Acta chirurgiae orthopaedicae et traumatologiae Cechoslovaca

Acta chirurgiae orthopaedicae et traumatologiae Cechoslovaca

Editorial / Editorial

ACTA CHIRURGIAE ORTHOPAEDICAE ET TRAUMATOLOGIAE ČECHOSL.,
79, 2012, p. 9 - 10

Konec mýtu o periostu

Debunking the Myth of the Periosteum

A. SARMIENTO
Department of Orthopedic and Rehabilitation University of Miami, Florida, USA

The foundations of Orthopaedics are a great deal better supported with evidence today than previously. Nonetheless, superstitions and myths have not completely disappeared. One of them is the role of the periosteum in fracture healing.

The anatomy and physiology of the periosteum under normal circumstances have been studied for many a decades, and its role in the growth and development of tubular bones well defined. The evidence regarding its participation in fracture healing in non-rigidly immobilized fractures cannot be questioned at this time. However, extrapolations on its participation in rigidly immobilized fractures are open to question. I submit that under rigid immobilization conditions the periosteum plays a minimal role and that rather than assisting in expediting healing, it retards it (1, 2, 3, 4). (Fig. 1).

ACHOT 1/2012
ACHOT 1/2012

In the same category of "superstitions" is the role of the hematoma in fracture healing. Rather than converting into bone, the hematoma is likely to undergo resorption in order to allow the process of enchondral ossification to take place. Likewise, the importance of coverage of bone with thick muscles being important for osteogenesis suggesting that the myoblast is capable of undergone osteoblastic metaplasia, which is not the case. The theory loses further value as one observes that fractures with minimal or no muscle coverage heal as readily as fractures in other bones with large muscle coverage as exemplified by fractures of the metacarpals, metatarsals, phalanges, the clavicle, the fibula as well as the ribs.

It has become an almost sacred obsession to accept the importance the periosteum has in fracture healing. This is true only if rigid immobilization of the fragments is not created. In the nonimmobilized fracture of a long bone, peripheral callus forms as a result of the intervention of capillaries from the periosteum and the surrounding tissues. Studies that we and others have conducted have demonstrated that in the nonimmobilized diaphyseal fracture this massive invasion of capillaries begins to take almost immediately after the initial insult (Fig. 2).

The newly created capillaries are probably a response the irritation that motion between the fragments creates. (3) The perithelial and endothelial cells of the capillaries undergo metaplasia into osteoblasts. Therefore the greater number of capillaries the greater the osteoblastic activity. (Fig. 4a, b and c).

The idea that plates that have projections on their bone side protect the periosteum is an illusion. With or without projections, peripheral callus does not form. The same applies to long plates applied with the so-called minimally invasive techniques. (Fig. 5)

Based on the above presented evidence one must conclude that the role of the periosteum in fracture healing is dictated by the environment into which the healing process unfolds. What determines the presence or absence of peripheral callus is motion at the fracture site. The rigid immobilization of a fracture silences the periosteum, in such a manner that healing is of an endo-steal nature, and mechanically weaker. Since plates, nails and external fixator have very definite indications, their role must be clearly understood. (5) Their mechanical and practical advantages in millions of instances are partially offset by their biological disadvantages. These fractures eventually heal from endosteal activity - not from periosteal callus. The endosteal callus is weak and forms very slowly.

References

Celá stať v dokumentu PDF

Zpět


Nabídka nakladatelství:

 

Peter Wendsche, Radek Veselý et al.
Úskalí a komplikace při léčení zlomenin

Úskalí a komplikace při léčení zlomenin

 

Petr Chládek
Femoroacetabulární impingement syndrom

Femoroacetabulární impingement syndrom

 

Ctibor Povýšil
Patomorfologie chorob kostí a kloubů

Patomorfologie chorob kostí a kloubů