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    1.1 Biology of Bone Healing

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    Cristian Cumpănă
    1) Bone healing occurs through either direct or indirect healing processes depending on the stability of the fracture. 2) Indirect healing involves callus formation when there is a gap over 2mm and controlled motion between fragments. Direct healing does not involve callus when the gap is under 2mm and there is no movement. 3) The type of healing is determined by the mechanical environment and strain levels, with absolute stability leading to direct healing and relative stability resulting in indirect callus formation.

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    1.1 Biology of Bone Healing

    Uploaded by

    Cristian Cumpănă
    42 views32 pages
    1) Bone healing occurs through either direct or indirect healing processes depending on the stability of the fracture. 2) Indirect healing involves callus formation when there is a gap over 2mm and controlled motion between fragments. Direct healing does not involve callus when the gap is under 2mm and there is no movement. 3) The type of healing is determined by the mechanical environment and strain levels, with absolute stability leading to direct healing and relative stability resulting in indirect callus formation.

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    1.1 Biology of bone healing

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    1) Bone healing occurs through either direct or indirect healing processes depending on the stability of the fracture. 2) Indirect healing involves callus formation when there is a gap over 2mm and controlled motion between fragments. Direct healing does not involve callus when the gap is under 2mm and there is no movement. 3) The type of healing is determined by the mechanical environment and strain levels, with absolute stability leading to direct healing and relative stability resulting in indirect callus formation.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    42 views32 pages

    1.1 Biology of Bone Healing

    Uploaded by

    Cristian Cumpănă
    1) Bone healing occurs through either direct or indirect healing processes depending on the stability of the fracture. 2) Indirect healing involves callus formation when there is a gap over 2mm and controlled motion between fragments. Direct healing does not involve callus when the gap is under 2mm and there is no movement. 3) The type of healing is determined by the mechanical environment and strain levels, with absolute stability leading to direct healing and relative stability resulting in indirect callus formation.

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    Biology of bone healing

    AO Trauma Basic Principles Course


    Learning objectives

    • Explain the different processes of bone healing and review direct


    and indirect bone healing
    • Describe the factors that influence the healing process and those
    that may lead to delayed union or nonunion
    • Recognize the importance of soft tissues for bone healing
    • Discuss the effects and influence of osteosynthesis on the bone
    and its healing process
    Bone structure

    Cortical

    Cancellous
    trabecular
    Bone structure

    Cortical

    Cancellous
    trabecular
    Cancellous trabecular bone
    Cortical bone

    • Made up of osteons
    • Continually remodelled by
    cutting cones
    Blood supply
    Bony anatomy
    Different types of bone healing
    Bone healing—definitions

    Radiological

    Visible callus formation

    Indirect healing

    No visible callus formation

    Direct healing
    Bone healing—callus

    • Left alone, a broken bone will heal by callus formation


    • Callus is the natural response of living bone
    to interfragmentary movement
    Indirect bone healing—inflammatory phase

    • Coagulation
    • Fibrin fibers stabilize the hematoma (hematoma callus)
    Indirect bone healing—granulation phase, soft callus

    Natural bone healing process begins


    with soft callus:
    • New blood vessels invade the
    hematoma
    • Fibroblasts, derived from the
    periosteum, colonize the hematoma
    • Fibroblasts produce collagen fibers
    (granulation tissue)
    • Collagen fibers loosely link the bone
    fragments
    Indirect bone healing—granulation phase, soft callus

    • Granulation tissue gradually


    differentiates into fibrous tissue,
    and subsequently fibrocartilage
    Indirect bone healing—granulation phase, hard callus

    • Hard callus stage starts and lasts


    until the fragments are firmly united
    by new bone (3–4 months)
    • Endochondral ossification forms
    spindle-shaped bone cuffs
    • Starts at the periphery and moves
    toward the center, further stiffening
    the healing tissue
    Micromotion—Strain theory

    • Load applied to a material


    produces stress within the
    material and results in
    deformation (strain)

    • Following a fracture, any motion


    of one main fragment relative to
    the other is projected to the
    fracture zone
    High strain in small gaps

    • If only two fragments are


    involved, the sum of all motion
    will be projected into the single
    fracture gap
    • Motion amplitudes will limit the
    capacity of the soft repair tissue
    (hematoma  collagen  soft
    callus) to withstand shear and
    dislocation forces
    • If the “strain” on the tissue is too
    great, tissue integrity is disrupted
    Strain

    • Strain itself is considered to be


    an inductor of callus formation
    (compare embryologic tissue
    growth)
    • With the formation of tissues of
    increasing stiffness, the overall
    stability increases
    • Different healing qualities may
    exist simultaneously
    High strain in small gaps

    • In a minute gap with only few bridging


    cells, any micromotion not contained by
    absolute stability will exceed strain
    tolerance of the tissues involved and
    the cell structure is destroyed

    • Tissue specific strain tolerances:


    • Granulation tissue: 100%
    • Lamellar bone: 2%
    Low strain in large gaps

    • If the gap is widened (by bone


    surface resorption), the strain
    is shared by many more
    bridging soft-tissue elements
    and fragment motion does not
    create an intolerable strain on
    individual cells

    • In larger gaps, the strain on


    individual cells is reduced
    Strain

    • This phenomenon explains why strain


    sharing permits multifragmentary
    fractures to heal well
    • Multiple serial gaps share the overall
    displacement, and callus induction
    occurs despite relatively high total motion
    • Different strains in different gap sizes
    also explain why various tissues, ranging
    from loose connective and fibrocartilage
    tissue, may exist simultaneously
    Mechanobiology of bone healing

    Hematoma/ 100%
    Granulation

    Flexible
    Interfragmentary strain

    Soft callus 20%

    to
    rigid
    Hard callus 10%

    Bone 2%

    Indirect bone healing


    Direct bone healing
    Indirect bone healing

    Gap > 2 mm
    Controlled motion
    Living bone
    Indirect bone healing—mechanical effect

    As the callus forms and stiffens, movement is abolished


    and normal osteonal remodeling can occur
    Direct bone healing

    • No visible callus formation

    • Direct healing
    Direct bone healing

    Schenk and
    Willenegger
    1958
    Direct bone healing

    • Gap < 2 mm
    • No intermediate fibrous tissue
    • No movement
    Direct bone healing—osteonal remodeling

    • Osteoclasts cut tunnel


    into cortical bone
    • Behind osteoclasts,
    osteoblasts lay down
    concentric lamellae of
    bone, the osteon
    • This process relies on
    absolute stability
    Direct bone healing—mechanical effect of internal
    fixation Stable: no gap Osteonal remodelling

    Surgical stabilization abolishes movement, so no callus


    forms and osteonal remodeling proceeds immediately
    Take-home messages

    • Complex structure heals by replication and remodelling


    • Bone is programmed to heal:
    • Must be living
    • Controlled movement
    • Type of healing varies with mechanical environment
    Take-home messages

    • Bone healing is a cascade of biological events leading to


    restoration of the continuity and mechanical properties of the
    bone
    • Healing is dependent on mechanical and biological factors that
    are closely associated with bone blood supply
    • Fracture stability dictates the biologic response:
    • Absolute stability = direct healing
    • Relative stability = callus healing
    Take-home messages
    Spectrum of stability

    Direct Indirect
    healing healing

    Direct healing Indirect healing

    • Gap < 2 mm • Gap > 2 mm

    • No movement • Controlled movement

    • Good blood supply • Good blood supply

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