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J. Fernyhough, Jeffrey Schimandle, Margaret Weigel, C. Edwards, A. Levine (1992)Chronic Donor Site Pain Complicating Bone Graft Harvesting From the Posterior Iliac Crest for Spinal Fusion
D. Gershuni, R. Pinsker (1982)Bone grafting for nonunion of fractures of the tibia: a critical review.
The Journal of trauma, 22 1
James Romano, N. Iliff, Paul Manson (1993)Use of Medpor porous polyethylene implants in 140 patients with facial fractures.
The Journal of craniofacial surgery, 4 3
Steven Wei, C. Born, Anthony Abene, A. Ong, R. Hayda, W. DeLong (1999)Diaphyseal forearm fractures treated with and without bone graft.
The Journal of trauma, 46 6
R. Bucholz, A. Carlton, Ralph Holmes (1987)Hydroxyapatite and tricalcium phosphate bone graft substitutes.
The Orthopedic clinics of North America, 18 2
J. Russell, J. Block (2000)Surgical harvesting of bone graft from the ilium: point of view.
Medical hypotheses, 55 6
P. Scranton, C. Frey, K. Feder (2006)Outcome of osteochondral autograft transplantation for type-V cystic osteochondral lesions of the talus.
The Journal of bone and joint surgery. British volume, 88 5
R. Murugan, S. Ramakrishna (2005)Development of nanocomposites for bone grafting
Composites Science and Technology, 65
R. Daher, N. Chahine, P. Razzano, Sohum Patwa, Nicholas Sgaglione, D. Grande (2011)Tendon repair augmented with a novel circulating stem cell population.
International journal of clinical and experimental medicine, 4 3
A. Nauth, M. McKee, E. Schemitsch (2011)Managing Bone Defects
Journal of Orthopaedic Trauma, 25
D. Ring, C. Allende, K. Jafarnia, B. Allende, J. Jupiter (2004)Ununited diaphyseal forearm fractures with segmental defects: plate fixation and autogenous cancellous bone-grafting.
The Journal of bone and joint surgery. American volume, 86 11
Rory Wright, G. Schmeling, Jeffrey Schwab (1997)The necessity of acute bone grafting in diaphyseal forearm fractures: a retrospective review.
Journal of orthopaedic trauma, 11 4
G. Rajan, J. Fornaro, O. Trentz, R. Zellweger (2006)Cancellous allograft versus autologous bone grafting for repair of comminuted distal radius fractures: a prospective, randomized trial.
The Journal of trauma, 60 6
A. Marcus, T. Coyne, Judah Rauch, D. Woodbury, I. Black (2008)Isolation, characterization, and differentiation of stem cells derived from the rat amniotic membrane.
Differentiation; research in biological diversity, 76 2
Hindawi Publishing Corporation Advances in Orthopedic Surgery Volume 2014, Article ID 572586, 4 pages http://dx.doi.org/10.1155/2014/572586 Research Article Evaluation of Amniotic-Derived Membrane Biomaterial as an Adjunct for Repair of Critical Sized Bone Defects 1 1 1,2 Mikael Starecki, John A. Schwartz, and Daniel A. Grande Department of Orthopaedic Surgery, North Shore/LIJ Health System, 300 Community Drive, Manhasset, NY 11030, USA Orthopaedic Research Laboratory, Feinstein Institute for Medical Research, 350 Community Drive, Manhasset, NY 11030, USA Correspondence should be addressed to Daniel A. Grande; email@example.com Received 12 September 2013; Accepted 9 March 2014; Published 2 April 2014 Academic Editor: Vinod K. Panchbhavi Copyright © 2014 Mikael Starecki et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Introduction. Autogenous bone graft is the gold standard in reconstruction of bone defects. eTh use of autogenous bone graft is problematic because of limited bone as well as donor site morbidity. This study evaluates a novel biomaterial as an alternative to autogenous bone graft. eTh biomaterial is amniotic membrane, rich in growth factors. Methods. Twenty-one adult male Sprague- Dawley rats were implanted with biomaterial using the rat critical size femoral gap model. Aeft r creation of the critical size femoral gap animals were randomized to one of the following groups: Group 1 (control):gap leftempty andreceivednotreatment; Group 2 (experimental): the gap was filled with commercially available bone graft; Group 3 (experimental): the gap was filled with bone graft plus NuCel amniotic tissue preparation. Results. eTh experimental groups demonstrated new bone formation compared to controls. eTh results were evident on radiographs and histology. Histology showed Group 1 controls to have 11.1% new bone formation, 37.8% for Group 2, and 49.2% for Group 3. These results were statistically significant. Conclusions. eTh study demonstrates that amniotic membrane products have potential to provide bridging of bone defects. Filling bone defects without harvesting autogenous bone would provide a significant improvement in patient care. 1. Introduction of natural origin to form tissue constructs. eTh advantage to thetissueengineeredapproachtobonerepairasreportedin Although autologous iliac crest bone graft (AICBG) remains this study is the use of materials that are rapidly degrading the “gold standard” in the reconstruction of bone defects, and nonimmunogenic. there are disadvantages, including a limited amount of eTh objectiveofthisstudy wastoevaluateanovel bone and donor site morbidity . Many bone graft sub- biomaterial, already FDA approved for other musculoskele- stitutes have therefore been developed, including silicone, tal reconstructions for the repair of bone fractures and polymethylmethacrylate (PMMA) , porous polyethylene resections.Currently,autogenousbonegrasft , allogenicbone grafts, or bone graft substitutes are used for such repairs, , hydroxyapatite, demineralized bone matrix (DBM), and tricalcium phosphate . As foreign bodies, however, these but these methods have the limitations and disadvantages alloplastic materials have their own inherent disadvantages, described previously. eTh biomaterial evaluated is amniotic including increased infection and extrusion rates. Recent membrane-derived allogra.ft This material has been shown developments in the treatment of bone defects include the to be rich in growth factors that can direct mesenchymal reamer irrigator aspirator system (RIA), Masquelet technique stem cell dieff rentiation. It is known to be quantitatively (induced membrane), bone marrow aspirate concentrate much higher in concentration of growth factors per unit (BMAC), and BMP-2 combined with cancellous allograft volume compared to human embryonic stem cells as well as human bone marrow-derived mesenchymal stromal cells . Although novel, these new techniques lack high-level evidence for their widespread adoption. Tissue engineering . These factors make it highly attractive for clinical use. has provided an attractive alternative to the use of synthetic We have previously shown the addition of circulating stem implants and growth factors by using biodegradable materials cells to significantly improve the biomechanical strength of 2 Advances in Orthopedic Surgery rat Achilles tendons following transection and repair . A the surrounding extant bone matrix (𝑛≤5 ). All images were much broader application of this technology would be for taken at 1360× 1024 pixel resolution. repair of long bone fractures, spinal fusion, and resections. Each image was loaded into ImageJ (National Institute In this study we implanted this biomaterial in rat femurs of Health, Bethesda, Maryland, USA) in order to determine using the rat critical size femoral gap model and evaluated the percentage of new bone growth present in the observed bone regeneration through radiographs of defect sites and area. Once each region was selected, area measurements were histology studies. made.Thenew bone growth area wascalculatedasaper- centage of the total area. Mean percentage area and standard deviation for each sample group was calculated. A one-way 2. Materials and Methods analysis of variance (ANOVA) was performed between the 3 groups using IBM SPSS Statistics software ( 𝛼=0.05 ). 2.1. Study Design. Aeft r creation of the critical size femoral gap defects animals were randomized to one of the following three groups: (1) control, which did not receive any treatment 3. Results and was left empty; (2) bone graft alone, which was filled with a commercially available bone graft material; (3) bone graft The surgery was well tolerated but there was one animal plus the addition of NuCel amniotic tissue preparation. per group lost to follow-up due to failure of the hardware. The control, empty group exhibited little bone filling upon radiographic imaging. In contrast both experimental groups 2.2. Animal Model. Twenty-one adult male Sprague-Dawley demonstrated excellent conduction of new bone formation rats (300–400 g) were acquired and acclimated in individ- across the critical size gap (Figure 1). ual cages for at least one week before beginning surgical Histological analysis of the control samples showed a procedures. eTh use of animals was in accordance with partially organized network of tissue containing a mixture of protocols approved by the Institutional Animal Care and Use cells including marrow elements as well as inflammatory cells. Committee at the North Shore-Long Island Jewish Health There was little evidence of bone filling although some woven System/the Feinstein Institute for Medical Research. bone was detected at the defect margins (Figure 2). Group 2 bone graft samples showed improved osteoconduction 2.3. Surgical Technique. The animals were anesthetized in with partialbridgingofthe osteotomysite. Typicallythere accordance with IACUC protocol. The skin overlying the remained a small layer of cartilage within the middle of the femur was shaved using surgical clippers. With the use of callus with woven bone surrounding the fragments of bone aseptic technique, a longitudinal skin incision was made graft ( Figure 3). In contrast, group 3 showed near complete directly over the femur. One hind limb was randomly bridging of the defect gap with abundant periosteal woven assigned to either a control or experimental group. eTh bone formation observed (Figure 4). Quantitative histology femur was exposed by longitudinal incision and isolated. A demonstrated that Group 1 empty controls had an average of HMW polyethylene fracture xa fi tion plate was attached to 11.1% new bone formation in the defect site. Group 2 showed the femur by 4 threaded Kirschner wires and two cerclage an improved new bone formation rate of 37.8%. Group 3 wires. After rigid xa fi tion of the plate, an 8 mm transverse achieved the highest new bone formation rate of 49.2%. eTh middiaphysealbonesegment wasremoved by usingarotary results of the one-way ANOVA showed that there was a osteotomy burr along with the adherent periosteum. The significant difference between the 3 groups ( 𝑃<0.001 ). Post critical size gap is typically the same as the bone diameter. hoc Tukey’s HSD test showed that there was a significant The defect was either left empty as a control or packed with difference between Groups 3 and 1 ( 𝑃 < 0.001 ). However, either a commercial bone graft preparation (positive control) there was only a marginal difference between Groups 2 and or a bone graft preparation mixed with amniotic-derived 3(𝑃=0.062 )(Figure 5). tissue (experimental group). Following treatment the muscles are opposed with the fascia. Skin closure was performed 4. Discussion in a routine manner with use of 4-0 Vicryl sutures. The animals were not immobilized postoperatively. At 6 weeks The clinical experience of treatment of osseous bone defects aer ft surgery, the animals were sacrificed and the femurs were with autografts has had mixed results. While many studies harvested for radiographic assessment followed by formalin have been shown to yield good to excellent results [7–9], fixation and processing for histology. several trials have reported mixed outcomes using autologous bone grafting. Rates of union in a trial of comminuted 2.4. Histology Image Analysis Methods. All samples were forearm fracture were equivocal in those treated with or stained with Mallory’s trichrome and were observed using without autograft [ 10, 11]. Patients treated for tibial nonunions Olympus model BH-2 at 4x magnification (40x total mag- with autograft [ 12], while reporting a union rate of 85% still nification) in order to identify regions of interest (ROI) had significant deformity in the repair. exhibiting new bone growth at the site of the original defect The primary limitation of autografts is the persistent site. Upon identification, these areas were then observed morbidity associated with the donor harvest site . The under 100x total magnification. Multiple pictures were taken most common complication is pain at the donor site, which in order to encompass both the area of new bone growth and can be as high as 50% and lasting as long as one year in 29% Advances in Orthopedic Surgery 3 (a) (b) (c) Figure 1: Radiographs of critical size femoral gap defects in the rat. (a) Control group 1 empty defect. Note the lack of any significant bone present. (b) Group 2 bone graft alone; new bone is present but not bridging. (c) Group 3 bone graft plus the addition of amniotic membrane allograft with robust bone formation and complete bridging of defect gap. Figure 2: Photomicrograph of control Group 1 defect; prominent Figure 4: Photomicrograph of Group 3 bone graft plus amniotic gap is present with no new bone formation. Mallory’s trichrome membrane allograft; note robust new bone formation throughout ×200 original magnification. the defect site. Mallory’s trichrome×200 original magnification. Mean percentage of new bone growth induced Bone graft + NuCel Defect + bone graft Defect only Figure 3: Photomicrograph of Group 2 bone graft alone; bone Figure 5: Graph of quantitative histological results using image conduction is present adjacent to the bone graft granules. Mallory’s trichrome×200 original magnification. analysis defining new bone formation among the groups tested. Mean % of new bone growth 4 Advances in Orthopedic Surgery of patients [7, 14]. eTh se n fi dings have increased the need for plate fixation and autogenous cancellous bone-grafting,” Journal of Bone and Joint Surgery A, vol. 86, no. 11, pp. 2440–2445, 2004. new materials for bone graft. Our results demonstrated strong radiographic differences  P.E.ScrantonJr.,C.C.Frey, andK.S.Feder,“Outcome of osteochondral autograft transplantation for type-V cystic among the groups although it did not demonstrate a signi-fi osteochondral lesions of the talus,” Journal of Bone and Joint cant histological difference between bone graft and bone graft Surgery B,vol.88, no.5,pp. 614–619,2006. plus the addition of amniotic allograft tissue. We attribute this  R. R. Wright, G. J. Schmeling, and J. P. Schwab, “The necessity n fi ding to several factors including the small 𝑛 enrolled and of acute bone grafting in diaphyseal forearm fractures: a the surgical dropouts from the groups leading to a loss of retrospective review,” Journal of Orthopaedic Trauma,vol.11,no. statistical power. Other factors may be extravasation of the 4, pp. 288–294, 1997. material away from the defect site leading to loss of a critical  S. Y. Wei, C. T. Born, A. Abene, A. Ong, R. Hayda, and W. concentration of active material. G. DeLong Jr., “Diaphyseal forearm fractures treated with and In this study we examined the use of a new technol- without bone graft,” Journal of Trauma-Injury, Infection and ogy utilizing amniotic-derived allograft material combined Critical Care,vol.46, no.6,pp. 1045–1048, 1999. with bone graft. Amnion-based materials are a rich source  D. H. Gershuni and R. Pinsker, “Bone grafting for nonunion of of cytokines, growth factors, and hyaluronic acid aeft r fractures of the tibia: a critical review,” Journal of Trauma,vol. childbirth. Orthopaedic surgeons continually seek advanced 22, no. 1, pp. 43–49, 1982. techniques andtechnologiestoincreasepositivesurgical  J.L.Russell andJ.E.Block,“Surgical harvesting of bone graft outcomes. us, Th using amniotic-based materials to aid in from the ilium: point of view,” Medical Hypotheses,vol.55, no. fracture healing of large boney defects is a potential alter- 6, pp. 474–479, 2000. native to autologous bone graft. Further research will be  J. C. Fernyhough, J. J. Schimandle, M. C. Weigel, C. C. Edwards, required to define the exact molecular mechanism of action; and A. M. Levine, “Chronic donor site pain complicating bone however, amniotic membrane growth factors are a promising graft harvesting from the posterior iliac crest for spinal fusion,” possible alternative that may one day become part of the Spine,vol.17, no.12, pp.1474–1480,1992. orthopaedic surgeons’ armamentarium. Conflict of Interests No conflict of interests were declared by the authors. References  A. Nauth, M. D. McKee, T. A. Einhorn, J. T. Watson, R. Li, and E. H. Schemitsch, “Managing bone defects,” Journal of Orthopaedic Trauma,vol.25, no.8,pp. 462–466, 2011.  R. Murugan and S. Ramakrishna, “Development of nanocom- posites for bone grafting,” Composites Science and Technology, vol. 65, no. 15-16, pp. 2385–2406, 2005.  J.J.Romano, N. T. Ili,a ff nd P. N. Manson,“Useofmedpor porous polyethylene implants in 140 patients with facial frac- tures,” Journal of Craniofacial Surgery,vol.4,no. 3, pp.142–147,  R.W.Bucholz,A.Carlton,and R. E. Holmes,“Hydroxyapatite and tricalcium phosphate bone graft substitutes,” Orthopedic Clinics of North America,vol.18, no.2,pp. 323–334, 1987.  A. J. Marcus, T. M. Coyne, J. Rauch, D. Woodbury, and I. B. Black, “Isolation, characterization, and differentiation of stem cells derived from the rat amniotic membrane,” Dieff rentiation , vol. 76,no. 2, pp.130–144,2008.  R. J. Daher, N. O. Chahine, P. Razzano, S. A. Patwa, N. J. Sgaglione, andD.A.Grande, “Tendonrepairaugmented with a novel circulating stem cell population,” International Journal of Clinical and Experimental Medicine,vol.4,no. 3, pp.214–219,  G.P.Rajan,J.Fornaro,O.Trentz, andR.Zellweger,“Cancellous allograft versus autologous bone grafting for repair of commin- uted distal radius fractures: a prospective, randomized trial,” Journal of Trauma-Injury, Infection and Critical Care,vol.60, no. 6, pp. 1322–1329, 2006.  D.Ring, C. Allende, K. Jafarnia,B.T.Allende,and J. B. 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