Radiological Bone Healing Research Articles

Safety of vertical osteotomies in segmental Le Fort I procedures: a one-year radiological follow-up study

The aim of this study was to evaluate the frequency of dental and periodontal injuries, as well as radiological bone healing, at the vertical osteotomies in patients treated with segmental Le Fort I (LFI) osteotomy, as observed on cone beam computed tomography (CBCT) scans. This retrospective study analysed 105 patients who underwent segmental LFI osteotomy, in whom vertical osteotomies between the lateral incisor and canine were performed using a bur and extended in depth with an osteotome. CBCT scans were obtained preoperatively and at the 1-week and 1-year follow-ups. Measurements at the 1-week follow-up included interdental distances, root injuries, and periodontal detachment, while assessment at the 1-year follow-up included endodontic treatment and healing of the vertical osteotomies. The results showed no damage to the 420 roots at risk adjacent to the osteotomies; however, the osteotomy extended into the periodontal ligament in 38 roots. The mean preoperative minimum distance between roots differed significantly between osteotomy sites with intact periodontal ligament and those with periodontal ligament detachment (P < 0.001). One tooth was endodontically treated at the 1-year follow-up. Incomplete healing of the vertical osteotomy occurred more frequently in female patients than in male patients (P = 0.012). The study findings suggest that segmental LFI osteotomy is safe when performed with a bur and osteotome, provided a minimum distance of 2.5 mm between roots is maintained.

Treatment of non-hypertrophic pseudoarthrosis of long bones with a Tissue Engineered Product loaded with autologous bone marrow-derived Mesenchymal Stromal Cells: Results from a phase IIa, prospective, randomized, parallel, pilot clinical trial comparing to iliac crest autograft

BackgroundAtrophic pseudoarthrosis is a serious complication with an incidence of 5–10 % of bone fractures located in the diaphysis of long bones. Standard treatments involve aggressive surgical procedures and re-interventions requiring the use of autografts from the iliac crest as a source of bone-forming biological activity (Standard of Care, SoC). In this context, regenerative ex vivo expanded osteogenic cell-based medicines could be of interest. Particularly, Mesenchymal Stromal Cells (MSC) offer new prospects to promote bone tissue repair in pseudoarthrosis by providing biological activity in an osteoconductive and osteoinductive environment. MethodsWe conducted a phase IIa, prospective, randomised, parallel, two-arms, open-label with blinded assessor pilot clinical trial to compare SoC vs. a tissue-engineered product (TEP), composed of autologous bone marrow (BM)-derived MSCs loaded onto allogeneic decellularised, lyophilised spongy bone cubes, in a cohort of 20 patients with non-hypertrophic pseudoarthrosis of long bones. Patients were followed up for 12 months. Radiological bone healing was evaluated by standard X-ray and computed tomography (CT) scanning. Quality of life was measured using the EUROQOL-5D questionnaire. ResultsTen patients were randomized to TEP and 10 to SoC with iliac crest autograft. Manufacturing of TEP was feasible and reproducibly achieved. TEP implantation in the bone defect was successful in all cases and none of the 36 adverse events (AE) reported were related to the treatment. Efficacy analyses were performed in the Full Analysis Set (FAS) population, which included 17 patients after 3 patients withdrew from the study. The degree of consolidation, estimated by measuring Hounsfield units (HU) on CT, showed no significant differences between the two treatment groups at 12 months post treatment (main efficacy variable) (p = 0.4835) or at 6 months. ConclusionsAlthough only a small number of patients were included in our study, it is notable that no significant differences were observed between the experimental treatment and SoC, thus suggesting TEP as an alternative where autograft is not available or contraindicated.

Assessment of Nutrition Status and Its Effect on Outcomes in Patients With Limb Injuries Using the Subjective Global Assessment as a Screening Tool.

Background Malnutrition in hospitalized patients is a significant problem. This study aimed to assess the utility of the Subjective Global Assessment (SGA) in predicting the association between serum biomarkers and malnutrition in patients with limb injuries as well as the impact of malnutrition on clinical and radiological bone healing. Methodology This prospective study included 93 patients with limb injuries. Basic demographic details, serum biomarker levels, nutritional status assessed using the SGA, and the correlation of the Radiological Union Shaft Tibia (RUST) score with nutrition status were assessed along with the secondary outcomes. Results According to the SGA, patients were classified into Group A (well-nourished), Group B (moderately malnourished), and Group C (severely malnourished). Serum biomarkers (albumin, hemoglobin, platelets, and total leucocyte count) were significantly higher in Group A than in Group B + C (p < 0.0001). The nutritional status of patients from admission up to six months in Group A was significantly higher (p < 0.0001) compared to Group B + C. The radiological healing according to the RUST score had a negative correlation with C-reactive protein and a positive correlation with various parameters at six months. Conclusions The serum biomarker levels and the clinical and radiological bone healing, as measured by the RUST scoring system, showed a positive correlation with the nutritional status of the patients. Malnutrition significantly increases the chance of developing complications such as wound infection, decubitus, and infected implants.

Paediatric Mandibular FractureAn Enigma of its Own: A Case Report

Mandibular fractures are very rare in the paediatric age group; however, they remain the most common maxillofacial trauma occurring in children. A paediatric mandibular fracture can cause severe pain and discomfort for the patient. Due to the complex anatomy of the developing mandible, such as the presence of permanent tooth buds and its small size, the treatment of mandibular fractures in the paediatric age group differs markedly from that in adults. Treatment of maxillofacial fractures in the paediatric population has always been a challenge for the operating surgeon. Different treatment modalities for managing paediatric mandibular fractures include closed reduction or surgical intervention. Open/closed cap splint provides closed reduction and stabilisation of paediatric mandibular fractures without any risk of damage to permanent tooth buds. It is more commonly preferred over Open Reduction and Internal Fixation (ORIF) of the fractures. However, for highly displaced fractures, ORIF is the preferred treatment. In the present case report, the author present and describe the management of a mandibular symphyseal and medial pole of the right condyle fracture in a seven-year-old patient. Since the bone fragments were highly displaced and occlusion was severely deranged with an anterior open bite, conservative treatment using a cap splint was not considered. ORIF was performed under general anaesthesia. At the oneyear follow-up, complete clinical and radiological bone healing was observed. Occlusion was satisfactory, and mouth opening was maintained. There was normal eruption of permanent teeth with no complications or delays associated with the eruption pattern.

Comparison of internal and external fixation after debridement in the Masquelet technique for Cierny-Mader type IV tibial post-traumatic osteomyelitis

ObjectiveTo compare the effect of internal fixation vs. external fixation after debridement in stage I of the Masquelet technique for Cierny-Mader (C-M) type Ⅳ chronic post-traumatic tibial osteomyelitis. MethodsThis retrospective observational study included patients with tibial osteomyelitis who underwent staged treatment with the Masquelet technique between January 2016 and June 2020 at the 920 Hospital of Joint Logistic Support Force of the PLA. The patients were grouped according to the fixation they received after stage I. Infection recurrence, time to radiological bone healing and full weight-bearing, self-rating anxiety scale (SAS) score, Hospital for Special Surgery (HSS) Knee Score, and American Orthopedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Score were compared. ResultsSixty-three patients were included (50 males and 13 females). There were 40 and 23 patients with internal and external fixation, respectively. There were no significant differences between the two groups regarding the preoperative and intraoperative data (all P>0.05). After stage I operation, the infection control rates were 85.0% and 82.6% in the internal and external fixation groups (P=0.803), and these rates were 92.5% and 95.7% after stage II (P=0.621). There were no differences in the SAS scores (P=0.278), time to radiological union (P=0.795), time to full weight-bearing (P=0.725), AOFAS scores (P=0.302), HSS scores (P=0.085), and complication rates (P=0.593). There were 27 times complications in 19 patients, with an incidence of 42.9%, without significant differences between groups. ConclusionThere were no differences between the two fixation methods after debridement in stage I of the Masquelet technique for C-M type Ⅳ chronic post-traumatic tibia osteomyelitis.

A pilot study of circulating levels of TGF-β1 and TGF-β2 as biomarkers of bone healing in patients with non-hypertrophic pseudoarthrosis of long bones

BackgroundPseudoarthrosis or non-union is a complication with an incidence of 5–10% of bone fractures, most frequently located in the diaphysis of long bones. The management of this complication is addressed by means of complex surgical procedures and is a concern for orthopaedic and trauma surgeons nowadays. The use of biomarkers for diagnosing patients at risk of non-union would help us to establish special measures for early corrective treatment. MethodsProspective exploratory pilot study with a cohort of 20 patients diagnosed of non-hypertrophic pseudoarthrosis of long bones who were treated surgically with either autologous bone graft or a Tissue Engineering Product composed of bone marrow-derived Mesenchymal Stromal Cells. Patients were followed for 12 months and plasma blood samples were obtained to determine circulating levels of Transforming Growth Factor Beta 1 and Beta 2 (TGF-β1 and TGF-β2, respectively) at inclusion, and at 1 week, 2 weeks, and months 1, 2, 3, 6 and 12 after surgery. Radiological bone healing was evaluated by the Tomographic Union Score (TUS). ResultsBasal levels of TGF-β1 and TGF-β2 were determined in the twenty patients (26,702 ± 14,537 pg/mL and 307.8 ± 83.1 pg/mL, respectively). Three of them withdrew from the study, so complete follow-up was conducted on 17 patients (9 successfully healed vs. 8 that did not heal). Statistically significant differences between the bone healing group and the non-union group were found at month 12 for both TGF-β1 (p = 0.005) and TGF-β2 (p = 0.02). ConclusionsTGF-β1 and TGF-β2 are biomarkers that correlate with clinical evidence of bone regeneration and may be used to monitor patients, although early predictive value after intervention needs to be further studied in combination with other molecules.

Distal Metatarsal Minimally Invasive Osteotomy (DMMO): Surgical technique, variants, indications, and treatment decision-tree

BackgroundMetatarsal osteotomy is a major means of treating mechanical metatarsalgia. Open techniques are widely used, and notably that described by Weil. They have, however, certain drawbacks, and new types of osteotomy have been developed. Percutaneous techniques are presently very much in favor, and Distal Metatarsal Minimally Invasive Osteotomy (DMMO) has emerged as a treatment for metatarsalgia. Although very widely used, it is poorly codified in the literature. MethodThe present study detailed DMMO techniques and their variants (oblique and reverse), with corresponding indications and treatment decision-tree. ResultsInitial findings seem encouraging, with functional results comparable to those of open surgery. Postoperative edema and radiologic bone healing time seem to be longer in DMMO. There is, on the other hand, no difference regarding stiffness. ConclusionDMMO is an effective option to treat metatarsalgia, with variants enabling adaptation to foot morphology, but needing confirmation by studies with higher levels of evidence.

Piezoelectric tools versus traditional oscillating saw for distal linear osteotomy in hallux valgus correction: Triple-blinded, randomized controlled study

BackgroundThe main goal of the surgical correction of the hallux valgus is the morphological correction associated with the functional rebalancing of the first ray. The aim of this triple-blinded, randomized controlled study was to show the efficacy of piezosurgery in performing distal linear osteotomy of the first metatarsal bone in HV correction, in terms of clinical and radiological outcomes at 1-year final follow up. Methods and materialsThis study was performed collecting prospectively pre-operative and post-operative data for all patients. 34 patients were included in the trial and were randomly allocated (1:1) in a Piezoelectric Group (PG) that involved the use of piezoelectric tools and in a Control Group (CG) that provided for the use of a traditional oscillating saw. In both groups, all patients were treated with a distal linear osteotomy of the first metatarsal bone. Clinical and radiographic assessments were performed. ResultsThe AOFAS score between the two groups was similar pre-operatively and during the follow-up period, with a slight superiority in the PG at each evaluation. The osteotomy surgical time was registered for both groups. Among the endpoints of the study, the radiological bone healing time was independently assessed by a radiologist that reported a lower mean value in the piezoelectric group compared with the control group. ConclusionsThis trial has shown that piezoelectric surgery is not inferior to traditional methods from the clinical-functional point of view, but can even lead to an evident reduction of bone healing time with a statistical significance. Level of evidenceLevel I.

Induced membrane technique for clavicle reconstruction in paediatric patients: Report of four cases

BackgroundClavicular reconstruction in paediatric patients is a rarely performed procedure that often raises complex technical challenges and produces unreliable outcomes. The induced membrane technique is an innovative two-stage procedure involving cement spacer placement into the defect to induce the development of a membrane, followed by the implantation of a cortical-cancellous bone graft. The primary objective of this study was to assess the medium- and long-term clinical and radiographic outcomes of clavicular reconstruction using the induced membrane technique in children and to highlight the advantages and drawbacks of this technique. The secondary objectives were to evaluate the fixation and the outcomes according to age and to the underlying diagnosis. HypothesisClavicular reconstruction using the induced membrane technique produces good outcomes in paediatric patients. Patients and methodsThe induced membrane technique was used for clavicular reconstruction in 4 children with a mean age of 9.7 years (range, 7.4–12.3 years). The diagnosis was congenital pseudarthrosis of the clavicle in 3 patients and aneurysmal bone cyst in 1 patient. Shoulder pain and mobility were assessed at last follow-up. Radiological bone healing was evaluated using the total radiographic union score (RUS, range, 0–10). Complications and number of procedures per patient were recorded. ResultsMean follow-up was 3.9 years (range, 1–8.4 years). None of the patients had pain or motion range limitation. After 6 months, the clavicle was healed with a RUS of 10 in all patients. The mean number of surgical procedures per patient was 3.75 (range, 3–5). Two patients required revision surgery for distal pin migration and another for a subcutaneous abscess under the pin. DiscussionWhen used for clavicular reconstruction, the induced membrane technique is effective and associated with a low complication rate. The induced membrane technique therefore deserves to be viewed as an alternative to other methods. Level of evidenceIV, retrospective observational study.

Intra-medullary osteosclerosis of the tibia in children

BackgroundIntra-medullary osteosclerosis of the tibia is a rare condition characterised by chronic pain due to diaphyseal hyperostosis with no detectable triggering factor. The main differential diagnoses are stress fracture and osteoid osteoma. Of the few cases reported to date, most were in adults. The objective of this study was to assess paediatric patients with intra-medullary osteosclerosis to determine whether the first visit provides sufficient information to establish the diagnosis and rule out both osteoid osteoma and stress fracture, whether a biopsy is required, and which treatment is optimal. HypothesisThe diagnosis of intra-medullary osteosclerosis of the tibia can be made at the first visit. Patients and methodsSeven paediatric patients, 4 males and 3 females, with a mean age of 11 years, were included in this retrospective study. We evaluated the clinical features, findings from imaging studies (standard radiographs, computed tomography, magnetic resonance imaging, and bone scintigraphy), and treatment outcomes. ResultsAt the first visit, all patients had a painful swelling at the middle of the shin and imaging study evidence of antero-lateral tibial cortical thickening extending into the medullary cavity; in 5 patients, a linear lucency was visible. No other bone abnormalities were seen. Treatments included non-operative measures, pinning, and nailing. None of these treatments provided permanent bone healing or pain relief, although transitory freedom from pain with or without radiological bone healing was achieved. DiscussionIntra-medullary osteosclerosis of the tibia is rarely reported and therefore probably underdiagnosed. Distinctive characteristics of the cortical and endosteal thickening include location at the antero-lateral mid-diaphysis and, in some cases, the concomitant presence of a linear lucency that can provide the early diagnosis. The distinctive radiological features allow differentiation from a stress fracture. The management is challenging. Level of evidenceIV, retrospective observational study.

Acceleration of Fracture Healing in Experimental Model: Platelet-Rich Fibrin or Hyaluronic Acid?

In this study, we compared the bone-healing effects of the local application of platelet-rich fibrin (PRF) and hyaluronic acid (HA) to bilateral tibial fractures in rats. Twenty-three adult male Sprague-Dawley rats were used. Twenty-two animals were randomly allocated to a control group (n = 6) and 2 study groups: PRF (n = 8) and HA (n = 8). The 23rd rat was used as a donor to obtain PRF. Each group was divided into 2 subgroups for histomorphometric and radiologic assessments at 2 and 6 weeks. Foreign body reaction, necrosis, inflammation, new bone formation, and fibrosis were investigated as bone healing parameters in terms of histopathologic analysis. The difference between the groups for these parameters was evaluated. The radiologic evaluation was performed by comparing the 3-dimensional reconstruction images of the fracture sites between the study and control groups. Histomorphometric evaluation showed that at 2 weeks postoperatively, the control group showed lesser bone formation (26.1 ± 6.6%) when compared to the study (HA: 54.7 ± 9.7%; PRF: 75.3 ± 19.2%) groups and PRF group showed highest total ossification. At 6 weeks postoperatively the PRF group showed lesser total ossification (50.7 ± 28.2%) when compared to control (76.3 ± 21.7%) and HA group. The HA (88.8 ± 13.3%) showed highest total ossification. In the control group, fibrosis was more prominent at week 6, whereas in the HA and PRF groups the amount of ossification increased. In contrast to histopathologic healing, radiologic bone healing did not differ significantly among the study and control groups 2 weeks after surgery, whereas at 6 weeks, the results of radiologic bone formation were in accordance with those of histopathologic bone healing.

Teriparatide for treatment of patients with bisphosphonate-associated atypical fracture of the femur.

Little clinical data are available on the use of teriparatide for the treatment of bisphosphonate-associated atypical femur fractures (AFF). The goal of the Fix-IT study was to determine if immediate therapy with teriparatide was superior for fracture healing after an AFF compared to a 6-month delay in teriparatide therapy. This randomized pilot clinical trial included 13 women with an AFF who were randomized to immediate teriparatide vs a delay of 6months. All were followed for 12months on teriparatide. The primary outcomes included individual and composite measures of radiologic bone healing (scored 1 point [no healing] to 4 points [complete healing]) at 6 and 12months. Secondary outcomes included bone mineral density of the unfractured contralateral hip, spine, 1/3 distal radius, and adverse events. We found there was a trend for superior healing with the composite score (12.6 vs 11.2 at 6months and 15.4 vs 13.2 at 12months), and lesser bone mineral density declines at the 1/3 distal radius (12-month change -1.9 vs -6.1%) in the immediate vs the delayed group. There were no differences in adverse events. There was one implant failure in the delayed group. There is a preliminary signal for greater improvements with immediate teriparatide therapy vs delayed therapy. However, because an AFF is a rare event, and only a small number of patients were included, the results must be interpreted with caution.

Digital Joint Reconstruction with Osteotendinous Joint Allograft: Experimental Study in Rats.

Background:Fresh or frozen nonvascularized osteotendinous joint allografts (OTJA) have not been used previously, clinically or experimentally, for metacarpophalangeal joint reconstruction. Therefore, we evaluated the viability of OTJA for metatarsophalangeal joint (MTJ) reconstruction in rats.Methods:In the experimental group of 12 Lewis rats, we reconstructed the MTJ of the third digit of the hindlimb with a fresh, nonvascularized OTJA obtained from the same digit from 12 donor rats. In the control group of 6 Lewis rats, an autologous composite osteotendinous graft of the MTJ of the same digit was obtained and repositioned in situ as an auto-transplant. Weight, pain, edema, dehiscence, and wound infection were evaluated every 24 hours for 30 days postoperatively. At the end of 30 days, we evaluated digit position, flexion and extension, passive mobility, radiological bone healing, and histological grades of rejection.Results:We found no statistically different changes in weight, edema, pain, digit position, or radiological bone healing in either group. No wound dehiscence or infection was seen in any of the rats. Ten degrees of flexion and extension mobility were lost in the control group; the experimental group lost up to 30 degrees (P = 0.009). Histologically, 9 of the experimental group rats (9/12, 75%) showed rejection reactions compared with none of the controls (0%) (P = 0.009).Conclusions:Fresh nonvascularized OTJA caused an immune reaction without exposure of the graft, but with bone resorption. However, the rats maintained digital form and alignment with decreased passive flexion and extension of 10–30 degrees.

Functional and radiological evaluation of treatment of infected nonunited fracture shaft femur using Ilizarov external fixator

Background The treatment of infected nonunion of long bones has always been a challenge for orthopedic surgeons. Treatment goals were eradication of infection and bony union. During distraction osteogenesis, physiological bone loading and mobilization are very important. Aim This study aimed at evaluating the functional and radiological outcome of using Ilizarov external fixator in treating patients with infected nonunited fracture femoral shaft. Patients and methods Fifteen patients with infected nonunion of the shaft of the femur were included in the study between 2007 and 2009. The mean age of the patients was 39.5 years (range 19-68 years). The follow-up period lasted for 14-36 months with a mean of 25.7 months. Bone and functional results were measured and complications were categorized according to the Association for the Study and Application of the Method of Ilizarov guidelines. Results The infection was eradicated in 12 patients before the fixator removal. Excellent radiological bone healing was found in 12 patients, and excellent functional result in eight out of 15 patients. There were a total of 20 complications in 15 patients. Conclusion Ilizarov external fixator is an effective method for the treatment of infected nonunited fracture shaft femur with acceptable radiological and functional outcome and low serious complications.

Invited Commentary

Surgical site infections (SSIs) are the third most commonly reported nosocomial infection after cardiac surgery. The most devastating form is post-sternotomy mediastinitis, which seldom occurs but is associated with high mortality, morbidity, and serious economic burdens. In the majority of cases, the endogenous flora is the origin of involved microbes; therefore, preventive measures are used to reduce microbial contamination such as skin decolonization, shaving, skin decontamination, antibiotic prophylaxis, and minimal invasive access. Today, many cardiac surgical procedures can be performed by a limited access, avoiding full sternotomy. Mitral and tricuspid valve diseases can be treated surgically through a right mini-thoracotomy. Often, a left mini-thoracotomy is suitable access for coronary artery revascularization or aortic valve replacement. Furthermore, partial sternotomy or para-sternotomy access can be used for aortic valve surgery and for more demanding procedures, such as aortic surgery. Nevertheless, many cardiac surgical procedures are facilitated by standard sternotomy; therefore, it is of great interest to develop new strategies to prevent SSI in patients undergoing full sternotomy or partial sternotomy. Vestergaard and colleagues [1Vestergaard R.F. Nielsen P.H. Terp K.A. Søballe K. Andersen G. Hasenkam J.M. The effect of hemostatic material on sternal healing after cardiac surgery.Ann Thorac Surg. 2014; 97: 153-160Scopus (20) Google Scholar] investigate the effects of different hemostatic materials on sternal healing after cardiac surgery. The study demonstrates that radiologic bone healing is not completed 3 months after surgery. This information is useful for sternal wire removal, if needed, because generally this is done as early as 3 months postoperatively. Although bone healing is not completed in 3 months, a water-soluble polymer wax (Ostene; Ceremed Inc, Los Angeles, CA), compared with standard bone wax, was associated with a statistically significant improvement as documented by semiquantitative computed tomography analysis. This finding correlated with a better physical functionality score in favor of the Ostene group. This aspect of the study is crucial and unique because quality of life is pivotal in this study. Another important issue, pointed out by the authors, is that Ostene is a plausible alternative to bone wax if topic hemostasis is required. Many procedures can be performed without any kind of topic sternal hemostatic material. The number of patients in this study is limited; therefore, no plausible correlation between the different topic hemostatic agents and occurrence of SSI can be made. To investigate this, a large prospective randomized multicenter study is needed. Effect of Hemostatic Material on Sternal Healing After Cardiac SurgeryThe Annals of Thoracic SurgeryVol. 97Issue 1PreviewPostoperative sternal infection and dehiscence cause increased morbidity, mortality, and socioeconomic costs as well as patient discomfort and pain. Some predisposing factors have been uncovered but others remain uninvestigated. Among these are the influence of topical hemostatic agents such as bone wax (BW) and Ostene (Ceremed Inc, Los Angeles, CA) a new, water-soluble polymer wax (WSW). The object of this study was to investigate the impact of topical hemostatic agents on sternal healing in patients. Full-Text PDF

Effect of Hemostatic Material on Sternal Healing After Cardiac Surgery

Postoperative sternal infection and dehiscence cause increased morbidity, mortality, and socioeconomic costs as well as patient discomfort and pain. Some predisposing factors have been uncovered but others remain uninvestigated. Among these are the influence of topical hemostatic agents such as bone wax (BW) and Ostene (Ceremed Inc, Los Angeles, CA) a new, water-soluble polymer wax (WSW). The object of this study was to investigate the impact of topical hemostatic agents on sternal healing in patients. In total, 50 patients subjected to elective cardiac surgery and requiring intraoperative hemostatic treatment were randomized to 1 of 2 treatment groups: BW or WSW. Twenty-five patients without need for sternal hemostasis constituted a control group. The doctors analyzing the endpoints were blinded to the treatment. Radiologic bone healing was assessed by a radiologist using computed tomography at 3 and 6 months postoperatively. Quality of life and bodily pain was assessed by questionnaires (Short Form-36 and Visual Analogue Scale). No patients displayed complete radiologic healing at 3 months. Bone healing (evaluated semi-quantitatively at a score from 0 to 10) was significantly impaired in the BW group compared with both the control and WSW groups at both 3 and 6 months postoperatively (p < 0.0001). Radiologic bone healing was positively correlated with physical functioning score (Short Form-36) (p < 0.001). Pain scores were generally low (<1) at both 3 and 6 months with no significant difference between study groups. The results from this study suggest that WSW provides a useful alternative to BW when topic hemostasis on the sternum is required.

Arthroscopic posterior bone block augmentation in posterior shoulder instability

Posterior instability is a relatively rare and challenging condition to treat. Soft-tissue procedures do not always provide satisfactory results. We present the results after arthroscopic posterior bone block augmentation with an iliac crest bone graft and a minimum of 12 months' follow-up. Between 2008 and 2009, we performed 19 arthroscopic posterior bone blocks on 18 patients with posterior instability (bilaterally in 1 patient). The mean age was 29.85 years at the time of surgery. The mean follow-up was 20.5 months. All patients had a painful, unstable shoulder. Preoperative etiology included trauma, glenoid dysplasia, Ehlers-Danlos syndrome, and arthrosis with posterior glenoid erosion. The Rowe score improved from 18.4 points to 82.1 points, and the Walch-Duplay score improved from 37.4 points to 82.9 points, both statistically significant (P < .01). Radiologic bone healing was achieved in all cases. Nine cases had an excellent result with return to the previous level of sports, six were satisfied, and three had a persistently painful shoulder. Subsequent removal of screws improved symptoms in two of these patients, and in one patient, a cause for the pain and persistent instability was not found. Arthroscopic posterior bone block augmentation presents a reliable technique for the treatment of symptomatic posterior instability with varying origin. Although this is a technically demanding procedure, in our experience, the potential benefits and minimally invasive nature outweigh the risks and benefits of more invasive procedures.

Open reduction and internal fixation of mandibular fracture in an 11-month-old infant: a case report

Mandibular fractures in infants are rare. This case report describes management of a mandibular fracture in an 11-month-old infant using a microplate and screws with open reduction. The surgical treatment was successful. Because the bone fragments were displaced and only the primary incisors had erupted, conservative treatment, such as an acrylic splint and circummandibular wiring, was not recommended. Nine weeks after surgery, the microplate was removed. The results showed complete clinical and radiological bone healing with normal eruption of deciduous teeth.

Reconstructive Surgical Treatment Without Bone Grafting in Nonunions of Humeral Surgical Neck Fractures

To evaluate reconstruction surgery without bone grafting in humeral surgical neck nonunions using either a blade plate or the "Humerusblock" implant in small head fragments. Retrospective cohort study, Evidence-Based Medicine Level IV. Paracelsus Medical University Salzburg, Department of Traumatology and Sports Injuries. Fifty-five patients (mean age, 66.2 years) with symptomatic nonunion after humeral surgical neck fractures were subjected to surgical reconstruction. In 45 patients, open reduction and internal fixation using a blade plate was performed (Group 1). In 10 patients, the Humerusblock device was used (Group 2), because the head fragment of each of these patients was too small for plating. In no patients was bone grafting used. Shoulder function, level of pain, and bone healing. After a mean follow-up time of 74 months, the overall mean Constant score improved from 30.4% preoperatively to 83.2% postoperatively. The improvement was from 30.5% to 85.3% in Group 1 and from 32.2% to 75.4% in Group 2, which represented statistically significant improvements for both groups (P < 0.01). Radiologic bone healing was achieved in 51 patients (93%). The overall complication rate was high, 15%, and complications included plate loosening, avascular head necrosis, persistent nonunion, and infection. Nonunion of humeral surgical neck fractures can be successfully treated by surgical reconstruction without bone grafting using either a blade plate or the Humerusblock for small head fragments. However, an increased complication rate is associated with this challenging posttraumatic pathology.

Radiographic Healing With Hemispherical Allogeneic Femoral Head Bone Grafting for Opening-Wedge High Tibial Osteotomy

The aim of this study was to investigate the remodeling process after hemispherical femoral head allograft grafting in opening-wedge high tibial osteotomy with a plate and screw. The study group included 105 knees in 92 women and 7 knees in 7 men from January 2007 through December 2007. The radiographic bone remodeling process was determined by use of a modification of the radiologic rating system described previously by van Hemert et al. in 4 groups: group A, 7-mm plate correction; group B, 9-mm plate correction; group C, 11-mm plate correction; and group D, 13-mm plate correction. The postoperative femorotibial angle and tibial slope were not significantly changed at latest follow-up in comparison to immediate postoperative status. The mean follow-up period was 25.4 months (range, 18 to 30 months). In all groups radiologic bone healing higher than phase 3 was successfully achieved between 3 and 6 months. The healing process slowed with increasing correction angle. A hemispherical femoral head allograft is a good alternative osseous graft material when patients are selected appropriately with the following criteria: body mass index lower than 40, no symptomatic osteoarthritis of the patellofemoral joint and lateral compartment, no systemic inflammatory arthritis, no history of fracture or previous open surgery to the lower limb, and no flexion contracture. Level IV, therapeutic case series.