Bony Gap Research Articles

Prevention of Temporal Depression That Follows Fronto-orbital Advancement for Craniosynostosis

Contour abnormalities presenting after fronto-orbital advancement for craniosynostosis are common. Often there is bilateral temporal depression, the result of leaving a coronal bony gap posterior to the advanced segments. The authors present techniques to prevent this temporal depression by utilizing full-thickness bone grafts for structural support in the inferior coronal defects, and cortico-cancellous graft in the remaining superior coronal and parietal donor defects. Prior to contouring and repositioning the frontal elements, a hand-driven Hudson brace and D'Ericco bit is used to harvest cortico-cancellous bone "mush" from the endo- and ectocortical surfaces. The bandeau and frontal elements are advanced and secured, and the resultant coronal gap is measured. Full-thickness cranial bone grafts are harvested from the parietal regions (near the vertex) and secured in the coronal defect behind the frontal elements. The temporalis muscle is rotated, advanced, and secured to the bandeau. Bone mush is used to fill the remaining superior coronal and donor site defects. Representative case examples are presented.

Free Fibula Flap Elbow-Joint Hemiarthroplasty Reconstruction for Chronic Osteomyelitis of the Distal Humerus

The vascularized fibula flap has become a major tool in upper limb reconstruction. Free fibula flap reconstructions of the humeral part of the shoulder and the radial part of the wrist joints are well-documented, but reports of elbow joint reconstruction are rare. The authors report a 53-year-old patient with chronic osteomyelitis of the distal humerus that was unsuccessfully treated by many local surgical debridements and long-term systemic antibiotics. The patient underwent a wide debridement of the distal two-thirds of the humerus, and a spacer was inserted to fill the bony humeral gap. At a second stage, the distal humerus was reconstructed with a free fibula flap that included the proximal fibular head. The fibular shaft was used to bridge the bony gap and the fibular head created an elbow joint with the olecranon process. At an 18-month follow-up after surgery, the patient has stable and sufficient function of his elbow joint with no signs of infection. The free fibula flap has an important role for distal humerus reconstruction, both for bridging the bony gap with a vascularized bone, and for restoring elbow joint function.

Bone graft versus BMP-7 in a critical size defect—Cranioplasty in a growing infant model

Little data are available as regards to the action of bone morphogenetic protein-7 (rhBMP-7) in growing organisms. We put forward two hypotheses: Firstly, that regeneration of calvarial defects with autologous bone grafts would result in equivalent volume and shape as compared to calvaria regenerated with BMP-7. Secondly, that cranial development would remain undisturbed in infant individuals. A one-sided defect of the parietal bone (2 × 4 cm) including the coronal suture was generated in 2-month-old minipigs ( n = 17). Group 1: no further treatment ( n = 5); group 2: particulated iliac bone graft ( n = 6); group 3: rhBMP-7-composite (500 μg/g collagen + Carboxymethylcellulose, n = 6). After the experimental period (4 months) with fluorochrome labeling, examination was performed by computed-tomography and non-decalcified histology. Group 1: major bony gaps remained, proving that defects of critical size were generated. Group 2: minor bony gaps remained, the bone volume was significantly reduced on the treated as compared to untreated sides ( P = 0.028). Group 3: bony continuity was seen in all cases and no significant difference of bone volumes of treated versus untreated sides ( P = 0.075) was found. Skull diameters increased by 16.4% but the physiological centrifugal cranial expansion remained undisturbed. Our first hypothesis was contradicted: contrary to our former assumption, bone induction by rhBMP-7 was superior to particulated bone transplants. In this growing model, calvaria approaching normal volume and shape were observed. However, only the quantity not the quality of bone regenerates was different. Our second hypothesis was confirmed: disruption of further cranial development was not seen after bone transplantation or rhBMP-7 implantation.

Morphological and Radiologic Evaluation of the Human Nasopalatine Duct

In several mammals, a direct connection between the nasal cavity and the oral cavity is a common finding. The structure is named the nasopalatine duct (NPD). It has been hypothesized to be functional in terms of transportation of odorants from the oral cavity to the nasal cavity. In humans, the NPD exists during embryological development. The connection between the nasopalatine infundibulum and the incisive fossa is typically closed at the time of birth. We present the case of a 24-year-old man who presented with a persistent NPD. By means of a thin, soft tube, it was possible to probe the NPD. Magnetic resonance imaging revealed a bony gap between the hard palate and the alveolar process of the maxillary bone with a length of 16 mm and a width of 6 mm. In light of the literature of the past 500 years, this represents a rare finding of a persistent NPD.

環椎後弓欠損の２例

Partial or complete aplasia of the posterior arch of the atlas is a rare anomaly. The purpose of this paper is to illustrate radiological findings and review literature on congenital defects of the posterior arch of the atlas. Case 1 : A 20-year-old woman diagnosed with abnormality of the posterior arch of the atlas was referred for further diagnostic follow-up in this hospital. She complained of nonspecific neck pain and headache, but neurological examination results were normal. Roentgenograms and CT scans revealed absence of the posterior arch of the atlas except for the posterior tubercle. Case 2 : A 20-year-old woman underwent medical check-up for cubital pain and numbness. Routine lateral view of cervical X-rays showed abnormality of the posterior arch of the atlas. There was partial defect of posterior arch of the atlas in 3D-CT. The posterior arch of the atlas became gradually thin in the axial view of CT. As a result, the posterior atlantodens interval remained wide. The symptoms of both subsided quickly with conservative treatment. In recent studies, bony gaps in the posterior arch are bridged by loose connective tissue rather than cartilage, suggesting that the anomaly is a result of defective development of the cartilage rather than disturbance of ossification per se.

Improving the iliac crest donor site by plate insertion after harvesting vascularized bone

The iliac crest is among the most frequent sites for free vascularized bone donation. However, donor site morbidity is often marked with persistent pain, abnormal sensation, abdominal herniation, musculoskeletal imbalance and a disfigured appearance. The authors present a technique of reconstructing the bony gap after iliac crest harvest by inserting a metal plate. Apart from restoration of the iliac contour after skin closure, the plate enables fixation of the transected abdominal wall muscles. This results in less postoperative pain and shorter rehabilitation, as well as an improved musculoskeletal balance and a reduced risk of abdominal wall herniation.

Quadruple distraction interne avec avancement fronto-facial précoce pour faciocraniosténose

Frontofacial monobloc advancement (FFMA), known as a high risk procedure, was evaluated in combination with distraction. Twenty patients with faciocraniosynostosis, were treated with FFMA and quadruple internal distraction. Mean age at surgery was 3.2 Years and mean follow-up was 14 Months (3-32 Months). Four distractors were used per patient in combination with complete osteotomy FFMA. Rate of distraction was classical (0.5 mm to 1mm per day) starting on day 7. The rate of short-term complications was evaluated. Correction of exorbitism and the dental occlusion relationship were assessed to evaluate achievement of advancement. Rate of relapse was evaluated by measuring the orbital bony gap on horizontal CT slices, before and 6 Months after removal of the distractor. Respiratory impairment when present was also evaluated. Distraction was completed in 18/20 patients. Fifteen patients completed their distraction uneventfully during the initial period. In three patients with CSF leaks, distraction was delayed at day 14 and 16, but was resumed and completed normally. Second operations were required for two patients during the early phase: the distractor failed in one requiring immediate reoperation to change the device; distraction was completed successfully. Device infection developed in two patients requiring removal of the device and abortion of distraction. One patient died the day after surgery from acute tonsillar herniation before distraction could be initiated. Exorbitism was clinically corrected in all cases in whom distraction was completed (n=18). Class I occlusion was obtained in 16/18 patients. When present, respiratory impairment was corrected in all cases. Septic frontal necrosis occurred in one patient two Months after distraction was completed and necessitated removal of the forehead flap. Distractors were easily removed through a coronal approach at 6 Months, but reossification was limited. Relapse was observed in three patients whose retaining phase was less than five Months. Rate of relapse was much lower when distraction was maintained more than six Months. Internal distraction can provide early correction of respiratory impairment due to faciocraniosynostosis in infancy and can reduce the major risks of frontofacial monobloc advancement. Morbidity is higher in patients with prior surgery before FFMA. Further evaluation is necessary to determine whether the two stage treatment strategy for faciocraniosynostosis (fronto-orbital advancement before one Year of age, and later facial Lefort III type advancement) could be replaced by a routine FFMA procedure.

Operative Treatment of Diaphyseal Forearm Fracture in Children

Purpose : This article presents a retrospective study of treatment modality for children’s diaphyseal forearm fractures. Materials and Methods : A total 148 forearm fractures (October. 1997-October. 2001) were examined, of which 19 required operation, a teenager whose growth plate had closed was excluded from the study. 17 patients required intramedullary K-wire fixation, 2 patients required open reduction and plate fixation. Time to radiologic union, complications at the last follow up were evaluated. Results : In 17 intramedullary K-wire fixation patients, the average time to union was 6 weeks and complications including 1 ulnar shortening, 1 pin infection, 1 osteomyelitis, which developed due to a patient’s mistake. In 2 plating patients, average union time was 6 weeks with no complications. Conclusion : We think that the treatment method of pediatric forearm fracture should be decided upon based on the fracture site and type of fracture. Intramedullary K-wiring for diaphyseal forearm fracture is an effective method and we recommend that the wire is inserted across the physis in cases of diaphyseal fractures of the forearm bone close to the metaphysis. If the diaphyseal forearm fracture is refracture or a bony gap is shown at the fracture site, open reduction and plate fixation is needed. If reduction and fixation of the bone alone in a diaphyseal fracture of both forearm bones restores the stability of other fracture, fixation of the other bone can be avoided.

Assessment of Stability in Children's Minimally Displaced Lateral Humeral Condyle Fracture by Magnetic Resonance Imaging

We studied 12 children who had minimally displaced lateral humeral condyle fractures. Bony gaps at the fracture site were <2 mm on the anteroposterior view of plain radiographs. To determine the stability of the fractures, we used a magnetic resonance imaging (MRI) study of the distal humerus and elbow joint. In the results, two types of fractures were classified by the extent of the fracture line in MRI. Type I showed that the line coursed from the lateral metaphysis to the growth plate but not through it. In type II, the line crossed the growth plate to enter the joint space. We concluded that the MRI study distinguished the potentially unstable fracture (type II) from the minimally displaced fracture and recommend the use of a percutaneous pin fixation for the expected unstable fracture.

Fetal bone gap healing in utero

The healing of fetal tibial bone after osteotomy with and without stable fixation has been reported previously. The present study was designed to evaluate fetal bone gap healing using a tibial ostectomy model in fetal sheep. Eighteen time-dated pregnant ewes (20 fetuses, 34 experimental hind limbs) underwent intrauterine surgery at 95 days gestation (term, 145 days). A titanium miniplate was applied to the anterior aspect of the tibia and a longitudinal length of bone approximately 1.5 times its diameter was removed and the incision closed. The pregnancies were then allowed to progress until the ewe was killed at postoperative weeks 1, 2, 4, or 7. Assessments at that time included evaluation of gross morphology, histologic and radiologic appearance, and collagen analysis and hydroxyproline determination of the tissue within and at the borders of the gap. At 7 weeks, seven of nine bone gap specimens exhibited radiographic and histologic evidence of union with woven and lamellar bone. Hydroxyproline concentrations gradually increased within the bone gap over the period of the study. At all intervals, type I collagen composed over 90% of the collagen within the healing bony gap. Histologically and biochemically, the process appears to be similar to postnatal bone healing, albeit occurring at an accelerated rate.

Improved Primary Surgical and Dental Treatment of Clefts

The improved combination of surgical and dental teamwork in the primary treatment of clefts presented here is consistent with principles. In fact, this is a staged design for correction of classic clefts of the lip and palate that, based on biological principles, facilitates the continuance of the failed embryonic "migrations" toward a normal end point. Positioning of the alveolar segments, dissection of mucoperiosteum out of the cleft, and union of mucoperiosteum across the alveolar and anterior hard palate cleft make it possible to create a periosteal tunnel across the bony gap and set up a condition conducive to bone formation and eventual tooth eruption in the cleft area. Lip closure by adhesion reduces the tension of the primary lip closure and allows gentle molding until solidification of the arch occurs. Thus a complete cleft has been rendered an incomplete cleft. With a balanced, stabilized maxillary platform, the definitive lip and nose corrections can be carried to completion early (by 2 to 4 years of age). These planned actions bypass a persistent cleft, fistulas, raw areas, malposition of alveolar segments, and probably the necessity for later bone grafting. The only question not totally answered is the effect of this approach on final growth. Although most reports seem to indicate that growth has and will proceed within normal limits, another 10 years of careful follow-up is indicated and, in fact, is in progress.

Fronto-ethmoidal encephalomeningocele with extravasation of CSF

A case of Fronto-Ethmoidal Encephalomeningocele which resulted into rapid puffiness of the major portion of the face is presented in this paper. In order to avoid post-operative CSF leak in such a case the importance of fascia lata graft in the closure of the bony gap is stressed.

Segmental replacement of the femur in baboons

A titanium-fiber metal implant was used to replace large segments of both femurs in four baboons. Immediate mechanical stabilization was produced by short intramedullary rods at each end of the implant and a plate bridging the bony gap. On the left side the rods were coated by fiber-metal permitting fixation through bone Ingrowth. On the right side the rods were solid and fixation achieved with methylmethacrylate. Autologous bone grafts were added on both sides. Two animals were sacrificed at three months, and two after six. The results were evaluated histologically and pullout tests were done to determine the strength of the fixation. Complete bone bridging of the replacement segment occurred in all limbs. In the fiber-metal coated rods bone Ingrowth was always found, more so after six than after three months. The strength of the bone increased from three to six months in both groups of animals. It is concluded that in the specimens with fiber-metal coated intramedullary rods this increase in bond strength was due to an increase in bone Ingrowth mainly into the coating of the rod, and that in the cemented specimens, it was due to Ingrowth of bone into the fiber-metal of the prosthetic segment where it faced the cut ends of the residual femoral cortex.

Healing of the Bony Gap with Periosteal Osteogenesis After Tibial Diaphysectomy in Adult: Report of A Case

Healing of the Bony Gap with Periosteal Osteogenesis After Tibial Diaphysectomy in Adult: Report of A Case