Ovine Model for Critical-Size Tibial Segmental Defects

A segmental tibial defect model in a large animal can provide a basis for testing materials and techniques for use in nonunions and severe trauma. This study reports the rationale behind establishing such a model and its design and conclusions. After ethics approval of the study, aged ewes (older than 5 y; n = 12) were enrolled. A 5-cm mid diaphyseal osteoperiosteal defect was made in the left tibia and was stabilized by using an 8-mm stainless-steel cross-locked intramedullary nail. Sheep were euthanized at 12 wk after surgery and evaluated by using radiography, microCT, and soft-tissue histology techniques. Radiology confirmed a lack of hard tissue callus bridging across the defect. Volumetric analysis based on microCT showed bone growth across the 16.5-cm³ defect of 1.82 ± 0.94 cm³. Histologic sections of the bridging tissues revealed callus originating from both the periosteal and endosteal surfaces, with fibrous tissue completing the bridging in all instances. Immunohistochemistry was used to evaluate the quality of the healing response. Clinical, radiographic, and histologic union was not achieved by 12 wk. This model may be effective for the investigation of surgical techniques and healing adjuncts for nonunion cases, where severe traumatic injury has led to significant bone loss.Abbreviations: BMP2, bone morphogenic protein 2; CATK, cathepsin K; VEGF, vascular endothelial growth factorThe human tibia is the most frequently broken long bone, often with significant bone loss.⁴ Segmental tibial defects can occur as a result of large tumor removal, trauma such as motor vehicle accidents, and more recently, blast injuries as seen with the escalating number of global conflicts. Treatment of these large bone and surrounding soft tissue defects is an ongoing, costly, and challenging clinical problem; no surgical technique has currently achieved preeminence.⁴ The general consensus on factors that affect healing include concomitant disease, age, and degree of trauma.⁵ When the first 2 factors, which are patient-related, are removed from the equation, healing is influenced by the size, anatomic location, and soft-tissue coverage of the defect. The ability to study these situations in a well-controlled, robust, and reproducible preclinical model would be advantageous to help establish effective surgical techniques and evaluate implants and materials.A literature review revealed that many ovine models for bone defects have been used, but all have limitations^{6,12,14,15,20,21,24,25,27,31,37,39,40} (Figure 1). Variations in protocols, such as age of the animals, size of the defect, and the bone and stabilization techniques used, limit meaningful comparison between studies.^33,34 Although some studies have investigated material performance in the healing of defects, they did not rigorously quantify control defects,^17,20 and others used no controls at all.³⁹ There is often no explanation regarding the use of a particular defect size, leading to the question of whether the defect size was critical.²⁴ The choice of bone used has been also varied; the femur,¹⁵ tibia,³⁷ and metatarsus⁴⁰ have all been studied. A noncritical-size defect implies that healing would eventually occur without the presence of any graft materials. One study,¹² for example, used a 3-cm defect at an average of 1.8 times the diameter of the tibias in question and found that empty controls achieved as much as 26% of the stiffness of an intact tibia after 12 wk. Stabilization methods include plating,^21,40 external fixtures,²⁰ intramedullary nails,^6,16 and a combination of intramedullary nails and plating.³⁷Open in a separate windowFigure 1.A limited summary of the many studies where a segmental tibial has been used with their references.The criteria used in the present study for a critical-size segmental tibial defect model were based on the following factors. The ovine tibia closely resembles that of the human tibia in terms of size, shape, and physical properties and is commonly used when studying human orthopedic diseases.^26,34 Intramedullary nailing has become the most commonly used method of tibial fracture fixation in human orthopedic surgery.^8,22 An 8-mm intramedullary nail is commonly used in the treatment of human fractures, further confirming the size similarity between the ovine and human tibiae.¹⁹The aim of this study was to establish and characterize a preclinical ovine 5-cm osteoperiosteal critical-size tibial segmental defect model in mature sheep. The endpoints included those commonly used clinically, such as radiography and microCT. Histology to investigate the degree of healing and immunohistochemistry to characterize the healing process were included to complete the evaluation process.