Standard Bone Graft Research Articles

Is bone-grafting or bone-healing adjunct always necessary for the treatment of non-union ? Our experience of treating non-unio by primary osteosynthesis in chronically neglected shaft of femure fractures

Non-union of bone is a frightening consequence of fracture management. This condition usually occurs when the body's natural healing process cannot bridge the gap and restore the continuity of the bone. Non-infected non-union can be classified into two main types: Hypertrophic and Atrophic. Our research aims to determine the results after primary osteosynthesis without bone graft or adjuvant in neglected shaft femur fracture aseptic non-unions.We performed a retrospective chart review to include consequative series of neglected shaft of femur fracture non-unions treated by primary osteosynthesis surgery during a span of 3 years from 2020-2022. We excluded cases with partial union, identifiable systemic or external causes of non-union and those belonging to pediatric & elder age groups.We included 13 neglected cases of shaft femur fractures. Out of 13 patients, 7 (53.8%) were males. The mean age was 43 (range 23-55) years, and the mean injury presentation interval was 9 (range 4-18) months. Nine had hypertrophic, 2 had atrophic and 1 had undefinable non-union. At one year follow-up, 12 out of 13 showed completely united fractures with no functional limitation. Only one patient showed delayed union and eventually united Discussion: Treating non-union requires a comprehensive approach tailored to the fracture personality. The original AO principles (1960) of fracture healing remain the mainstay of fracture healing. Besides the gold standard autologus bone graft, many biological agents like BMP are currently available to augment bone healing. However, most of them have failed to provide consistent and promising results when there is an absence of innate osteogenic potential.In our experience, an excellent union rate can be achieved without the use of bone-grafting or bone-healing adjuvants in chronically neglected long bone fractures where no previous surgical attempt was made in absence of systemic and exteral risk factors for non-union.

1078 Performance of Improved Forms of Demineralized Bone Fiber Allografts in Rabbit Posterolateral Spine Fusion Model

INTRODUCTION: Biologic fusion is often critical for successful spine procedures. Autograft remains the Gold Standard bone graft due to osteogenic properties but has limitations in practice. New bone graft forms that efficiently incorporate autograft or bone marrow aspirate (BMA) and provide osteoinductive and osteoconductive properties were evaluated in the current study. Grafts were made using demineralized bone fibers (DBF) produced by a patented method that provides long fibers that can effectively entangle autograft and be formed into open cylinders (PAK) that contain and prevent autograft migration and absorb BMA. METHODS: DBF was produced from rabbit cortical bone using the same processes as human clinical product. Pak grafts were made with 1.5cc Fibers formed into a cylinder with 1.5cc volume. Implants into the rabbit PLF model were harvested after 8 weeks and evaluated for fusion by manual palpation and x-rays. RESULTS: All graft forms demonstrated robust new bone formation. Each group demonstrated high fusion rates. Across the groups 10/11 levels were 100% fused (91%) with the remaining 1/11 being 95% reduced motion (functionally fused). Note radiolucency of Group 3 at post-op and appearance of new bone at 8 weeks. CONCLUSIONS: The new graft forms demonstrated robust bone formation and fusion in PLF model. The DBF Fibers provided excellent entanglement of autograft to prevent migration. The PAK form eliminated autograft migration, and absorbed BMA providing osteogenesis to the osteoconductive and osteoinductive graft.

The Efficiency of Highly Porous β-Tricalcium Phosphate With Bone Marrow Aspirate Concentrate in Midfoot Joint Arthrodesis.

Nonunion is one of the most common and devastating complications following midfoot joint arthrodesis. Many different types of bone grafts and bone substitutes have been used to promote osseous fusion. However, there is no consensus on the gold standard bone grafting material and whether biologic materials should be used alone or in combination. The purpose of this study is to investigate the efficiency of highly porous β-tricalcium phosphate (β-TCP) with bone marrow aspirate concentrate (BMAC) in midfoot joint arthrodesis. This retrospective comparative study included patients who underwent midfoot joint arthrodesis using compression screws. Patients were classified into 2 groups: arthrodesis with highly porous β-TCP and BMAC (group A) and arthrodesis without them (group B). The osseous union rate was compared between the 2 groups. A total of 44 patients (46 feet) including 89 joints were included in this study. There was a significant difference in the union rate between the 2 groups: 91.5% (43/47 joints) in arthrodesis with highly porous β-TCP and BMAC (group A) and 76.2% (32/42 joints) in arthrodesis without highly porous β-TCP and BMAC (group B; P = .048). This study investigated the efficiency of highly porous β-TCP and BMAC to promote bony healing in midfoot joint arthrodesis. A significantly higher union rate was shown when arthrodesis was performed with highly porous β-TCP and BMAC, compared with arthrodesis performed without them. We suggest that highly porous β-TCP and BMAC can be a viable and effective adjunct to the fixation in midfoot joint arthrodesis. Level III: Retrospective comparative analysis.

The Use of Stromal Vascular Fraction in Long Bone Defect Healing in Sheep.

The objectives of the present study were to evaluate (a) the feasibility of using stromal vascular fraction (SVF) and nanocrystalline hydroxyapatite (nHA) paste in combination for the treatment of segmental bone defect, (b) the quality of the callus produced, (c) the potential improvement of the autograft technique, and (d) the direct comparison of the biomaterial to the use of autogenous cancellous bone. Unilateral, segmental mid-diaphyseal bone defect was created on the right metatarsus of skeletally mature sheep animals (n = 24) under anesthesia (D0). Residual segments were stabilized by stainless-steel plates and appropriate screws. Defects were managed as follows: group A: use of nHA paste to filling, group B: use of autogenous bone graft mixed with nHA bone paste, placed in defect, group C: use of SVF mixed with nHA bone paste injected into defect, group D: use of bone graft and SVF with nHA paste before apposition in bone defect. SVF had been previously isolated from adipose tissue of the animals intra-operatively after digestion with collagenase solution and neutralization. Animals were evaluated clinically and by X-raying and ultrasonographic examination of the defect, at regular intervals, until D90. Ultrasonographic assessment performed along the length of the defect included calculation of the length of the bone defect and assessment of vascularization. SVF was successfully isolated from group C and D animals, with the average yield being 1.77 × 106 cells. The comparison of clinical scores (based on the 'Kaler scale') on each post-operative day indicated significant differences between the four groups on D1 to D30 (p < 0.01); the median clinical score within group A was 2.5 for D1-D30 and 1 for the entire period; respective scores for other groups were 1.5 (p = 0.07) and 0 (p = 0.033). Differences in radiographic assessment scores were significant for scores obtained on D60 (p = 0.049) and D90 (p = 0.006). There was a significant difference between the four groups in the length of the bone defect, as assessed ultrasonographically, for the entire length of the study; median values were 8, 8.5, 6, and 8 mm for groups A, B, C, and D, respectively (p = 0.008). There was a significance in the differences between median scores obtained during the histopathological examination: 2, 11, 13.5, and 12 for group A, B, C, and D (p = 0.022). There was an inverse correlation between the overall scores of histopathological evaluations and the length of the bone defect (observed on D90) (p < 0.0001) and a correlation between the overall scores and the radiographic assessment scores (obtained on D90) (p < 0.0001). This is the first study in which the efficacy of fresh autologous Stromal Vascular Fraction (SVF) from adipose tissue in enhancing bone healing in a long, weight-bearing, diaphyseal bone was evaluated. It is concluded that the lumbosacral region was an attractive site for harvesting adipose tissue, the use of SVF contributed to faster rehabilitation post-operatively, and SVF significantly enhanced bone formation; in general, the results indicated an osteogenic potential of SVF comparable to the gold standard autologous bone graft.

Osteoinductive effect β-TCP and vitamin D3 on RUNX2 mRNA expression

Although the autograft is regarded as the gold standard bone graft, β-TCP artificial alloplastic is widely used in bone defect healing and has been accepted in human and animal studies to be resorbed and interchanged by vital bone. The active form of vitamin D3 is calcitriol, on mesenchymal stem cells (MSCs) it has a direct influence on encouraging their osteogenic differentiation which is identified as osteoinductive. The need for osteoinductive ability is a demanding issue regarding medical and dental care. RUNX2 regards an essential transcriptional factor for osteoblast differentiation. Adult male New Zealand rabbits (Twenty-four) with an average weight of (1.5-2 kg) were elected in this study. Four holes were made intra-bone in both tibias of each animal. The experimental groups divide as follows: Group C: Bone defect will be left to heal naturally as control; Group TCP: Bone defect will be occupied with β-TCP. Group vitamin D3: Bone defect will be filled with vitamin D3; Group TCPD: Bone defect will be filled with a combination of β-TCP and vitamin D3. Animals sacrificed at (1 and 3 weeks). Purification of total RNA from formalin fixed paraffin embedded (FFPE), The cDNA of RUNX2 and VDR amplify in RT-PCR and detected with sybr green. One-way Analysis of Variance (ANOVA) and least significant difference (LSD) was used as a tool for statistical analysis. Results at 7 days highest mean value of mRNA RUNX2 gene expression Fold Change estimated in TCP followed by TCPD experimental group while at 21 days, the highest mean value in TCPD. All measured parameters showed highly significant differences in the course of healing periods from 7 days to 21 days. In mRNA VDR gene expression parameters showed a highly significant difference in 7days and 21 days durations among experimental groups and the highest mean value of mRNA VDR gene expression Fold Change is recorded in TCPD followed by vitamin D3 groups in both durations. These findings suggest positive inductive effects of local application of vitamin D3 combined with β-TCP as well as vitamin D3 on osteoblast cells and induced bone defect healing.

A National Racial Disparity in the Timing of Alveolar Bone Grafting

Objective: Standard bone grafting between ages 6 and 12 has become the preferred treatment of choice for alveolar clefts. Given the importance of surgical timing in complete cleft palate repairs, it is important to identify any populations at-risk for delayed alveolar bone grafting. The objective of this study is to identify whether a racial disparity is present nationally in the timing of alveolar bone grafting. Methods: A retrospective analysis of the American College of Surgeons National Surgical Quality Improvement Program pediatric database was performed from 2012 to 2019. Inclusion criteria involved patients who underwent alveolar bone grafting identified by current procedure terminology (CPT) code 42210. Patients were stratified by age at time of operation based on the following parameters: early bone grafting (before 6 years of age), standard bone grafting (between 6 and 12 years of age), and late bone grafting (after 12 years of age). Results: Overall, 20.28% of the cohort received alveolar bone graft after 12 years of age. African American (29.33%) and Hispanic (24.42%) patients received late alveolar bone grafting more frequently than other racial and ethnic groups (p < 0.001). Conclusion: Racial and ethnic disparities are present in the frequency at which patients receive late alveolar bone grafting for complete cleft palates. Given the suboptimal surgical results of late compared to standard alveolar bone grafting, it is important to further investigate the driving factors of these disparities. Corresponding Author: Darin Patmon, 4254 Oak Forest Ct. SE Apt H8, Grand Rapids, MI 49546

A Novel Technique for Tarsal Metatarsal Joint (TMTJ) Fusion using Calcaneal Precision Bone Graft: Reducing Morbidity Associated with Bone Graft Donor Site

Category: Midfoot/Forefoot; Basic Sciences/Biologics; Other Introduction/Purpose: TMTJ fusion has long been used as a treatment for TMTJ disease. Bone grafting has been shown to potentially improve union rates and often the iliac crest as a donor site has been used to achieve this. Indications for bone grafting include severe disease with greater bone loss and deformity, multiple joints being fused or revision surgery. In our paper we report on our experience of TMTJ fusion using localised bone grafting from either the calcaneum or cuneiform. This incorporates a novel operative technique for graft placement which increases contact area for healing and restores foot biomechanics. This may also therefore reduce non-union rate. Additionally, this localised form of bone grafting avoids the morbidity associated with iliac crest donor sites providing a better tolerated procedure. Methods: Twenty patients were included between 2016 and 2019 who underwent fusion of 39 TMTJs in total. Of these 39 joints 9 were first, 16 were second and 14 were third TMTJ. Two of the first TMTJ Fusions were revisions with double plating and bone grafting for non union. Fourteen patients had standard bone grafting and donor sites were as follows; 7 calcaneal, 1 cuneiform, 6 iliac crest. Seven patients had excision of OA joint and bone graft using precision instruments and surgery using our described technique. Locking plates were used in all twenty patients. Post-operative care included a wound check at two weeks, non-weight- bearing in a cast for 6 weeks and then weight-bearing cast for a further 6 weeks. Patients were followed up in clinic to observe radiological and clinical union. Ct scanning employed when delayed union was suspected. Complications with wound healing and infection were also recorded. Results: 15 of patients were female with a mean age of 59. 38 out of 39 fused joints went on to unite. 10 patients were initially assessed in the Specialist Limb Service (SLS) clinic with gait analysis prior to surgery. One non-union was diagnosed on CT scan in the traditional bone graft technique group. Graft was harvested from iliac crest in this case. All other graft sites resulted in fusion of the joint. All seven patients (100%) who had excision and bone graft using precision bone instruments with the new technique had union without delay. One patient underwent removal of metalware due to prominence. This was a revision double plating case. There were no wound healing problems and no postoperative infections. 80% of patients were satisfied with the results of surgery and reported improvement in quality of life. Conclusion: TMTJ fusion with looking plates remains an appropriate treatment for TMTJ disease providing high rates of successful union. Local donor site for bone grafting does not generate inferior outcomes whilst avoiding the morbidity associated with iliac crest harvesting. Additionally, this work presents a novel technique using precision bone graft instruments and cylindrical bone graft to fuse the TMTJ in the presence of OA. This technique generates increased fusion surface area and may provide better restoration of normal foot biomechanics.

The Efficiency of Highly Porous β-Tricalcium Phosphate (β-TCP) with Bone Marrow Aspirate Concentrate (BMAC) in Midfoot Joint Arthrodesis

Category: Midfoot/Forefoot Introduction/Purpose: Nonunion is one of the most common and devastating complications following midfoot joint arthrodesis. Many different types of bone grafts and bone substitutes have been used to promote osseous fusion. However, there is no consensus on the gold standard bone grafting material and whether biologic materials should be used alone or in combination. The purpose of this study is to investigate the efficiency of highly porous β-tricalcium phosphate (β-TCP) with Bone Marrow Aspirate Concentrate (BMAC) in midfoot joint arthrodesis. Methods: This retrospective comparative study included patients who underwent midfoot joint arthrodesis using compression screws from January 2014 to May 2019. A total of 44 patients (46 feet) including 89 joints were included in this study. The cohort was then stratified into two groups: 25 patients (26 feet) in arthrodesis with highly porous β-TCP and BMAC (group A) and 19 patients (20 feet) in arthrodesis without highly porous β-TCP and BMAC (group B). The osseous union rate was compared between the two groups. Demographic and operative data including age, sex, body mass index (BMI), smoking, etiology of arthritis, comorbidities such as diabetes mellitus and rheumatoid arthritis, number of joints fixed, use of bone graft or bone substitute, and postoperative midfoot anatomic alignment in the two groups were compared. Results: There was a significant difference in the union rate between the two groups: 91.5 % (43 out of 47 joints) in arthrodesis with highly porous β-TCP and BMAC (group A) and 76.2 % (32 out of 42 joints) in arthrodesis without highly porous β-TCP and BMAC (group B) (P = 0.048). During the follow-up period, a total of four postoperative complications were reported in this study. In group A, two patients developed hardware irritation, and all of them underwent removal of hardware procedure. In group B, one patient had a superficial wound infection, which was resolved completely without further treatment. The other patient in group B developed a deep wound infection with dehiscence, and it was managed with irrigation and debridement followed by vacuum assisted wound closure therapy. Conclusion: This study investigated the efficiency of highly porous β-TCP and BMAC to promote bony healing in midfoot joint arthrodesis. A significantly higher union rate was shown when arthrodesis was performed with highly porous β-TCP and BMAC compared to arthrodesis without them, suggesting that highly porous β-TCP and BMAC can be a viable and effective adjunct to the fixation in midfoot joint arthrodesis.

Bioactive glass granules versus standard autologous and allogeneic bone grafts: a randomized trial of 49 adult bone tumor patients with a 10-year follow-up.

As a synthetic bone void filler, bioactive glasses (BGs) may enhance angiogenesis and osteogenesis. In this randomized trial, we compared the clinical efficacy of BG granules and standard bone grafts in patients undergoing surgery for benign bone tumors. 49 recruited patients were randomized to receive BG granules or undergo conventional bone grafting to fill defects following tumor removal. As the standard of care, small-sized defects were filled with autologous graft, and large-sized defects were filled with allogeneic graft. The primary endpoint was treatment success at 1 year, defined by no reoperation, no tumor recurrence, and no device-related adverse events. Secondary endpoints included patient-reported outcomes (Rand-36 and pain scores) and quantitative assessment of blood flow and metabolic activity by means of 18F-fluoride PET/CT imaging. As an off-trial group, 15 children and adolescents (age < 18 years) underwent tumor removal and BG-filling, without randomization. At 1-year, 21 of 25 BG-treated patients (risk estimate 0.84, 95% confidence interval [CI] 0.70-0.98) and 20 of 24 patients in the standard of care group (0.83, CI 0.68-0.98) met the criteria for treatment success. The groups had similar Rand-36 scores. In patients with small defects, BG filling was associated with shorter operative time and less postoperative pain at 1 month. In patients with large defects, blood flow was similar, but BG-filled defects showed higher metabolic activity than allograft-filled defects at 1-year. The survey of the postoperative period ≥10 years revealed no BG-related adverse events. BG granules had similar overall rates of treatment success compared with autografts and allografts, but large-scale trials are needed for the confirmation of clinical equivalence. The extended metabolic activity confirms the expected cellular responses of osseointegrated BG granules.

Racial Disparities in the Timing of Alveolar Bone Grafting.

Standard bone grafting between ages 6 and 12 has become the preferred treatment of choice for alveolar clefts. Given the importance of surgical timing in complete cleft palate repairs, it is important to identify any populations at-risk for delayed alveolar bone grafting. The purpose of this study is to identify whether a racial disparity is present nationally in the timing of alveolar bone grafting. Retrospective analysis Setting: Hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). Inclusion criteria involved patients who underwent alveolar bone grafting identified by current procedure terminology (CPT) code 42210 between years 2012 and 2019. Patients were stratified by age at time of operation based on the following parameters: early bone grafting (before 6 years of age), standard bone grafting (between 6 and 12 years of age), and late bone grafting (after 12 years of age). Racial and ethnic differences in the age of patients at the time of alveolar bone grafting. Overall, 20.28% of the cohort received alveolar bone graft after 12 years of age. African American (29.33%) and Hispanic (24.42%) patients received late alveolar bone grafting more frequently than other racial and ethnic groups ( P &lt; .001). Racial and ethnic disparities are present in the frequency at which patients receive late alveolar bone grafting for complete cleft palates. Given the suboptimal surgical results of late compared to standard alveolar bone grafting it is important to further investigate the driving factors of these disparities.

Comparison of the Coracoid, Distal Clavicle, and Scapular Spine for Autograft Augmentation of Glenoid Bone Loss: A Radiologic and Cadaveric Assessment

Background: Glenohumeral instability caused by bone loss requires adequate bony restoration for successful surgical stabilization. Coracoid transfer has been the gold standard bone graft; however, it has high complication rates. Alternative autologous free bone grafts, which include the distal clavicle and scapular spine, have been suggested. Study Design: Controlled laboratory study. Purpose: The purpose of this study was to determine the percentage of glenoid bone loss (GBL) restored via coracoid, distal clavicle, and scapular spine bone grafts using a patient cohort and a cadaveric evaluation. Methods: Autologous bone graft dimensions from a traditional Latarjet, congruent arc Latarjet, distal clavicle, and scapular spine were measured in a 2-part study using 52 computed tomography (CT) scans and 10 unmatched cadaveric specimens. The amount of GBL restored using each graft was calculated by comparing the graft thickness with the glenoid diameter. Results: Using CT measurements, we found the mean percentage of glenoid restoration for each graft was 49.5% ± 6.7% (traditional Latarjet), 45.1% ± 4.9% (congruent arc Latarjet), 42.2% ± 7.7% (distal clavicle), and 26.2% ± 8.1% (scapular spine). Using cadaveric measurements, we found the mean percentage of glenoid restoration for each graft was 40.2% ± 5.0% (traditional Latarjet), 53.4% ± 4.7% (congruent arc Latarjet), 45.6% ± 8.4% (distal clavicle), and 28.2% ± 7.7% (scapular spine). With 10% GBL, 100% of the coracoid and distal clavicle grafts, as well as 88% of scapular spine grafts, could restore the defect (P < .001). With 20% GBL, 100% of the coracoid and distal clavicle grafts but only 66% of scapular spine grafts could restore the defect (P < .001). With 30% GBL, 100% of coracoid grafts, 98% of distal clavicle grafts, and 28% of scapular spine grafts could restore the defect (P < .001). With 40% GBL, a significant difference was identified (P = .001), as most coracoid grafts still provided adequate restoration (congruent arc Latarjet, 82.7%; traditional Latarjet, 76.9%), but distal clavicle grafts were markedly reduced, with only 51.9% of grafts maintaining sufficient dimensions. Conclusions: The coracoid and distal clavicle grafts reliably restored up to 30% GBL in nearly all patients. The coracoid was the only graft that could reliably restore up to 40% GBL. Clinical Relevance: With “subcritical” GBL (>13.5%), all autologous bone grafts can be used to adequately restore the bony defect. However, with “critical” GBL (≥20%), only the coracoid and distal clavicle can reliably restore the bony defect.

Enhanced bone regenerative properties of calcium phosphate ceramic granules in rabbit posterolateral spinal fusion through a reduction of grain size

Osteoinductivity is a crucial factor to determine the success and efficiency of posterolateral spinal fusion (PLF) by employing calcium phosphate (Ca-P) bioceramics. In this study, three kinds of Ca-P ceramics with microscale to nanoscale gain size (BCP-control, BCP-micro and BCP-nano) were prepared and their physicochemical properties were characterized. BCP-nano had the spherical shape and nanoscale gain size, BCP-micro had the spherical shape and microscale gain size, and BCP-control (BAM®) had the irregular shape and microscale gain size. The obtained BCP-nano with specific nanotopography could well regulate in vitro protein adsorption and osteogenic differentiation of MC3T3 cells. In vivo rabbit PLF procedures further confirmed that nanotopography of BCP-nano might be responsible for the stronger bone regenerative ability comparing with BCP-micro and BCP-control. Collectedly, due to nanocrystal similarity with natural bone apatite, BCP-nano has excellent efficacy in guiding bone regeneration of PLF, and holds great potentials to become an alternative to standard bone grafts for future clinical applications.

A Composite Lactide-Mineral 3D-Printed Scaffold for Bone Repair and Regeneration

Orthopedic tumor resection, trauma, or degenerative disease surgeries can result in large bone defects and often require bone grafting. However, standard autologous bone grafting has been associated with donor site morbidity and/or limited quantity. As an alternate, allografts with or without metallic or polyether-etherketone have been used as grafting substitutes. However, these may have drawbacks as well, including stress shielding, pseudarthrosis, disease-transmission, and infection. There is therefore a need for alternative bone substitutes, such as the use of mechanically compliant three-dimensional (3D)-printed scaffolds. Several off-the-shelf materials are available for low-cost fused deposition 3D printing such as polylactic acid (PLA) and polycaprolactone (PCL). We have previously described the feasibility of 3D-printed PLA scaffolds to support cell activity and extracellular matrix deposition. In this study, we investigate two medical-grade filaments consistent with specifications found in American Society for Testing and Materials (ASTM) standard for semi-crystalline polylactide polymers for surgical implants, a pure polymer (100M) and a copolymeric material (7415) for their cytocompatibility and suitability in bone tissue engineering. Moreover, we assessed the impact on osteo-inductive properties with the addition of beta-tricalcium phosphate (β-TCP) minerals and assessed their mechanical properties. 100M and 7415 scaffolds with the additive β-TCP demonstrated superior mesenchymal stem cells (MSCs) differentiation detected via increased alkaline phosphatase activity (6-fold and 1.5-fold, respectively) and mineralized matrix deposition (14-fold and 5-fold, respectively) in vitro. Furthermore, we evaluated in vivo compatibility, biosafety and bone repair potential in a rat femur window defect model. 100M+β-TCP implants displayed a positive biosafety profile and showed significantly enhanced new bone formation compared to 100M implants evidenced by μCT (39 versus 25% bone volume/tissue volume ratio) and histological analysis 6 weeks post-implantation. These scaffolds are encouraging composite biomaterials for repairing bone applications with a great potential for clinical translation. Further analyses are required with appropriate evaluation in a larger critical-sized defect animal model with long-term follow-up.

Evaluation of 3D computer-assisted patient’s specific scaffold seeded with autogenous stem cells and platelet-rich fibrin in alveolar cleft repair.

Purpose: Evaluation of the treatment outcome of using patient-specific implantable scaffolds seeded with autogenous bone marrow mononuclear cell layer containing stem cells and platelet-rich fibrin in the treatment of alveolar cleft defect. Materials and methods: 12 alveolar cleft defects were divided into 2 groups; group A, six alveolar defects were treated using 3D printed patient’s specific implantable PLLA scaffolds seeded with autogenous bone marrow mononuclear cell layer containing stem cells and platelet-rich fibrin. Group B, six alveolar defects were treated with standard anterior iliac crest cortico-cancellous alveolar bone grafting procedures. Clinical and radiographic assessments were done to compare between two groups. Results: The results Showed that after 6 months group A was radiographically significantly less dense than the autogenous grafting group and when compared to Bergland’s scale there was no significant difference in bone loss after 6 months. Conclusion: Although this technique may not be the best choice regarding the density of bone formation, however within the limitations of this study, the results showed that this technique may be a new solution for transformation of the persistent cases of chronic oronasal fistula patients who underwent multiple failed autogenous bone grafting from a state of chronic fistulation to normal alveolar bone augmentation candidates.

Is sclerotherapy with polidocanol a better treatment option for aneurysmal bone cyst compared to conventional curettage and bone grafting?

BackgroundThe standard treatment of Aneurysmal bone cyst is curettage and grafting and is associated with high morbidity. Hence minimal invasive alternative treatment methods such as sclerotherapy are gaining much popularity. Though sclerotherapy has been attributed to reasonable cure rates, undetermined tissue diagnosis often impedes with initiation of treatment. This study examines if sclerotherapy with polidocanol based on clinic-radiological picture is comparable with the standard intralesional curettage and bone grafting. Attempting biopsy and treatment simultaneously based on the clinico-radiological presentation makes this study unique. MethodsWe divided 48 patients into two treatment groups. Group 1 treated with percutaneous sclerotherapy using polidocanol and group 2 those treated with extended curettage and bone grafting. We assessed time to healing and recurrence, pain relief, and radiological outcome using modified Neer's criteria for the radiological healing of the bone cysts. 31 patients from Group 1 and 17 from Group 2 were available for study. The minimum follow-up was 2 years. ResultsAt last follow-up, 100% in Group 1 and 82% in Group 2 had achieved complete healing and there was no statistical difference in outcome at 24 months (p = 0.255). Complications in Group 1 were injection site necrosis, pain and hypopigmentation, all of which resolved spontaneously. In Group 2, three patients had recurrence. Despite similar healing rates, we found higher incidence of clinically pertinent complications, poor functional outcomes and increased cost of treatment associated with intralesional excision.Three cases were excluded from sclerotherapy group as the final diagnosis turned up to be secondary ABC. ConclusionsPercutaneous sclerotherapy using polidocanol is a highly effective, cost efficient and safe treatment option with good cosmesis and reduced morbidity. In this study, we found comparable outcomes for both treatment methods however this will require confirmation in larger studies.

Synthetic Bone Graft Materials in Spine Fusion: Current Evidence and Future Trends.

Historically, iliac crest bone autograft has been considered the gold standard bone graft substitute for spinal fusion. However, the significant morbidity associated with harvesting procedures has influenced decision-making and practice patterns. To minimize these side effects, many clinicians have pursued the use of bone graft extenders to minimize the amount of autograft required for fusion in certain applications. Synthetic materials, including a variety of ceramic compounds, are a class that has been studied extensively as bone graft extenders. These have been used in combination with a wide array of other biomaterials and investigated in a variety of different spine fusion procedures. This review will summarize the current evidence of different synthetic materials in various spinal fusion procedures and discuss the future of novel synthetics.

Comparison of radiographs and computed tomography (CT) imaging for preoperative evaluation and planning for shoulder arthroplasty

BackgroundThe purpose of this study was to determine if addition of CT to axillary radiographs (AXR) alters preoperative decision making for shoulder arthroplasty. MethodsPreoperative deidentified images (XR alone and XR with CT) of 50 patients with glenohumeral arthritis were reviewed independently by 3 reviewers in a blinded fashion. Each reviewer graded images for glenoid wear pattern as simple (Walch A1 or B1) or advanced [A2, B2, C]), adequacy of AXR and need for advanced imaging. The reviewers determined a preoperative plan for all patients based on XR alone vs. XR and CT including the arthroplasty type (anatomic or reverse total shoulder) and their plan for treating glenoid wear (eccentric or standard reaming vs. bone graft or augment). Kappa values (κ) were calculated to determine inter-rater agreement and consistency among multiple reviewers. Fisher's exact test was used to assess any difference in preoperative plan once the shoulders were separated into simple and advanced glenoid wear patterns. ResultsThe 3 reviewers agreed that quality of AXRs was significantly inadequate (P < .001) for assessing glenoid wear in advanced glenoid wear patterns compared to simple wear patterns. Following evaluation on AXRs alone, the need for CT imaging was significantly higher in advanced glenoid wear patterns compare to simple ones (81% vs. 31%; P < .001). The addition of CT images did not result in a significant change to the preoperative plan in simple glenoid wear patterns but in advanced glenoid wear, addition of CT can change the preoperative plan with respect to arthroplasty type and/or strategy for addressing glenoid wear. ConclusionAxillary radiographs are often inadequate for preoperative planning in shoulder arthritis with advanced glenoid wear patterns (Walch A2, B2, C types). Addition of CT imaging to radiographs in shoulder arthritis with advanced glenoid wear can affect the preoperative decision with respect to type of shoulder arthroplasty and/or plan for addressing glenoid wear (reaming, bone graft or augmented glenoids). Level of evidenceLevel IV

Early injection of autologous bone marrow concentrates decreases infection risk and improves healing of acute severe open tibial fractures

IntroductionOpen fractures are at risk of nonunion; surgeons are reluctant to propose early standard bone grafting after open fractures, preferring to wait in order to adequately assess the facture status of infection. Bone marrow contains mesenchymal stem cells (MSCs) and granulocyte and macrophage precursors identified in vitro as colony forming units-granulocyte macrophage (CFU-GM), both of which have a prophylactic action against infection. We therefore tested the hypothesis that early injection of bone marrow concentrate would be useful in these fractures. MethodsWe evaluated a series of 231 patients who had received early percutaneous implantation of bone marrow concentrate (BMC) to treat open fractures (with gap less than 10 mm) that were Gustilo-Anderson Type II or III. The results were compared with those of 67 control (no early graft) patients and with those of 76 patients treated with an early, standard of care, iliac bone graft. All patients were treated with external fixation and were considered to have an aseptic fracture at the time of early grafting, but the actual status of infection was re-assessed at the time of grafting by histology and/or analysis of the aspirate. The bone marrow graft contained after concentration 49,758 ± 21,642 CFU-GM-derived colonies/cc and 9400 ± 1435 MSCs/cc which represents an important increase compared to the level of CFU-GM cells and MSCs present in a standard auto-graft. Healing was evaluated at 9 months. ResultsThe rate of unsuspected infections was higher than 15% in the 3 groups. Bone union and removal of external fixation was achieved at 9 months by 50.7% of patients in the Control Group, by 86.8% of patients in the group with a standard bone graft, and by 87.4% of patients in the bone marrow group. A 90% risk reduction (p = 0.005) in the need for an invasive standard bone graft to treat a nonunion and in the risk of infection was observed when bone marrow was proposed as early injection to the treatment of type II or type-III tibial fractures. ConclusionBone marrow concentrate for early grafting in open fractures with limited gap was efficient for healing while decreasing infection.

Improved osseointegration using porcine xenograft compared to demineralized bone matrix for the treatment of critical defects in a small animal model.

Autograft (AG) is the gold standard bone graft due to biocompatibility, osteoconductivity, osteogenicity, and osteoinductivity. Alternatives include allografts and xenografts (XG). We investigated the osseointegration and biocompatibility of a decellularized porcine XG within a critical defect animal model. We hypothesized that the XG will result in superior osseointegration compared to demineralized bone matrix (DBM) and equivalent immune response to AG. Critical defects were created in rat femurs and treated with XG, XG plus bone morphogenetic protein (BMP)-2, DBM, or AG. Interleukin (IL)-2 and IFN-gamma levels (inflammatory markers) were measured from animal blood draws at 1week and 1month post-operatively. At 1month, samples underwent micro-positron-emission tomography (microPET) scans following 18-NaF injection. At 16weeks, femurs were retrieved and sent for micro-computerized tomography (microCT) scans for blinded grading of osseointegration or were processed for histologic analysis with tartrate resistant acid phosphatase (TRAP) and pentachrome. Enzyme linked immunosorbent assay testing demonstrated greater IL-2 levels in the XG vs. AG 1week post-op; which normalized by 28days post-op. MicroPET scans showed increased uptake within the AG compared to all groups. XG and XG+BMP-2 showed a trend toward increased uptake compared with DBM. MicroCT scans demonstrated increased osseointegration in XG and XG+BMP groups compared to DBM. Pentachrome staining demonstrated angiogenesis and endochondral bone formation. Furthermore, positive TRAP staining in samples from all groups indicatedbone remodeling. These data suggest that decellularized and oxidized porcine XG is biocompatible and at least equivalent to DBM in the treatment of a critical defect in a rat femur model.

PRONATOR QUADRATUS MUSCLE PEDICLED BONE GRAFT FOR DELAYED UNION SCAPHOID

Background: The human scaphoid bone is one of the carpal bones of the wrist. Its fracture is the most common type of carpal bone fracture. Scaphoid nonunion is a well-known and common problem. Both clinical and biological factors contribute to the development of nonunion. Several techniques of bone grafting have been used in the management of scaphoid fracture nonunion. The union rate achieved with standard nonvascularized bone grafts was poor, especially in case of avascular necrosis and pseudarthroses, whereas the use of vascularized bone grafts results in better union rates. Pronator quadratus pedicled bone graft is described as one of the successful techniques that treat delayed union of the scaphoid fracture. Objective: To evaluate the outcomes and results of pronator quadratus muscle pedicle bone graft for patients who were suffering from delayed union or nonunion of scaphoid bone fracture. Patients and Methods: Ten patients suffering from delayed and non-united scaphoid fractures, seven males and three females, aging from 17 to 54 years old. We used the pronator quadratus muscle pedicled bone graft to treat all these patients. Results: Complete union was achieved in seven patients, 6 patients of them were suffering from waist non united scaphoid fracture, and one patient of four patients suffering from non-united proximal pole scaphoid fracture. Conclusion: The use of the pronator quadratus pedicled bone graft in delayed union of the scaphoid waist fractures achieved a high rate of union with excellent and good functional outcomes. A poor result occurred on using the pronator quadratus pedicled bone graft in delayed union of the scaphoid proximal pole fracture.