Bone Graft Failure Research Articles

A new pedicled periosteal flap for alveolar bone graft surgery: a technical note

Achieving a good bone volume is an important aspect of secondary alveolar bone grafting in patients with alveolar clefts. Wound breakdown is a major cause of bone graft exposure and graft failure. We describe a new technique using a pedicled periosteal flap to achieve a double layered wound closure during secondary alveolar bone graft surgery. We report the first use on a unilateral alveolar cleft. Good wound healing and bone volumes were noted on 6 months review. Bone formation by the grafted periosteum was expected in addition to wound protection.

Therapeutic evaluation of intertransverse bone graft for single segmental thoracic spinal tuberculosis

?To explore the effectiveness of intertransverse bone graft after debridement and fusion combined with posterior instrumentation in patients with single segmental thoracic tuberculosis. ?Between March 2014 and May 2015, 17 cases of thoracic tuberculosis were treated by the surgery of intertransverse bone graft after debridement and fusion combined with posterior instrumentation. There were 10 males and 7 females with an average age of 48.5 years (range, 18-70 years), and with a mean disease duration of 4 months (range, 1-9 months). The affected segments included T4, 5 in 2 cases, T6, 7 in 5 cases, T7, 8 in 3 cases, T9, 10 in 2 cases, T10, 11 in 4 cases, and T11, 12 in 1 case. The operation time, intraoperative blood loss, and hospitalization time were recorded. Postoperative plain radiography was taken to assess the decompression and internal fixation, and the fusion effect was evaluated by X-ray or CT examination. The erythrocyte sedimentation rate (ESR), C reactive protein (CRP), visual analogue scale (VAS), Oswestry disability index (ODI), and Kyphosis angle were recorded and compared; the nerve function was evaluated by American Spinal Injury Association (ASIA). ?The mean operation time, intraoperative blood loss, and hospitalization time were 184 minutes (range, 165-220 minutes), 231 mL (range, 150-800 mL), and 18 days (range, 12-26 days) respectively. No complication of hematoma or wound dehiscence was found. All patients were followed up 17.9 months on average (range, 9-22 months). No bone graft failure, internal fixation broken, pleural effusion, cerebrospinal fluid leakage, wound infection, fistula formation, and other complications occurred. Satisfactory intervertebral fusion was obtained in all patients at 3-8 months (mean, 5.3 months) after surgery. The ESR, CRP, VAS score, ODI score, and Kyphosis angle were significantly improved at immediate after operation and last follow-up when compared with preoperative ones (P<0.05), and the ESR, CRP, VAS score and ODI score at last follow-up were significantly better than those at immediate after operation (P<0.05). At last follow-up, the nerve function was recovered to ASIA grade E from grade C (1 case) and grade D (6 cases). ?Intertransverse bone graft is a reliable, safe, and effective way of bone graft applied to the single segmental thoracic spinal tuberculosis.

Is the size of the acetabular bone lesion a predictive factor for failure in revisions of total hip arthroplasty using an impacted allograft?

ObjectiveThe aim of this study was to determine the acetabular bone lesion size (in millimeters) from which impacted bone graft failure starts to occur more frequently, through simple anteroposterior hip radiographs, and whether measurement of the defect on simple radiographs maintains the same pattern in inter and intraobserver assessments. MethodsThirty-eight anteroposterior pelvic-view radiographs from patients undergoing revision of an acetabular prosthesis were retrospectively analyzed and assessed. In the vertical plane, the bilacrimal line was measured in millimeters from the farthest point found on the bone edge of the acetabular osteolysis to the top edge of the cementation or of the acetabular implant in uncemented cases. The base was taken to be a line perpendicular to bilacrimal line, with the aim of eliminating any pelvic tilt effects. This measurement was named the vertical size of failure. Radiographs produced four years after the operation were analyzed to investigate any failure of the technique. ResultsThe graft failure rate in the study group was 26.3%. The failures occurred in cases with an initial bone defect larger than 11mm. No cases with measurements smaller than this evolved with failure of the revision. The highest incidence of graft failure occurred in cases described as advanced according to the “Paprosky” classification. ConclusionFailure of acetabular revision arthroplasty using an impacted graft did not present any statistically significant correlation with the vertical extent of the lesion on simple anteroposterior radiographs, as a predictor of treatment failure.

Investigating Clinical Failure of Bone Grafting through a Window at the Femoral Head Neck Junction Surgery for the Treatment of Osteonecrosis of the Femoral Head.

AimsThis study aimed to analyze the clinical factors related to the failure of bone grafting through a window at the femoral head-neck junction.MethodsIn total, 119 patients (158 hips) underwent bone grafting for treatment of avascular necrosis of the femoral head. The patients were classified by their ARCO staging and CJFH classification. All patients were clinically and radiographically followed up every three months during the first year and every six months in the following year. The clinical follow-up comprised determination of pre- and postoperative Harris hip scores, while serial AP, frog lateral radiographs, and CT scan were used for the radiographic follow-up.ResultsThe clinical failure of bone grafting was observed in 40 patients. The clinical failure rates in patients belonging to ARCO stage II period, IIIa, and III (b + c) were 25.9%, 16.2%, and 61.5%, respectively, while those in patients belonging to (C + M + L1) type and L2, L3 type disease groups were 1.7%, 38.9%, and 39%, respectively. The clinical failure rates in patients aged below 40 and those aged 40 and over were 20.5% and 39.0%, respectively (all P < 0.05).ConclusionDisease type, disease stage, and patient age are risk factors for failure of bone graft surgery. Patients belonging to ARCO stage II and IIIa showed a good overall response rate, while patients belonging to ARCO stage IIIb and IIIc and those with necrotic lesions involving the lateral pillar (L2 and L3 type) showed high surgical failure rates.

O tamanho da lesão óssea acetabular é fator preditivo para a falha nas revisões de artroplastia total do quadril com enxerto impactado?

ObjectiveThe aim of this study was to determine the acetabular bone lesion size (in millimeters) from which impacted bone graft failure starts to occur more frequently, through simple anteroposterior hip radiographs, and whether measurement of the defect on simple radiographs maintains the same pattern in inter and intraobserver assessments. MethodsThirty‐eight anteroposterior pelvic‐view radiographs from patients undergoing revision of an acetabular prosthesis were retrospectively analyzed and assessed. In the vertical plane, the bilacrimal line was measured in millimeters from the farthest point found on the bone edge of the acetabular osteolysis to the top edge of the cementation or of the acetabular implant in uncemented cases. The base was taken to be a line perpendicular to bilacrimal line, with the aim of eliminating any pelvic tilt effects. This measurement was named the vertical size of failure. Radiographs produced four years after the operation were analyzed to investigate any failure of the technique. ResultsThe graft failure rate in the study group was 26.3%. The failures occurred in cases with an initial bone defect larger than 11mm. No cases with measurements smaller than this evolved with failure of the revision. The highest incidence of graft failure occurred in cases described as advanced according to the “Paprosky” classification. ConclusionFailure of acetabular revision arthroplasty using an impacted graft did not present any statistically significant correlation with the vertical extent of the lesion on simple anteroposterior radiographs, as a predictor of treatment failure.

Reconstructive approach to hostile cranioplasty: A review of the University of Chicago experience

Hostile sites for cranioplasty occur in patients with a history of radiation, infection, failed cranioplasty, CSF leak or acute infection. We review our series of autologous cranioplasties and present an approach to decision-making for reconstructing these complex defects. Patients with cranioplasty of a hostile cranial site at the University of Chicago between 2003 and 2012 were identified. They were stratified into three groups: chimeric free flap with vascularized bone (the vascular group), non-vascularized bone with local coverage (the non-vascular group) and non-vascularized bone with free flap (the mixed group). The primary outcome measure was a major complication in the year following cranioplasty, identified by flap or bone graft failure. We reviewed 33 cases; 14 "vascular", 13 "non-vascular", and 8 "mixed". There was no difference in flap or bone graft failure rates, which were 7% (1/14) for the vascular group, 8% (1/13) for the non-vascular group, and 0% for the mixed group (p = NS). Overall complication rate was statistically different between the three groups (p = 0.01). The non-vascular group had the lowest complication rate (31%). Based on our data we developed an assessment score (The University of Chicago CRAnial Severity Score of Hostility, CRASSH) for patient and treatment stratification. Vascularized, non-vascularized and mixed reconstructive methods can be used successfully in these challenging situations. We offer the CRASSH to aid in aligning patients with the most appropriate autologous reconstruction method for their hostile cranial sites.

Low Parathyroid Hormone Levels in Patients Who Underwent/Would Undergo Hemodialysis Result in Bone Graft Failure After Posterolateral Fusion

Case series. To reveal the association between levels of parathyroid hormone (PTH) and outcome of bone fusion in patients who underwent/would undergo hemodialysis. Among the different bone lesions observed in patients who underwent/would undergo hemodialysis, adynamic bone disease is regarded as a factor associated with bone graft failure because of severely reduced bone turnover. Although PTH levels reflect the pathological findings of bone lesions in patients who underwent/would undergo hemodialysis, the relationship between PTH levels and the outcome of bone fusion in patients who underwent/would undergo hemodialysis has not been investigated. Patients who underwent/would undergo hemodialysis (n = 48) with lumbar spine lesion underwent posterolateral spinal fusion with instrumentation. The outcome of bone fusion was assessed radiographically 12 months after surgery, and sensitivity and specificity were determined using preoperative PTH levels as the standard. A significant difference in PTH levels was observed between the good fusion (mean, 235.4 pg/mL) and poor fusion (mean, 100.0 pg/mL) groups. The intersection of the sensitivity and specificity plots, generated using preoperative PTH levels, was 150 pg/mL, and the area under the receiver operating characteristic curve was 0.72. Low PTH levels are a risk factor for bone graft failure in patients who underwent/would undergo hemodialysis. Accordingly, PTH level can be a useful predictor of the outcome of bone fusion. 4.

Alternative Approaches to Managing the Cleft Alveolus

The cleft alveolus component of the oral cleft deformity is addressed with a separate surgical stage. Several host and operator related factors affect the surgical outcome. When factors that increase the likelihood of secondary alveolar bone graft failure are identified, alterative methods like dentoalveolar distraction (DAD) may be employed. In infants, molding of the alveolar segments is possible and when a synergistic surgical approach is used, the possibility of successful alveolar cleft repair is increased. The authors present two case reports wherein the use of nasoalveolar molding (NAM) and DAD helped to tackle the alveolar cleft deformity.

Biomechanical comparison of three types of bone graft for anterior spondylodesis

Anterior spondylodesis with bone grafting for fusion of spinal motion segments is a common procedure in clinical routine. Bone grafts for fusion include autologous, allogenic and xenogenic grafts that are inserted in the unstable spinal motion segment. Nevertheless, biomechanical data for autologous, allogenic and xenogenic grafts are rare. The purpose of this study was to conduct biomechanical comparison of native and conserved bone grafts used in spondylodesis of the spine. Grafts examined were native ovine tricortical iliac crest grafts, bovine cancellous bone blocks and ovine, tricortical iliac crest grafts, conserved in the same way as the bovine cancellous bone blocks. The grafts were tested biomechanically to failure. Compared parameters were maximum torque, maximum rotation angle and graft stiffness at failure. The Mann-Whitney-U test with Bonferroni adjustment was used for statistical analysis. Maximum torque at failure of the bovine cancellous bone graft did not differ significantly from that of the native ovine tricortical graft. Comparison of the conserved ovine tricortical graft revealed significantly lower values compared to the native ovine tricortical bone graft.Maximum rotation angle at failure of the untreated ovine tricortical bone grafts was significantly higher compared to the other grafts tested. Regarding graft stiffness no significant differences were found. Based on the functional demands exerted on the spinal motion segment, our results suggest that torsional strength and deformational behavior of the bone graft influence the stability of the spondylodesis. The native tricortical graft best fulfills this requirement.

Assessment of Bone Grafts

Thank you for the latest copy of the ADJ. I read the articles with interest, in particular the scientific article regarding the assessment of bone grafts performed within a maxillofacial training programme.1 The article notes that 75 patients were included and 1.3% of them had diabetes mellitus. By my rough calculation that translates to 1 patient having diabetes mellitus out of 75. The article goes on to note that there were 10 graft failures, 1 of which was in the diabetes patient. It is not clear if the diabetes patient received multiple grafts and how many of them failed. The authors then find a statistically significant relationship between diabetes mellitus and graft failure. This brings to mind the phrase ‘there are three kinds of lies: lies, damned lies, and statistics’. (PS. I liked the editorial on plagiarism and I will happily admit that I don’t know who coined the phrase.)2 From a non-statistician’s perspective, just because the only diabetic patient in the study had a bone graft failure doesn’t mean that diabetes is a risk factor. If there had been multiple diabetic patients with failures and no or minimal diabetics with success, the statistics would make sense. In this study the number of diabetic patients appears to be too low for the statistics to yield a meaningful result. It appears to me that the desire to attribute a statistician’s number to a relationship has overruled a common sense approach. While diabetes may be a risk factor for the success of bone grafting, I do not think the article’s results support its conclusion about diabetes. May I suggest that statistics have their place but as with any tool it needs to be used appropriately.

Assessment of Bone Grafts: Authors’ Reply

We thank Dr Tan for his comments regarding our study. Statistics are used to test the validity of aims and hypotheses of a scientific study. Therefore, we used statistics to assess factors affecting the survival of bone grafts and these gave us a number of interesting and unexpected results.1 We agree the significance of diabetes was a surprise with the numbers involved, however it is consistent as a risk factor for bone graft failure, both in the clinical and scientific setting.2 The p value for this was 0.006 which is very significant. Diabetes is, however, not a contraindication for implant placement although significant complications related to risk of infection, can occur with placement of implants in diabetics with poor glycaemic control.3, 4 The other interesting finding the statistics revealed from our present study was that smoking was not a significant risk factor for graft failure. This was unexpected and counter-intuitive, particularly in relation to the vascularity issues required for revascularization related to smoking5 and the number of failures found in the smoking group. Some of these peculiarities with the statistical findings may be related to the modest numbers used in the study. We do, though, plan to revisit this topic when numbers are increased. This study was in effect, a preliminary audit of our results to date within the setting of an oral and maxillofacial surgical training programme. With statistics, you win some and you lose some, but they are there to serve a purpose. Sometimes you get some unexpected results, but these aren’t lies, they are just unexpected. If these results are relevant to the aims of the study, then they should be included.

A case of application of bone transport and bone graft using Auto-tooth bone for alveolar cleft repair

Introduction: Secondary autogenous cancellous bone grafting is a widely used method for the treatment of alveolar clefts and oronasal fistulae. However, failure of iliac bone grafting sometimes occurs due to inadequate covering with the surrounding soft tissue and marked scar formation, or large clefts. We report a case of application of the combination for alveolar cleft repair of Maxillary bone transport surgery and Auto-tooth bone graft system using autogenous extracted teeth developed in Korea.

Fixed Rehabilitation of Severely Atrophic Jaws Using Immediately Loaded Basal Disk Implants After In Situ Bone Activation

Rehabilitation of severely atrophic jaws is facilitated when basal disk implants are used after activation of the future bony implant bed with a purpose-designed instrument (Osteotensor) 45 to 90 days before implant surgery. Fabrication of a highly rigid, screw-secured fixed prosthesis that acts as an external orthopedic fixator permits immediate functional loading. This protocol also represents a second chance for patients who have experienced complete implant loss and/or bone graft failure.

Maxillary Sinus Augmentation Following Removal of a Maxillary Sinus Pseudocyst After a Shortened Healing Period

Dome-shaped radiopacities on the floor of the maxillary sinus are commonly interpreted as a sinus cyst on radiographs during dental implant planning. They might present an obstacle in sinus grafting, leading to bone graft failure or implant loss later. The therapeutic approaches to the removal of such cystic lesions and the following sinus augmentation are still controversial. The purpose of this article is to present a modified technique that can be used for predictable removal of a maxillary sinus cyst and sinus augmentation after a shortened healing period in patients with maxillary sinus pseudocysts. A total of 11 patients with a mean age of 43.7 years with a radiographic dome-shaped opacity in the posterior maxilla sinus were included in this study. A lateral sinus window (with a diameter of about 5 mm) was prepared, and removal of the cyst was performed with grasping forceps. Three months after removal of the cyst, a conventional sinus augmentation with xenogeneic material was undertaken. Dental implants were placed 6 months later. Panoramic radiography and coronal/axial computed tomography were performed to diagnose the sinus lesion preoperatively and for follow-up. A total of 11 pseudocysts were removed from the sinuses of 11 patients under local anesthesia. Histologic evaluation showed antral pseudocysts in all specimens. A soft tissue scar was evident after 3 months of healing at the time of sinus augmentation. No sinus membrane perforation was seen or occurred during the sinus augmentation. A total of 17 implants were placed and restored prosthetically. No clinical complications were observed. The patients were followed up for a mean of 29.2 months (range, 17-43 months) after prosthetic loading, during which no implants were lost and no recurrence of the antral pseudocyst was observed. The described modified surgical technique allows the minimally invasive removal of the antral pseudocyst and histologic verification of the diagnosis without compromising the nasoantral entrance as well as the anatomy of the sinus for future sinus augmentations. It can be performed under local anesthesia without endoscopic equipment while shortening the treatment period.

Effects of Acquired Glenoid Bone Defects on Surgical Technique and Clinical Outcomes in Reverse Shoulder Arthroplasty

Reverse total shoulder arthroplasty is the accepted method of treatment for selected shoulder disorders. The purpose of this study was to compare primary reverse shoulder arthroplasty surgical techniques as well as clinical and radiographic outcomes in patients with acquired glenoid bone defects and in those with normal glenoid morphology. Preoperative three-dimensional computed tomography scans were performed on 216 shoulders in 211 patients undergoing primary reverse shoulder arthroplasty between 2004 and 2007. The glenoids were classified as normal or abnormal on the basis of preoperative radiographs and three-dimensional reconstructions of the scapula. One hundred and forty-three shoulders had been followed for two years. There were eighty-seven normal and fifty-six abnormal glenoids. The surgical techniques that were compared included bone-grafting and glenosphere selection. The clinical outcomes for the two groups were compared with respect to the American Shoulder and Elbow Surgeons score. Surgical technique differed between the groups. All fifty-six glenoids with acquired bone defects had center screw placement along an alternative (scapular spine) centerline. A bone graft was used in twenty-two shoulders with acquired glenoid bone defects compared with none of those with normal glenoid morphology (p = 0.016). Shoulders with glenoid defects were treated with larger glenospheres (36 or 40 mm) more often than those with normal glenoids (p < 0.001). No significant difference was detected between the groups with regard to the preoperative or postoperative American Shoulder and Elbow Surgeons scores. Radiographs did not demonstrate failure or resorption of a glenoid bone graft when present. All outcomes improved significantly postoperatively. There were five complications, and one patient was unsatisfied with the result. Glenoid bone defects, when managed with an alteration of surgical technique, including bone-grafting when indicated, are not a contraindication to reverse total shoulder arthroplasty.

Intraoral Distraction of Segmental Osteotomies and Miniscrews in Management of Alveolar Cleft

Management of a wide alveolar cleft and alveolar bone graft failure is among the most difficult tasks for both surgeon and orthodontist. This article aims to introduce the techniques of intraoral distraction of segmental osteotomy for solving a wide alveolar cleft, and orthodontic management with miniscrews for solving alveolar bone graft failure; and also to evaluate the feasibility and clinical results of moving teeth into alveolar clefts. Interdental distraction osteogenesis was performed to minimize the alveolar cleft before alveolar bone grafting in 21 patients whose alveolar cleft was wider than a maxillary canine. All clefts were successfully approximated, and the 4- to 5-year results were shown to be stable. In addition, orthodontic protraction of the buccal teeth by using miniscrews as a temporary anchorage device was performed in 13 cases to minimize and/or eliminate the residual bony bridge or alveolar cleft after the previous failure of an alveolar bone graft. The buccal teeth were protracted with intermittent light continuous force. The results revealed that the residual bony bridges or alveolar clefts were minimized and that the space of the cleft was completely closed. The periodontal apparatus of the teeth that were moved into the residual bony bridge or alveolar cleft remained similar before and after the treatment. The orthodontic tooth movement into a residual alveolar cleft is clinically feasible in certain circumstances. However, the long-term status of the periodontal apparatus of the teeth that were moved into the alveolar cleft should be monitored.

Total knee replacement – the evolving sub-Saharan experience

Patients with moderate to severe osteoarthritis of the knee underwent primary elective knee arthroplasty in a well-equipped hospital in Accra, Ghana. Our main outcome measures was the new modified Oxford Knee scores (preoperative and postoperative scores). Median preoperative and postoperative knee scores were 10 and 42.5, respectively, at last follow-up with a P value<0.05 showing the reliability and significance of the scores. The average duration of inpatient hospital stay was 10 days. Of the seven patients who had surgery, one patient developed a chest infection postoperatively and another had failure of bone graft and required a revision. There was no postoperative wound infection or joint instability. The clinical outcome for this series of patients among other factors has been good within the prevailing circumstances and this shows that knee arthroplasty in developing Africa is a reality in the horizon.

Total Hip Arthroplasty in Patients with Bone Deficiency of the Acetabulum

Total hip replacement (THR) requires revision in only a minority of cases (approximately 17% of prosthetic hips fail), but when THR failures occur there may be significant acetabular bone deficiency. There is a variety of surgical hardware and strategies available to address this problem. The causes of primary THR revision include aseptic loosening or particle disease, infection, recurrent dislocation, implant failure, periprosthetic fracture, and leg length discrepancy. Almost all patients who need THR revision undergo a standard radiographic evaluation of the pelvis and hip. In general, CT is an excellent tool for evaluating loosening of the prosthesis caused by either mechanical reasons or infection, and MR imaging is best suited for evaluating the soft tissues surrounding the prosthesis. Nuclear medicine studies are performed when results of CT and MR imaging are inconclusive. When patients are evaluated for revision THR, radiologists must check for acetabular cup loosening, the amount and type of bone stock loss, the amount of component migration, and the presence or absence of liner wear. Before revision hardware is placed, bone stock loss must be repaired, either by using bone grafting or by placing accessory acetabular hardware such as cups, rings, or cages. The long-term success of revision acetabular surgery varies; there is acetabular cup presence at 5 years after surgery in 60%-94% of cases. Complications include postoperative infections, repeat liner wear, bone graft failure, periprosthetic or prosthetic fractures, dislocation, vascular injury, and nerve injury.

Detection of Bone Graft Failure in Lumbar Spondylodesis: Spatial Resolution with High-Resolution Peripheral Quantitative CT

In spinal surgery, anterior spondylodesis is often combined with bone grafting, and graft integration is assessed with CT. High-resolution peripheral quantitative CT offers a resolution of 82 mum. The aim of this study was to compare the outcome of anterior spondylodesis as assessed with three radiologic procedures. Monosegmental lumbar spondylodesis with autologous iliac crest graft or solvent-preserved bovine cancellous bone was performed on seven sheep. The fused spinal segments were explanted after 24 weeks and examined with clinical 64-MDCT, high-resolution peripheral quantitative CT, and contact radiography. In 2D views, the area of the disk space bridged by bone was assessed, and the grafts were examined for fractures. In three of seven sheep, clinical CT erroneously showed stable consolidation, whereas contact radiography revealed a clearly visible graft fracture, as did high-resolution peripheral quantitative CT. There was a statistically significant difference (p = 0.038) between bone volume assessed with clinical CT and that assessed with contact radiography. There was an almost significant difference (p = 0.053) between volumes assessed with high-resolution peripheral quantitative CT and clinical MDCT. High-resolution peripheral quantitative CT, a technique approved for clinical use, has higher resolution in imaging of bone structure than does 64-MDCT. Our results show that high-resolution peripheral quantitative CT is superior to 64-MDCT in assessing osseous implant integration after anterior spondylodesis. The specimen size limit, however, prohibits in vivo use of this method in evaluation of the human spine. Our results suggest that in clinical practice, persisting symptoms despite radiologic findings of consolidated spondylodesis may be related to graft failure, which cannot be detected with clinically available methods.

Oral Bisphosphonates and Dental Implants: A Retrospective Study

The objective of this retrospective study was to examine whether patients who take medications containing bisphosphonates (BPs) are at greater risk of bone graft and implant failure than other patients. This study involved the examination of 42 patients (101 implants) who had taken medications containing BPs prior to surgeries involving oral bone grafting or endosseous implant placement. Patients had been taking BP medications from 6 months to 11 years prior to implant surgery, and most continue to take these medications through the present time. Patients were examined to determine implant loss, changes in pocket depth bleeding on probing, the height of the ridge, and any evidence of osteonecrosis of the jaw. Five implants failed, giving a 95% success rate, which is comparable to the normal success rate of 96.5% by the same operator. No patient showed signs of osteonecrosis of the jaw. Patients who take oral BPs are no more at risk of implant or bone graft failure than other patients.