Bone Transfer Research Articles

The medial femoral condyle free corticoperiosteal flap versus traditional bone graft for treatment of nonunions of long bones: a retrospective comparative cohort study

Fracture healing is a complex process and many factors change the local biology of the fracture and reduce the physiologic repair process. Since 1991 the free vascularised corticoperiosteal graft has been proposed to treat nonunions. In this study we compare the healing rate and the healing time of the free vascularised corticoperiosteal graft harvested from medial femoral condyle versus the traditional cancellous bone graft from the iliac crest combined with other biologic or pharmacologic factors. We performed a retrospective cohort study. The main measures of outcomes were the rate of bone union and the mean healing time from surgery. The authors performed 10 free vascularised corticoperiosteal grafts in the cohort A and 10 patients received traditional cancellous bone graft plus other biologic or pharmacologic treatment in the same period in the cohort B. The mean follow up in cohort A was 18.6 months with a healing rate of 100% (10/10). In cohort B the mean follow up was 22.5 month with a healing rate of 90%. The mean time to obtain union (healing time) in the group that was treated with the free flap procedure was significantly shorter, 3.2 months versus a mean time of 8.8 months in the other group. Some studies describe a high healing rate of recalcitrant nonunions with treatments different from vascularized bone flaps: it is difficult to compare the results of vascularized bone transfers with the results of other case series. Our groups are very homogeneous even if it is difficult to define correct inclusion criteria because there is still no agreement about what is defined a recalcitrant or difficult nonunion, and the number of trials of previous surgery before to perform a vascularized free flap. Even if our study cohort is small, we have demonstrated that the MFCCF generally seems to give a better healing chance with a shorter healing time compared to other treatments.

Nutrient Foramen of Fibula in Relation to Distal end, Potential Implications for Vascularised Done Graft Surgery

Background Free vascularised fibular bone grafting has gained popularity in various Orthopaedic and Oral & maxillofacial reconstructive surgeries. The objective of the present study was to identify the morphology and topography of nutrient foramina of fibula and to determine the foraminal index (FI) of the fibula using a more surgeon friendly bony landmark. Methods The study comprised examination of 100 fibulae specimens. Each bone was divided into 03 parts and topographical analysis was performed on each section. The nutrient foramina were identified macroscopically using size 24-gauge needle. Modified Hughes formula was used to calculate the foraminal index using distance of foramen (DF) from distal end which is easier to palpate in living human beings, total length of fibula (TL); and the formula was DF/TL x100. Results With respect to fibulae, 98% had single foramen and foramen was absent in 2%. The mean foraminal index (FI) was 56% for fibulae using modified Hughes’ formula. The majority of the fibulae showed nutrient foramen in the middle 3rd in relation to distal end of fibula. Conclusion The study provides information on the morphology of nutrient foramina in relation to easily palpable landmark on living human beings, which can provide guidance to surgeon while performing microvascular bone transfer procedures.

Large Osteochondral Lesions of the Talus Treated With Autologous Bone Graft and Periosteum Transfer.

Background:The treatment of large osteochondral lesions of the talus (OLTs) is challenging due to the poor intrinsic reparative capability of the damaged articular cartilage. Autologous transfer of bone and periosteum has been used successfully in the treatment of large defects in animals, and therefore it was believed that this technique might show similar results in humans. The purpose of this study was to assess the outcome of an innovative technique for autologous transplantation of cancellous tibial graft with periosteal transfer in large OLTs.Methods:Forty-one patients (22 females, 19 males), with a mean age of 34.9 years (range, 18-72 years), with a large OLT (>200 mm2) were treated with autologous bone graft and periosteum transfer. OLTs averaging 310 mm2 were identified on a preoperative computed tomography scan. The procedure consisted of malleolar osteotomy, curettage of sclerotic bone, autologous bone graft from the proximal tibia, and transfixion of periosteum over the graft. Outcome measures, including the pain visual analog scale (VAS), ankle range of motion (ROM), American Orthopaedic Foot & Ankle Society (AOFAS) score, and Foot & Ankle Disability Index (FADI), were compared between preoperative and 1 and 2 years following surgery.Results:There were significant improvements in VAS pain score from 7.7 before surgery to 1.1 at 1 year after surgery and 0.4 at 2 years or more after surgery. The AOFAS and FADI scores were also significantly improved from 40.3 and 53.3 preoperatively to 95 and 93.2 postoperatively at 1 year and 95 and 93.2 at 2 or more years postoperatively, respectively. Postoperative complications included 2 patients who required removal of medial malleolar osteotomy tension bands due to symptomatic hardware. There were no nonunions or malunions of the osteotomies and no donor site complications.Conclusion:Autologous bone graft and periosteum transfer was an effective treatment for large OLTs leading to significant decreases in pain and improvement in functional scores at more than 2 years after surgery.Level of Evidence:Level IV, retrospective case series.

The Instability Severity Index Score Revisited: Evaluation of 217 Consecutive Cases of Recurrent Anterior Shoulder Instability

Objectives: The instability severity index score (ISIS) was designed to predict the risk of recurrence after arthroscopic instability shoulder surgery and to better predict those who would benefit from an open or bone transfer operation. Although this score has been widely disseminated to predict recurrence, there are certain areas in which preoperative assessment is limited, especially in radiographic workup. The objective of this study was to examine the validity of ISIS based on its existing variables, as well as to evaluate additional imaging and patient history variables pertinent to the potential redevelopment of a new score to assess risk of recurrent anterior instability following an arthroscopic Bankart repair. Methods: All consecutive patients were prospectively enrolled with recurrent anterior shoulder instability who subsequently underwent an arthroscopic stabilization with minimum 24 months follow-up. Exclusion criteria included, prior surgery on the shoulder, posterior or multidirectional instability, or a rotator cuff tear. All instability severity index score variables were recorded (age <20, degree and sport type, hyperlaxity, Hill Sachs on AP xray, glenoid loss of contour on AP xray), as well as additional variables: 1. Position of arm at dislocation; 2. Number of instability events; 3. Total time of instability; 4. Glenoid bone loss percent; 5. Amount of attritional glenoid bone loss; 6. Hill Sachs measures (H/W/D and volume), and outcomes (recurrent instability) and scores (WOSI, ASES and SANE). Regression analysis was utilized to determine preoperative variables that predicted outcomes and failures. Results: There were 217 consecutive patients (209 male-96.5%, 8 female-3.5%) who met criteria and were all treated with a primary arthroscopic shoulder stabilization during a 3.5-year period (2007-2011), with mean follow-up of 42 (range, 26-58 mos). The mean age at first instability event was 23.9 (range, 16-48), with 55% right shoulder affected, 60% dominant shoulder. Outcomes were improved from mean scores preoperative (WOSI=1050/2100, ASES=61.0, SANE=52.5) to postoperative (WOSI=305/2100, ASES=93.5, SANE=95.5), and 11.5% (25/217) had evidence or recurrent instability or subluxation. A total of 51/217 were 20 years or under, hyperlaxity in 5, Hill Sachs on internal rotation XR in 77, glenoid contour on AP XR in 41, with an overall mean ISIS score of 3.6. Factors associated with failure were glenoid bone loss greater than 14.5%(p<0.001), total time of instability symptoms >11.5 months(p<0.03), Hill Sachs volume > 1.3 cm3 with H>1.5 cm, W>1.0 cm and D>5 mm(p<0.01), contact sport (p<0.01) and age 20 or under (p<0.01). There was no correlation in outcomes with Hill Sachs on IR or glenoid contour on XR (p>0.45), sports participation, and Instability Severity Score (mean=3.4 success, vs 3.9 failure, p>0.44). Conclusion: At nearly four years of follow-up, there was an 11.5% failure rate of scope stabilization surgery. However, there was no correlation between treatment outcome and the ISIS measure given a mean score of 3.4 with little difference identified in those that failed. However, several important parameters previously unidentified were detected including, glenoid bone loss >14.5%, Hill Sachs volume >1.3 cm3, and time length of instability symptoms. Therefore, the ISIS measure may need to be redesigned in order to incorporate variables that more accurately portray the actual risk of failure following arthroscopic stabilization.

Dynamic Anterior Shoulder Stabilization With the Long Head of the Biceps Tendon: A Biomechanical Study

Background: The concept of dynamic anterior shoulder stabilization (DAS) combines a Bankart repair with the additional sling effect of the long head of the biceps (LHB) tendon to treat anterior glenohumeral instability. This surgical technique was created to close the gap between the indications for isolated Bankart repair and those requiring bone transfer techniques. Purpose: To biomechanically investigate the stabilizing effects of the DAS technique in comparison with the standard Bankart repair in different defect models. Study Design: Controlled laboratory study. Methods: Twenty-four fresh-frozen cadaveric shoulders (mean ± SD age, 60.1 ± 8.6 years) were mounted in a 6 degrees of freedom shoulder testing system. With cross-sectional area ratios, the rotator cuff muscles and LHB tendon were loaded with 40 N and 10 N, respectively. Anterior and inferior glenohumeral translation was tested in 60° of abduction and 60° of external rotation (ABER position) while forces of 20 N, 30 N, and 40 N were applied to the scapula in the posterior direction. Total translation and relative translation in relation to the native starting position were measured with a 3-dimensional digitizer. Maximal external rotation and internal rotation after application of 1.5-N·m torque to the humerus were measured. All specimens went through 4 conditions (intact, defect, isolated Bankart repair, DAS) and were randomized to 1 of 3 defect groups (isolated Bankart lesion, 10% anterior glenoid defect, 20% anterior glenoid defect). The DAS was performed by transferring the LHB tendon through a subscapularis split to the anterior glenoid margin, where it was fixed with an interference screw. Results: Both surgical techniques resulted in decreased anterior glenohumeral translation in comparison with the defect conditions in all defect groups. As compared with isolated Bankart repair, DAS showed significantly less relative anterior translation in 10% glenoid defects at translation forces of 20 N (0.3 ± 1.7 mm vs 2.2 ± 1.8 mm, P = .005) and 30 N (2.6 ± 3.4 mm vs 5.3 ± 4.2 mm, P = .044) and in 20% glenoid defects at all translation forces (20 N: –3.2 ± 4.7 mm vs 0.8 ± 4.1 mm, P = .024; 30 N: –0.9 ± 5.3 mm vs 4.0 ± 5.2 mm, P = .005; 40 N: 2.1 ± 6.6 mm vs 6.0 ± 5.7 mm, P = .035). However, in 20% defects, DAS led to a relevant posterior and inferior shift of the humeral head in the ABER position and to a relevant increase in inferior glenohumeral translation. Both surgical techniques did not limit the rotational range of motion. Conclusion: In the context of minor glenoid bone defects, the DAS technique demonstrates less relative anterior translation as compared with an isolated Bankart repair at time zero. Clinical Relevance: The new DAS technique seems capable of closing the gap between the indications for isolated Bankart repair and bone transfer techniques.

Microsurgical Reconstruction of the Lower Extremity.

Reconstruction of bony and soft tissue defects of the lower extremity has been revolutionized by the advent of microsurgical tissue transfer. There are numerous options for reconstruction. Possibilities include transfer of soft tissue, composite (bone and soft tissue) tissue, and functional muscle. Many lower extremity reconstructions require staged procedures. Planning is of paramount importance especially in regard to vascular access when multiple free flaps are required. Soft tissue reconstruction of the lower extremity may be accomplished with muscle flaps such as the rectus femoris and latissimus dorsi covered with a skin graft. Fasciocutaneous flaps such as the anterolateral thigh flap may be more appropriate in a staged reconstruction which requires later elevation of the flap. Loss of a significant portion of bone, such as the tibia, can be difficult to manage. Any gap greater than 6 cm is considered a reasonable indication for vascularized bone transfer. The contralateral free fibula is the donor site of choice. Functional reconstruction of the anterior compartment of the leg may be performed with a gracilis muscle transfer, effectively eliminating foot drop and providing soft tissue coverage. Muscle tensioning is critical for effective excursion and dorsiflexion of the foot. Long-term results of microsurgical reconstruction of the lower extremity show good results and reasonable rates of limb salvage.

Surgical Management of Oral Squamous Cell Carcinoma in Dhaka Dental College Hospital; 31 patients

Cancer is a major cause of death throughout the world. Oral cancer is one of the six most frequently occurring cancer.1 In Bangladesh, the number of new cancer cases of whole body per year is about 200000 of which oral cancer is about 20%.2 In our neighboring country India, accounts for thirty-five percent of all newly diagnosed cancers in men. The etiology of oral cancer is well established in most instances with consumption of tobacco in any form and alcohol being the most common etiologic agents. Recently, however, exposure to the human papilloma virus has been implicated in young patients with oral carcinoma. The exact mechanism of carcinogenesis in this setting remains to be elucidated .3 Surgery is the most well established mode of initial definitive treatment for a majority of oral cancers. The factors that affect the choice of treatment are related to the tumor and the patient. Primary site, location, proximity to bone and depth of infiltration are factors, which influence particular surgical approach. Advanced reconstructive techniques that allow free transfer of soft tissue and bone improve the functional and aesthetic outcomes following major ablative surgery .Over the course of the past thirty years there has been improvement in the overall survival of patients with oral carcinoma largely due to the improved understanding of the biology of local progression, early identification and treatment of metastatic lymph nodes in the neck and employment of adjuvant post-operative radiotherapy or chemotherapy. Either the role of surgery in oral cancer has evolved with integration of multidisciplinary treatment approaches employing chemotherapy and radiotherapy sequentially or concurrently .Surgical expertise is required for rehabilitation of functional and aesthetic defects created by initial treatment of cancer. Thus, surgery and services of a surgeon remain central to the management of oral cancer.4 A cross sectional study of 31patients undergoing surgery for the treatment of oral squamous cell carcinoma was carried out at Department of Oral & Maxillofacial Surgery ,Dhaka Dental college & hospital from May 2016 to July2017. Here 31 patients, of them male 13 and female 18 having 31 to 80years age ranges of oral squamous cell carcinoma who underwent surgery and reconstruction were included in this study. All patients were referred to oncologist after surgery. Aim of this study was to assess the status of disease, to provide the patient surgical treatment as a first line therapy, to find out any post-operative complications.
 Update Dent. Coll. j: 2018; 8 (2): 10-13

Clinical results and quality of life after reconstruction following sacrectomy for primary bone malignancy

Sacrectomy is a rare and demanding surgical procedure that results in major soft tissue defects and spinopelvic discontinuity. No consensus is available on the optimal reconstruction algorithm. Therefore, the present study evaluated the results of sacrectomy reconstruction and its impact on patients' quality of life (QOL). A retrospective chart review was conducted for 21 patients who underwent sacrectomy for a primary bone tumour. Patients were divided into groups based on the timing of reconstruction as follows: no reconstruction, immediate reconstruction or delayed reconstruction. QOL was measured using the EQ-5D instrument before and after surgery in patients treated in the intensive care unit. The mean patient age was 57 (range 22-81) years. The most common reconstruction was gluteal muscle flap (n = 9) and gluteal fasciocutaneous flap (n = 4). Four patients required free-tissue transfer, three latissimus dorsi flaps and one vascular fibula bone transfer. No free flap losses were noted. The need for unplanned re-operations did not differ between groups (p = 0.397), and no significant differences were found for pre- and post-operative QOL or any of its dimensions. Free flap surgery is reliable for reconstructing the largest sacrectomy defects. Even in the most complex cases, surgery can be safely staged, and final reconstruction can be carried out within 1 week of resection surgery without increasing peri‑operative complications. Sacrectomy does not have an immoderate effect on the measured QOL.

A Modification of an Established Method of Intercalary Extremity Bone Defect Reconstruction: The "Hemi-Capanna" Technique.

Skeletal reconstruction of segmental defects of the appendicular skeleton is among the most challenging tasks in reconstructive surgery. A popular method of reconstruction of large osseous defects is the combination of massive allografts and vascularized bone transfer. We present and discuss our experience with a modification of the traditional Capanna technique in which the allograft is split in half longitudinally to provide for more space for postoperative fibula hypertrophy. Patients who underwent reconstruction of segmental intercalary defects of the tibia using our modified technique were retrospectively identified. The following parameters were retrieved: patient age, race, sex, length of skeletal defect, recipient vessels, type of microsurgical anastomosis, union rate, complication rate, ambulation (yes/no), and follow-up (in months). Two male patients underwent reconstruction of the tibia via the modified "hemi-Capanna" technique. The tibia defect measured 12 and 13 cm, respectively. No intraoperative or postoperative complications were encountered. Osseous union was obtained in both patients who are both ambulatory. The hemi-Capanna technique not only leaves more room for hypertrophy of the vascularized fibula, but also simplifies the technique of combining an allograft with vascularized bone transfer in reconstructions of segmental skeletal defects of the appendicular skeleton.

Individualized Titanium Mesh Combined With Platelet-Rich Fibrin and Deproteinized Bovine Bone: A New Approach for Challenging Augmentation.

Autologous bone transfer is regarded as the gold standard for ridge augmentation before dental implantation, especially in severe bony defects caused by tumor resection or atrophy. In addition to the advantages of autologous bone, transplantation has several disadvantages, such as secondary operation, increased morbidity and pain. The present study reports, for the first time, a combination of a xenogeneic bone substitute (BO) with platelet-rich fibrin (PRF), which is a fully autologous blood concentrate derived from the patient's own peripheral blood by centrifugation. Solid A-PRF+ and liquid i-PRF together with an individualized 3-D planned titanium mesh were used for reconstruction of a severe tumor-related bony defect within the mandible of a former head and neck cancer patient. The BO enriched with regenerative components from PRF allowed the reconstruction of the mandibular resective defect under the 3-D mesh without autologous bone transplantation. Complete rehabilitation and restoration of the patient's oral function were achieved. Histological analysis of extracted bone biopsies confirmed that the new bone within the augmented region originated from the residual bone. Within the limitations of the presented case, the applied concept appears to be a promising approach to increase the regenerative capacity of a bone substitute material, as well as decrease the demand for autologous bone transplantation, even in cases in which autologous bone is considered the golden standard. PRF can be considered a reliable source for increasing the biological capacities of bone substitute materials.

Virtual Surgical Planning: The Pearls and Pitfalls.

Objective:Over the past few years, virtual surgical planning (VSP) has evolved into a useful tool for the craniofacial surgeon. Virtual planning and computer-aided design and manufacturing (CAD/CAM) may assist in orthognathic, cranio-orbital, traumatic, and microsurgery of the craniofacial skeleton. Despite its increasing popularity, little emphasis has been placed on the learning curve.Methods:A retrospective analysis of consecutive virtual surgeries was done from July 2012 to October 2016 at the University of Montreal Teaching Hospitals. Orthognathic surgeries and free vascularized bone flap surgeries were included in the analysis.Results:Fifty-four virtual surgeries were done in the time period analyzed. Forty-six orthognathic surgeries and 8 free bone transfers were done. An analysis of errors was done. Eighty-five percentage of the orthognathic virtual plans were adhered to completely, 4% of the plans were abandoned, and 11% were partially adhered to. Seventy-five percentage of the virtual surgeries for free tissue transfers were adhered to, whereas 25% were partially adhered to. The reasons for abandoning the plans were (1) poor communication between surgeon and engineer, (2) poor appreciation for condyle placement on preoperative scans, (3) soft-tissue impedance to bony movement, (4) rapid tumor progression, (5) poor preoperative assessment of anatomy.Conclusion:Virtual surgical planning is a useful tool for craniofacial surgery but has inherent issues that the surgeon must be aware of. With time and experience, these surgical plans can be used as powerful adjuvants to good clinical judgement.

Gradual bone transfer for the correction of the pubic diastasis using the Ilizarov technique in closure of bladder and cloacal exstrophy.

In the patient of the cloacal exstrophy, cloaca with local abdominal wall is disrupted and exposed inner surface of the bladder needs early closure. Pelvic osteotomies are required for severe cases whose bladder cannot be closed by the suture of soft tissue only. We developed a technique involving the gradual positioning of bone fragments using a light, Ilizarov external fixator. The usefulness of the technique was assessed. We enrolled 3 patients with cloacal exstrophy and 1 with bladder exstrophy as a gradual transfer group and 6 patients who were treated by other osteotomies as a control group. The patients aged 6.7-8.4months at the time of surgery were followed up for 4.0-8.6 years. An external fixator with carbon fiber half-rings was placed to internally rotate and anteriorly move the distal bone fragment over 2 weeks. Then, the bladder was closed. Computed tomography (CT) images were used to assess the pelvis form. Wound dehiscence and number of the surgeries after the osteotomies are also compared between the two groups. CT analysis of correction of the pelvic deformity achieved more and less decreasing its volumetric capacity in the gradual transfer group. No patients had wound dehiscence after the primary closure with pelvic osteotomy in the gradual transfer group but all had them in the control group. The mean number of the surgeries after the osteotomies were 2.25 in the gradual transfer group whereas 5.5 in the control group. Sufficient closure of the abdominal wall and bladder was achieved in all cases in the gradual transfer group. The correction of pelvic bones were more with less decreasing of their pelvic capacities, no patients had wound dehiscence after the closure and there was an effect to decrease the number of the surgeries after the treatment by this method.

* Tissue Engineering Strategies to Improve Osteogenesis in the Juvenile Swine Alveolar Cleft Model.

Alveolar (gumline) clefts are the most common congenital bone defect in humans, affecting 1 in 700 live births. Treatment to repair these bony defects relies on autologous, cancellous bone transfer from the iliac crest. This harvest requires a second surgical site with increased surgical time associated with potential complications, while providing only limited cancellous bone. Improvements in treatment protocols that avoid these limitations would be beneficial to patients with clefts and other craniofacial bone defects. There have been steady advances in tissue-engineered (TE) solutions for long-bone defects and adult patients, but advances for the pediatric craniofacial skeleton have been slower to emerge. This study utilizes a previously established juvenile swine model with a surgically created, critical size alveolar defect to test the efficacy of umbilical cord (UC) mesenchymal stem cells (MSCs) treatments on nano-microfiber scaffolds. At 1 month after implanting our TE construct, mineralized tissue in the surgical gap was quantified through computed tomography (CT), and histology, and excised tissue was subjected to mechanical testing. Both undifferentiated and predifferentiated (toward an osteogenic lineage) UC MSCs generated bone within the cleft on a scale comparable to iliac crest cancellous bone, as evidenced by histology and CT scans. All of the pigs treated with scaffold/stem cell combinations had mineralized tissue within the defect, although without filling the entire defect. Several of the experimental animals exhibited poor and/or asymmetric maxillary growth 1 month after the initial surgery, especially if the surgical defect was located on the smaller side of an already asymmetric pig. Our results demonstrate that tissue engineering approaches using UC MSCs are a promising alternative for repair of the alveolar cleft. Data in the pig model demonstrate that implanted scaffolds are at least as good as the current gold standard treatment based on harvesting cancellous bone from the iliac crest, regardless of whether the cells seeded on the scaffold are precommitted to an osteogenic fate.

Trends in Surgical Management of Shoulder Instability.

Background:Optimal surgical management of anterior shoulder instability remains controversial. There is a need to assess the most recent trends for primary and revision shoulder stabilization surgery using a national database significantly larger than those previously utilized.Hypothesis:Most shoulder stabilization procedures are performed arthroscopically. Examining revision procedures, we hypothesized that open procedures would result in decreased revision stabilizations compared with arthroscopic procedures and that most revision procedures would be open Bankart or bone transfer procedures regardless of the index procedure technique.Study Design:Descriptive epidemiology study.Methods:The MarketScan Database was searched using International Classification of Diseases–Ninth Revision (ICD-9) and Current Procedural Terminology (CPT) codes to identify patients who underwent any shoulder stabilization procedure between 2008 and 2012. Regression analysis was used to evaluate trends between patient groups. The Cochran-Armitage trend test was used to identify differences in trends seen yearly. Odds ratios (ORs) were calculated to compare the likelihood of undergoing a revision stabilization procedure.Results:A total of 66,564 shoulder stabilization procedures were identified from 2008 through 2012: 60,248 arthroscopic stabilization procedures (90.5%) and 6316 open stabilization procedures (9.5%), including 1623 bone block procedures. Arthroscopic stabilization procedures increased in total number and percentage of all procedures in each year of the study. Bone block procedures increased in number each year, although other open procedures decreased during the study period. Males underwent more stabilization procedures, while patients between the ages of 10 and 19 years were most likely to undergo any procedure. Patients who underwent bone block stabilization were significantly less likely to undergo a second stabilization procedure during the study period when compared with open Bankart repair (OR, 0.582; 95% CI, 0.405-0.836; P < .05) and arthroscopic Bankart repair (OR, 0.587; 95% CI, 0.418-0.824; P < .05). No statistically significant difference in revision stabilization was seen when comparing arthroscopic versus open Bankart repair (OR, 0.934; 95% CI, 0.863-1.139).Conclusion:Although the number of arthroscopic shoulder stabilization surgeries continues to increase, our data show a consistent increase, not seen in prior studies, in the number of bone block procedures. Contrary to some studies, there was no significant difference in the likelihood of a second procedure between patients initially undergoing arthroscopic compared with open Bankart repair.

Open shoulder stabilization: current trends and 1-year postoperative complications

BackgroundShoulder instability is commonly treated by arthroscopic stabilization. However, open stabilization procedures remain important in management of complex instability. Despite continued use of these procedures, the relative frequency of related complications remains poorly described. This study investigates current trends in open shoulder stabilization and characterizes major postoperative complications.MethodsPearlDiver, a national insurance database of orthopedic patients, was used to identify open shoulder stabilization procedures from 2007 to 2010. Current Procedural Terminology codes for 4 procedures—Bankart repair, coracoid transfer, and anterior and posterior glenoid bone grafting—were used to track procedural trends. The 1-year postoperative complications were identified and categorized into 5 groups: dislocation treated with closed reduction, closed manipulation under anesthesia, reoperation with arthroscopy, reoperation with open surgery, and others. χ2 analysis determined statistical significance.ResultsThere were 2678 open shoulder stabilization procedures performed, with a 1-year complication rate of 12.3%. Relative proportion of open Bankart repairs decreased (82.5% to 69.8%), whereas proportion of coracoid transfers increased (7.7% to 19%). Posterior glenoid bone grafting had the highest complication rate (20.7%). Rate of total complications was 9.8% in patients 10-24 years, 13.6% in patients 25-54 years, and 25.9% in patients >55 years.ConclusionsBased on our patient database sample, a significant decline in the relative use of open Bankart repair was observed. Our analysis indicates that the use of bone transfer procedures was correlated with significantly higher reoperation rates than open Bankart repair, particularly in the older patient cohort. Further studies comparing open stabilization procedures with contemporary arthroscopic techniques are indicated.

Surgeon-Based 3D Printing for Microvascular Bone Flaps

Background Three-dimensional (3D) printing has developed as a revolutionary technology with the capacity to design accurate physical models in preoperative planning. We present our experience in surgeon-based design of 3D models, using home 3D software and printing technology for use as an adjunct in vascularized bone transfer. Methods Home 3D printing techniques were used in the design and execution of vascularized bone flap transfers to the upper extremity. Open source imaging software was used to convert preoperative computed tomography scans and create 3D models. These were printed in the surgeon's office as 3D models for the planned reconstruction. Vascularized bone flaps were designed intraoperatively based on the 3D printed models. Results Three-dimensional models were created for intraoperative use in vascularized bone flaps, including (1) medial femoral trochlea (MFT) flap for scaphoid avascular necrosis and nonunion, (2) MFT flap for lunate avascular necrosis and nonunion, (3) medial femoral condyle (MFC) flap for wrist arthrodesis, and (4) free fibula osteocutaneous flap for distal radius septic nonunion. Templates based on the 3D models allowed for the precise and rapid contouring of well-vascularized bone flaps in situ, prior to ligating the donor pedicle. Conclusions Surgeon-based 3D printing is a feasible, innovative technology that allows for the precise and rapid contouring of models that can be created in various configurations for pre- and intraoperative planning. The technology is easy to use, convenient, and highly economical as compared with traditional send-out manufacturing. Surgeon-based 3D printing is a useful adjunct in vascularized bone transfer. Level of Evidence Level IV.

Latarjet procedure combined with inferior capsular shift for recurrent anterior shoulder instability in patients with hyperlaxity

Background Recurrent unidirectional anterior shoulder instability is a common disease especially among professional athletes. Open latarjet operation is a common surgical procedure used for the treatment of this condition, especially in cases associated with a high instability severity index score (ISIS) including cases with humeral bone loss (Hill–Sachs lesion) or anteroinferior glenoid bone loss. Persistent apprehension or recurrence of instability after the latarjet procedure might be attributed to associated anterior capsular laxity that was not addressed in the primary surgery. Hypothesis Combining coracoid bone transfer with capsulorraphy and capsular shift, and maintaining the sling effect of the conjoint tendon might be beneficial in patients with recurrent anterior shoulder instability associated with anterior capsular redundancy (ACR). Patients and methods A total of 30 patients with recurrent unilateral symptomatic involuntary unidirectional anterior shoulder instability were studied. All patients had an evidence of joint hyperlaxity with a Beighton score ranging from 6 to 9, mean 7.63±1.07. Evidence of ACR (Sulcus sign) was present. ISIS was superior than or equal to 4. In this study, the ISIS ranged from 6 to 10, with a mean of 8.38 and SD of 0.89. All of the patients underwent an open Latarjet procedure with superior capsular shift and capsulorraphy using Ethibond N:5 sutures wrapped around the serrations of the screw. All the patients were interrogated, examined clinically, and scored according to the Constant–Murley scoring system. Results The most important finding of this study is the marked improvement in the symptoms of instability as well as the level of function after surgery. There was a highly statistically significant difference between the preoperative and the postoperative Constant–Murley score. Conclusion In anterior shoulder instability with ACR, the Latarjet procedure associated with an anteroinferior capsulorrhaphy is an effective alternative to arthroscopic or open capsular shift and should help in reducing postoperative apprehension. The sooner the reconstructive surgery is performed, the better the functional outcome.

Colgajos libres en cirugía de la mano: nuestra experiencia en 49 casos

ObjectiveTo review the free flaps most frequently used in hand reconstruction and evaluate their results, advantages and complications. Material and methodsA total of 49 patients, with a mean age of 41 years old (25-57), underwent different microsurgical transfers for hand reconstruction between 2011 and 2014. The type of transfer performed depended on the location of the defects: a) 29 free flaps for finger reconstruction, b) 11 free transfers for hand coverage (dorsal coverage and first web space: 5 patients; volar hand defects: 2 patients; coverage of both regions of the hand at the same time: 4 patients, and c) 9 free vascularised bone transfers for non-unions (7 cases) and joint reconstructions (2 cases) in hand and fingers.The results were evaluated in terms of flap survival, complications, secondary procedures, and patient satisfaction. In addition, when fingertip reconstruction was involved, the two-point discrimination test was also assessed. ResultsThe survival rate was 100%. A secondary tenolysis was necessary in 5 cases, and another patient underwent two more surgeries to split the fingers (lateral arm used for volar coverage of the fingers). Good aesthetic and functional results and a high level of satisfaction were obtained. The means 2-PD in fingertip reconstruction was 9.1mm (8-11). ConclusionsIn our opinion, the use of free flaps for hand surgery reconstruction provides better outcomes, without sacrificing, in contrast to local flaps, other areas of the hand, with good aesthetic and functional results, as well as low donor site morbidity.

Microsurgical MTP

Introduction: In the treatment of radial dysplasia or radial club hand the surgical methods are changing from centralization to microsurgical bone and joint transfer to stabilize the hand with a growing autogenous bone. Materials: Thirty-four radial club hand extremities have been treated with a microsurgical metatarsal bone and joint transfer. Patients’ age has been optimally between 2 and 5 years at the time of operation. Methods: The operation is done in 2 stages. (1) Preoperative distraction and alignment of the hand using the speed of 0.5 mm/day. (2) After about 6 to 7 weeks, a microvascular transfer of second metatarsophalangeal (MTP) joint and metatarsal bone has been done. Results and Conclusions: In a group of 19 patients with long-term follow-up, the growth of the forearm has occurred well without additional growth disturbance. Also, the wrist alignment has been adequate in long term or only 29 degrees of radial deviation has returned. These patients gain best with the new mobile wrist. The wrist motion will be typically from 20° extension to 80° flexion. With the growing experience, the results have got even better and the technique has become refined.

Morphological And Topographical Anatomy of Nutrient Foramina In Human Upper Limb Long Bones And Their Surgical Importance

Objectives: To study the morphology and topography of nutrient foramina and to determine the foraminal index of the upper limb longbones. Materials and Methods: The study comprised of 243 upper limb long bones, which included humeri, radii, and ulnae. The nutrientforamina were identified macroscopically in all the bones and an elastic rubber band was applied around these foramina. The bones werephotographed with the digital camera and foramen index was calculated. Each bone was divided into five equal parts and was analyzedtopographically. Results: From our observations, 93.8% of the humeri had single nutrient foramen. The double foramen was observed in3.1% of the cases and the foramen was found absent in 3.1% of the humeri. In case of radius, 94.4% had single foramen, 1.4% haddouble foramen, and in 4.2% of the cases, it was absent. With respect to ulna, all the 75 bones had single foramen. The mean foraminalindex was 57.6 for the humerus, 34.4 for both the ulna and radius. The majority (70%) of the foramina in humerus were located at the 3/5 th part, 83.6% of the ulnae foramina at the 2/5th part and 87.7% of the radii foramina at the 2/5th part. Conclusions: The study has providedadditional information on the morphology and topography of nutrient foramina in upper limb long bones. The knowledge about theseforamina is useful in certain surgical procedures to preserve the circulation. As microvascular bone transfer is becoming more popular,a convention for the anatomical description of these foramina is important.