Nonviable Bone Research Articles

Peri-operative zoledronic acid attenuates peri-prosthetic osteolysis in a rat model of cemented knee replacement.

Progressive osteolysis can occur at the cement-bone interface of joint replacements and the associated loss of fixation can lead to clinical loosening. We previously developed a rat hemiarthroplasty model that exhibited progressive loss of fixation with the development of cement-bone gaps under the tibial tray that mimicked patterns found in human arthroplasty retrievals. Here we explored the ability of a bisphosphonate (zoledronic acid, ZA) to attenuate cement-bone osteolysis and maintain implant stability. Sprague-Dawley rats (n = 59) received a poly(methylmethacrylate) cemented tibial component and were followed for up to 12 weeks. Treatment groups included peri-operative administration of ZA (ZA group), administration of ZA at 6 weeks postop (late ZA group), or vehicle (Veh group). There was a 60% reduction in the rate of cement-bone gap formation for the ZA group (0.15 mm3/week) compared to Veh group (0.38 mm3/week, p = 0.016). Late ZA prevented further progression of gap formation but did not reverse bone loss to the level achieved in the ZA group. Micromotion from five times body weight toggle loading was positively correlated with cement-bone gap volume (p = 0.009) and negatively correlated with the amount of cement in the metaphysis (p = 0.005). Reduced new bone formation and enduring nonviable bone in the epiphysis for the ZA group were found. This suggests that low bone turnover in the epiphysis may suppress the early catabolic response due to implantation, thereby maintaining better fixation in the epiphysis. This preclinical model presents compelling supporting data documenting improved maintenance of the cement-bone fixation with the use of peri-operative bisphosphonates.

Dead or alive — use of indocyanine green angiography for intraoperative assessment of bone vitality in nonunion fractures: a controlled case series of four patients

Background. Indocyanine green (ICG) fluorescence imaging is a surgical tool with increasing applications in various surgical disciplines. During nonunion resection, the assessment of bone vascularization is currently based only on the surgeon’s experience. We introduced the use of indocyanine green (ICG) angiography in orthopedics. The aims of the study: 1) to use ICG fluorescence angiography to evaluate the bone perfusion in patients with atrophic nonunion, where poor or absent ICG flow reveals avascular tissue associated with bone necrosis requiring surgical resections; 2) to describe our case series of patients operated with this technique. Methods. We used ICG angiography in patients operated for tibial nonunion resection. We administered 0.5 mg/kg of ICG powder dissolved in sterile saline at 2.5 mg/ml concentration. The time from the injection to the beginning of appreciation of the green dye was measured. Non-viable bone was resected accordingly. Patient underwent routine follow-up. We enrolled all the suitable patients operated from April 2019 to June 2021 and matched three control patients for each of them. We reviewed their medical records and noted any relevant data. Results. We enrolled 4 cases and 12 controls, all male. The mean age was 30.8±6.9 years. The mean duration from trauma to surgery was 10.5 (0.7-25.0) months. The mean duration of surgery was 190.8±40.3 min. The defect size was 4.89±2.03 cm. ICG allowed rapid visualization of bone vascularization after 25-45 sec. No adverse events were observed. The mean external fixation time was 11.8±5.0 months. The mean external fixation index was 2.69±1.10. Seven patients needed a surgical revision during treatment. Three patients underwent reintervention after frame removal. There are no statistically significant differences between cases and controls. Conclusions. The research findings of this study are limited by the small number of observations. However, this technique is safe, easy, and rapid and may contribute to intraoperative decision of how much to resect. Using ICG could objectively demonstrate bone perfusion to help surgeons to avoid massive bone defects.

Maintenance of a cement spacer as definitive treatment of post traumatic osteomyelitis, a case report.

Background Septic nonunion is a devastating outcome following a tibial plafond fracture, causing significantly increased morbidity and a lengthy recovery. Treatment options include antibiotics and irrigation and debridement procedures focused on preventing posttraumatic osteomyelitis. If these options fail, surgical intervention is necessary to clear infection and debride nonviable bone, often resulting in a substantial bony void. Masquelet technique and Cement augmentation are well studied, multi-stage procedures designed specifically for combatting these defects. These procedures are associated with significant patient burden, a long non-weight-bearing period, and a lengthy recovery. The case presented here today highlights a variation of these techniques that reduced the need for the standard second stage procedure and resulted in a quicker return to normal activity. Case A 51-year-old obese male presented with a septic nonunion with posttraumatic osteomyelitis following a tibial plafond fracture. The patient underwent implant removal with simultaneous irrigation and debridement of all nonviable bone resulting in a substantial bony void. The nonunion was then stabilized with an antibiotic tibial nail, and an antibiotic cement spacer to fill the bony void. The patient was allowed to partial weight bear post operatively and quickly progressed weight bearing status. By postoperative week eight, the patient’s activity level had returned to near his baseline, and the patient was not interested in another procedure to remove the spacer and bone graft. At this time, it was elected to permanently maintain the cement spacer, and only exchange it for bone graft as needed. By one-year, radiographic films demonstrating bony healing around the cement spacer, and the patient was back to full pain-free function. Conclusions Permanently maintaining the cement spacer in cement augmentation or the Masquelet technique allowed this patient to quickly progress weight-bearing status, regain function, and return to normal life without the need for the stage two procedure.

Reconstruction of Scalp Defects Using Rotational Flaps After Revascularization Surgery in Patients with Moyamoya Disease

Treating scalp defects after revascularization surgery is difficult because the scalp microcirculation is severely compromised. We aimed to review the clinical effects of using rotational flaps in scalp defect reconstruction and explore risk factors for wound-related complications (WRC) after reconstruction surgery. We retrospectively identified patients with scalp defects after combined revascularization surgery who were surgically treated with rotational flap reconstruction at our institution between January 2018 and December 2022. We analyzed treatment results in different surgical technique and revascularization strategy cohorts, including direct bypass superficial temporal artery branch selection, indirect bypass types, and skin incisions. Eleven patients were included. The superficial temporal artery parietal branch was selected for direct bypass surgery in 10 (90.9%) patients, 4 (40%) of whom had WRC after flap reconstruction. Five types of indirect bypass surgeries were performed; three patients treated by encephalo-duro-myo-arterio-perio-synangiosis and 1 patient treated by encephalo-duro-myo-perio-synangiosis had WRC after flap reconstruction. Question mark (n= 6, 54.5%), curved (n= 4, 36.65%), and Y-shaped (n= 1, 9.1%) incisions were used; in the first three incision cohorts, 2 patients in each cohort had WRC after flap reconstruction. Patients had the following commonalities that may be risk factors for WRC after flap reconstruction: 1) wounds with nonviable bone exposure after revascularization surgery; 2) three or more tissues used as donor tissues and donor tissues containing the periosteum; and 3) thin scalp around the defect.

The Progress in Reconstruction of Mandibular Defect Caused by Osteoradionecrosis.

Osteoradionecrosis (ORN) is described as a disease with exposed, nonviable bone that fails to heal spontaneously or by means of conservative treatment after radiotherapy in at least 3 months. Though traditional theories in the early stage including hypoxic-hypocellular-hypovascular and fibro-atrophic in addition to new findings such as ferroptosis were put forward to explain the mechanisms of the osteoradionecrosis, the etiology of ORN is still unclear. With the high rate of occurrence in the head and neck area, especially in the mandible, this disease can disrupt the shape and function of the irradiated area, leading to a clinical presentation ranging from stable small areas of asymptomatic exposed bone to severe progressive necrosis. In severe cases, patients may experience pain, xerostomia, dysphagia, facial fistulas, and even a jaw defect. Consequently, sequence therapy and sometimes extensive surgery and reconstructions are needed to manage these sequelae. Treatment options may include pain medication, antibiotics, the removal of sequesters, hyperbaric oxygen therapy, segmental resection of the mandible, and free flap reconstruction. Microanastomosed free-flaps are considered to be promising choice for ORN reconstruction in recent researches, and new methods including three-dimensional (3-D) printing, pentoxifylline, and amifostine are used nowadays in trying increase the success rates and improve quality of the reconstruction. This review summarizes the main research progress in osteoradionecrosis and reconstruction treatment of osteoradionecrosis with mandibular defect.

Management of fracture non-union long bones by limb reconstruction devices

Background: The limb reconstruction system (LRS), rail road fixator, and Ilizarov fixator are used to treat open fractures with bone loss and infective non-union of long bones. It benefits the fracture site by permitting distraction, compression, and further enhancing micromotion at the level of fracture site which plays an important part in healing. The LRS is a straightforward, unidirectional arrangement that provides exceptional strength and rigidity. The limb rebuilding procedure has proven to be an effective treatment option in instances of fracture infective non-union of long bones. Aims and Objectives: This study is to evaluate and to observe the use of limb reconstruction devices (such as the Ilizarov fixator and the rail road fixator) in the treatment of open fractures with bone loss and infective non-union of long bones. Materials and Methods: Twenty patients (15 males and five females) with fracture non-union of long bones were involved in this study after taking permission from ethic committee and consents from all 20 individuals. These patients then underwent thorough debridement and resection of non-viable bone ends with the application of limb reconstruction devices which were then followed by bone transport to fill the bone gap. This was done by means of Ilizarov in 13 patients and by rail road fixator in the remaining seven patients. The average time of union and complications were evaluated. Results: Mean duration of fracture union was 7.9 months. While one patient had failure resulting in non-union, other 19 patients achieved union by limb reconstruction devices. Majority of the cases had no complications. Mean period of hospital stay for Ilizarov was 68.13 days and for rail road fixator 53.17 days. After applying independent “t-test,” no statistically significant differences were observed in fracture union duration between Ilizarov and rail road fixator, since the calculated P value was observed to be >0.05. Mean union of Ilizarov and rail road fixator application was found to be 7.6 months and 8.2 months, respectively. Conclusion: Limb reconstruction devices in our present study can be utilized as an effective way to tackle infective non-union of long bones and open fracture with bone loss for achieving better stabilization. Both Ilizarov and rail road fixator perform a crucial role in causing early mobilization of the patient and also in fracture union by distraction osteogenesis.

The modified Dunn procedure can be performed safely in stable slipped capital femoral epiphysis but does not alter avascular necrosis rates in unstable cases: a large single-centre cohort study.

Purpose:The modified Dunn procedure for slipped capital femoral epiphysis (SCFE) remains controversial. We reviewed our series over ten years to report our learning curve, experience with intraoperative monitoring of femoral head perfusion and its correlation with postoperative Single-photon emission computed tomography (SPECT-CT) bone scan and femoral head collapse in stable and unstable SCFE.Methods:We retrospectively assessed 217 consecutive modified Dunn procedures performed between 2008 and 2018. In all, 178 had a minimum of one-year follow-up (mean 2.7 years (1 to 9.2)) including 107 stable and 71 unstable SCFE. Postoperative viability was assessed with a three-phase Tc99 bone scan and SPECT-CT. From 2011, femoral head perfusion monitoring was performed intraoperatively using a Codman Intracranial Pressure transducer and the capsulotomy was modified.Results:With intraoperative monitoring, the rate of non-viable femoral heads in stable SCFE decreased from 21.1% to 0% (p < 0.001). In unstable SCFE, the rate remained unchanged from 35.7% to 29.8% (p = 0.669). The positive predictive value (PPV) of pulsatile monitoring for no collapse was 100% in stable and 89.1% in unstable SCFE. Pulsatile monitoring and viable SPECT-CT bone scan gave a 100% PPV for all cases. A non-viable scan defines those hips at risk of collapse since 100% of stable and 68.2% of unstable hips with non-viable bone scans went on to collapse.Conclusion:Our protocol enables safe performance of this complex procedure in stable SCFE with intraoperative monitoring being a reliable asset. The avascular necrosis rate for unstable SCFE remained unchanged and further research into its best management is required.Level of evidence:Level III

Scaphoid Nonunion Volar Plating with Pure Nonvascularized Cancellous Autograft.

Surgical treatment of scaphoid nonunion has evolved over the years to include a variety of procedures and techniques involving a number of vascularized and nonvascularized bone grafting options and fixation strategies. Volar plating of scaphoid nonunions with use of pure cancellous nonvascularized autograft is a safe and effective treatment method with good functional outcomes and union rates1. Volar plating of the scaphoid nonunion is performed via a volar approach, with debridement and reduction of the nonunion site. A nonvascularized pure cancellous bone autograft is then harvested and impacted from the distal aspect of the ipsilateral radius or the olecranon. Finally, a low-profile volar locking plate is applied for fixation2. There is no consensus regarding the optimal treatment of scaphoid nonunion. Headless compression screws are currently popular, and advances have been made over time to include various nonvascularized and vascularized corticocancellous grafts. The advent of plate fixation of the scaphoid has enabled the surgical treatment of nonunion to better replicate scaphoid morphology, allowing for improved biomechanical stability and optimizing the biologic milieu for healing. Headless compression screws, although a reasonable option for most acute scaphoid fractures, may not be the most appropriate application for nonunions. Compression, in itself, is not required for the surgical treatment of scaphoid nonunion, and can even prove detrimental by forcing the reduction into a malunion. The stability of headless compression screws must rely on a structural graft to resist the compression and create friction. The more structural the graft, however, the less biologically active it tends to be. Further, the simple placement of a metallic screw within the fracture site is counter to orthopaedic principles because it dramatically lowers the surface area available for union. Volar locking plates address the shortcoming of headless compression screws by (1) directly buttressing the deforming forces superior to headless screws3-6; (2) utilizing the most accessible, biologically active nonvascularized bone graft, which is pure cancellous graft; (3) allowing for maximal surface area contact for union; and (4) preserving the intraosseous vascular network within the scaphoid and its vascular supply at its dorsal ridge. Volar scaphoid plating with cancellous bone grafting is a reliable technique with excellent union rates and favorable functional outcomes. A review of 34 patients with scaphoid nonunions with segmental defects treated with volar plates and pure cancellous autograft demonstrated 100% union as verified by computed tomography scans postoperatively1. Average Disabilities of the Arm, Shoulder and Hand scores and grip strengths improved by final follow-up. Another series of 13 scaphoid nonunions with osteonecrosis treated with volar plating and pure cancellous autograft showed 100% union and good patient-reported and functional outcomes, despite smokers, proximal poles, and previous failed surgical procedures in the cohort2. These favorable results are consistent with earlier reports of the modern plating systems; however, concerns for hardware-related complications have been elucidated over the years, including symptomatic hardware impingement7. This risk can be mitigated by proper surgical technique and plate placement. Clear visualization of the entire volar surface of the scaphoid is crucial. Take care not to reflect too much capsule, so as to cause ulnar translation of the carpus.Thorough debridement of nonviable bone is paramount. Using a 2.0 or 3.0-mm low-speed burr with continuous irrigation can be helpful. We have had successful unions even in cases in which the remaining proximal pole was just a cortical shell and essentially a hollow vessel for graft.Err on the side of verticalization of the scaphoid, overextending and supinating the distal pole. Overstuffing the nonunion site with cancellous autograft aids in reduction and maximizes the osteoinductive and osteoconductive properties of the graft.Impaction of the graft is crucial, and the surgeon should harvest more autograft than one might initially anticipate.Secure the plate to the proximal portion of the scaphoid first. There is less room for error on the proximal portion where plate positioning is more critical.Do not cross the scaphoid "line in the sand"; to do so will result in plate impingement on the radius. Proper placement of the plate is just distal to the point at which the convex surface of the proximal pole transitions to become the concave surface of the scaphoid waist, as viewed from a volar approach.Plate modification for proximal pole fractures and nonunions: removal of the most proximal hole in the plate allows for improved fixation despite the plate itself remaining behind the scaphoid "line in the sand." In these cases, the locking screws must be directed so that they buttress the subchondral bone of each pole, especially the proximal pole.

Fluorescent tetracycline bone labeling as an intraoperative tool to debride necrotic bone during septic hip revision: a preliminary case series.

A plausible cause of persistent infection after septic hip revision may be the presence of nonviable osteomyelitic bone. Since surgical excision of these necrotic fragments is often challenging, the use of fluorescent tetracycline bone labeling (FTBL) as an intraoperative tool may pose an additional assessment aid to provide a visual index of surgical debridement. Methods: We present a single-center study performed in a university hospital from January 2018 to June 2020, in which all consecutive cases of chronic hip periprosthetic joint infection (PJI) undergoing revision using FTBL were retrospectively reviewed. In all cases, the patient was under treatment with tetracyclines at the moment of the revision surgery. During the surgery, all bone failing to fluoresce was considered nonviable and thus removed and sent for both culture and histology. Results: We include three cases in which the FTBL technique was used. In all cases, the histopathological examinations of the nonfluorescent removed bone were consistent with chronic osteomyelitis. Conclusion: The intraoperative use of FTBL successfully aided the surgeon to detect the presence of nonviable bone in all the presented cases of chronic prosthetic hip infection.

Multiple Burr Hole as an Alternative Treatment for Large Scalp Defect

Background: Scalp defect with exposed bones is a serious injury that is often occurred after electrical burn injury. The coverage treatment may vary from local flap to free flap. Coverage becomes a major problem when flaps fails or is contraindicated and resulting in further morbidity. In this paper we report 1 patient with large scalp defect after electrical burn injury.Methods : In this study, we report 1 patient with large scalp defect after electrical burn, which treated in our department. Fourteen days after the electrical burn injury, surgical debridement was done by the plastic surgeon, and multiple burr holes were made by the neurosurgeon in the nonviable bone. The distance between each burr holes was 15 mm. The defect was keep moist with absorbent. The scalp defects were treated with soft tissue debridement every 3 days in the policlinics to keep the wound presented viable. To date, the wound already treated for 90 days.Results : The granulation tissue appears in between the burr holes within 14 days. After the defect was covered with granulation tissues, a further closure such as skin graft application was necessary. No postoperative infection, osteomyelitis, or cranial bone sequestration was reported in this case.Conclusions: Multiple cranial burr holes can be chosen as an alternative treatment for large scalp defect. These technique, allow the formation of a vascular bed suitable for skin grafting. This technique is safe, swift and effective for cases of extensive exposure for the skull bone expose of the periosteum following trauma.

Surgical Strategies: Cement Spacer for Staged First Metatarsophalangeal Arthrodesis After Failed Arthroplasty

Revision arthrodesis following surgery for first metatarsophalangeal arthritis (hallux rigidus) is a complex problem. Failed implants, arthroplasty, primary fusion, or infection may result in bone loss with abnormal soft tissue tensions. This requires technically challenging revision surgery necessitating debridement of nonviable bone, culture, and bone grafting of resultant defects. We describe a 2-stage technique for first metatarsophalangeal arthrodesis in the setting of osteolysis, infection, or bone loss. This staged technique allows for the restoration of appropriate soft tissue tension through the use of a temporary cement spacer before structural grafting.

Human placenta‐derived matrix with cancellous autograft and demineralized bone matrix for large segmental long‐bone defects in two dogs with septic nonunion

To report the successful treatment of septic nonunion in two dogs with large segmental defects secondary to long-bone fractures by using a novel human placenta-derived matrix (hPM) as adjunct to fixation. One 3-kg 9-year-old neutered male Yorkshire terrier with a distal antebrachial fracture and one 6-kg 4-year-old spayed female miniature pinscher with a distal humeral fracture. Short case series. Both dogs presented for septic nonunion after internal fixation of Gustilo type II open diaphyseal fractures from dog bite injuries. During revision, debridement of nonviable bone resulted in segmental defects of 32% and 20% of the bone length for the antebrachial and humeral fractures, respectively. The antebrachial fracture was stabilized with a circular external fixator, and the humeral fracture was stabilized with biaxial bone plating. The fracture sites were not collapsed, and full length was maintained with the fixation. Autogenous cancellous bone graft and canine demineralized bone allograft were packed into the defects, and hPM was injected into the graft sites after closure. Radiographic union was documented at 8 weeks and 6 weeks for the antebrachial and humeral fractures, respectively. Both dogs became fully weight bearing on the affected limbs and returned to full activity. Augmenting fixation with grafts and hPM led to a relatively rapid union in both dogs reported here.

Commercially available antibiotic-laden PMMA-covered locking nails for the treatment of fracture-related infections - A retrospective case analysis of 10 cases.

Introduction: Fracture-related infections (FRIs) are a devastating complication. FRIs are challenging and should be addressed with a multidisciplinary approach. An FRI should be addressed surgically by non-viable bone debridement, local antibiotic deposition, minimization of dead space and fracture stabilization. Antibiotic-laden PMMA-covered nails are a viable option to face these complications. To demonstrate the safety and utility of commercially available antibiotic-laden PMMA-covered nails, we performed a review of the cases operated in our institution and a cost analysis to compare the cost of a commercial nail to other available alternatives.Material and methods: We designed a retrospective study of consecutive cases to demonstrate the safety and efficacy of antibiotic-laden PMMA-covered commercial nails and designed a cost analysis of commercial coated nails compared to other custom-made alternatives.Results: We treated seven tibias and three femurs. Nine patients fully fit the criteria for FRI. There was one case of reintervention because of persistent drainage. All fractures healed, and in the first year post-intervention, there were no signs or symptoms of infection. There were no complications related to the commercially available nail that was used. There is a small increase in the direct quantifiable cost in commercially available nails, but non-quantifiable cost should be assessed individually.Conclusions: Commercially available antibiotic-laden PMMA-covered nails are a safe and useful treatment option for complicated cases of lower limb long bone reconstruction. The low complication rate and the straightforward technique compensate for the direct cost increase in most situations.

A Review on the Orthoplastic Approach to Lower Limb Reconstruction.

Just as in the craft of carpentry, a stable foundation and framework are absolutely essential to the final function of a building, but no more important than the drywall, trim, and paint that make the building functional, durable, and livable. Reconstruction of the lower extremity is similar; the orthopaedic surgeon must obtain stable fixation of the damaged or diseased bone once a thorough debridement of nonviable bone is performed, while the plastic or orthopaedic soft tissue surgeon must provide vascularized, stable coverage. These two components are complementary and both contribute to the success or failure of functional limb restoration. The stability of bone repair will predict the ultimate functional status, while the vascularized envelope will enhance the biology of bone and soft tissue healing. When both components are properly attended to, the result is often a functional limb with an acceptable appearance. While a single surgeon need not perform both of these tasks (although some may choose to do so), the orthopaedic and plastic surgeon involved in this care must have a clear understanding of each other's role and their importance for a good outcome. This is what we call the orthoplastic approach to reconstructive surgery of the extremities, that is, the application of principles and practice of both specialties applied simultaneously to optimize the outcomes in limb reconstruction. In this review article, we discuss the history of orthoplastic surgery, the key elements of orthoplastic surgery, and thoughts on factors that lead to good outcomes through select cases.

Optimal Management of the Patient With an Open Distal Femur Fracture

Open fractures of the distal femur present several challenges to the treating surgeon as well as the patient. Patients who sustain this injury are at risk for a variety of complications including nonunion, malunion, post-traumatic arthritis, limited function, need for multiple surgical procedures and in some cases, amputation. This article will review initial care of the injured patient, important facets of open fracture care, management of injured soft tissues, strategies for internal fixation in order to optimize outcomes and minimize complications. Additionally, management of nonunion and malunion of the distal femur, including the role for creation of anticipated nonunion following aggressive debridement of nonviable bone, are addressed.

Presurgical localization of infected avascular bone segments in chronic complicated posttraumatic osteomyelitis in the lower extremity using dual-tracer PET/CT

BackgroundLocalizing and removing the infected sequestrum in long-standing trauma-related chronic osteomyelitis remains a clinical challenge. PET/CT with 18F-fluorodeoxyglucose (FDG-PET) has a high sensitivity for chronic osteomyelitis and 18F-sodium-fluoride PET/CT (NaF-PET) has a high specificity for identifying non-viable bone. Combining both, high signal on FDG-PET in the bone without signal on NaF-PET could potentially guide surgery to become more precise with curative intent.Eight patients with long-standing (average 22 years) posttraumatic (n = 7) or postoperative (n = 1) chronic osteomyelitis in the lower extremity and with multiple futile attempts for curative surgery were recruited in this prospective pilot study. FDG-PET and NaF-PET were performed within a week in between using standard scanning protocols. The most likely location of the culprit sequestrum was identified and was surgically removed. Based on perioperative tissue cultures, antibiotics were given for 6–8 months. Dual-tracer (FDG- and NaF-PET/CT) was performed again after 12 months to rule out persisting signs of infection.ResultsA likely culprit sequestrum could preoperatively be identified by dual-tracer PET in all eight cases and in four cases an additional sequestrum was identified at a location with no clinical sign of infection. The infected necrotic tissue was removed during surgery. Follow-up dual-tracer PET revealed no signs of persistent infection. All patients recovered with no clinical signs of recurrence for a follow-up of mean 4.5 (SD 1.3) years.ConclusionsDual-tracer PET/CT with FDG and NaF allows successful precise surgery with curative intent in patients with long-standing complicated posttraumatic chronic osteomyelitis with severely deranged anatomy.

Airbag cover impact: a rarely seen reason for mandibular defects.

Airbags and seatbelts are among the primary means of preventing severe injuries after motor vehicle accidents. Nonetheless, many studies have examined injuries that were related to airbag deployment. To our knowledge, this is the first case report of multiple mandible fractures caused by impact with the airbag cover. Removal of non-viable bone fragments was performed and the resulting hemi-mandible defect was reconstructed with a free iliac crest flap. A radial forearm free flap was used to reconstruct the mucosal defect. Airbags can prevent deadly injuries; however, they can also cause serious harm to the maxillofacial bones at the time of deployment.

Distraction Osteogenesis by Ilizarov Technique for Infected Gap Non-Union of the Femur

Introduction: Purpose- To review records of 36 patients who underwent distraction osteogenesis or bone transport by Ilizarov fixator for infected gap non-union of femoral shaft. Materials and Methods: 30 men and 6 women aged 20 to 57 years underwent adequate debridement and resection of the nonviable bone, followed by bone transport using Ilizarov fixator for infected gap non-union of the femoral shaft. All patients had a bone defect of >4 cm. The lengthening index, x-ray consolidation index, functional status, bone healing and complications encountered during the treatment were assessed. Results: The patients had undergone a mean of 3 (range 1-6) surgical procedures before presentation. The mean duration from trauma to presentation was 6.5 (range 5-16) months. The mean bone defect after adequate resection was 8.9 (range 4.5-13) cm. The mean treatment time was 8.5 (range 6-16) months. The mean lengthening index was 12.5 (range 10.5-14) days/cm. The mean treatment index was 25.5 (range 25-45) days/cm. The mean follow up time was 18.5 (range 15-45) months. Functional outcome was excellent in 20, good in 10 and fair in 6 patients. All patients had solid union and eradication of infection. None had neurovascular complications and refracture of the regenerated bone, but encountered knee stiffness (n=7) i.e, knee extension contracture which was managed by Judet’s Quadriceps Plasty later on, we did not do any bone grafting for any cases. Conclusion: Bone transport by Ilizarov fixator is safe, stable, and effective for treating infected gap non-union of the femoral shaft.

COMPARISON OF DIFFERENT CORE DECOMPRESSION TECHNIQUES FOR TREATMENT OF EARLY STAGES OF OSTEONECROSIS OF THE FEMORAL HEAD

Today one of the most interesting organ surgical interventions for patients with osteonecrosis of the femoral head are still different core decompression procedure. However, in the literature, we could not find any indication on what stage of the disease is different proposed techniques is the most effective.Purpose of the study compare the results of different methods of core decompression in the early stages of the disease, before the development of hip osteoarthritis.Materials and methods. From 2006 to 2015 we treated 84 patients (96 hips) with a diagnosis of osteonecrosis of the femoral head. The mean age of patients was 37,4±9,1 (from 18 to 71) years. Classification Association Research Circulation Osseous (ARCO) was used to determine the stage of the disease. 20 patients core decompression performed on stage II, 71 stage III and 5 in stage IV of disease. Core decompression by one tunnel 9 mm diameter was performed in 55 cases, and in 33 cases, the destruction of the core to the healthy bone has been made. Grafting of the residual cavity has been made by allogeneic bone, calcium sulfate, a combination of calcium sulfate and p3-calcium phosphate and p3-calcium phosphate. Eight joints operated by core decompression multiple tunnels of small diameter without subsequent plastic tunnels. We assessed the results on the basis of X-ray and CT scan data of the operated hip, and according to Oxford Hip Score at 3, 6 and 12 months, and then once in 1 year after surgery. In case of subsequent hip replacement was performed pathological examination area of core osteonecrosis of the femoral head.Results. The average period of follow-up was 31,6 months (from 12 to 110 months). Preventing hip arthroplasty during this time managed in 43 cases (44.8%), 53 joints (55.2%), total hip replacement has been made in the period from 4 to 72 months (average 21.6 months) from the date of implementation of core decompression. The greater the number of good and satisfactory results have shown methods aimed at complete destruction of nonviable bone on the border of core osteonecrosis healthy bone.Frequency of hip replacement is directly dependent on the stage of the disease.In the second stage of the disease hip replacement made in 4 cases (20%) at the third stage satisfactory performance were observed mainly in the case of small and medium sized core osteonecrosis of the femoral head (4, 18 and 16 of the joints 27, respectively). In the fourth stage of the disease arthroplasty was performed in all five cases.Conclusions. Different techniques of core decompression are most effective before the formation of the Impressions of the loaded part of the femoral head, which corresponds to stage III ARCO classification inclusive. Efficacy techniques depends not only on the stage but also on the size and location core of osteonecrosis.

Use of Vancomycin-Impregnated Calcium Sulfate in the Treatment of Osteomyelitis of the Jaw

The aim of this study was to describe the effect of vancomycin-impregnated calcium sulfate in the treatment of osteomyelitis of the jaw. Twelve patients who were diagnosed with osteomyelitis of the jaw underwent treatment with vancomycin-impregnated calcium sulfate since July 2014 at the Department of Oral and Maxillofacial Surgery, School of Stomatology, China Medical University (Shenyang, China). All patients underwent debridement of nonviable bone and implantation of vancomycin-impregnated calcium sulfate. The wounds were covered with an acellular dermal matrix and sutured. Ten patients had satisfactory wound healing. However, 2 cases of maxillary central osteomyelitis had delayed wound healing. The wounds healed after the surgical site was resutured under local anesthesia. At 3months, the panoramic radiograph showed that most implants had been reabsorbed and replaced by new bone formation. All patients in this study had no recurrence of infection at 6 to 18months (mean, 10.8months) of follow-up. The use of vancomycin-impregnated calcium sulfate in the surgical debridement site for chronic osteomyelitis of the jaw has shown encouraging results. In addition, calcium sulfate can promote the formation of new bone to a certain extent.