Bony Defects Research Articles

Clavicle nonunion

After conservative treatment nonunion (pseudarthrosis) of the clavicle can be observed approximately 10times more frequently (15-24%) than after surgical treatment (1.4%). Risk factors include the fracture location, displacement, fracture type, sex, the severity of the accident and refractures. The diagnosis of pseudarthrosis of the clavicle can be made by athorough medical history, clinical examination and imaging procedures. The main symptom is pain, often accompanied by malalignment, instability, neurological symptoms and restricted mobility of the affected shoulder. The diagnosis is confirmed by X‑ray images and, if necessary, acomputed tomography (CT) scan. Pseudoarthrosis is classified according to the morphological appearance in X‑ray images and the cause. A differentiation is made between vital and nonvital pseudarthroses. Only symptomatic pseudarthrosis requires treatment. Nonoperative methods, such as magnetic field therapy or ultrasound are minimally effective. Surgical interventions are indicated for pain, movement restrictions or neurovascular problems. The goals of surgical treatment are to restore the vitality, bone length and stability through angular stable osteosynthesis. In cases of surgical pretreatment the anteroinferior plate position offers agood alternative to the superior plate position. In some cases double plating osteosynthesis can be indicated. Autogenous bone material, allogeneic substitute material and vascularized grafts are used for bony defects. Surgical treatment shows high rates of healing but also carries an increased risk of infection.

The efficacy of reconstructive therapy in the surgical management of peri-implantitis: A 3-year follow-up of a randomized clinical trial.

To assess whether guided bone regeneration (GBR) treatment of peri-implantitis-related bony defects could improve healing compared to open flap debridement (OFD) at 36 months. In a multi-centre, randomized clinical trial, 32 individuals received OFD (control group [CG]) and 34 GBR treatment (test group [TG]). Radiographic defect fill (RDF), probing pocket depth (PPD), bleeding on probing (BOP) suppuration (SUP), mucosal recession (MREC) and patient-reported outcomes (PROs) were evaluated at 36 months. Fifty individuals attended a supportive peri-implant therapy program and completed the 36-month follow-up. GBR treatment resulted in an RDF of 2.13 ± 1.26 mm compared to 1.64 ± 1.54 mm following OFD (p = .18). No difference was found in PPD, BOP, SUP, REC or PROs between the groups. Successful treatment (no additional bone loss, PPD ≤ 5 mm, no BOP and no SUP) was achieved in 46.2% in TG and 20% in CG (p = .053). Treatment results obtained at 12 months were generally maintained up to 36 months. No significant changes were noticed between 12 and 36 months. At 36 months, treatment results obtained at 1 year were sustained following both GBR and OFD in patients attending supportive peri-implant therapy. GBR resulted in more RDF and higher composite treatment success rate than OFD (ClinicalTrials.gov Identifier [NCT02375750]).

Dentigerous Cysts in Children: Clinical, Radiological, and Healing Aspects.

Background and Objectives: Dentigerous cysts are one of the most frequent pathologies associated with unerupted or impacted teeth. Such cysts show a male predilection and a preference for the mandibular region. Also, they commonly occur in the second and third decades of life, with only 9% occurring in the first decade. The aim of this work is to apply and study the therapeutic algorithms developed for dentigerous cysts and their outcomes, from the early diagnostic stage to the complete healing phase of pediatric patients diagnosed with this medical condition. Materials and Methods: The study included 19 pediatric patients diagnosed with dentigerous cysts who underwent the enucleation and extraction or conservative attitude of the associated tooth. The bony healing was also followed-up 9 months after the surgery. Results: A higher incidence in the posterior area of the mandible and maxilla was observed, as well as a higher incidence in boys. The 9 months postoperative radiographic assessment showed that the bony defects were completely healed. Conclusions: A thorough understanding of the nature of the lesion backed by a good clinical history and by state-of-the-art radiographic and radiologic examinations can go a long way in helping the surgeon to choose the correct therapeutic approach and to ameliorate the medical condition in the best long-term interest of the young patient. The considered dentigerous cyst cases demonstrated that an early diagnosis and treatment of this pathology is followed by a responsive treatment.

Healthy and diabetic primary human osteoblasts exhibit varying phenotypic profiles in high and low glucose environments on 3D-printed titanium surfaces.

The revolution of orthopedic implant manufacturing is being driven by 3D printing of titanium implants for large bony defects such as those caused by diabetic Charcot arthropathy. Unlike traditional subtractive manufacturing of orthopedic implants, 3D printing fuses titanium powder layer-by-layer, creating a unique surface roughness that could potentially enhance osseointegration. However, the metabolic impairments caused by diabetes, including negative alterations of bone metabolism, can lead to nonunion and decreased osseointegration with traditionally manufactured orthopedic implants. This study aimed to characterize the response of both healthy and diabetic primary human osteoblasts cultured on a medical-grade 3D-printed titanium surface under high and low glucose conditions. Bone samples were obtained from six patients, three with Type 2 Diabetes Mellitus and three without. Primary osteoblasts were isolated and cultured on 3D-printed titanium discs in high (4.5 g/L D-glucose) and low glucose (1 g/L D-Glucose) media. Cellular morphology, matrix deposition, and mineralization were assessed using scanning electron microscopy and alizarin red staining. Alkaline phosphatase activity and L-lactate concentration was measured in vitro to assess functional osteoblastic activity and cellular metabolism. Osteogenic gene expression of BGLAP, COL1A1, and BMP7 was analyzed using reverse-transcription quantitative polymerase chain reaction. Diabetic osteoblasts were nonresponsive to variations in glucose levels compared to their healthy counterparts. Alkaline phosphatase activity, L-lactate production, mineral deposition, and osteogenic gene expression remained unchanged in diabetic osteoblasts under both glucose conditions. In contrast, healthy osteoblasts exhibited enhanced functional responsiveness in a high glucose environment and showed a significant increase in osteogenic gene expression of BGLAP, COL1A1, and BMP7 (p<.05). Our findings suggest that diabetic osteoblasts exhibit impaired responsiveness to variations in glucose concentrations, emphasizing potential osteoblast dysfunction in diabetes. This could have implications for post-surgery glucose management strategies in patients with diabetes. Despite the potential benefits of 3D printing for orthopedic implants, particularly for diabetic Charcot collapse, our results call for further research to optimize these interventions for improved patient outcomes.

Poster 152: Clinical Outcomes for Dermal Allograft Glenoid Augmentation in Patients With Anterior Shoulder Instability and Subcritical Bone Loss

Objectives: To assess minimum 1-year magnetic resonance imaging (MRI) and clinical outcomes for 20 cases of dermal allograft augmentation of subcritical glenoid bony defects. Methods: Twenty patients with subcritical glenoid bone loss underwent arthroscopic dermal allograft augmentation along with labral repair. All patients were evaluated with postoperative MRI at a minimum of 12-month follow-up. Preoperative and postoperative patient-reported outcomes were collected including University of California Los Angeles Shoulder (UCLA) scores, Visual Analogue Scale (VAS) scores, and American Shoulder and Elbow Surgeons (ASES) scores. Scores were assessed for statistical significance using the analysis of variance test. Results: Average postoperative follow-up was 19 months (range 12-54 months). The average preoperative bony defect size was 16% (range 6.6-39%), with 19 of the patients having defects under 20%. Postoperative MRIs (Figure 1) revealed an average of 32% (range 27.7-37.4%) increase in glenoid diameter size and the average glenoid size was restored to 102.3% (range 94-114%), with excellent incorporation of the graft. There were statistically significant improvements in preoperative and postoperative scores with respect to UCLA scores (21.25 to 33.7, p &lt; 0.05), VAS scores (5.4 to 0.2, p &lt; 0.05) and ASES scores (58.6 to 96.4, p &lt; 0.05). One patient had a recurrent traumatic dislocation (5%) and underwent a Latarjet procedure at 13 months from the index surgery. At the time of the Latarjet, the dermal allograft was harvested and sent for histologic analysis. Histologic analysis of the glenoid augmentation graft at the time of revision surgery revealed recellularization with fibroblast-like cells, revascularization, and incorporation of the graft into the surrounding tissue with bony ingrowth. (Figure 2) Conclusions: Subcritical glenoid bone loss has been associated with high failure rates when treated with standard labral repair. While a Latarjet procedure can provide stability, high complication rates and the risk of long-term arthritis makes this procedure less than ideal when bone loss is under 20%. Arthroscopic labrum repair with the addition of a dermal allograft is a viable option in patients with subcritical bone loss. In the case series with 1-year follow-up, 20 patients who underwent arthroscopic labrum repair with the addition of a dermal allograft had a significant improvement in outcome scores, and excellent incorporation of the graft as seen on MRI at 12 months from the index procedure. In the 1 failure that later underwent revision surgery, histologic analysis demonstrated recellularization and revascularization, with incorporation of the graft.

IMPACTION BONE GRAFTING OF LARGE DEFECTS IN ANKLE AND HINDFOOT FUSIONS

BackgroundAnkle and hindfoot fusion in the presence of large bony defects represents a challenging problem. Treatment options include acute shortening and fusion or void filling with metal cages or structural allograft, which both have historically low union rates. Impaction grafting is an alternative option.MethodsA 2 centre retrospective review of consecutive series of 32 patients undergoing hindfoot fusions with impaction bone grafting of morselised femoral head allograft to fill large bony void defects was performed. Union was assessed clinically and with either plain radiography or weightbearing CT scanning. Indications included failed total ankle replacement (24 patients), talar osteonecrosis (6 patients) and fracture non-union (2 patients). Mean depth of the defect was 29 ±10.7 mm and mean maximal cross-sectional area was 15.9 ±5.8 cm2. Tibiotalocalcaneal (TTC) arthrodesis was performed in 24 patients, ankle arthrodesis in 7 patients and triple arthrodesis in 1 patient.ResultsMean age was 57 years (19–76 years). Mean follow-up of 22.8 ±8.3 months. 22% were smokers. There were 4 tibiotalar non-unions (12.5%), two of which were symptomatic. 10 TTC arthrodesis patients united at the tibiotalar joint but not at the subtalar joint (31.3%), but only two of these were symptomatic. The combined symptomatic non-union rate was 12.5%. Mean time to union was 9.6 ±5.9 months. One subtalar non-union patient underwent re-operation at 78 months post-operatively after failure of metalwork. Two (13%) patients developed a stress fracture above the metalwork that healed with non-operative measures. There was no bone graft collapse with all patients maintaining bone length.ConclusionImpaction of morselised femoral head allograft can be used to fill large bony voids around the ankle and hindfoot when undertaking arthrodesis, with rapid graft incorporation and no graft collapse despite early loading. This technique offers satisfactory union outcomes without the need for shortening or synthetic cages.

Enamel matrix derivative proteins used for regeneration of bony defects in periodontitis

EDITORIAL

Pulsatile Tinnitus: Differential Diagnosis and Approach to Management.

The purpose of this review is to provide an updated approach to the evaluation and management of pulsatile tinnitus (PT), an uncommon but often treatable subtype of tinnitus. Secondary PT can be due to either vascular or non-vascular etiologies, including, but not limited to: neoplasm, arteriovenous malformation or fistula, idiopathic intracranial hypertension, dural venous sinus stenosis, otoacoustic etiologies (e.g., otosclerosis, patulous eustachian tube) and bony defects (e.g., superior semicircular canal dehiscence). Computed tomography (CT) and magnetic resonance imaging (MRI) imaging have comparable diagnostic yield, though each may be more sensitive to specific etiologies. If initial vascular imaging is negative and a vascular etiology is strongly suspected, digital subtraction angiography (DSA) may further aid in the diagnosis. Many vascular etiologies of PT can be managed endovascularly, often leading to PT improvement or resolution. Notably, venous sinus stenting is an emerging therapy for PT secondary to idiopathic intracranial hypertension with venous sinus stenosis. Careful history and physical exam can help establish the differential diagnosis for PT and guide subsequent evaluation and management. Additional studies on the efficacy and long-term outcome of venous sinus stenting for venous stenosis are warranted.

Are Cellular Bone Matrix Allografts a Viable Option for Mandibular Tissue Engineering and Reconstruction?

BackgroundTraditional mandibular reconstruction has relied on the use of vascularized and non-vascularized autografts. The use of allografts and tissue engineering modalities has risen as an alternative. PurposeThe purpose of this study was to determine the success of a cellular bone matrix (CBM) allograft composed of lineage committed bone forming cells for mandibular tissue engineering and reconstruction. Study design, setting, sampleA retrospective cohort study was implemented using data from subjects treated with a CBM at the University of Louisville from 2019 to 2023. Subjects were excluded if they were not treated with a CBM, data were not complete, or postoperative follow-up time was less than 3 months. Predictor variablesThe predictor variables were composed of heterogenous variables grouped into the following categories: demographics (age, sex), medical history (history of penicillin (PCN) allergy, history of diabetes mellitus (DM) and tobacco use), etiology (benign tumor, ballistic trauma, non-ballistic trauma, odontogenic cyst, osteomyelitis/MRONJ), mandibular resection length (cm) and type (marginal, segmental), delayed vs immediate reconstruction, and whether an autograft (proximal tibia, TBG) with platelet rich fibrin (PRF) was used in combination with the CBM. Main outcome variableThe primary outcome variable was graft success (yes or no). Success was defined as bony union and defect fill (demonstrated on panoramic radiograph) and mandibular stability (based on postoperative clinical examination at 3 months). CovariatesNot applicable. AnalysesDescriptive statistics were calculated for each variable. To measure the associations between the risk factors and graft success, Fisher’s exact test for categorical variables and the Wilcoxon rank sum test for numeric data were used. A p-value of <0.05 was considered significant. ResultsThe sample included 38 subjects. The median age of all subjects was 46 (IQR 32.6) years. Overall, 28 (73.7%) cases were successful. Subjects with a reported PCN allergy or a history of DM had significantly lower success (2, 7.1% with PCN allergy or DM) compared to those who did not (p = 0.008, PCN allergy; p = 0.03, DM). Conclusions and RelevanceThis is the largest case series of CBM based mandibular reconstruction relative to the available maxillofacial surgery literature. The clinician should consider confirmation of penicillin allergy so penicillin-type antibiotics can be used. CBMs may be an alternative to autografts.

Effect of Local Simvastatin on the Healing of Surgically Created Critical-Sized Bone Defects: An experimental Study on sheep.

Background and objective: the role of simvastatin in lowering serum cholesterol levels is well described. However, recent findings suggest they have a role in bone formation as well. The study aims to determine the effect of local simvastatin application on bone defect healing and compare the amount of new bone produced by a simvastatin-treated defect with that produced by a bone graft (biphasic calcium phosphate) and non-treated defects (left empty) histologically. Methods: Forty-five critical-size defects were created (8mm in diameter and depth) in the iliac bone of 6 sheep. For the first three sheep (5 defects/ilium), the five defects on the right ilium were left empty as a Control group, while the five defects on the left ilium were filled with biphasic calcium phosphate as Test 1 group. For the other three sheep, 5 defects were created on the right ilium, the defects were filled with 10mg crushed simvastatin tablet with gelfoam (as a carrier) as Test 2 group. The animals were sacrificed over periods of 1, 2, and 3 months. Histopathological studies were done for all the samples. SPSS version 28 was used to analyze the results. The numerical variables were checked for normality using Smirnov – Kolmogorov test, then analyzed using ANOVA and unpaired t-test (p–values ≤ 0.05 were considered statistically significant). Results: All 6 adult male sheep passed the scheduled periods uneventfully. During the wound healing period, there was no complication such as infection, excessive hematoma, or wound dehiscence. All 45 standardized iliac bone defects were included in the final analysis (n= 45). The histologic results showed that Test 2 group (defect filled with simvastatin) in the 1st, 2nd, and 3rd months had significantly higher bone formation at the surface and depth of the defects than Test 1 and Control group with P values (&lt;0.0001) at all period intervals. Conclusion: Simvastatin enhances bone formation and accelerates the healing process of the bony defect. Keywords: Bone formation, Bone graft, Bone healing, Simvastatin, Statin.

Clinical and Radiographic Outcomes and Graft Incorporation Rate Assessed by CT Scan After Reverse Shoulder Arthroplasty With Glenoid Structural Bone Graft Reconstruction.

Reverse total shoulder arthroplasty (RTSA) with structural bone graft has been described as a technique in addressing glenoid bony defects. Studies have demonstrated acceptable outcomes with structural autograft or allograft. However, most of these studies are relatively small and rarely evaluate bone graft incorporation with CT scan. The aim of this study was to assess clinical and radiographic outcomes and report graft incorporation assessed on CT scan after RTSA where structural bone autograft or allograft was used to reconstruct the glenoid. From May 2011 through June 2016, 38 patients underwent RTSA with structural bone graft. Of these, 35 were available for a minimum 2-year follow-up and retrospectively enrolled. From July 2016 through February 2019, 32 patients undergoing RTSA with structural bone graft were prospectively enrolled. Preoperative and postoperative American Shoulder and Elbow Surgeons and visual analog scale (for pain) scores and radiographs were obtained. CT scan was obtained at least 1 year postoperatively. Thirty-five patients were enrolled retrospectively (52.2%) and 32 prospectively (47.8%). Autograft was used in 46 cases (68.7%) and allograft in 21 cases. The mean American Shoulder and Elbow Surgeons score improved from 33.1 (SD 18.5) to 78.2 (SD 22.4), with P < 0.0001. On postoperative radiographs, 63 cases (94.0%) showed stable RTSA constructs while four cases (6.0%) developed glenoid baseplate subsidence. Postoperative CT scan demonstrated complete graft incorporation in 45 cases (90.0%) while partial incorporation was noted in 4 cases (8.0%), and in 1 case (2.0%), there was no graft incorporation. No correlation was observed between baseplate subsidence and graft type (autograft versus allograft) or primary versus revision surgery. Reverse shoulder arthroplasty with structural bone autograft and allograft is reliable for glenoid augmentation in patients undergoing RTSA in both primary and revision settings. Bony incorporation of autograft and allograft as evaluated on CT scan is predictably high.

Glenoid Concavity Affects Anterior Shoulder Stability in an Active-Assisted Biomechanical Model.

The treatment of bony glenoid defects after anteroinferior shoulder dislocation currently depends on the amount of glenoid bone loss (GBL). Recent studies have described the glenoid concavity as an essential factor for glenohumeral stability. The role of glenoid concavity in the presence of soft tissue and muscle forces is still unknown. Glenoid concavity would have a major impact on glenohumeral stability in an active-assisted biomechanical model including soft tissue and the rotator cuff's compression forces. Controlled laboratory study. In 8 human shoulder specimens, individual coordinate systems were calculated based on anatomic landmarks. The glenoid concavity was measured biomechanically and based on computed tomography. Static load was applied to the rotator cuff tendons and the deltoid muscle. In a robotic test setup, anteriorly directed force was applied to the humeral head until translation of 5 mm (Nant) was achieved. Nant was used as a parameter indicating shoulder stability. This was performed in the following testing stages: (1) intact joint, (2) labral lesion, (3) 10% GBL, and (4) 20% GBL. The 8 specimens were divided equally into 2 subgroups (low concavity [LC] versus high concavity [HC]), with 4 specimens each, according to the previously measured concavity. Anterior glenohumeral stability was highly correlated with the native glenoid concavity (R 2 = 0.8). In the testing stages 1 to 3, we found a significantly higher mean stability in the HC subgroup compared with the LC subgroup (P≤ .0142). The HC subgroup still showed higher absolute Nant values with 20% GBL; however, there was no significant difference from the LC subgroup. The loss of stability in 20% GBL was correlated with the initial concavity (R 2 = 0.86). Thus, a higher loss of Nant in the HC subgroup was observed (P = .0049). In an active-assisted model with intact soft tissue surrounding and muscular compression forces, the glenoid concavity correlates with shoulder stability. In bony defects, loss of concavity is an essential factor causing instability. Due to their significantly higher native stability, glenoids with HC can tolerate a higher amount of GBL. Glenoid concavity should be considered in an individualized treatment of bony glenoid defects. Further studies are required to establish reference values and develop therapeutic algorithms.

Endoscopic transorbital approach to the petrous apex: is orbital rim removal worthwhile for the exposure? An anatomical study with illustrative case.

The endoscopic transorbital approach (ETOA) has been demonstrated to be a feasible ventral route to the petrous apex. Yet, it has been pointed to as a deep and narrow corridor for anterior petrosectomy; particularly, medialization of the instruments can become an issue when targeting the petroclival area. To overcome this limitation, an ETOA with orbital rim removal (ETOA-OR) has been suggested, but not de facto compared, with a transorbital approach without removal of the rim. This addition could augment the surgical exposure and freedom of movement when accessing the petrous apex area. Five human cadaveric heads (10 sides) were dissected. First, anterior petrosectomy was performed via a conventional ETOA (without orbital rim removal). Second, en bloc removal of the orbital rim was performed, with enlargement of the orbital craniectomy and, subsequently, further drilling of the medial petrous apex. Qualitative and quantitative comparisons are provided. An illustrative surgical case is also shown. The transorbital route allowed the authors to perform an anterior petrosectomy in all specimens. The landmarks of bone removal are superposed onto those in the transcranial route. The ETOA-OR increased the volume of craniectomy (from 4.0 mL to 5.5 mL), the lateromedial angulation, and superoinferior angulation of the instruments within the petrous area. Thus, this approach improved the exposure of the medial petroclival area, allowing for an augmented petrosectomy (from 1.4 mL to 2.0 mL, 39.5% increase) and for increased maneuverability, both in the petrous area (from 44.1 cm2 to 76.5 cm2, 73.3% increase) and in the posterior fossa (from 20.2 cm2 to 52.0 cm2, 158% increase). The ETOA-OR was also pragmatically applied to treat a recurrent petroclival meningioma. Complete removal was achieved, the abducens nerve palsy improved, and the trigeminal neuralgia decreased in severity, yet still required medication. The authors provide the first formal anatomical comparison between the transorbital approach with preservation of the orbital rim and a transorbital approach with removal of the rim to access the petrous apex. In addition, an illustrative case is used as a proof of concept and feasibility. According to the authors' data, the ETOA-OR significantly improves surgical exposure and the surgeon's comfort in this deep region. The bony defect can be reconstructed to avoid cosmetic deformities, maintaining the minimally disruptive concept of transorbital surgery.

The MOCART (magnetic resonance observation of cartilage repair tissue) 2.0 Ankle Score

ObjectivesThe aim of this study was to introduce the MOCART 2.0 ankle score and evaluate its utility and reproducibility for the radiological assessment of cartilage repair tissue in the ankle joint.MethodsThe MOCART 2.0 ankle score evaluates seven individual variables, including “volume fill of (osteo)chondral defect,” “Integration into adjacent cartilage and bone,” “surface of the repair tissue,” “signal intensity of the repair tissue,” “bony defect and bony overgrowth,” “presence of edema-like-marrow signal,” and “presence of subchondral cysts.” Overall, a MOCART 2.0 ankle score between 0 and 100 points may be reached. Two independent readers assessed the 3-T MRI examinations of 48 ankles, who had undergone cartilage repair of a talar cartilage defect using the new MOCART 2.0 ankle score. One of the readers performed two readings. Intra- and interrater reliability were assessed using intraclass correlation coefficients (ICCs) for the overall MOCART 2.0 ankle score.ResultsForty-eight ankles (mean age at surgery 30.2 ± 11.2 years) were evaluated. The overall interrater (ICC = 0.75; 95%CI 0.60–0.85), as well as the intrarater (ICC = 0.83; 95%CI 0.72–0.90) reliability of the MOCART 2.0 ankle score was good. For individual variables the interrater reliability ranged from a kappa value of 0.29 (95%CI 0.01–0.57) for “surface of the repair tissue” to 0.83 (95%CI 0.71–0.95) for “presence of subchondral cysts”.ConclusionsThe newly introduced MOCART 2.0 ankle score, which encompasses the distinct anatomy of the ankle joint, demonstrates good intra- and interrater reliability.Critical relevance statementThe newly introduced MOCART 2.0 ankle score may facilitate the standardized assessment of cartilage repair in the ankle joint and allow an objective comparison of the morphological outcome between alternative treatment options and between different studies.Key PointsThis study introduces the MOCART 2.0 ankle score.The MOCART 2.0 ankle score demonstrated good intra- and interrater reliability.Standardized reporting may improve communication between radiologists and other physicians.Graphical

Decision Tree for Reconstructive Treatment of Peri-implantitis Defects.

Peri-implantitis, a common complication among patients receiving implant-supported restorative therapy, often requires surgical intervention for effective treatment. Understanding the specific configuration of peri-implant bony defect and adjacent bone peaks is crucial for tailoring treatment strategies and improving outcomes. A decision tree for reconstructive peri-implantitis therapy has been developed based on the new classification of defect configurations (Class I to V), guiding clinicians in selecting treatment options, including biomaterials, techniques, and healing approaches. Furthermore, clinicians are encouraged to consider various factors such as local predisposing factors (such as soft tissue characteristics, prosthetic design, and implant position in three-dimensional perspective), clinical factors (surgeon skill and experience), and patient-related factors (such as local and systemic health, preferences, and cost) when evaluating reconstructive therapy options.

Selective ion doping core-shell bioceramic fiber-derived granules readily tuning biodegradation and initiating osteoporotic bone defect repair

Osteoporotic bone defect repair is one of the challenges in orthopedics because there are no preferable biomaterials to readily initiate new bone regeneration in critical-size pathological bone damage. Our previous studies revealed that core–shell Ca-phosphate/silicate microspheres can tune time-evolving biodegradation, which is beneficial for modulating bone repair. Herein, we expanded this strategy to develop core–shell-type 5 % Sr- and 8 % Zn-doped wollastonite fiber-derived granules with different porosities (0 %, 10 %, 20 %) in the shell layer. Physicochemical analyses indicated that granules with higher porosity in the shell layer exhibited more appreciable Sr and Zn ion release and biodissolution in vitro. Osteoporotic femoral bony defects in rabbits were used to verify the osteogenic efficacy of the core–shell granules. The granules with 10 % porosity could initiate more osteogenesis within 6 weeks, and the new bone tissue could grow into the defect region, while the new bone tissue only migrated into the periphery pores under the other granule conditions. Histological evaluation also revealed appreciable new bone ingrowth in the granules with 10 % porosity, whereas the other implant groups had limited new bone tissue. These findings demonstrate that bone repair initiation can be enhanced by finely designed local porosity in specific components of core–shell bioceramic fiber-tailoring granules to control bioactive ion release and osteo-stimulation in vivo; moreover, such bioceramic fabrication is promising for developing osteo-stimulative implants to resolve clinically challenging bone defect repair.

Versatility of the medial corticoperiosteal flap: from recalcitrant non-unions up to large bony defects.

Reconstructive microsurgery techniques using vascularized bone grafts have revolutionized the treatment of complex cases associated with recalcitrant non-unions or osteomyelitis. The medial femoral corticoperiosteal flap (MFCP flap) has emerged as a valuable option in bone reconstruction. Its clinical applications have been extended over the years considering this flap from non-unions with minimal bone lost, up to large intercalary defects of the upper and lower extremities. This article aims to present the clinical applications and outcomes of the MFCP flap in various reconstructive scenarios. Seventy-nine patients with persistent non-union and bone defects of the upper and lower limb were evaluated from June 2008 to October 2020. All of them were reconstructed with a corticoperiosteal flap from the medial femoral condyle in our hospital. Previous procedures, bone gap and type of flap used were recorded. Postoperative functional status was assessed with time of bone healing, complications and clinical final outcome. Radiological evidence of bone union was observed at 4.09months (range 2-9). Healing rate was 97% with periosteal corticocancellous flaps (PCC flaps) and 93% with corticoperiosteal flaps (CP flaps). Average follow-up was 14.5months (range 5-28). There were no significant donor site complications. The MFCP flap offers a versatile and reliable option for bone reconstruction. Its ability to provide vascularized bone tissue with low morbidity enhances the healing process and improves outcomes. The MFCP flap has been increasing its applications and it serves as a valuable option in the treatment of recalcitrant non-unions or bony defects irrespective of site and size up to 5cm in the upper and lower extremities.

Delphi Consensus on Diagnostic Criteria for LUMBAR Syndrome

To develop consensus on diagnostic criteria for LUMBAR syndrome, the association of segmental infantile hemangiomas that affect the Lower body with Urogenital anomalies, Ulceration, spinal cord Malformations, Bony defects, Anorectal malformations, Arterial anomalies and/or Renal anomalies. These diagnostic criteria were developed by an expert multidisciplinary and multi-institutional team based on analysis of peer-reviewed data, followed by electronic-Delphi consensus of a panel of 61 international pediatric specialists. After two Delphi rounds, a 92% or higher level of agreement was reached for each Delphi statement. 98% of panelists agreed with the diagnostic criteria, and 100% agreed the criteria would be useful in clinical practice. The diagnosis of LUMBAR requires the presence of a segmental, or patterned, infantile hemangioma of the lumbosacral, sacrococcygeal, or pelvic cutaneous regions plus one additional criterion of the urogenital, spinal, bony, anorectal, arterial, or renal organ systems. These diagnostic criteria will enhance clinical care by improving screening, detection, and overall awareness of this poorly understood neurocutaneous disorder. The criteria can be utilized by a wide variety of pediatric subspecialists. In addition, formal criteria will improve phenotypic uniformity among LUMBAR syndrome cohorts and a patient registry, allowing investigators to assess clinical features, long-term outcomes, and results of genetic sequencing in a standardized manner. Finally, these criteria will serve as a starting point for prospective studies to establish formal screening and management guidelines.

Mimicking the mechanical properties of cortical bone with an additively manufactured biodegradable Zn-3Mg alloy

Additively manufactured (AM) biodegradable zinc (Zn) alloys have recently emerged as promising porous bone-substituting materials, due to their moderate degradation rates, good biocompatibility, geometrically ordered microarchitectures, and bone-mimicking mechanical properties. While AM Zn alloy porous scaffolds mimicking the mechanical properties of trabecular bone have been previously reported, mimicking the mechanical properties of cortical bone remains a formidable challenge. To overcome this challenge, we developed the AM Zn-3Mg alloy. We used laser powder bed fusion to process Zn-3Mg and compared it with pure Zn. The AM Zn-3Mg alloy exhibited significantly refined grains and a unique microstructure with interlaced α-Zn/Mg2Zn11 phases. The compressive properties of the solid Zn-3Mg specimens greatly exceeded their tensile properties, with a compressive yield strength of up to 601 MPa and an ultimate strain of >60 %. We then designed and fabricated functionally graded porous structures with a solid core and achieved cortical bone-mimicking mechanical properties, including a compressive yield strength of >120 MPa and an elastic modulus of ≈20 GPa. The biodegradation rates of the Zn-3Mg specimens were lower than those of pure Zn and could be adjusted by tuning the AM process parameters. The Zn-3Mg specimens also exhibited improved biocompatibility as compared to pure Zn, including higher metabolic activity and enhanced osteogenic behavior of MC3T3 cells cultured with the extracts from the Zn-3Mg alloy specimens. Altogether, these results marked major progress in developing AM porous biodegradable metallic bone substitutes, which paved the way toward clinical adoption of Zn-based scaffolds for the treatment of load-bearing bony defects. Statement of significanceOur study presents a significant advancement in the realm of biodegradable metallic bone substitutes through the development of an additively manufactured Zn-3Mg alloy. This novel alloy showcases refined grains and a distinctive microstructure, enabling the fabrication of functionally graded porous structures with mechanical properties resembling cortical bone. The achieved compressive yield strength and elastic modulus signify a critical leap toward mimicking the mechanical behavior of load-bearing bone. Moreover, our findings reveal tunable biodegradation rates and enhanced biocompatibility compared to pure Zn, emphasizing the potential clinical utility of Zn-based scaffolds for treating load-bearing bony defects. This breakthrough opens doors for the wider adoption of zinc-based materials in regenerative orthopedics.

A Rare Case of an Isolated Intra-Thoracic Meningocele: Case Report and Review of the Literature

A spinal meningocele is a saccular protrusion of the meninges through a dilated intervertebral foramen or a bony defect of the vertebral column. Intrathoracic meningocele is a rare condition. Only a few cases were related in the literature. It is usually associated with neurofibromatosis type 1. Isolated intrathoracic meningoceles without neurofibromatosis is a very rare entity few cases have been reported in the medical literature. Regardless of the treatment plan cross-sectional imaging techniques such as CT and MRI are essential not only for the diagnosis but also to determine the relationship to the surrounding structures and the exclusion of other neuromas and any skeletal deformities. Surgical excision is the treatment of choice in symptomatic patients.