BONE HEALING

Ifran Saleh Dept.Orthopaedic & Traumatology Faculty of Medicine, Univ.of Indonesia Cipto Mangunkusumo Hospital Jakarta

Bone Histology
Cells in Bone

Bone Histology Thin Section of Compact Bone

Bone Histology Periosteum & Endosteum

BONE
Structure & Composition
Bone consists of mesenchymal cells imbedded within abundant extra cellular matrix Bone matrix contains mineral gives tissue great strength & stiffness in compression and bending Organic component primary type I collagen great strength in tension Nerves Lymphatics

BONE
Two forms of bone tissue
Cortical or compact bone Cancellous or trabecular bone Two types of bone (mechanical & biological properties) Woven or immature bone Lamellar or mature bone

WOVEN BONE
More rapid rate of deposition & resorption Irregular woven pattern of matrix collagen fibril Four times the number of osteocyte per unit volume Irregular pattern of matrix mineralization

Less stiff & more easily deformed

Potential of mesenchymal cells to deferrentiate

FRACTURE HEALING
Sequence of fracture healing

Inflammation Repair Remodeling

Fracture Healing Inflammation

Fracture damages the bone, blood vessels, bone matrix and surrounding soft tissue

Haematoma Inflammatory mediators

-Dilatation blood vessel - Plasma exudat - inflammatory cells Release by - PMN lecocytes platelets inj.cells - Macrophages - Lymphocytes

FRACTURE HEALING

Inflammation
Macrophage Degranulating platelets release
- Cytokines (PDGF, TGF ) - Interleukin 1 & 6 - Prostaglandin E2 (PGE2)

Invitiation of the repair process

FRACTURE HEALING
INFLAMMATION
Inflammatory Necrosis Tissue and Exudate Resorbed

Fibroplasty & Chondrocytes Appears

Produce new matrix (The fracture callus)

BONE HEALING REPAIR Growth factors Fibroblast Growth factor Angiogenesis Osteoclast Osteoblast Bone formation Mesenchymal cells Hard callus intramembranous bone Soft callus endochondral ossification Fracture callus matrix glycosaminoglycans, proteoglycans and collagen type I & III

BONE HEALING

REPAIR

Bone Healing
First phase of woven bone formation

Later phase in woven bone formation

Bone Healing

Cronology of mineralization in subchondral bone

BONE HEALING

Remodelling
Replacement of woven bone by lamellar bone Resorption of unneeded callus mechanical Stability

BONE HEALING REMODELING

Remodeling of bone trabecula

Accretion and remodeling of bone

BONE HEALING

BONE HEALING Fracture healing with rigid stabilization

* Healing with primary bone healing mechanism
Gap healing Haversian remodeling

Osteoclast resorb fracture line deposition osteoblast Blood vessels formation He new bone matrix + osteocytes form new Haversian Systems or primary osteons

Bone Healing

Direct bone formation in stabilized gap bone

Courtesy AO Risert laboratory

BONE HEALING

Variables Influence Fracture Healing

INJURY VARIABLES

* Open Fractures
Impeding or preventing formation # Hematoma Delaying formation repair tissue Risk of infection * Severity of Injury Retard fracture healing

BONE HEALING

INJURY VARIABLES
* Intra articular fractures If the alignment & congruity joint surface is not restored Delayed healing or non union Joint stiffness * Segmental fractures * Soft tissue interposition * Damage to the blood supply

BONE HEALING
Variables Influence Fracture Healing

Patient Variables
* Age * Nutrition Healing process needs - Energy - Proteins & carbohydrates

BONE HEALING
Patient variables * Systemic hormones - Corticosteroid ( ) - Growth hormone - Thyroid hormone - Calcitonin - Insulin - Anabolic steroids - DM - Hypervitaminosis D - Rickets * Nicotine

Rate fracture healing

Frame healing

- Inhibit fracture healing ( Vascularization?)

BONE HEALING Variables Influence Fracture Healing

Tissue Variables
* Cancellous or cortical bones * Bone necrosis * Bone disease Pathologic fracture
Osteoprosis Osteomalacia Primary malignant bone tumors Metastatic bone tumors Benign bone tumors Bone cysts Osteogenesis imperfecta Pagets disease Fibrous dysplacia Hyperparathyroidism

* Infection

BONE HEALING Variables Influence Fracture Healing

Treatment Variables

Apposition of fracture fragments Loading & micromotion

Loading a fracture site stimulates bone formation Micromotion promotes fracture healing

BONE HEALING

Treatment Variables

Fracture stabilization
-Traction - Cast Imm - Ext.Fixation - Int.Fixation
Facilitate fracture healing by Preventing repeated disruption of Repair tissue

Potential disadvantage of int.fixation : Surgical exposure disrupted hematoma, blood supply Risk of infection Rigid fixation alter fracture remodeling, bone density

BONE HEALING
Promote Fracture Healing Bone Grafting Autografts Freezing & Freez drying allografts Bone transport callus distraction Electrical fields Stimulate cell proliferation Promote bone formation Ultra Sound

Aggrecan gene expression Concentration intracellular Ca in callus chondrocyte Demineralized bone matrix, growth factors & antologus bone narrow

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