Autogenous Cancellous Graft Research Articles

Plate Fixation With Cancellous Graft for Scaphoid Nonunion With Avascular Necrosis

Currently, there is no consensus on the optimal treatment for scaphoid nonunion with avascular necrosis (AVN). Various techniques, often involving vascularized corticocancellous bone grafting, have been proposed. The authors hypothesized that similar outcomes might be possible with volar plate fixation augmented with autogenous pure cancellous graft. The authors performed a retrospective chart review of 13 cases of scaphoid nonunions with AVN in 12 patients treated with plate fixation and pure cancellous bone grafting. Surgical management included a volar incision, reduction, impaction of cancellous bone graft from the ipsilateral olecranon and/or distal radius, and application of a volar locking plate. Postoperative outcome measures included time to union based on computed tomography, patient-reported pain and disability scores, grip strength, range of motion, and return to work and sports. The average patient was 32 years old (range, 17-50 years) and treated an average of 18 months after initial injury (range, 6-49 months). Two of 12 patients (15.7%) were female, 3 of 12 patients (25%) were smokers, and 5 of 12 patients (41.7%) had failed union with previous screw fixation. Twelve scaphoids (92.3%) were treated for AVN associated with a proximal pole fracture, and 1 (7.7%) for AVN proximal to a scaphoid waist fracture. Mean follow-up was 19.5 months (range, 12-29 months). Union was achieved in all patients. Two scaphoids (15%) achieved union by 12 weeks, 7 scaphoids (54%) by 18 weeks, 2 scaphoids (15%) by 24 weeks, and 2 scaphoids (15%) by 30 weeks (range, 8.9-28 weeks). Mean Disabilities of the Arm, Shoulder, and Hand score improved from 30.6 ± 6.2 before surgery to 17.2 ± 6.5 after surgery. All 11 employed patients returned to work, although 3 (27.2%) did not return to full capacity. Scaphoid plate fixation and pure nonvascularized cancellous bone grafting for scaphoid nonunion with AVN yields excellent union rates and good patient-reported and functional outcomes. Therapeutic IV.

Novel, vacuum-assisted method for harvesting autogenous cancellous bone graft and bone marrow from the proximal tibial metaphysis

Category: Other Introduction/Purpose: Autogenous cancellous bone graft and bone marrow aspirate are commonly used in lower extremity fusion procedures. Autologous graft is considered the gold standard as it is osteogenic, osteoinductive, and osteoconductive, and is without the potential risks of graft-associated infection and immunologic reaction. Disadvantages include graft harvest time and donor site morbidity due to the surgical incision, approach and bone corticotomy. This study evaluated the safety and efficacy of a novel vacuum-assisted bone graft harvesting device which was able to obtain both cancellous bone and bone marrow for insertion into the arthrodesis sites of patients undergoing complex primary and revision lower extremity fusion procedures. Methods: Between March and November 2017, 9 patients had a foot and/or ankle complex primary or revision arthrodesis performed, with autogenous cancellous graft and bone marrow harvested from the ipsilateral proximal tibia. All patients were 18 years or older with no prior history of knee pain, injury, or surgery at the proximal tibia. Following a circular corticotomy, cancellous bone was harvested using a novel suction-powered, hand-driven bone curettage system (Avitus Orthopaedics, Farmington, CT). The donor site was backfilled with bone graft substitute. Incision length was recorded as well as surgical time from donor site incision to completion of graft acquisition. The volume of cancellous graft and bone marrow were separately recorded. All patients were non-weight bearing on the involved extremity for a minimum of 6 weeks post-operatively and all were evaluated at 2 and 6 weeks post-operatively for donor site pain and associated complications. Results: There were five male and four female patients with an average age of 51 years and 8 months. Procedures included six complex primary fusions and three revision subtalar or tibio-talar-calcaneal fusions for nonunion. Mean incision length was 2 cm (range 1.80-2.75 cm). Mean volume of obtained graft material included 25 cm3 of cancellous bone (range 9-30 cm3) and 21 cm3 bone marrow aspirate (range 10-40 cm3). Mean procedure time was 5 mins (range 4-8 mins), and average blood loss was less than 1 mL. Two patients had mild pain at 2 week follow-up; however, no patients reported donor site pain at 6 week follow-up. There were no major or minor complications including fracture, infection, hematoma formation, sensory changes, or wound healing issues. Conclusion: The use of an innovative, vacuum-assisted bone harvesting device allows large volumes of autogenous cancellous bone graft and marrow to be rapidly and readily obtained from the ipsilateral proximal tibia with minimal donor site morbidity.

Outcomes of Unstable Scaphoid Nonunion With Segmental Defect Treated With Plate Fixation and Autogenous Cancellous Graft.

Treatment of scaphoid nonunion with a segmental defect presents a challenging clinical problem. Various techniques have been proposed, often involving structural grafting with vascularized and nonvascularized bone. The authors hypothesize that satisfactory clinical and radiographic outcomes are possible with a relatively simplified technique of volar plate fixation with autogenous, purely cancellous graft. The authors performed a retrospective review of 34 patients with scaphoid nonunions with segmental defects, treated with plate fixation and purely cancellous bone grafting. Cases with avascular necrosis were excluded. Surgical management included a volar incision, reduction, bone grafting from the ipsilateral distal radius and/or olecranon, and application of a volar locking plate. Postoperative outcome measures included time to union based on computed tomography, return to work and sports, patient-reported pain and disability scores, grip strength, and range of motion. Thirty-four patients with an average age of 31 years (range, 16-55 years) were treated with volar plate fixation and cancellous grafting, an average of 34 months after initial injury. Twenty-six patients (76%) were treated for nonunion at the scaphoid waist, 7 (21%) at the proximal pole, and 1 (3%) at the distal pole. Mean final follow-up was 18.7 months (range, 12-34 months). When union was defined by computed tomography evidence of healing, 2 (6%) scaphoids healed by 6 weeks after surgery, 28 (82%) healed by 12 weeks, and 100% healedby18 weeks. Mean Disabilities of the Arm, Shoulder, and Hand score improved from 27.1 ± 7.3 before surgery to 11.8 ± 5.8 after surgery. Grip strength, corrected for hand dominance, improved from 77.5% of the nonsurgical side before surgery to 90.5% after surgery. All employed patients returned to work, although 3 (9%) did not return to full capacity. The combination of scaphoid plate fixation and pure cancellous bone grafting for scaphoid nonunion with segmental defects yields reliable union rates and good patient outcomes. Autogenous cancellous grafting may be an alternative to more technically demanding or morbid grafting proceduresfor the treatment of scaphoid nonunion. Therapeutic IV.

Outcomes of Scaphoid Nonunion with Segmental Defect Treated with Plate Fixation and Autogenous Cancellous Graft: First Clinical Report

There is no financial information to disclose. Treatment of scaphoid nonunion with segmental defect presents a challenging clinical problem. Various techniques have been proposed, usually involving vascularized bone grafting with or without structural bone. Outcomes of these complex procedures have been inconsistent in the medical literature. The authors hypothesize that similar or perhaps better clinical and radiographic outcomes are possible with a relatively simplified technique of volar plate fixation augmented with autogenous pure cancellous graft. The authors performed a retrospective chart review of 49 consecutive patients with scaphoid nonunion with segmental defect treated with plate fixation and pure cancellous bone grafting. Surgical management included a single volar incision, reduction, insertion of bone graft from ipsilateral olecranon and/or distal radius, and application of a volar locking plate. Post-operative outcome measures included time to union based on computerized tomography (CT), return to work, patient-reported pain and disability scores, grip strength, and range of motion (ROM). The average patient was 31 years old and treated an average of 28 months after initial injury. Twenty-nine patients (59.0%) were treated for nonunion at the scaphoid waist, 19 (38.8%) at the proximal pole, and 1 (2.0%) at the distal pole. 13 patients (26.5%) were treated specifically for avascular necrosis confirmed with magnetic resonance imaging (MRI). Mean follow-up was 18.9 months (range, 12-34). Union was achieved in all patients and average time to union was 78 +/- 18.4 days post-operatively. Complications included symptomatic hardware that required plate removal for 1 patient. Mean DASH score improved from 13.4 +/- 0.5 pre-operatively to 41.4 +/- 3.7 post-operatively. Mean visual analogue scale (VAS) improved from 7.0 +/- 0.7 pre-operatively to 2.1 +/- 0.7 post-operatively. All employed patients returned to work, although 5 (13.9%) did not return to full capacity. Grip strength improved from 79.9% of the non-operative side pre-operatively, to 93.5% post-operatively. At final follow-up, ROM including wrist flexion, extension, ulnar deviation, and radial deviation improved 128%, 173%, 112%, and 164%, respectively, compared to pre-operative ROM. •The combination of scaphoid plate fixation and pure cancellous bone grafting for scaphoid nonunions with segmental defects yields reliable union rates and good patient outcomes.•Autogenous cancellous bone grafting is a reliable alternative to more technically demanding or morbid grafting procedures for the treatment of scaphoid nonunions with segmental bone defects.•In cases of avascular necrosis, outcomes of volar locked plating with pure cancellous grafting appear to be similar, if not superior, to those reported for vascularized bone grafting techniques.

Immediate Trans-Oral Tissue Engineered Allogeneic Bone Grafting for Large Continuity Defects. Less Morbidity, More Bone. A Paradigm in Benign Tumor Mandibular Reconstruction?

Reconstruction of hard tissue continuity defects caused by ablative tumor surgery have been traditionally reconstructed with autogenous cancellous marrow grafts or microvascular free flaps. Although results have been predictable from both methods of reconstruction, the morbidity associated with bone harvest is quite significant for the patient. With the advances made in tissue engineering, successful and predictable results has been obtained with using a combination of 100% cadaver bone, Bone Marrow Aspirate Concentrate (BMAC) and rhBMP-2 for immediate reconstruction for benign tumor extirpations via extra-oral approach. In light of these successful outcomes the same combination was evaluated with an intraoral approach. This case study aims to evaluate the success of immediate mandibular reconstruction via intra-oral approach without any autogenous bone harvesting.

Tibial Bone Grafting for Wrist Reconstruction.

Background Iliac crest bone graft harvesting is routinely performed for upper extremity orthopedic procedures despite high complication rates associated with sensory nerve injury, hematoma, chronic pain, and fracture. Description of Technique Cancellous bone graft is harvested from the proximal tibia using a medial approach, minimizing donor site morbidity. Patients and Methods A retrospective review was undertaken of 14 patients who underwent cancellous proximal tibia bone graft harvesting to augment healing of wrist reconstruction, with 2 months minimum follow-up. We report donor limb tourniquet time, time to union, visual analog scale (VAS) pain score, and complications. Patients were also contacted by phone to administer a retrospective questionnaire and record experiences with the harvesting technique. Results Average donor site VAS for the immediate postoperative period was 7.4. Average tourniquet time was 28 minutes. Average time to union of the recipient site was 45 days. One patient experienced delayed union after corrective osteotomy, attributed to osteoporosis. Two patients underwent hardware removal from the operative wrist, unrelated to bone graft harvesting. One patient with a history of chronic neuropathy and foot drop developed dysesthesia and allodynia about the ipsilateral ankle, but was asymptomatic at the proximal tibia donor site; ankle symptoms resolved 3 weeks postoperatively. No patient reported any residual donor site difficulties 24.2 months postoperatively. Conclusion In consideration of the minimal complication rate, favorable clinical parameters, and excellent patient tolerance, we advocate proximal tibia bone graft harvesting as opposed to iliac crest harvesting for wrist reconstruction when a moderate amount of autogenous cancellous graft is needed. Level of Evidence IV.

The Utilization of Allogeneic Bone, Bone Morphogenetic Protein and Bone Marrow Aspirate Concentrate for Immediate Reconstruction of Benign Tumor continuity defects

Reconstruction of hard tissue continuity de- fects caused by ablative tumor surgery has been tradition- ally reconstructed with autogenous cancellous marrow grafts or microvascular free flaps. Although results have been predictable from both methods of reconstruction, the morbidity associated with bone harvest is quite signif- icant for the patient. With the advances made in tissue en- gineering,itisouropinionthatsuccessfulandpredictable results can be obtained with using a combination of 100% cadaver bone, Bone Marrow Aspirate Concentrate (BMAC) and rhBMP in immediate reconstruction for benign tumor extirpations. Material and Methods: The aim of this retrospective study is to share our experience with the use of 100% allo- geneicboneincombinationwithBMPandBMACforimme- diate reconstruction of continuity defects resulted from benigntumorsurgery.Thepresentstudyreviewedpatients

English

There is definite value of bone grafting in Orthopedics, especially allografts as and when required. There are bone banks in some metro cities and procuring the grafts is difficult and costly tasks. Such facilities are not available in peripheral and rural set up in developing countries like India. One has to depend and develop his own solutions to the problem being faced in day to day activities. Lytic lesions and bone loss in traumatic patients remain challenge when autogenous cancellous graft is scanty or difficult to retrieve such as those in younger child. We have developed our own technique of using cancellous, copious allograft from autoclaved femoral head which are available following arthroplasty. Tissue typing is not required as the graft is autoclaved. We have gratifying results and are waiting for long term follow-up.

The comparative efficacy of decalcified allogenic bone matrix and intra-oral free osseous autografts in the treatment of periodontal intrabony defects

Background and Objectives:The primary goal of periodontal treatment is the maintenance of the natural dentition in health and comfortable function. The shift in therapeutic concepts from resection to regeneration has significantly impacted the practice of periodontology. The objective of the present study is to compare the relative efficacy of intra-oral autogenous graft and decalcified allogenic bone matrix (DABM) in the treatment of periodontal intrabony defects.Materials and Methods:In the present study, 30 patients in the age group of 30-50 years with two almost identical intrabony defects, on either side of the mouth/upper and lower jaw, based upon the radiographic observations were selected from amongst the patients visiting the Department of Periodontology and Oral Medicine, Punjab Government Dental College and Hospital, Amritsar. One of the defect was selected randomly and filled with autogenous cancellous graft and the other with DABM. Post-operative assessment was done by taking radiographs, 12 weeks and 24 weeks post-operatively.Results:Definite bone fill was achieved both with intra-oral free osseous autograft and with DABM at 12 weeks observation, which further increased significantly at 24 weeks observation. The bone fill obtained with intra-oral free osseous autograft was found to be significantly higher than that with DABM both at 12 weeks and 24 weeks post-operative observation.Conclusion:Within the limitations of this study, it establishes the superiority of the intra-oral free osseous autograft over that of DABM graft in correcting the intrabony defects.

The use of solid form-fitting antibiotic cement spacers in bone loss of the lower extremity

Background The purpose of this study was to report on the ease and success of using a solid form-fitting antibiotic cement spacer to manage critical-sized bone defects of the lower extremity. Our hypothesis was that these form fitting spacers will prevent the involution of structures at risk and allow for easy access to the bone defect for secondary bone grafting. Furthermore, antibiotic cement spacers have been demonstrated to form an induced membrane supportive of healing for subsequent bone grafting. Methods Nineteen patients with tibial shaft fractures and two patients with distal femoral fractures with critical-sized bone defects were treated using solid form-fitting antibiotic cement spacers. At the time of definitive closure, a solid form-fitting antibiotic cement spacer was used to fill the defect. After maturity of the coverage, the spacers were removed and replaced with bone graft or bone graft substitute. Results The average defect size was 4cm (2--16cm) and a minimum of 50% of the cortical circumference. The average time to bone grafting was 11 weeks (6--31 weeks). In all patients, a pseudocapsule had formed over the spacer making exposure extremely easy. The spacers prevented involution of muscle, nerves, and vascular structures in all patients. Conclusions The use of a solid form-fitting antibiotic cement spacer to prevent involution of muscle and neurovascular structures to defects eased bone-grafting procedures and is recommended. No soft-tissue coverage difficulties occurred after extensive grafting. The pseudocapsule facilitated secondary bone grafting, and all defects treated with autogenous cancellous graft healed.

Aneurysmal Bone Cyst of the Patella

Aneurysmal bone cysts account for less than 1% of primary bone tumors and have a predilection for the metaphyses of the long bones of the leg. Only 1% of all aneurysmal bone cysts occur in the patella. We report on a 24-year-old man with a primary aneurysmal bone cyst in the left patella treated with curettage. The defect was filled with autogenic and allogeneic cancellous bone graft. The patient experienced no pain or tenderness and had a full range of knee movement.

Evaluation of the activity of intraarticular hyaluronic acid in the repair of experimentally induced osteochondral defects of the stifle joint in dogs

The present study examined the results of using hyaluronic acid with autogenetic cancellous grafts in the treatment of experimentally induced osteochondral defects in the stifle joints of dogs. In this study, 10 mature dogs of different breeds, weights and of both sexes were used. General anesthesia and usual operation procedures were followed. A 10 mm deep defect was created on the femoral sulcus of the trochlea with a drill tip of 8 mm in diameter. The defects in the right and left legs were filled with autogenic cancellous grafts taken from the metaphysial region of the tibia. The left legs constituted the experimental group while the right legs served as control group. In the experimental group, 2 mg/kg intraarticular hyaluronic acid was twice administered into the stifle joint, i.e., immediately subsequent to the operation and 1 month afterwards. Parenteral antibiotics were prescribed postoperatively for ten days. Five animals were sacrificed at the third and sixth month after surgery. Macroscopic and microscopic findings obtained from each case were evaluated. On macroscopical examination, trochlear defects were determined to be incompletely filled at the third month in both control and experimental groups. On histopathologic examination, a loose fibrovascular formation in the area where the graft was applied was observed to be present in both control and experimental groups. However, in the experimental group this formation was more superficial, ossification activity was greater and trabeculous bone formation had been initiated. Macroscopical examination carried out in the sixth month determined that in the control group the defect surface did not fill up to the trochlear sulcus level. In the histopathologic examination, in control groups it was found that fibrocartilageous structures were developing in the fibrovascular space even though ossification was incomplete. The macroscopic examination showed that in the experimental group, the defect surface reached the trochlear sulcus level of defects in this month. The histopatologic examination revealed that fibrous tissue comprised a thin layer, under which ossification processes were complete and bone trabeculates fully formed. It was concluded that the usage of autogenic cancellous graft along with hyaluronic acid may be useful in the repair of large osteochondral defects.

C2 Pedicle Screw and Plate Combined With C1 Titanium Cable Fixation for the Treatment of Alantoaxial Instability not Suitable for Placement of C1 Screw

A method of atlantoaxial stabilization using individual fixation of the C1 posterior arch and the C2 pedicle with C2 pedicle screws and plates combined with C1 titanium cables is described. In addition, the clinical results of this method on 8 patients are described. To describe the method and the clinical and radiographic results for posterior C1-C2 fixation with a combined implant system. Stabilization of the atlantoaxial complex is a challenging procedure because of the unique anatomy of this region. Fixation by plate or rod and C1 and C2 screw and structural bone grafting leads to excellent fusion rates. The technique is technically demanding and has a potential risk of the injuries to the vertebral artery, the internal carotid artery, spinal cord, and hypoglossal nerves. In addition, how to stabilize the atlantoaxial complex in the cases not suitable for placement of C1 screw is not described in the literature. To address these limitations, a method of C1-C2 fixation has been developed: bilateral insertion of C2 pedicle screws and rolling of C1 titanium cable through the posterior arch of atlas and the cranial hole of the plate, followed by C1-C2 plate fixation. From February 2003 to March 2006, 8 patients with atlantoaxial instability and not suitable for placement of C1 screw were included in this study: 5 cases of broken C1 pedicle screw trajectory and 3 cases of C1 anatomic anomalies. Skull traction was performed in each patient preoperatively. The pedicle screws were inserted into C2 pedicles in the direction as its axis. C1 titanium cable was rolled superior to lower through posterior arch of atlas in the cases not suitable for placement of C1 screw. The C1-C2 plate was slightly bent to fit the upper cervical contour. Hyperflexion alignment of the atlantoaxial complex was corrected by application of extension force created by tightening of the nut on the pedicle screws and the C1 titanium cable, which was passed through the cranial hole of the plate. Morselized autogenous cancellous iliac grafts were placed on the surface of the posterior arches of both atlas and axis. All patients were assessed clinically for neurologic recovery by Odom's method. There were 5 males and 3 females with a mean age of 37.8 years (range, 17 to 59 y). There were 2 cases of old odontoid fracture, 2 cases fresh odontoid fracture (Aderson II C), 2 cases atlas transverse ligament laxation, 2 cases atlas transverse ligament rupture, and in these cases, 5 cases had failed placement of C1 screw because of broken C1 pedicle screw trajectory and 3 cases not suitable for placement of C1 screw because of anatomic anomalies. There were no spinal cord and vertebral artery and nerve injury after surgery. Follow-up duration was from 18 to 55 months with the average of 29 months. The plant bones all fused and there were no internal fixation rupture and mobility. All the patients showed improvement. C2 pedicle screw and plate combined with C1 titanium cable could be used to treat atlantoaxial instability in the cases not suitable for placement of C1 screw.

Internal fixation with autogenous cancellous grafting for communicated fractures of acetabular posterior wall

随着交通运输业和建筑业的发展,由高能量损伤导致的髋臼骨折日趋增多.其中髋臼后壁骨折最为多见[1,2],约占所有髋臼骨折的25%～33%,加之前后柱骨折伴后壁骨折总数达70%～80%.其中有相当一部分为后壁粉碎性骨折,由于其潜在复杂性,如邻近关节面的塌陷骨折,后壁骨块的严重粉碎,关节软骨面的挫伤和剥离等,手术切开复位内固定相当棘手.有学者报道髋臼后壁骨折切开复位内固定的临床不满意率达30%[3].我院从2002年1月至2006年12月收治粉碎性髋臼后壁骨折(包括伴有后壁骨折)共12例应用取髂骨加盖植骨取得较好疗效。

External fixation of tibial pilon fractures and fracture healing

Distal tibial fractures are rare and difficult to treat because the bones are subcutaneous. External fixation is commonly used, but the method often results in delayed union. The aim of the present study was to find out the factors that affect fracture union in tibial pilon fractures. For this purpose, prospective data collection of tibial pilon fractures was carried out in 1998-2004, resulting in 159 fractures, of which 83 were treated with external fixation. Additionally, 23 open tibial fractures with significant > 3 cm bone defect that were treated with a staged method in 2000-2004 were retrospectively evaluated. The specific questions to be answered were: What are the risk factors for delayed union associated with two-ring hybrid external fixation? Does human recombinant BMP-7 accelerate healing? What is the role of temporary ankle-spanning external fixation? What is the healing potential of distal tibial bone loss treated with a staged method using antibiotic beads and subsequent autogenous cancellous grafting compared to other locations of the tibia? The following risk factors for delayed healing after external fixation were identified: post-reduction fracture gap of >3 mm and fixation of the associated fibula fracture. Fracture displacement could be better controlled with initial temporary external fixation than with early definitive fixation, but it had no significant effect on healing time, functional outcome or complication rate. Osteoinduction with rhBMP-7 was found to accelerate fracture healing and to shorten the sick leave. A staged method using antibiotic beads and subsequent autogenous cancellous grafting proved to be effective in the treatment of tibial bone loss. Healing potential of the bone loss in distal tibia was at least equally good as in other locations of the tibia.

Bone Marrow Transplantation and Autogenic Cancellous Bone Grafting in Healing of Segmental Radial Defects: An Animal Study

Emami M.J., Oryan, A., Meimandi-Parizi, A.M., Kasraee, R., Tanideh, N. and Mehrabani, D. 2006. Bone marrow transplantation and autogenic cancellous bone grafting in healing of segmental radial defects: an animal study. J. Appl. Anim. Res., 30: 69–72. To compare the healing effect of bone marrow (BM) injection with the effects of autogenic cancellous bone graft (ABG), eighteen female and male New Zealand White rabbits (1 year, 2 kg) were randomly divided into three equal groups and osteotomy and extraction of a 5 mm piece of bone was done in the mid-portion of the right radius of all rabbits. In group A, 2 ml of BM was injected in the proximal femur for five consecutive days. Group B received autogenic cancellous bone graft from ileum and group C was the control group and received no intervention. After 45 days, in group A, 83% and 17% of rabbits showed good and medium healings, respectively, while in group B, 40% showed good and 60% medium healings. In control group, medium healing was 17% and poor healing was 83%. The mean healing score was significantly higher in BM injection group, compared with B and C groups (17.1, 15.2 and 6, respectively; P<0.05). BM injection could increase the quality of healing and was much more effective than bone grafting.

Plate augmentation leaving the nail in situ and bone grafting for non-union of femoral shaft fractures. Answer to Dr. Trikha and Dr. Varshney

We thank Dr. Trikha and Dr. Varshney for their great interest and thoughtful comments on our article. The interlocking intramedullary nail reduces fracture motion, but it does not abolish the fracture motion completely. Fracture healing can be achieved by the formation of peripheral callus, since considerable motion is present at the fracture site. However, If there is too much motion in comminuted fractures and fractures in the distal dia-metaphyseal junction of the femur, the mechanical strength will be unpredictable, with some cases of non-union. As they assert, it may be difficult to draw objective criteria to determine continuous motion at the fracture preoperatively. According to the classification by Weber and Brunner [2], the type of non-union was hypertrophic in one case and oligotrophic in 14 cases. In addition, there was visible motion at the fracture site at operation before the plate fixation. However, the motion disappeared after the plate augmentation. Thus, we believed that the most important factor of the non-union was the instability at the fracture site. A non-union was defined as persistent pain at the fracture site, which was combined with the absence of progressive healing on three consecutive radiographs taken at one month interval or as failure to unite at six months after surgery. Autogenous bone grafting is advisable in all cases of atrophic non-union and in certain cases of oligotrophic non-union. However, the value of bone grafting for non-union has been disputed. Pihlajamaki et al [1] reported that classifying non-unions into atrophic and hypertrophic was not applicable to consolidation failures after intramedullary nailing. This is why an autogenous cancellous graft was performed at the non-union site to treat the bony defect and to increase the rate of healing. We believe that reamed exchange nailing is still the optimal treatment for non-union following intramedullary nailing of femoral shaft fractures, but plate augmentation and bone grafting, leaving the nail in situ, can be effective in those cases in which stability is lacking only with an interlocking nail, such as non-union of a comminuted fracture in the mid-shaft of the femur or fractures in the distal dia-metaphyseal junction of the femur. Sincerely, Yong-soo Choi, Ki-soo Kim

Augmentation of intertransverse process lumbar fusion

Spinal fusion surgery for alleviation of intractable lower back pain in humans is currently a primary therapeutic technique, with failure rates averaging between 5 to 35%. Implanted and external source-based electrical stimulation devices have been investigated in an attempt to increase osteogenesis at the fusion site in an attempt to reduce spinal fusion failure rates. The purpose of our study was to evaluate the efficacy of two co-processor systems and an additional system with an SIS generation field at 15.8 mA (rms) using biomechanical, dual-energy X-ray absorptiometry (DXA), and histomorphometric analyses, in rabbits following dorsolateral (= posteriolateral [in humans]) spinal fusion. Fifty-six male New Zealand White underwent bilateral lumbar spinal fusion by performing decortication of the transverse processes of lumbar vertebrae four and five with placement of autogenic cancellous bone graft harvested from the ilial wings. Four study groups were designated based on the type of IES device used for stimulation or as a control. Eight weeks after surgery all subjects were sacrificed and the quality and strength of the fusion masses were compared using radiographic, biomechanical, histomorphometry, and qualitative histological evaluation. While some variation existed within and between groups, Group 2 showed a significant improvement in all parameters measured as compared to the control group (P < 0.05). The use of adjunct non-invasive surface IES for improving bony fusion rates for patients undergoing lumbar spinal fusion is supported by this study.

Evaluation of healing in feline femoral defects filled with cancellous autograft, cancellous allograft or Bioglass

Cancellous bone grafting is a widely accepted technique in human and veterinary orthopaedic surgery. However, the use of autogenous bone graft is limited by the additional surgical time required to harvest the graft, the morbidity associated with the donor site, and the limited availability of cancellous bone, especially in feline patients. Various allografts and bone graft substitutes are available commercially but have not been fully evaluated for efficacy in the cat. The purpose of this study was to compare the incorporation of autogenous and allogenous cancellous bone graft and Bioglass, a synthetic bone graft substitute, in femoral defects in cats. Four (4.0 mm diameter) defects were created in the lateral diaphyseal cortex of the left femur with an orthopaedic drill. In each femur, one of the cortical defects was filled with autogenous cancellous graft (harvested from the tibia), one was filled with allogenic cancellous graft, and one was filled with Bioglass. The fourth defect remained unfilled. Graft incorporation within the femoral defects was evaluated by radiographic evaluation every two weeks. Six weeks after the grafting procedure, the cats were euthanatized and high detailed radiography, dual energy X-ray absorptiometry (DEXA), histopathology and histomorphometry of the defects were performed. Satisfactory bone healing was observed within all of the defects.

Clinical results of harvesting autogenous cancellous graft from the ipsilateral proximal tibia for use in foot and ankle surgery.

The harvesting of autogenous cancellous bone graft has many uses in foot and ankle surgery. The most common referenced donor sites are the iliac crest, distal tibia, and calcaneus. These all have demonstrated limitations, the high morbidity rate associated with the iliac crest and the poor quantity of graft from distal sources. Between April 1995 and February 2000, 155 patients were retrospectively identified who had undergone a foot or ankle procedure utilizing the ipsilateral, proximal tibia as the donor site for autogenous cancellous graft. The patients were 18 years or older with no history of previous bony surgery to the tibia used and no history of previous injury or pain in the knee. The group included patients with isolated reconstructions as well as multiextremity trauma patients. All were kept nonweightbearing on the involved extremity for a minimum of 6 weeks postoperatively. There were 90 male and 65 female patients. The average age was 41 years and 5 months. There were 51 smokers averaging 17.6 pack years (range, 1-50 pack years). Twenty-six patients were admitted alcoholics, and 12 admitted to prior intravenous drug use. Cancellous graft was utilized in both traumatic and reconstructive settings. Eighty-nine fractures in 86 patients received grafting. Sixty-nine reconstructions or fusions of the hindfoot or midfoot were done using this technique. There were no reported major complications due to this procedure. No fractures, infections, or wound breakdowns occurred during this study. There were no reported long-term problems with knee pain or function. There was one postoperative hematoma that resolved over time. There were three incidents of sensory changes at the incision site. The use of the ipsilateral proximal tibia as a source for autogenous cancellous bone graft is a procedure with low added morbidity and a source of adequate graft material.