. Expression of collagen type X increased up to 20 days. No significant changes in the mRNA expression of osteopontin or osteonectin were observed. Immunohistochemistry confirmed the presence of cartilage, which was positive for collagen types I and II at 10 days and only for collagen type II at 20 days. At 20 days postsurgery the onset of bone formation was also observed. At 40 days postsurgery, the reactive tissue had almost completely turned into bone. The quality and amount of cartilage formed 10 days postsurgery make this technique potentially useful to fill large cartilage and bone defects. Also, periosteal callus formation, providing possible useful information for tissue engineering techniques, can be studied with this model.

Vascularized Periosteal Flaps of Distal Forearm and Hand

BACKGROUND

Vascularized periosteal flaps (VPFs) are flexible osteogenic flaps, suitable for the reconstruction of small skeletal defects. Pedicled VPFs, harvested near the recipient site, minimize donor-site morbidity and procedure duration. The donor sites and the potential recipient sites for pedicled VPFs of the distal forearm-hand were identified in this study.

METHODS

In 16 fresh cadaver upper extremities, the dimensions and arcs of rotation of the VPF pedicle(s) were studied.

RESULTS

Pedicled VPFs with mean dimensions ranging between 0.5 x 3 cm and 2.5 x 4 cm could cover, after adequate mobilization, the distal half of the forearm, wrist, and hand to the proximal interphalangeal joints.

CONCLUSION

The VPFs identified in this study can be used for the reconstruction of small skeletal defects and for the treatment of osteonecrotic lesions and nonunions of the distal forearm, wrist, and hand. The choice of the most suitable VPF will be based on the anatomic location and the dimensions of the recipient site.

Periosteal cells in bone tissue engineering

In 1742, H.L. Duhamel published a report in which the osteogenic function of periosteum was described. In 1932 H.B. Fell was the first to successfully culture periosteum; Fell concluded that this tissue might have the capability to form mineralized tissue in vitro. In the 1990s the research group of A.L. Caplan pioneered work exploring the osteogenic potential of periosteal cells in the field of bone engineering. On the basis of these studies a number of research groups have developed hard tissue generation concepts that aim to repeat the clinical success of bone autografts by culturing cells from periosteum and seeding a sufficient quantity of those cells into scaffolds made of biomaterials of natural and synthetic origin. The highly porous matrices support the induction of bone regeneration by creating and maintaining a space that facilitates progenitor cell migration, proliferation, and differentiation as well as graft revascularization. In this way, a host tissue-scaffold cell interphase might be created that allows reproduction of the intrinsic properties of autogenous bone, including the ability to be incorporated into the surrounding host bone and to continue normal bone-remodeling processes. This review discusses the history and state of the art of bone tissue engineering from a periosteum and periosteal cell source point of view and attempts to indicate future research directions.

Magnetic resonance imaging of periosteum with ultrashort TE pulse sequences

PURPOSE

To assess the values of pulse sequences with ultrashort echo times (0.08 msec) for detecting and characterizing periosteum.

MATERIALS AND METHODS

Two normal volunteers aged 33 and 58 years and 12 patients aged seven to 55 years were studied. A total of 10 of the patients had contrast enhancement with intravenous Gadodiamide. Two ovine tibias were examined before and after the periosteum was stripped from the bone.

RESULTS

High signal regions were observed adjacent to cortical bone in all parts of the skeleton imaged. They were generally more conspicuous after fat suppression and contrast administration. In the ovine tibia there was a reduction in the high signal normally seen at the surface of the bone after periosteal stripping. The detached periosteum produced a high signal. Mean T(2)* values for adult human periosteum ranged from 5.3 to 11.4 msec. After enhancement the signal intensity increased. In two patients with tibial fractures, increased periosteal signal was seen and this showed marked enhancement. Signals from periosteum could be simulated by fat, contrast-enhanced blood and artifacts.

CONCLUSION

The periosteum can be visualized with ultrashort echo time pulse sequences in health and disease.