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Surgical Grafts for Skin, Tendon, and Bone Healing
 

Surgical Grafts for Skin, Tendon, and Bone Healing

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Overview of skin, tendon, & bone grafts used in foot & ankle surgery.

Overview of skin, tendon, & bone grafts used in foot & ankle surgery.

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  • I now usually use a new technique called the 'strip and shoelace' I have developed involving weaving a free-dried dermis graft into the tendon. See slides 46-49 for images of the technique. The following couple of slides show the same technique used on a peroneal tendon rupture. I have recently submitted this technique for publication in a medical journal and am presently awaiting review and approval. There are a wide variety of different surgical techniques available, each with its own advantages and disadvantages. For some patients (e.g. elderly, inactive, etc.) nonsurgical repair is more appropriate. Email me if you have any additional questions.
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  • what method of repair do you think is most succesful for an acute rupture of the Achilles tendon?
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    Surgical Grafts for Skin, Tendon, and Bone Healing Surgical Grafts for Skin, Tendon, and Bone Healing Presentation Transcript

    • Simplifying the Science - Advances in Wound, Tendon, and Bone Grafts
      J. Palmer Branch, DPM
      Comprehensive Foot and Ankle, LLC
      www.comprehensivefootandankle.net
      DrCuboid@aol.com
      Lilburn, GA (770-921-8800) Cumming, GA (770-886-6833)
      1
    • INTRODUCTION
      2
    • Overview
      Many similarities in healing process
      Skin
      Tendon
      Bone
      Understand the graft concept (allow for ingrowth of new tissue)
      - Science is secondary.
      Understand the basic graft healing process and timing of events, then you can determine what to do and when and advance your techniques.
      3
    • BASIC CONCEPT
      The process of skin, soft tissue and bone graft healing is analogous to ivy growing into a lattice or scaffold.
      Other products and specialized grafts stimulate the healing process itself
      - Growth factors
      - BMP
      - Magnetic bone stimulators
      4
    • SKIN HISTOLOGY
      1) Epidermis - stratified squamous epithelium
      epidermal ridges
      2) Dermis
      a) Papillary layer - small blood vessels, lymph & nerves fine collagen & elastic fibers
      b) Reticular layer - vascular plexus, lymph, nerves & appendages
      compact collagen fibers & thick elastic fibers
      3) Hypodermis (subcutaneous)
      mainly adipose tissue, sweat glands, blood vessels
      5
    • Basics of wound healing
      6
    • Growth factors & wound healing
      7
    • Bone Structure
      8
    • Bone histology - micro
      Haversian canal and nutrient artery
      Woven bone with collagen matrix
      9
    • Bone trabeculation
      Trabeculae 
      10
    • Bone healing
      - Inflammatory cells
      - Soft callous formation
      - Transitions to hard callous
      - Primary vs. Secondary bone healing – primary facilitated by close contact, stability, compression
      11
    • Bone healing
      Phase 1 (Days 0-4)
      blood clot then fibrin network forms,
      TGP PDGF stimulate the chemotaxis and later proliferation of primitive mesenchymal cells
      Phase 2 (Days 5-9)
      primitive mesenchymal cells differentiate into chondroblasts and chondrocytes
      subsequent production of cartilaginous matrix.
      This matrix is then invaded by capillaries
      Phase 3 (Days 10-21)
      Mesenchymal Cell Differentiation Into osteoblasts and osteocytes
      Type I collagen synthesis (Days 12 through 18)
      Multinucleated osteoclasts begin the process of bone remodeling.
      The osteoclasts and osteoblasts replace early bone and remaining calcified cartilage with bone ossicles.
      By Day 21, bone marrow differentiation occurs
      12
    • Bone healing pictures
      Active osteoblasts laying down compact bone
      Osteoblasts with multiple nuclei and foamy cytoplasm
    • Tendon Structure
      14
    • TENDON – NORMAL VS ABNORMAL
      A – NORMAL, B – ACUTE RUPTURE, C – TENDINTIS, D- TENDINOSIS
      15
    • Tendon healing process
      Week 1
      - Hemostasis, inflammation, growth factor release
      – Tendon ends retract / phagocytosis of debris
      - Fibroblastic splint / tendon callous
      Week 2
      – Vascularity of paratenon increases
      *Preservation of paratenon in surgical repair important.
      - fibroblasts continue to proliferate
      Week 3
      - Collagen fibers come together and align longitudinally
      - Classic stage for mobilization, but newer PT/ Achilles rehab studies call for earlier mobilization to reduce adhesions.
      Week 4
      - Inflammation reduces
      - Improved gliding function
      - Increased parallel organization and growth of collagen fibers
      * Maturation at about 8 weeks.
      * Repaired tendon typically has at best around 80% of original strength.
      16
    • GRAFTS
      Sorry – best phagocytosis shot I had.
      17
    • Split-thickness skin grafts
      18
      Classic problems
      Donor site morbidity
      Limited supply
      Difficulty healing
      Limited durability
    • New surgical products - scaffolds
      GraftJacket
      • Freeze-dried human dermis
      • Originally released as a cover for periosteum
      • Provides a collagen scaffold for ingrowth of granulation tissue
      Brigido - Compared single application of GraftJacket to sharp debridement, weekly dressing changes - 85.7% healed with GraftJacket at 12 weeks vs. 28.6% healed at 12 weeks without.
      Alloderm – similar product / human dermis, often used in burn wounds
      GammaGraft – Irradiated human dermis.
      Pegasus (OrthoAdapt) – Recently purchased by Synovis Life Technologies
      Source is equine pericardium
      Rejection a possibility
       
      19
    • GraftJacket – healing diagrams
    • GraftJacket – Sample case
      21
      After debridement
      Infected wound dehiscence ulcer– 6 weeks s/p I & D, & IV antibiotics
      GraftJacket applied in OR (Osteoset antibiotic beads and VAC also used.)
    • GraftJacket – Sample case
      22
      1 week post-op
      Osteoset absorbable antibiotic beads also noted
      2 weeks post - op
      8 weeks post-op
      Wound healed around 16 weeks post - op
    • Business Template
      23
    • Topical - Growth Factors
      Stimulate the healing process
      Dermagraft –
      Genzkow showed higher percent at 50% and 100% healed at 8 and 12 weeks vs. control. At 8 weeks 50% of ulcers healed with Dermagraft vs. 8% control 75% vs. 23% fully healed at 12 weeks.
       Apligraf
      Future
      Stem cell-derived products
      24
    • Skin substitute / matrix dressings
      Integra – dermal replacement, bilayered – allows for ingrowth of new skin
      Dermal layer - Acellular porous lattice - fibers of cross-linked bovine collagen with GAG (glycosaminoglycans)
      Epidermal layer – synthetic polymer ( polysiloxane)
      Oasis – Porcine intestinal submucosa, provides extracellular matrix for tissue ingrowth.
      25
    • BONE GRAFT EFFECTS
      • Osteoconduction –Provides scaffold for new bone growth -
      • Osteoinduction – Chemically stimulates new bone formation
      • Osteogenesis – Generation of new bone
      • Autograft only – living cells / osteoblasts
      • Structure / strength
      – hardening putty often best
      - tricortical wedge
      • Combination of above / multiple effects
      **Which is most important? - Depends on the situation
      26
    • Bone graft materials - benefits
      27
    • Bone graft types / examples
      • Autogenous - Grafts harvested from patient.
      • Donor Allograft bone– chips, wedges, etc.
      • Xenograft
      • CancelloPure(Wright) – Bovine bone - cancellous wedges – Biocleanse treated, terminally sterilized
      • ProOsteon (InterPore/BioMet -coral)
      • Synthetic / ceramic bone replacements
      • Hardening Putty / Injectable
      • Prodense, MIIG - Wright
      • Norien CRS FastSet Putty (Synthes)
      • Particulate or prefab products
      • Calcium sulfate – Nexa Orthopedics – wedges and plugs
      • Titanium – Biofoam Evans wedges
      28
    • Bone graft types / examples
      Osteoinductive substances
      DBM
      Grafton (Osteotech), AlloMatrix(Wright), Biomet DBM putty BioMet Platform injectable(Biomet), DBX (Synthes)
      Bone marrow aspirate harvest system
      Symphony(DePuy), Magellan (Medtronic)
      Adult stem cells
      Trinity Multipotential Cellular Bone Matrix (recent poster at ACFAS)
      Recombinant human bone morphogenetic protein-2
      INFUSE Bone Graft is rhBMP-2 (manufactured BMP)
      Combination products
      ProStim - ProDense with DBM
      Origen DBM Bioactive glass – particulate scaffold / chips with DBM
      Ignite Power Mix - injectable scaffold of demineralized bone matrix with aspirated red bone marrow.
       
      29
    • Bone Grafts - traditional
      30
      Cancellous chips
      Donor site morbidity must be considered (e.g. infections, chronic pain, scarring)
    • Osteoset
      Absorbable Antibiotic beads {e.g. Osteoset – calcium sulfate} Release antibiotic mixed into the beads into the surgical wound
      Usually Vancomycin, Tobramycin,
      and Gentamycin are used.
      Allows for extremely high local levels of antibiotic into the wound - usually several times over the MIC (minimal inhibitory concentration) for some antibiotic-resistant bacteria.
      **Polymethymethacrylate removable beads or free-formed spacers may be used for this purpose as well.
      - must be removed.
      31
      • Immediate intra-operative strength
      • Predictable bone regeneration
      • Stronger than autograft
      • 645% greater compressive strength at 13 weeks vs. autograft *
      • Faster, denser than autograft
      • 170% more new bone vs autograft at 13 weeks*
      • Remodels to normal bone
      • Easy-to use applicator
      *Urban, et al in canine proximal humerus model, June, 2007
      Pro-Dense Injectable Regenerative Graft
      32
    • 33
    • PRODENSELAPIDUS
      34
    • Prodense Evans Case
      35
      INTRAOP
      9 WEEKS POST-OP
    • Evans - ProDense + Tricortical wedge
      36
      Evans & T-N fusion
      Soft lateral calcaneus
      Tricortical wedge + ProDense injection
      Rapid ProDense incorporation , slow tricortical wedge incorporation
      1 WEEK POST-OP
      3 MONTHS POST-OP
      6 WEEKS POST-OP
    • Bone stimulators
      Stimulate the bone healing process
      - Piezoelectric effect / electronegativity at fracture site
      - Increase growth factor and receptors
      - Increase affect calcium flow across membranes
      - Stimulate endothelial cell and capillary growth and capillary formation.
      Electromagnetic fields
      - External
      - Biomet / EBI, Physio-Stim, DonJoy CMF OL1000
      - Internal
      - Biomet OsteoGen
      Ultrasound- Exogen (Low intensity pulsed ultrasound)
      - Mechanical pressure waves transmit through skin and soft tissue results in stimulated growth factors which stimulate bone healing process.
      37
    • GraftJacket
      Cryogenically processed human dermis
      - Many applications
      - High tensile strength
    • GRAFTJACKET® Regenerative Tissue Matrix
      Preserved vascular channels act as “template” for rapid revascularization
      Typical Freeze-drying
      Ice crystals damage collagen/elastin
      Body then recognizes as foreign
      Initiates inflammatory or immune response
      Cryogenic Processing
      Prevents ice crystal formation
      Structurally intact matrix with:
      -Collagen
      -Elastin
      -Proteoglycans
      Preserved vascular channels
      400x magnified image of non-implanted material demonstrating preserved vascular channel
      39
    • Tendon Grafts - examples
      GraftJacket (standard, MaxForce, MaxForce Extreme)
      Restore
      Cuffpatch
      Biotape XM Acellular porcine dermal matrix
      OrthAdapt (formerly Pegasus, now Synovis Life Technologies)
      rejection
      40
    • Right Achilles tendon repair.  Severe rejection of Pegasus / OrthoAdapt graft with large foreign body granuloma. 
    • Growth factors in tendon healing
      Platelet Derived Growth Factor (PDGF)
      produced shortly after tendon injury
      stimulates the production of other growth factors.
      TGF-beta complex
      active during the inflammatory and repair phases of tendon healing especially in the in the repair of injured tendons. 
      TGF-beta 1 aids an extra cellular matrix deposition; however, it’s over expression results in tissue fibrosis. 
      TGF-beta 2 functions similarly to TGF-beta 1. 
      TGF-beta 3 has been shown to improve tissue scarring. 
      Highest levels of TGF-beta receptor expression occur at day 14 post injury and decrease until day 56 post injury. 
      Vascular Endothelial Growth Factor (VEGF)
      stimulates endothelial cell proliferation
      enhances angiogenesis and increases capillary permeability. 
      VEGF RNA expression is detected at the repair site 7 days post injury with peak levels at 10 days post injury. 
      42
    • GraftJacket Achilles Tendon Repair standard cannoli wrap technique
      Improved strength allows for earlier rehab.
      Can be difficult to close paratenon if thick graft used.
      43
    • Tendon transfers / weaves
      Classic advantages
      – Improved strength
      - Earlier rehab to prevent adhesions
      Classic disadvantage
      - Loss of donor tendon function / donor site morbidity
      - Additional surgical site and prolonged OR time.
      FHL tendon transfer – Achilles repair
      Pulvertaft weave
      44
    • Alternate technique to cannoli wrap
      45
    • GraftJacket Strip & Shoelace weave
      46
      1 - Reapproximate tendon ends
      2 - Place inlay strip
      3 – Tie in weave strip
    • GraftJacket Strip & Shoelace Weave
      47
      5 – Weave strip is woven in a shoelace pattern – similar to Pulvertaft technique
    • GraftJacket Strip & Shoelace Weave
      48
      6 - Closure of the paratenon is facilitated.
    • Creating a GraftJacket weave strip
      49
    • GraftJacket Strip & Shoelace Peroneal Tendon Repair
      50
    • GraftJacket Strip & Shoelace Peroneal Tendon Repair
      51
    • Other tendon grafts / materials
      Flexiglide -
      - absorbable mesh graft
      - limited strength
      - mostly helpful in adhesion prevention
      Tenoglide – similar, more friable, difficult to handle
    • Other future graft types
      Hardening Injectable bone cement –immediate stabilization, limited scaffold effect
      Stem cells in surgical thread used to repair Achilles tendon.
      53
    • Selection of appropriate advanced therapy
      How can the healing process be best enhanced for the situation?
      Applying medical expertise and judgment to each situation
      Medicine is often more an art than a science.
      Know what each product can do – particular indications and benefits of each device or treatment.
      54
    • Summary
      Understand the basic science.
      Scaffold effect to reduce the defect.
      Strength when needed for bone and tendon.
      Growth factors and other means to speed healing when needed.
      Use the basic concept to enhance explaining planned procedures to patients.
      Be able to take your surgical plan to the next level when indicated by not getting hung up on the details of the basic grafting process.
      55
    • 56
      THANK YOU
      J. Palmer Branch, DPM – DrCuboid@aol.com
      Comprehensive Foot & Ankle, LLC
      www.comprehensivefootandankle.net
      Lilburn, GA (770-921-8800); Cumming, GA (770-886-6833)