Surgical Grafts for Skin, Tendon, and Bone Healing

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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

  1. 1. Simplifying the Science - Advances in Wound, Tendon, and Bone Grafts <br />J. Palmer Branch, DPM<br />Comprehensive Foot and Ankle, LLC <br />www.comprehensivefootandankle.net<br />DrCuboid@aol.com <br />Lilburn, GA (770-921-8800) Cumming, GA (770-886-6833)<br />1<br />
  2. 2. INTRODUCTION<br />2<br />
  3. 3. Overview<br />Many similarities in healing process<br />Skin <br />Tendon<br />Bone<br />Understand the graft concept (allow for ingrowth of new tissue) <br /> - Science is secondary.<br />Understand the basic graft healing process and timing of events, then you can determine what to do and when and advance your techniques.<br />3<br />
  4. 4. BASIC CONCEPT<br />The process of skin, soft tissue and bone graft healing is analogous to ivy growing into a lattice or scaffold.<br />Other products and specialized grafts stimulate the healing process itself<br />- Growth factors<br /> - BMP<br /> - Magnetic bone stimulators<br />4<br />
  5. 5. SKIN HISTOLOGY<br />1) Epidermis - stratified squamous epithelium<br />epidermal ridges<br />2) Dermis<br /> a) Papillary layer - small blood vessels, lymph & nerves fine collagen & elastic fibers<br /> b) Reticular layer - vascular plexus, lymph, nerves & appendages<br /> compact collagen fibers & thick elastic fibers<br />3) Hypodermis (subcutaneous)<br />mainly adipose tissue, sweat glands, blood vessels<br />5<br />
  6. 6. Basics of wound healing<br />6<br />
  7. 7. Growth factors & wound healing<br />7<br />
  8. 8. Bone Structure<br />8<br />
  9. 9. Bone histology - micro<br />Haversian canal and nutrient artery<br />Woven bone with collagen matrix<br />9<br />
  10. 10. Bone trabeculation<br />Trabeculae <br />10<br />
  11. 11. Bone healing<br />- Inflammatory cells<br />- Soft callous formation<br />- Transitions to hard callous<br />- Primary vs. Secondary bone healing – primary facilitated by close contact, stability, compression<br />11<br />
  12. 12. Bone healing<br />Phase 1 (Days 0-4)<br /> blood clot then fibrin network forms, <br /> TGP PDGF stimulate the chemotaxis and later proliferation of primitive mesenchymal cells <br />Phase 2 (Days 5-9)<br /> primitive mesenchymal cells differentiate into chondroblasts and chondrocytes <br /> subsequent production of cartilaginous matrix. <br /> This matrix is then invaded by capillaries<br />Phase 3 (Days 10-21) <br /> Mesenchymal Cell Differentiation Into osteoblasts and osteocytes<br /> Type I collagen synthesis (Days 12 through 18)<br /> Multinucleated osteoclasts begin the process of bone remodeling. <br /> The osteoclasts and osteoblasts replace early bone and remaining calcified cartilage with bone ossicles.<br /> By Day 21, bone marrow differentiation occurs<br />12<br />
  13. 13. Bone healing pictures<br />Active osteoblasts laying down compact bone<br />Osteoblasts with multiple nuclei and foamy cytoplasm<br />
  14. 14. Tendon Structure<br />14<br />
  15. 15. TENDON – NORMAL VS ABNORMAL<br />A – NORMAL, B – ACUTE RUPTURE, C – TENDINTIS, D- TENDINOSIS<br />15<br />
  16. 16. Tendon healing process<br />Week 1 <br /> - Hemostasis, inflammation, growth factor release<br /> – Tendon ends retract / phagocytosis of debris<br /> - Fibroblastic splint / tendon callous<br />Week 2 <br /> – Vascularity of paratenon increases <br /> *Preservation of paratenon in surgical repair important.<br /> - fibroblasts continue to proliferate<br />Week 3 <br /> - Collagen fibers come together and align longitudinally<br /> - Classic stage for mobilization, but newer PT/ Achilles rehab studies call for earlier mobilization to reduce adhesions.<br />Week 4 <br /> - Inflammation reduces<br /> - Improved gliding function<br /> - Increased parallel organization and growth of collagen fibers<br />* Maturation at about 8 weeks.<br />* Repaired tendon typically has at best around 80% of original strength.<br />16<br />
  17. 17. GRAFTS<br />Sorry – best phagocytosis shot I had.<br />17<br />
  18. 18. Split-thickness skin grafts<br />18<br />Classic problems <br /> Donor site morbidity<br /> Limited supply<br /> Difficulty healing<br /> Limited durability<br />
  19. 19. New surgical products - scaffolds<br />GraftJacket<br /><ul><li>Freeze-dried human dermis
  20. 20. Originally released as a cover for periosteum
  21. 21. Provides a collagen scaffold for ingrowth of granulation tissue</li></ul>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.<br />Alloderm – similar product / human dermis, often used in burn wounds<br />GammaGraft – Irradiated human dermis.<br />Pegasus (OrthoAdapt) – Recently purchased by Synovis Life Technologies<br />Source is equine pericardium<br />Rejection a possibility<br /> <br />19<br />
  22. 22. GraftJacket – healing diagrams<br />
  23. 23. GraftJacket – Sample case<br />21<br />After debridement<br />Infected wound dehiscence ulcer– 6 weeks s/p I & D, & IV antibiotics<br />GraftJacket applied in OR (Osteoset antibiotic beads and VAC also used.)<br />
  24. 24. GraftJacket – Sample case<br />22<br />1 week post-op <br />Osteoset absorbable antibiotic beads also noted<br />2 weeks post - op<br />8 weeks post-op<br />Wound healed around 16 weeks post - op<br />
  25. 25. Business Template<br />23<br />
  26. 26. Topical - Growth Factors <br />Stimulate the healing process <br />Dermagraft –<br />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.<br /> Apligraf<br />Future<br />Stem cell-derived products<br />24<br />
  27. 27. Skin substitute / matrix dressings<br />Integra – dermal replacement, bilayered – allows for ingrowth of new skin<br />Dermal layer - Acellular porous lattice - fibers of cross-linked bovine collagen with GAG (glycosaminoglycans) <br />Epidermal layer – synthetic polymer ( polysiloxane)<br />Oasis – Porcine intestinal submucosa, provides extracellular matrix for tissue ingrowth.<br />25<br />
  28. 28. BONE GRAFT EFFECTS<br /><ul><li>Osteoconduction –Provides scaffold for new bone growth -
  29. 29. Osteoinduction – Chemically stimulates new bone formation
  30. 30. Osteogenesis – Generation of new bone
  31. 31. Autograft only – living cells / osteoblasts
  32. 32. Structure / strength </li></ul>– hardening putty often best<br /> - tricortical wedge<br /><ul><li>Combination of above / multiple effects</li></ul>**Which is most important? - Depends on the situation<br />26<br />
  33. 33. Bone graft materials - benefits<br />27<br />
  34. 34. Bone graft types / examples<br /><ul><li>Autogenous - Grafts harvested from patient.
  35. 35. Donor Allograft bone– chips, wedges, etc.
  36. 36. Xenograft
  37. 37. CancelloPure(Wright) – Bovine bone - cancellous wedges – Biocleanse treated, terminally sterilized
  38. 38. ProOsteon (InterPore/BioMet -coral)
  39. 39. Synthetic / ceramic bone replacements
  40. 40. Hardening Putty / Injectable
  41. 41. Prodense, MIIG - Wright
  42. 42. Norien CRS FastSet Putty (Synthes)
  43. 43. Particulate or prefab products
  44. 44. Calcium sulfate – Nexa Orthopedics – wedges and plugs
  45. 45. Titanium – Biofoam Evans wedges</li></ul>28<br />
  46. 46. Bone graft types / examples<br />Osteoinductive substances<br />DBM <br />Grafton (Osteotech), AlloMatrix(Wright), Biomet DBM putty BioMet Platform injectable(Biomet), DBX (Synthes)<br />Bone marrow aspirate harvest system <br />Symphony(DePuy), Magellan (Medtronic)<br />Adult stem cells<br />Trinity Multipotential Cellular Bone Matrix (recent poster at ACFAS)<br />Recombinant human bone morphogenetic protein-2<br /> INFUSE Bone Graft is rhBMP-2 (manufactured BMP)<br />Combination products<br />ProStim - ProDense with DBM<br />Origen DBM Bioactive glass – particulate scaffold / chips with DBM<br />Ignite Power Mix - injectable scaffold of demineralized bone matrix with aspirated red bone marrow. <br /> <br />29<br />
  47. 47. Bone Grafts - traditional<br />30<br />Cancellous chips<br />Donor site morbidity must be considered (e.g. infections, chronic pain, scarring)<br />
  48. 48. Osteoset<br />Absorbable Antibiotic beads {e.g. Osteoset – calcium sulfate} Release antibiotic mixed into the beads into the surgical wound<br />Usually Vancomycin, Tobramycin,<br /> and Gentamycin are used.<br />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.<br />**Polymethymethacrylate removable beads or free-formed spacers may be used for this purpose as well. <br /> - must be removed.<br />31<br />
  49. 49. <ul><li>Immediate intra-operative strength
  50. 50. Predictable bone regeneration
  51. 51. Stronger than autograft
  52. 52. 645% greater compressive strength at 13 weeks vs. autograft *
  53. 53. Faster, denser than autograft
  54. 54. 170% more new bone vs autograft at 13 weeks*
  55. 55. Remodels to normal bone
  56. 56. Easy-to use applicator</li></ul>*Urban, et al in canine proximal humerus model, June, 2007<br />Pro-Dense Injectable Regenerative Graft<br />32<br />
  57. 57. 33<br />
  58. 58. PRODENSELAPIDUS<br />34<br />
  59. 59. Prodense Evans Case<br />35<br />INTRAOP<br />9 WEEKS POST-OP<br />
  60. 60. Evans - ProDense + Tricortical wedge<br />36<br />Evans & T-N fusion<br />Soft lateral calcaneus<br />Tricortical wedge + ProDense injection<br />Rapid ProDense incorporation , slow tricortical wedge incorporation<br />1 WEEK POST-OP<br />3 MONTHS POST-OP<br />6 WEEKS POST-OP<br />
  61. 61. Bone stimulators<br />Stimulate the bone healing process <br /> - Piezoelectric effect / electronegativity at fracture site<br /> - Increase growth factor and receptors<br /> - Increase affect calcium flow across membranes<br /> - Stimulate endothelial cell and capillary growth and capillary formation.<br />Electromagnetic fields<br /> - External <br /> - Biomet / EBI, Physio-Stim, DonJoy CMF OL1000<br /> - Internal<br />- Biomet OsteoGen<br />Ultrasound- Exogen (Low intensity pulsed ultrasound)<br />- Mechanical pressure waves transmit through skin and soft tissue results in stimulated growth factors which stimulate bone healing process.<br />37<br />
  62. 62. GraftJacket <br />Cryogenically processed human dermis<br /> - Many applications<br /> - High tensile strength<br />
  63. 63. GRAFTJACKET® Regenerative Tissue Matrix<br />Preserved vascular channels act as “template” for rapid revascularization<br />Typical Freeze-drying<br />Ice crystals damage collagen/elastin<br />Body then recognizes as foreign<br />Initiates inflammatory or immune response<br />Cryogenic Processing<br />Prevents ice crystal formation<br />Structurally intact matrix with:<br /> -Collagen<br /> -Elastin<br /> -Proteoglycans<br />Preserved vascular channels<br />400x magnified image of non-implanted material demonstrating preserved vascular channel<br />39<br />
  64. 64. Tendon Grafts - examples<br />GraftJacket (standard, MaxForce, MaxForce Extreme)<br />Restore<br />Cuffpatch<br />Biotape XM Acellular porcine dermal matrix<br />OrthAdapt (formerly Pegasus, now Synovis Life Technologies)<br />rejection<br />40<br />
  65. 65. Right Achilles tendon repair.  Severe rejection of Pegasus / OrthoAdapt graft with large foreign body granuloma.  <br />
  66. 66. Growth factors in tendon healing<br />Platelet Derived Growth Factor (PDGF) <br />produced shortly after tendon injury <br />stimulates the production of other growth factors.<br />TGF-beta complex<br />active during the inflammatory and repair phases of tendon healing especially in the in the repair of injured tendons.  <br />TGF-beta 1 aids an extra cellular matrix deposition; however, it’s over expression results in tissue fibrosis.  <br />TGF-beta 2 functions similarly to TGF-beta 1. <br />TGF-beta 3 has been shown to improve tissue scarring.  <br />Highest levels of TGF-beta receptor expression occur at day 14 post injury and decrease until day 56 post injury.  <br />Vascular Endothelial Growth Factor (VEGF)<br />stimulates endothelial cell proliferation<br />enhances angiogenesis and increases capillary permeability.  <br />VEGF RNA expression is detected at the repair site 7 days post injury with peak levels at 10 days post injury.  <br />42<br />
  67. 67. GraftJacket Achilles Tendon Repair standard cannoli wrap technique<br />Improved strength allows for earlier rehab.<br />Can be difficult to close paratenon if thick graft used. <br />43<br />
  68. 68. Tendon transfers / weaves<br />Classic advantages <br />– Improved strength<br />- Earlier rehab to prevent adhesions<br />Classic disadvantage<br />- Loss of donor tendon function / donor site morbidity<br />- Additional surgical site and prolonged OR time.<br />FHL tendon transfer – Achilles repair<br />Pulvertaft weave<br />44<br />
  69. 69. Alternate technique to cannoli wrap<br />45<br />
  70. 70. GraftJacket Strip & Shoelace weave<br />46<br />1 - Reapproximate tendon ends<br />2 - Place inlay strip<br />3 – Tie in weave strip<br />
  71. 71. GraftJacket Strip & Shoelace Weave<br />47<br />5 – Weave strip is woven in a shoelace pattern – similar to Pulvertaft technique<br />
  72. 72. GraftJacket Strip & Shoelace Weave<br />48<br />6 - Closure of the paratenon is facilitated.<br />
  73. 73. Creating a GraftJacket weave strip<br />49<br />
  74. 74. GraftJacket Strip & Shoelace Peroneal Tendon Repair<br />50<br />
  75. 75. GraftJacket Strip & Shoelace Peroneal Tendon Repair<br />51<br />
  76. 76. Other tendon grafts / materials<br />Flexiglide - <br /> - absorbable mesh graft<br /> - limited strength<br /> - mostly helpful in adhesion prevention<br />Tenoglide – similar, more friable, difficult to handle<br />
  77. 77. Other future graft types<br />Hardening Injectable bone cement –immediate stabilization, limited scaffold effect<br />Stem cells in surgical thread used to repair Achilles tendon.<br />53<br />
  78. 78. Selection of appropriate advanced therapy<br />How can the healing process be best enhanced for the situation?<br />Applying medical expertise and judgment to each situation <br />Medicine is often more an art than a science. <br />Know what each product can do – particular indications and benefits of each device or treatment.<br />54<br />
  79. 79. Summary<br />Understand the basic science.<br />Scaffold effect to reduce the defect.<br />Strength when needed for bone and tendon.<br />Growth factors and other means to speed healing when needed.<br />Use the basic concept to enhance explaining planned procedures to patients.<br />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.<br />55<br />
  80. 80. 56<br />THANK YOU<br />J. Palmer Branch, DPM – DrCuboid@aol.com <br />Comprehensive Foot & Ankle, LLC<br />www.comprehensivefootandankle.net<br />Lilburn, GA (770-921-8800); Cumming, GA (770-886-6833)<br />

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