Partial Union Research Articles

Maxillofacial reconstruction using custom-made artificial bones fabricated by inkjet printing technology

Ideally, artificial bones should be dimensionally compatible with deformities, and be biodegradable and osteoconductive; however, there are no artificial bones developed to date that satisfy these requirements. We fabricated novel custom-made artificial bones from alpha-tricalcium phosphate powder using an inkjet printer and implanted them in ten patients with maxillofacial deformities. The artificial bones had dimensional compatibility in all the patients. The operation time was reduced due to minimal need for size adjustment and fixing manipulation. The postsurgical computed tomography analysis detected partial union between the artificial bones and host bone tissues. There were no serious adverse reactions. These findings provide support for further clinical studies of the inkjet-printed custom-made artificial bones.

Reference study on the time frame for ossification of the distal radius and ulnar epiphyses on the hand radiograph

Hand radiographs from 554 male and 288 female subjects aged 10–30 years, which had been taken due to traumatological indications, were evaluated. A classification into five ossification stages was applied to assess the epiphyseal development of distal radius and distal ulna (1: epiphysis not ossified; 2: epiphysis ossified, nonunion of the epiphysis and metaphysis; 3: partial union of the epiphysis and metaphysis; 4: complete union of the epiphysis and metaphysis, epiphyseal scar visible; 5: complete union of the epiphysis and metaphysis, epiphyseal scar nondiscernable). It was established that male subjects with an ossification stage 4 of the radius or ulna and female subjects with an ossification stage 5 of the radius were at least 14 years old. The occurrence of ossification stage 5 of the radius proves that a male individual has reached the age of 18 years.

Allograft-Prosthetic Composite Reconstruction of the Proximal Part of the Tibia

Allograft-prosthetic composite reconstruction of the proximal part of the tibia is one option following resection of a skeletal tumor. Previous studies with use of this technique have found a high prevalence of complications, including fracture, infection, extensor mechanism insufficiency, and loosening. To address some of these problems, we adopted certain measures, including muscle flap coverage, meticulous tendon reconstruction, rigid implant fixation, and careful rehabilitation. The goal of the present study was to evaluate the functional outcome and complications in patients undergoing allograft-prosthetic composite reconstruction of the proximal part of the tibia. Twelve patients who underwent allograft-prosthetic composite reconstruction of the proximal part of the tibia after tumor resection were retrospectively evaluated at a median follow-up of forty-nine months. Clinical records and radiographs were reviewed to evaluate patient outcome, healing at the allograft-host junction, function, construct survival, and complications. Nine patients had no extensor lag, and three patients had 5 degrees to 15 degrees of extensor lag. The mean amount of knee flexion was 103 degrees (range, 60 degrees to 120 degrees ). The mean Musculoskeletal Tumor Society score was 24.3 (81%) of a maximum of 30. Complete bone union occurred in nine patients, and partial union occurred in three patients. At the time of writing, no secondary bone-grafting procedures had been required to achieve union, and no revision or removal of the reconstruction had been performed. Rotational or free flaps provided satisfactory wound coverage in all patients. A deep infection occurred in one patient whose allograft and prosthesis were successfully retained after treatment with surgical débridement and intravenous antibiotics. After osteoarticular resection of destructive tumors of the proximal part of the tibia, an allograft-prosthetic composite reconstruction can provide consistently good functional results with an acceptably low complication rate. Technical aspects of the procedure that may favorably affect outcome include soft-tissue coverage with muscle flaps and rigid fixation with a long-stemmed implant.

Age estimation from stages of union of the vertebral epiphyses of the ribs

This study attempts to fill a persistent gap in the literature by documenting the timing of epiphyseal union at the vertebral end of the ribs in a sample of modern Portuguese skeletons. The skeletal remains of 53 females and 45 males, between the ages of 11 and 30, were taken from the Lisbon documented skeletal collection. Individuals in the sample have been previously described as being representative of a middle-to-low socioeconomic segment of the early 20th century Lisbon population. Three anatomical locations were examined for epiphyseal union: the head, the articular tubercle and the nonarticular tubercle. The first epiphysis to show partial union is that of the nonarticular tubercle (females, 11-19 years; males, 11-19 years), followed by the epiphysis of the articular tubercle (females, 11-20 years; males, 16-20 years), and finally by the head epiphysis (females, 15-24 years; males, 16-22 years), which can still show incomplete epiphyseal closure at 25 and 24 years for females and males, respectively. A trend for earlier female maturation was observed, but the statistical tests only confirmed this result for some ribs and age groups. No directional asymmetry was found, but a significant fluctuating asymmetry was observed in all three epiphyses. A preliminary analysis showed that the asymmetric group of individuals in the study sample includes all the rural-to-urban migrants, relative to the symmetric group.

Intramedullary screw fixation in proximal fifth-metatarsal fractures in sports: clinical and biomechanical analysis

Intramedullary screw fixation (ISF) of proximal fifth-metatarsal fractures is known as first treatment option in young, sports active patients. No study analyzed functional and biomechanical outcome before. Hypothetically ISF leads to (1) a high bony union rate within 12 weeks, (2) normal hindfoot eversion strength, and (3) normal gait and plantar pressure distribution. Fourteen out of 22 patients were available for follow-up with an average follow-up of 42 months; clinical and radiological follow-up, and biomechanical evaluation by isometric muscular strength measurement (inversion, eversion strength) and dynamic pedobarography, comparing to the non-affected contralateral foot. Level of significance: 0.05. Subjective result: Excellent or good result in 14 patients, none fair or poor. AOFAS midfoot score: 100 points in 13 patients and 87 points in 1 patient. The same sports activity level (0-4) was reached in 13 out of 14 patients. Radiologic examination: consolidation after 6 weeks in 9 patients and after 12 weeks in another 4 patients, one partial union. Average maximal eversion strength 59 N (ratio to the contralateral foot: 0.92, not significant). Dynamic pedobarography showed ratios of 0.99-1.01 to the contralateral side for ground reaction force, ground peak time, peak pressure and contact area (not significant). A very-high patient-satisfaction, a fast bony healing and complete return to sports were documented. Muscular strength measurement and dynamic pedobarography showed complete functional rehabilitation. Therefore, ISF in proximal fifth-metatarsal fractures can be recommended as a secure procedure.

Age estimation of adolescent and young adult male and female skeletons II, epiphyseal union at the upper limb and scapular girdle in a modern Portuguese skeletal sample

This study completes previously reported ages for timing of epiphyseal union in the postcranial skeleton in a recent sample, with data from the scapula, clavicle, humerus, radius, and ulna. A sample of 121 individuals between the ages of 9 and 29 (females = 65, males = 56) was derived from the Lisbon documented skeletal collection. Epiphyseal union was scored at 16 anatomical locations, using a three-stage scheme: 1) no union; 2) partial union; and 3) completed union, all traces of fusion having disappeared. In the upper limb, the epiphyses of the elbow are the first to fuse at around 11 to 15 years of age, followed by those of the shoulder and wrist. In the scapular girdle, the coracoid area is the first to fuse, followed by the glenoid surface and remaining epiphyses, with the medial clavicle fusing last, by the age of 25-27. There is a sex difference in maturation, with females showing an advance relative to males of about 2 years in the upper limb. Sex differences in maturation are less noticeable in the scapular girdle, but data suggest that females are also ahead of males. Results suggest overall similar age ranges for stages of union as previous dry bone observations, but some studies show significant divergences which seem to derive from methodological issues. Although some radiographic reference standards provide comparable age ranges, they should probably be avoided when aging skeletal remains.

Epiphyseal union at the innominate and lower limb in a modern Portuguese skeletal sample, and age estimation in adolescent and young adult male and female skeletons

This study documents the timing of epiphyseal union at the innominate, femur, tibia, and fibula in a sample of modern Portuguese skeletons. The sample was taken from the Lisbon documented skeletal collection and it is comprised of 57 females and 49 males between the ages of 9 and 25. Individuals are mostly representative of the middle-to-low socioeconomic segment of the early 20th century Lisbon population. A total of 18 anatomical locations were examined for epiphyseal union using a three-stage scheme: 1) no union; 2) partial union; and 3) completed union, all traces of fusion having disappeared. Results show that females are ahead of males by 1-2 years and provide similar age ranges for the stages of union than previous studies. Some variations between studies can be explained by methodological differences between dry bone and radiographic observations. However, a review of the literature indicates that socioeconomic status of a given population seems to be of decisive importance to the rate of ossification and most of the differences in skeletal maturation across studies and populations can probably be ascribed to different levels of social and economic development of the societies in which the individuals lived. Although the effects of socioeconomic status in skeletal maturation are greater during childhood than in adolescence, as to make the timing of epiphyseal union a reliable estimate of age at death, they are not negligible and age estimates should take into account the likely socioeconomic status of the individual, whose remains are under examination.

Use of antibiotic cement rod to treat intramedullary infection after nailing: preliminary study in 19 patients

The treatment of intramedullary infections after nailing usually includes removal of the nail, debridement, and, in some cases, insertion of antibiotic-impregnated cement beads. We use this self-made antibiotic cement rod to treat intramedullary infections. Compared with the beads, it provides some limited mechanical support and can be preserved in the canal for a long time. We reviewed 19 infected patients who underwent removal of the nails, excision of sinus tracks, debridement of the canal and insertion of the rods. No recurrent infection occurred in 18 cases and 11 cases achieved bone healing, 6 cases achieved partial union. One patient had nonunion and one patient underwent amputation because of severe primary trauma and long-term infection. The rod was removed between 35 and 123 days after implantation. We conclude that the antibiotic cement rods could be a relatively effective, simple and inexpensive method of treating intramedullary infections after nailing.

Partial Union of Acute Scaphoid Fractures

Sixty-six patients with acute scaphoid fractures were treated non-operatively in a below elbow plaster for 8 to 12 weeks and underwent CT scans along the longitudinal axis of the scaphoid at 12 to 18 weeks. These scans showed that 14 fractures had not united and that 30 had united throughout the whole cross-section of the scaphoid. The other 22 had partially united with bridging trabeculae in some areas of the cross-section. These 22 partial unions were graded as 0% to 24% union (0 cases), 25% to 49% union (5 cases), 50% to 74% union (7 cases), and 75% to 99% union (10 cases). The 12 patients who had less than 75% fracture union were followed-up further and nine underwent another CT scan at 23 to 40 weeks after the initial injury. These showed union across the whole of the cross-section of the fracture in seven cases and 75% to 99% union in the other two cases, who had full and painless wrist function. We conclude that partial union of the scaphoid is a common occurrence but, in most cases, it progresses to full union without the need for prolonged plaster immobilization.

環椎後頭骨癒合症の２例

Assimilation of the atlas is a rare disease, and this condition is characterized by a partial or complete congenital union between the atlas and the base of the occiput. We report two cases of assimilation of the atlas.A 32-year-old male had been suffering from neck stiffness, progressive numbness of the extremities and walking disturbance since he was 13 years old. Assimilation of the atlas associated with atlantoaxial instability was seen and spinal cord was compressed at the atlanto-occiput junction severely on MRI. Removal of the posterior arch of the atlas and occipito-cervical fusion was pertormed using instruments and the symptoms improved.A 51-year-old female lost consciousness which driving and collided into a concrete fence. She regained consciousness after a few minutes but experienced walking disturbance and right hand numbness. No intracranial lesion was found but MRI indicated a high signal area in the spinal cord at the occpitocervical junction. In addition to spinal cord injury, computed tomography revealed assimilation of the atlas, atlantoaxial subluxation, and os odontoideum. Loss of consciousness was considered resulting from vertebral artery insufficiency. After more or less the same surgery as the previous case, she could leave the hospital by walking and lead daily life without difficulties.

Symptomatic, partial union of the hook of the hamate fracture in athletes.

Many clinicians believe that after fracture of the hook of the hamate, nonunions are the rule rather than the exception. To describe a previously unreported condition in which the fractured hook of the hamate unites only along its ulnar column and causes pain similar to that in cases of nonunion. Retrospective review. Eight patients who had sustained a hook of the hamate fracture were identified, on the basis of their persistent pain, as having achieved only partial union. This diagnosis was made despite evidence on computed tomography of healed bone across a significant portion of the fracture. All eight patients underwent subperiosteal excision of the hamulus because of persistent pain. At an average of 4 years after excision, each patient was evaluated by dynamometer grip strength testing and a subjective outcome assessment. All patients were able to return to their preinjury level of sports participation at an average 8 weeks after excision of the hook of the hamate. Grip strength was not adversely affected in any patient. Subjective evaluation of each patient revealed no residual pain. Chronic or unresolved pain on the ulnar side of the wrist after hook of the hamate fracture can be due to partial union. This condition should be managed no differently from a symptomatic nonunion, with excision of the hook of the hamate and repair of the ligament attachments.

Nonoperative Treatment of Intracapsular Fractures of the Proximal Femur

Of 2776 intracapsular fractures of the proximal femur, 18% of the patients were treated nonoperatively. Included in the group of patients who were treated conservatively were children, patients with cardiac problems or mental problems, stroke, renal failure, multiple disseminated malignancies, and patients who chose nonoperative treatment. The medical treatment protocol can be divided into two stages: Initially, (1) nursing of a bedridden patient with emphasis on the prevention of complications; and (2) once partial bone union has occurred, the attempted rehabilitation to independent ambulation. Paramedical services provide a major contribution during inpatient therapy and during the preparation for returning the patient to the community. A multidisciplinary medical team evaluates and assesses the patient's needs and rehabilitation potential and in cooperation with the patient and the family, an operative plan then is established.

Induction of a neoarthrosis by precisely controlled motion in an experimental mid-femoral defect

Bone regeneration during fracture healing has been demonstrated repeatedly, yet the regeneration of articular cartilage and joints has not yet been achieved. It has been recognized however that the mechanical environment during fracture healing can be correlated to the contributions of either the endochondral or intramembranous processes of bone formation, and to resultant tissue architecture. Using this information, the goal of this study was to test the hypothesis that induced motion can directly regulate osteogenic and chondrogenic tissue formation in a rat mid-femoral bone defect and thereby influence the anatomical result. Sixteen male Sprague Dawley rats (400±20 g) underwent production of a mid-diaphyseal, non-critical sized 3.0 mm segmental femoral defect with rigid external fixation using a custom designed four pin fixator. One group of eight animals represented the controls and underwent surgery and constant rigid fixation. In the treatment group the custom external fixator was used to introduce daily interfragmentary bending strain in the eight treatment animals (12° angular excursion), with a hypothetical symmetrical bending load centered within the gap. The eight animals in the treatment group received motion at 1.0 Hz, for 10 min a day, with a 3 days on, one day off loading protocol for the first two weeks, and 2 days on, one day off for the remaining three weeks. Data collection included histological and immunohistological identification of tissue types, and mean collagen fiber angles and angular conformity between individual fibers in superficial, intermediate, and deep zones within the cartilage. These parameters were compared between the treatment group, rat knee articular cartilage, and the control group as a structural outcome assessment. After 35 days the control animals demonstrated varying degrees of osseous union of the defect with some animals showing partial union. In every individual within the mechanical treatment group the defect completely failed to unite. Bony arcades developed in the experimental group, capping the termini of the bone segments on both sides of the defect in four out of six animals completing the study. These new structures were typically covered with cartilage, as identified by specific histological staining for Type II collagen and proteoglycans. The distribution of collagen within analogous superficial, intermediate, and deep zones of the newly formed cartilage tissue demonstrated preferred fiber angles consistent with those seen in articular cartilage. Although not resulting in complete joint development, these neoarthroses show that the induced motion selectively controlled the formation of cartilage and bone during fracture repair, and that it can be specifically directed. They further demonstrate that the spatial organization of molecular components within the newly formed tissue, at both microanatomical and gross levels, are influenced by their local mechanical environment, confirming previous theoretical models.

Employer Matters in 1999

Employers in 1999 continued their learning under the 1996 Act, viewed it favourably but did not greatly change their use of the regulatory instruments it offers. For this, they fell foul of an interventionist minister. Faced with partial union resurgence, they sought legislative changes to further weaken unionism. Overall, employer attitudes, as expressed through their associations, continued to show conver gence, while competition among associations intensified. Divergence was related to operational strategies of single employers and to the national policy level, including the Coalition's amendment package. Legislative defeat turned a year of promise for the 'Workplace Relations Club' into one of worrying defeat.

Clinical Utilisation of Computed Tomography of the Scaphoid.

Computed tomography is the best imaging modality to assess bony architecture. Scanning in the longitudinal plane of the scaphoid provides a greater appreciation of the humpback deformity. CT scan provides superior assessment of union and has a higher correlation with operative findings. A limitation of CT scanning is partial volume averaging which may give a false impression of a partial union when a nonunion exists. Height-to-length ratio provides superior observer variability for the assesssment of the humpback deformity. CT is useful to be able to "template" the proposed surgery of the scaphoid. It allows the surgeon to determine whether a structural bone graft is required, the preferred screw fixation and whether a volar or dorsal approach is required.

Bone age determination based on the study of the medial extremity of the clavicle.

The development of the medial clavicular epiphysis and its fusion with the clavicular shaft have been a subject of medical research since the second decade of this century. Computed tomography provides the imaging modality of choice in analyzing the maturation process of the sternal end of the clavicle. In a retrospective study, we analyzed normal development in 380 individuals under the age of 30 years. The appearance of an epiphyseal ossification center occurred between ages 11 and 22 years. Partial union was found from age 16 until age 26 years. Complete union was first noted at age 22 years and in 100 % of the sample at age 27 years. Based on these data, age-related standardized age distributions and 95 % reference intervals were calculated. Compared to the experience recorded in the relevant literature, there are several landmarks that show no significant change between different ethnic groups and different periods of publication; these are the onset of ossification, the time span of partial union, and the appearance of complete union. Despite the relatively long time spans of the maturation stages, bone age estimation based on the study of the development of the medial clavicular epiphysis may be a useful tool in forensic age identification in living individuals, especially if the age of the subject is about the end of the second or the beginning of the third decade of life (e. g. in determining the applicability of adult or juvenile penal systems). Another possible use is in identifying human remains whose age is estimated at under 30 years.

The radiographic appearances of allografts in total hip arthroplasty revisions

The aim of this study was to describe the radiographic appearances of femoral allografts in 29 total hip arthroplasty (THA) revision procedures among 21 patients. Each patient had evidence of severe bone loss in the proximal femur related to previous hip arthroplasty. Proximal femoral allografts and cortical strut allografts were used to supplement and reinforce the native femur. The radiographic appearances were reviewed over a mean follow-up period of 2.5 years. A definite pattern emerged as the graft proceeded to unite with the host bone. The earliest feature was haziness and blurring of the ends of the allograft, followed by rounding and tapering of the ends, several months later. Eventually, sclerosis and coarse trabeculation of the cortex was seen when the graft had incorporated. A minor degree of resorption occurred in all cases, most commonly beneath the cerclage wires binding the grafts to the host bone. Complications included infection, fracture of the allograft and the host femur, and resorption of the graft. There were 3 cases of complete non-union and 11 cases of partial union. A definite radiographic pattern is evident as allograft bone unites with host bone. Knowledge of this pattern is useful to assess progression towards bony unit. Le but de ce travail est de décrire les apparences radiographiques d'allogreffes femorales dans 29 cas d'arthroplasties totales de la hanche (ATH) chez 21 patients ayant subi une intervention corrective. Chacun des patients présentait une perte considérable de la masse osseuse du fémur proximal due à la précédente arthroplastic. Afin de renforcer et de compenser le fémur naturel on avait procédé à des allogreffes fémorales proximales et des allogreffes à étai cortical. Les apparences radiographiques ont été établis sur une période moyenne de suivi médical de deux ans et demi. Un schéma bien défini apparaît à partir du moment où la greffe commence à se souder à l'os récepteur. On observe d'abord l'apparition d'une tache trouble et voilée aux extrémités de l'allogreffe suivi plusieurs mois plus tard d'un effacement aux extrémités. Une fois la greffe prise, on remarque une sclérose et trabécule grossière du corteux. Dans tous les cas observés il s'était produit une résorption, en général au niveau des cerclages métalliques fixant la greffe à l'os récepteur. Parmi les autres complications il faut citer également l'infection, la fracture de l'allogreffe et du fémur récepteur et la résorption de la greffe elle-même Dans trois des cas la greffe ne s'était pas faite et dans onze des cas elle n'était que partielle. Il est ainsi possible d'observer au niveau radiographique le schéma évolutif d'une allogreffe tandis qu'elle se soude à l'os récepteur. Il est utile de savoir reconnaître cette évidence afin de pouvoir estimer la progression de la soudure des os.

Apparent and partial non-union of the scaphoid

Ten patients with radiological non-union of the scaphoid and four patients with suspected non-union were explored surgically. At operation, ten scaphoids looked united; five of these went on to definite union but the other five to non-union (in one case, despite a Herbert screw). In another four patients, there appeared at operation to be partial union; all proceeded to complete union. Even with the scaphoid in front of you, it can be difficult to decide whether it has united or not.

The creative room

The creative room refers to the area that arises when the third areas (intermediate spaces) of analyst and analysand overlap. This involves a partial union of the intermediate spaces of self and object. This overlapping space, the creative room, accommodates reflective observance as well as devoted association. A prerequisite for the creative room is the created room, the analytical framework. Other requirements concern properties of the analyst's and the patient's intermediate areas and their interrelationship. These circumstances are examined in the light of clinical examples. The primary concern, however is the absence of the third, when the creative room does not arise or rather, various positions of self and object around the point where the third either fails to arise or is eliminated. In a concluding section, there is an example of the creative room being extended in time for the continued creativity of the two parties (Bion and Beckett) for the rest of their lives.

Pattern of scaphoid fracture union detected by macroradiography

Stereoscopic macroradiography was used to study the pattern of union of scaphoid fractures. Of 21 patients who had partial union of a scaphoid fracture, 13 united on the ulnar side and five on the radial side only. In three it was on both sides but delayed in the centre. Where there was initial union on the ulnar side, all progressed to complete union, including two patients with displaced fractures. Four out of five patients with initial union on the radial side had displaced fractures, and three of these went on to non-union. We conclude that in those patients with partial union of a scaphoid fracture, if union is seen on the ulnar side, the fracture is likely to unite completely, whereas if there is partial union on the radial side, there is a high risk of non-union.