Corticocancellous Graft Research Articles

Anterior cruciate ligament reconstruction: Assessment of the hamstring autograft femoral fixation using the EndoButton CL ®

The objective of this study was to evaluate the clinical and radiological results of a prospective, continuous series of 105 ACL reconstructions using the STG tendons fixed to the femur by an EndoButton CL, with more than 4 years of follow-up. The subjective and objective clinical results as well as the radiological results (tunnel enlargement) obtained by a cortical, extra-anatomic femoral fixation are at least equivalent to the results obtained with other types of femoral fixation systems. One hundred and five patients aged with a mean 26 years (range, 12-56 years) were operated on for an anterior cruciate ligament rupture using the same technique and by the same operator: four-strand STG fixed to the tibia by a double fixation--BioRCI-HA screw and staple--and on the femur by an EndoButton CL (Smith and Nephew). The results were assessed at 6 months, 1 and 2 years and then at a mean follow-up of 51 months, both clinically (IKDC, Lysholm, KT-1000) and radiologically (Telos laximetry, tunnel position, and morphological analysis). No complications related to the use of the EndoButton were observed. No additional interference screw was necessary. According to the IKDC laxity classification, 91.4% of the patients were classified in category A or B, nine knees (8.6%) were classified C or D. Four failures required revision with a patellar tendon graft. On the final IKDC score, 63 patients (60%) were classified grade A, 37 grade B (35.3%), four grade C (3.8%), and one grade D (0.9%). On the Telos laximetry, 62 patients (59%) had a differential laxity less than or equal to 2 mm. The mean value was 1.8 mm (range, 0-11). Tibial tunnel enlargement was constant; femoral tunnel enlargement was significant (>2 mm) in 27.6% of the knees. No femoral tunnel diameter modification corresponding to the EndoButton passage was observed. The results of this series are comparable to the results of other series. Its reproducibility and the absence of iatrogenic complications for this femoral EndoButton CL fixation make it a top-choice technique, like the corticocancellous graft procedures, but without their disadvantages. No secondary elongation attributable to the EndoButton CL was observed. This femoral fixation procedure appeared necessary and sufficient to providing good mechanical stability for the graft in the femoral tunnel.

Did local teicoplanin delivery systems inhibit or aggravate implant-related infection?

Dear Editor, We read with great interest the article by Sener et al. [1] and would like to bring four issues to your attention. First, the authors analysed the difference in the bacterial density between four groups with repetitive Mann-Whitney U test. Unavoidably, type I error (α) would be magnified [2]. It would be appropriate to calibrate the P value as: [2]. Thus, we made a second statistical analysis (Table 1). The data showed, however, no difference was found between group 2 and group 3 nor between group 3 and group 4. Combined with the inferior performance of group 3 in both radiological findings and macroscopic findings, antibiotic-loaded bone cement did not show superiority over other treatment modalities. Table 1 Statistical results of subgroup comparison in microbiological evaluation Second, the results showed that teicoplanin-loaded bone graft could not help, and could even interfere, with the infection control. Apart from the mechanisms discussed by the authors, other interpretations may be considered (Fig. 1). For example, local subacute inflammation was assumed two weeks after the bacterial inoculation. Less encapsulation of granulation tissue and bone callus, more osteolysis and exudation, and greater hyperemia were anticipated compared with chronic osteomyelitis [3]. Also, teicoplanin releasing systems were placed at the fracture site, a more open space than the medullary cavity. As a result, the adopted model of implant-related infection might present greater dilution, absorption, distribution, and elimination of teicoplanin than that of chronic osteomyelitis [4]. Some hidden or distant bacteria might be spared from the locally compromised teicoplanin level and account for recurrence of infection. Moreover, it was reported that the length of time during which the local antibiotic level exceeded minimal inhibition concentration (T>MIC) highly predicted antimicrobial potency of glycopeptide releasing systems [4]. Applying morselised cancellous bone, lengthening the duration of immersion in antibiotic solution, and the technique of iontophoresis would facilitate the teicoplanin impregnation into bone and prolong the T>MIC [5]. The authors simply immersed the corticocancellous grafts in teicoplanin solution for only one hour. The adsorption was possibly far below the saturation threshold, which may underestimate the antimicrobial efficacy of teicoplanin-loaded bone grafts. To our disappointment, no in vivo investigation was attempted on the kinetics of antibiotic release from bone. Also, implant removal is a prerequisite for thorough debridement; however, the authors retained the infected implant, where bacteria colonised and biofilm probably developed (Fig. 1). It was difficult to reach effective antibiofilm concentrations of teicoplanin around the implant. Fig. 1 Schematic diagram of osteomyelitis models of subacute infection (a) and chronic infection (b). In comparison with the model of chronic osteomyelitis (b), the subacute animal model (a) had less encapsulation of granulation tissue and bone callus, more ... Third, substantial details concerning the fabrication of teicoplanin-loaded bone grafts and acrylic beads [5], such as the concentration and pH of teicoplanin solution, the surface area, the bulk volume and the weight of bone grafts and acrylic beads, were not mentioned, which made comparison on antimicrobial efficacy impossible. Fourth and finally, the authors indicated that use of antibiotic-loaded beads was superior to debridement and systematic antibiotic treatment while antibiotic-loaded autogenous bone was not. This did not seem reasonable. In fact, debridement and systematic teicoplanin treatment were also offered in groups 3 and 4. What differed from group 2 was additional teicoplanin-loaded beads and teicoplanin-loaded autogenous bone in groups 3 and 4, respectively. It seems more appropriate to conclude that the inhibition by both antibiotic delivery systems was inferior to their aggravation of infection.

HS02 NON VASCULARIZED CANCELLOUS BONE GRAFT FROM DISTAL RADIUS AND KIRSCHNER WIRE FIXATION AS A TREATMENT FOR CAVITARY TYPE SCAPHOID NONUNIONS EXHIBITING DISI

Purpose: Cavitary type scaphoid nonunions represent a difficult treatment challenge as they exhibit bone loss, scaphoid shortening, flexion (“humpback”) deformity and dorsal intercalated segmental instability (DISI), creating altered carpal mechanics which may proceed to the degenerative changes of scapholunate advanced collapse of the wrist. We present our technique for these problematic cavitary nonunions and discuss its rationale.Methodology: A retrospective analysis was undertaken on a consecutive cohort of 19 patients that were treated by the relatively simple method of (1) excising the nonunion via a volar approach (2) packing the volar defect with cancellous autograft, harvested from the ipsilateral distal radius and (3) holding it out to length with two Kirschner wires and a plaster cast. Wires are removed at 10–12 weeks.Results: Union was achieved in (18/19) 95% of cases, with no complications, in an average of 9.7 (range 8–12) weeks. Carpal mechanics were restored, with an average carpal height index of 1.52 ± 0.07 and an average scapholunate angle of 46 ± 10 degrees. Average follow up was 2.2 years.Conclusion: In this subset of patients we believe this technique is less technically demanding than the use of either corticocancellous grafts or various compression screws. Our success equals that of other published techniques, with all patients enjoying a full return to work even in occupations demanding heavy labour. We believe this may also be due to the ability of cancellous grafts to restore carpal height and normal carpal angles, thereby producing a better functional outcome.

Vascularized Medial Femoral Condyle Graft for Thumb Metacarpal Reconstruction: Case Report

The vascularized medial femoral condyle bone graft has many clinical applications. It can be harvested as a thin, pliable, corticoperiosteal graft and wrapped around recalcitrant nonunions in long bones to achieve osseous union. It can also be harvested as a small, structural, corticocancellous graft and used to treat small defects such as scaphoid avascular nonunion. We present a case of thumb metacarpal osteomyelitis resulting in a large segmental osseous defect. Reconstruction was performed using a large, structural, vascularized bone graft from the medial femoral condyle.

Spinal Fusion of an Unstable Atlantoaxial Fracture in a Completely Tetraplegic Patient Using Silicate-Substituted Calcium Phosphate.

Bone graft harvesting from the iliac crest constitutes the gold standard in spinal surgery due to its osteogenic, osteoconductive and osteoinductive properties. Large amounts of autograft can provoke complications like donor site morbidity, pain and the need for a second operation. Therefore, research into bone graft substitutes is of great interest. Silicate-substituted calcium phosphate (Actifuse(TM) Synthetic Bone Graft, ApaTech Ltd, London) was used in combination with morselized corticocancellous graft in a transarticular stabilization (modified Magerl) of a completely tetraplegic patient with an unstable atlantoaxial fracture. Computed tomography showed bone bridging between the segment C1/C2, the surface of the implant and the remodeled bone at follow-up at 8 months. The use of silicate-substituted calcium phosphate as a bone graft extender in spinal surgery could be an alternative to autografting from the iliac crest. Vegetative symptoms are often underestimated but can be triggered by donor site morbidity or pain in patients after spinal cord injury.

Surgical Treatment of Multifocal Giant Cell Tumor of Carpal Bones With Preservation of Wrist Function: Case Report

We report a rare case of multifocal giant cell tumor of bone involving the trapezium, trapezoid, capitate, and scaphoid with soft tissue extension. Following intralesional resection, an autogenous corticocancellous iliac crest bone graft was used to fill the resultant defect and preserve carpal height and radiocarpal motion. Successful union with no recurrence was noted at 1-year follow-up.

Successful Cementless Cup Reimplantation Using Cortical Bone Graft Augmentation after an Acetabular Fracture and Cup Displacement

To report repair of a periprosthetic acetabular fracture with concurrent component displacement after cementless total hip arthroplasty (THA). Clinical case report. Dog (n=1) with an acetabular fracture after THA. Acetabular repair was performed on a highly comminuted periprosthetic acetabular fracture after cementless THA. A bulk, structural corticocancellous autograft from the ipsilateral ilial wing was used for repair and reconstruction of the dorsal acetabular wall before reimplantation of a cementless acetabular component. Repair of a periprosthetic acetabular fracture with a bulk structural autograft was successful in reconstruction of the dorsal acetabular wall and in reestablishing a stable, functional cementless THA acetabular prosthesis. Structural corticocancellous autografts from the ilium can be successfully used in repair of periprosthetic acetabular fractures after THA. Structural corticocancellous grafting from the ilium can be considered as a treatment option for repair of periprosthetic acetabular fractures after THA.

O.185 Functional outcomes in oral reconstructions with ALT

The anterior maxillary osteoplasty restores adequate bone to the edentulous Class IV ridge prior to placement of endosseous implants. The aim of this retrospective study was to compare the long-term survival of implants placed into the particulate bone of an anterior alveolar osteoplasty to those placed into a ‘block’ onlay bone graft. Of 85 patients with Class IV ‘knife-edge’ alveolar ridges, 50 received interpositional particulate bone via an alveolar osteoplasty and 35 received an onlay cortico-cancellous graft. A total of 386 implants were placed as a secondary procedure and followed postoperatively (mean 6 years; 39 failures). There was improved cumulative survival of implants placed into the particulate bone of an osteoplasty compared to the block bone of an onlay graft. Implants supporting a fixed superstructure had a longer cumulative survival than those supporting a removable appliance. There was no statistical difference between implants placed into male and female bone, or between those in edentulous and partially dentate jaws. Within a partially dentate jaw there was a statistically significant increase in cumulative survival for implants within osteoplasty inlay bone compared to onlay bone grafts. Anterior osteoplasty is the surgical treatment of choice for augmentation of the resorbed Class IV alveolar ridge prior to placement of osseo-integrated implants.

Arthrodèse antérieure L5-S1 par voie rétropéritonéale et fixation par cage et plaque. Étude prospective de 40 cas avec un recul d’un à 2,2 ans (moyen 1,5 ans)

The aim of this prospective clinical study was to assess outcome after anterior retroperitoneal interbody arthrodesis for L5-S1 discopathy. We used a cage filled with an autologous corticocancellous graft and plate fixation.Forty patients with low back pain unresponsive to medical treatment for more than six months were included in this series. We noted the clinical signs and radiculalgia. Patients were assessed preoperatively, postoperatively, at one year and at last follow-up using the Oswestry score and a visual analog scale (VAS). The plain X-rays disclosed 30 cases of discopathy (16 primary and 14 postdiscectomy) and 10 cases of spondylolisthesis by L5 isthmic lysis (three Meyerding grade 0 and seven grade 1). MRI revealed signs of disc degeneration in all cases with a black disc or modification of the endplate signals (Modic type 1 in 23 and type 2 in 13). The anterior retroperitoneal approach was used in all cases for complete discectomy, arthrodesis with cage insertion and an autologous corticocancellous graft harvested from the iliac bone and fixation using a triangular plate (Pyramid, Medtronic, Memphis TN). Clinical and radiographic follow-up data were available at six weeks and three, six and 12 months in addition to last follow-up. A follow-up using MRI was performed in the event of complications.The population was composed of 25 women and 15 men, mean age 44 years and eight months (range 29-693 years). Thirteen patients presented radiculalgia. There were no vascular or gastrointestinal complications with the anterior approach. Bone healing was achieved at one year in 38 patients (95%). The mean Oswestry score improved from 52 to 16% and the mean VAS from 7.8 to 1.83 at 18 months follow-up. All occupationally-active patients but one resumed their former activity at mean 4.7 months. There were no sexual complications in this series. Low back pain persisted in three patients and five developed transient facet joint symptoms. Two patients developed secondary radiculalgia. We noted two cases of nonunion, in one grade 1 spondylolisthesis and in one grade 1 spondlylolisthesis (with revision for complementary posterior arthrodesis and a good outcome at latest follow-up).Anterior L5-S1 interbody fusion with a cage filled with a corticocancellous autograft fixed with a plate provides good clinical and radiographic results for the stabilization of painful discopathy. The results have been good for isolated L5-S1 discopathy and for grade 0 spondylolisthesis. The limit for this technique would appear to be grade 1 spondylolisthesis with a degraded disc. Performed via an anterior retroperitoneal approach, this method is a good alternative to the classical posterior approach, enabling very low morbidity.

Fracture pathologique de la patella sur kyste anévrismal osseux. À propos d’un cas

Aneurysmal bone cyst is a tumor-like lesion which accounts for about 1% of all biopsied tumors and tumor-like lesions of bone. We report an extremely rare case of aneurysmal bone cyst of the patella in an 18-year-old patient revealed by a pathological fracture. The unexpected appearance of a pathological fracture affects the whole therapeutical management. However, in the case of a well-preserved articular surface, curettage and corticocancellous grafting are considered to be successful methods of treatment for aneurysmal bone cyst of the patella, as revealed in our study.

Morphologic and clinical aspects in the treatment of infected shaft pseudarthrosis

By means of clinical and morphological findings the procedure in the treatment of infected diaphyseal non-unions is described. The necessity of adequate stabilization--especially with the help of the external fixatoris pointed out. The infected cortex, often as a compromise, has to be left in place in order to give a foundation for periosteal bone grafts. Such cortical bone which is not vascularized and prevents the infect from subsiding has to be removed in a second step from a medullary approach. The defect is then filled up with autologous cancellous grafts. In the forearm the whole infected area of bone can be removed and replaced by a cortico-cancellous graft which is stabilized by internal fixation with a plate.

Ten years of experience with the anterior maxillary and mandibular osteoplasty (class IV ridges): a retrospective analysis of implant survival rates

The anterior maxillary osteoplasty restores adequate bone to the edentulous Class IV ridge prior to placement of endosseous implants. The aim of this retrospective study was to compare the long-term survival of implants placed into the particulate bone of an anterior alveolar osteoplasty to those placed into a ‘block’ onlay bone graft. Of 85 patients with Class IV ‘knife-edge’ alveolar ridges, 50 received interpositional particulate bone via an alveolar osteoplasty and 35 received an onlay cortico-cancellous graft. A total of 386 implants were placed as a secondary procedure and followed postoperatively (mean 6 years; 39 failures). There was improved cumulative survival of implants placed into the particulate bone of an osteoplasty compared to the block bone of an onlay graft. Implants supporting a fixed superstructure had a longer cumulative survival than those supporting a removable appliance. There was no statistical difference between implants placed into male and female bone, or between those in edentulous and partially dentate jaws. Within a partially dentate jaw there was a statistically significant increase in cumulative survival for implants within osteoplasty inlay bone compared to onlay bone grafts. Anterior osteoplasty is the surgical treatment of choice for augmentation of the resorbed Class IV alveolar ridge prior to placement of osseo-integrated implants.

Reconstruction osseuse des os longs après exérèse carcinologique par l’utilisation de greffons fibulaires vascularisés chez l’enfant et l’adolescent: À propos d’une série de 13 cas à 50 mois de recul moyen

Purpose of the study The vascularized fibular graft is a widely used technique for the reconstruction of long bone defects after tumor resection. Complications are not uncommon despite the presence of a good vascular supply. We report our experience with long bone reconstructions in children and adolescents after resection of primary malignant bone tumors. Material and methods This retrospective analysis included thirteen patients aged 4-17 years (mean age 12 years). Preoperatively, the pathological diagnosis was Ewing tumor (n = 7), osteogenic sarcoma (n = 5), neuroepithelioma (n = 1). All patients except one were given chemotherapy preoperatively and postoperatively and four received adjuvant radiotherapy. Tumor resection created a gap (n = 8) or involved resection-arthrodesis (n = 5, three knees, one ankle, one elbow). All reconstructions used a vascularized fibular flap with a complementary corticocancellous autograft for seven. Results Complete carcinological resection was achieved in all cases. Mean follow-up was 50 months (range 12-144 months). There were no cases of local recurrence. Three patients presented lung metastasis; two patients died. Eleven of the twelve patients who underwent tumor resection involving the lower limb were able to walk with full weight bearing at 13.9 months (range 841 months), half of them without any supportive device. The MSTS score was 21/30 (range 7-29). Both ends healed for eleven of thirteen grafts. Outcome was good in four cases at 7.7 months (range 6-11), fair in seven (with 1-5 complementary procedures) at 14.8 months (range 10-45) and poor in two (nonunion at last follow-up). Among the fibular grafts which healed, primary healing of the distal end was noted in all cases, but not for the proximal end. Significant transplant hypertrophy was noted in 62% of patients, measured at mean 77.1% (range 25-128%). Complications were: skin necrosis (n = 2), nonunion (n = 4, three aseptic and one septic), disassembly (n = 3 with two transplant fractures), and spontaneous fracture which healed (n = 5, all but one treated orthopedically). There were four donor site complications: retraction of the hallux flexor (n = 3), regressive paresia of the common fibular nerve (n = 1). Discussion The rate of healing in this series was similar to earlier reports. Healing was always achieved for the distal focus but not for the proximal focus which receives its blood supply from a branch of the anterior tibial artery which is not harvested. The defective blood supply can thus hinder bone healing. It is necessary to spare the proximal quarter of the fibula or harvest a bipediculated graft. The rate of graft hypertrophy was also similar, as was the rate of complications. The MSTS score was lower due to the poor results obtained with resection-arthrodesis of the knee joint. Graft fractures and aseptic nonunion are the most common complications but septic complications are more serious and can threaten graft survival. Complications at the donor site are exceptional. Conclusion Long bone reconstruction using an autologous vascularized fibular graft is a reliable technique providing satisfactory functional results. Complications can be prevented by making solid fixation and using a corticocancellous graft creating a favorable osteoinducing environment. A massive allograft is another solution providing good immediate mechanical stability.

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.

Corrective Osteotomies in Malunions of the Distal Radius

Fifteen patients with symptomatic malunions of the distal radius were treated with osteotomies, corticocancellous bone grafting, and plate and screw fixation. We investigated the ability of precise preoperative planning of the size and shape of the corticocancellous bone graft to restore alignment of the radius to within 5 degrees angular deformity and 2 mm ulnar variance as compared with the opposite uninjured wrist. Only six of 15 patients (40%) satisfied these criteria. Inter-rater reliability of radiographic assessment was greater than 0.85. Five patients had residual radial inclination or sagittal tilt greater than 10 degrees with respect to the uninvolved wrist. Four patients had a residual ulnar variance greater than 2 mm with respect to the uninvolved wrist. Residual shortening (three of four patients), but not residual angulation, was associated with unsatisfactory pain and stiffness an average of 19.5 months after osteotomy (range, 11-32 months). We conclude that a distal radius osteotomy using a precisely planned and measured interpositional corticocancellous graft does not restore distal radius alignment in most patients, and that failure to restore length is associated with continued pain and stiffness. Therapeutic study, Level IV (case series).

Induction of a Barrier Membrane to Facilitate Reconstruction of Massive Segmental Diaphyseal Bone Defects: An Ovine Model

To report an ovine model that can be used to evaluate the efficacy of bone substitutes for repair of segmental diaphyseal bone defects. Experimental study. Eleven 2-year-old Pré-Alpes Sheep. Mid-diaphyseal metatarsal bone defects (25 mm long) were stabilized by a dynamic compression plate over a polymethylmethacrylate (PMMA) cement spacer, and by external coaptation. The PMMA spacer was removed at 6 weeks by incising the encapsulating membrane. The defect remained unfilled (Group 1; n=5) or was filled with morselized autologous corticocancellous graft (Group 2; n=6), the membrane sutured closed, and external coaptation applied for 6 months, when healing was evaluated. Radiographic, computed tomographic, and histologic examinations at 6 months after the 2nd surgery revealed non-union in ungrafted defects whereas grafted defects showed bone healing. The induced membrane had blood vessels, CBFA1+ cells, and very few macrophages entrapped in a collagenous tissue positive for type I collagen. This ovine metatarsal defect model resulted in a critical-size defect (non-union) that healed when grafted. The PMMA-induced membrane constrained the graft, was well vascularized, and may have osteogenic properties. This model may be useful to evaluate new strategies in bone tissue engineering because the PMMA-induced membrane may help confine bone morphogenetic proteins, skeletal stem cells, or other agents to the defect cavity where they could be useful to enhance bone formation.

Results of an Alternative Autogenous Iliac Crest Bone Graft Harvest Method

This article reports the results using a previously described technique of obtaining iliac crest bone graft using an acetabular reamer in a consecutive series of patients with complex acute traumatic injuries and nonunions. A retrospective chart review was conducted on a cohort of 34 consecutive patients who underwent complex orthopedic procedures for the definitive management of acute or reconstructive problem fractures and nonunions using autogenous iliac crest bone graft. All of the patients had autogenous bone graft prepared using a low speed, high torque power source and small acetabular reamers. The inner or outer wall of the ileum or the posterior superior iliac spine was reamed providing a large volume of corticocancellous graft. This material was used to pack defects in established nonunions, to augment plate osteosynthesis in segmental fractures, or to facilitate arthrodesis. Follow-up averaged 10 months (range: 6-18 months). Thirty-three out of 34 patients went on to uneventful union. No patients experienced morbidity from the graft harvest site. Specifically, no patients developed a superficial or deep wound hematoma or infection, nor did they experience persistent donor-site pain or paresthesias. Autogenous iliac crest bone graft harvest using the reaming technique provides a large volume of corticocancellous graft that has proven effective in treating complex acute nd reconstructive trauma cases.

Résultats à long terme des greffes cortico-spongieuses non vascularisées pour pseudarthrose du scaphoïde carpien: Cinquante-huit cas revus au recul moyen de 8,8 ans

Purpose of the study We conducted this retrospective study to analyze outcome obtained in 58 cases of carpal scaphoid nonunion treated with a non-vascularized corticocancellous graft. Our objective was to search for factors influencing outcome and identify appropriate indications. Material and methods Between 1984 and 1999, 103 patients were treated with a non-vascularized corticocancellous graft. Fifty-seven patients (58 wrists) were retained for analysis (4 deaths, 30 not attending follow-up consultation far from their residence, and 12 lost to follow-up). Mean follow-up was 106 months (range 19 — 212). Mean age was 36 years (20 — 62). Mean time to diagnosis of fracture was 35 months (6 — 252); the fracture was not recognized initially in 45 patients. According to the Schernberg classification, fractures were localized in zone II (n = 11), zone III (n = 40), and zone IV (n = 7). Using the Alnot classification, nonunion was grade I (n = 13), grade IIA (n = 20), grade IIB (n = 22), grade IIIA (n = 2), and grade IIIB (n = 1). Mean immobilization after grafting was 2.7 months. Results At three months, bone healing was achieved in 42 wrists. Thirty-six patients were very satisfied, 18 satisfied and four not satisfied. Twenty-seven patients presented significant pain at the graft harvesting site which regressed in all. There were no harvesting sequelae. Compared with the healthy wrist, we noted reduced flexion (8.7° on average), extension (12.8° on average), and radial inclination (10.5° on average). Other wrist motions were not affected, particularly pronation and supination. The index of carpal height was 0.54 on average (range 0.47 — 0.57); carpal height was diminished in nine wrists. The radiolunate angle was 4.8° on average (-17° to + 27°). Dorsal intercalated segmental instability (DISI) was noted in twenty wrists. Bone healing was not achieved in eleven wrists, seven of which presented initial necrosis of the proximal pole. Pain improved in all patients. Persistence of DISI favored osteoarthritic degeneration. Discussion With this technique, we achieved bone healing in 81% of the cases. Non-vascularized grafting cannot provide cure in the event of advanced osteoarthrtic degeneration. Correction of DISI appears to be an indispensable element for the prevention of osteoarthritis. This technique should not be proposed for patients with a necrotic proximal pole, a vascularized graft would be preferable.

Scaphoid non-union:: The Role of Vascularized Grafting in Recalcitrant Non-Unions of the Scaphoid

Achieving union using conventional grafts has a high chance of failure in patients with recalcitrant non-union (persistent pseudarthrosis) of the scaphoid bone, an avascular proximal fragment and previous failed surgeries because of poor host bed vascularity. Eleven patients with long-standing non-union were treated with vascularized pedicle bone grafting and supplementary corticocancellous grafting. Five had screw fixation and six were fixed with K-wires. The average age of the patients was 28 years, average duration of the non-union was 39 months and mean radiological follow-up was 32 months. There were no significant skeletal complications, although two patients developed neuromata. At review, only six of the 11 non-unions were united. Whilst this is a difficult clinical problem and achieving union is a formidable challenge, we believe that there is a role for such extensive surgery in order to achieve good postoperative function.

Delayed Reconstruction of Alveolar Clefts Without Corticocancellous Grafts: 65 Cases Treated with Recombinant Human Bone Morphogenetic Protein-2 and Absorbable Collagen Sponge

Delayed Reconstruction of Alveolar Clefts Without Corticocancellous Grafts: 65 Cases Treated with Recombinant Human Bone Morphogenetic Protein-2 and Absorbable Collagen Sponge