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Background: Recently, arthroscopic double-button Latarjet (AL) has provided an alternative to conventional open Latarjet (OL) in the treatment of anterior shoulder instability with glenoid bone loss. Therefore, theoretically, the faster fusion is obtained, the sooner return to sports under safe conditions can occur. The emerging flexible fixation of the bone block has clearly offered a new approach to achieve bone fusion. However, the period required to achieve this goal remains controversial. Purpose/Hypothesis: The purpose was to compare computed tomography (CT) scan results of AL and OL in the early postoperative period. It was hypothesized that the bone block fusion with AL would require a longer time than that with OL. Study Design: Cohort study; Level of evidence, 3. Methods: In a retrospective 1-year study, the authors compared 17 primary double-button AL to 22 primary 2-screw OL procedures indicated for anterior shoulder instability in patients with an Index Severity Instability Score >3 points. These patients were reviewed with a CT scan at 1 day, 3 months, and 6 months postoperatively. The characteristics for the 2 groups were comparable. CT scans aimed to analyze graft position, bone contact area with the scapula, and fusion at 3 and 6 months. Clinical assessment was based on the Walch-Duplay and Rowe scores. Results: The mean preoperative Index Severity Instability Score was 5.3 ± 1.9 points, with a mean anterior glenoid bone loss of 9.1% ± 4.6%. At 3 months, the rates of fusion were 41% and 100% for the AL and OL groups, respectively ( P < .001). This rate increased to 70% in the AL group at 6 months ( P = .006). In the axial and sagittal planes, there was no difference in graft position between the AL group and the OL group. The bone block was longer and there was a more extensive bone contact area in the OL group (AL, 131 mm2 vs OL, 223 mm2; P < .001). At 6 months of follow-up, no significant difference in clinical scores was noted between the groups: Walch-Duplay score, 93.0 ± 10.9 points versus 91.8 ± 12.5 points ( P = .867); and Rowe score, 99.0 ± 2.2 points versus 95.0 ± 8.4 points ( P = .307) for the AL and OL groups, respectively. Conclusion: AL required more time to achieve bone block fusion than OL. This finding should be taken into account when considering this procedure for patients in a hurry to return to sports involving the shoulder.

The primate skull hosts a unique combination of anatomical features among mammals, such as a short face, wide orbits, and big braincase. Together with a trend to fuse bones in late development, these features define the anatomical organization of the skull of primates—which bones articulate to each other and the pattern this creates. Here, I quantified the anatomical organization of the skull of 17 primates and 15 non-primate mammals using anatomical network analysis to assess how the skulls of primates have diverged from those of other mammals, and whether their anatomical differences coevolved with brain size. Results show that primates have a greater anatomical integration of their skulls and a greater disparity among bones than other non-primate mammals. Brain size seems to contribute in part to this difference, but its true effect could not be conclusively proven. This supports the hypothesis that primates have a distinct anatomical organization of the skull, but whether this is related to their larger brains remains an open question., BE-A has received financial support through the Postdoctoral Junior Leader Fellowship Programme from “la Caixa” Banking Foundation (LCF/BQ/LI18/11630002). Open Access funding provided thanks to the CRUE-CSIC agreement with Springer Nature.

To explore which TLIF techniques are advantageous in reducing the risk of complications and conducive to bone fusion under the vibration. The L1-L5 finite element lumbar model was modified to simulate three different TLIF techniques (a unilateral standard cage, a crescent-shaped cage, and bilateral standard cages). The results showed that the crescent-shaped cage may reduce the risk of subsidence and provide a more stable and suitable environment for vertebral cell growth under the vibration compared to the other TLIF techniques. Unilateral cage may increase the risk of adjacent segment disease and cage failure including fatigue failure under vibration.

The study of contact biomechanics of the wrist is a challenge. This is partly due to the relatively small size of the joint as well as the lack of space in the radiocarpal joint which makes the delivery of investigative materials such as pressure sensitive film without causing artifact, difficult. Fortunately, a number of authors have studied the intact wrist, the scapholunate ligament injured wrist, the proximal row carpectomy and the scaphoid excision, four bone fusion. Despite some contrasting findings, there are some general concepts that we understand about wrist mechanics.

Objective To investigate the bone fusion and clinical effect of laminoplasty combined with ARCH plate fixation in the treatment of lumbar intraspinal tumors. Methods This was a clinical study. From June 2017 to January 2019, 24 patients (seven males and 17 females, average age 40 ± 16 years) with lumbar intraspinal tumors underwent laminoplasty combined with ARCH plate fixation in our hospital. The bone fusion was evaluated by X‐ray and computed tomography (CT) scans that were taken 15.2 ± 2.17 months postoperatively. Each segment showed a bone bridge on one side, which was classified as “segmental partial fusion.” Each segment showed bilateral bone bridges, which were classified as “segmental complete fusion”. When all segments of the patient showed bilateral bone bridging so that the replanted lamina and the host lamina became a unit on the CT scan, it was defined as “complete fusion”. In addition, the operation time and blood loss were recorded. Fisher's exact test was used to analyze the potential influencing factors of bone healing, including age (≤40 years vs >40 years), gender, number of operated levels (single vs two). Paired t‐test was used to analyze pre‐ and postoperative Oswestry Disability Index (ODI) scale and low back and leg pain visual analog scale (VAS). Results A total of 33 segments of laminoplasty were successfully performed in 24 patients. The average operation time was 128 ± 18 minutes. The average blood loss was 110 ± 19 mL. All patients were followed up at least 12 months after operation (average, 15.2 ± 2.17 months). At the final follow‐up, according to the definition of this study, the proportion of “segmental partial fusion” and “segmental complete fusion” were 30.3% (10/33) and 69.7% (23/33), respectively. And the proportion of patients with “complete fusion” was 70.8% (17/24). Age, gender, and number of operated levels were not associated with the fusion (P = 1.0, 0.37, and 0.06, respectively). ODI and VAS were much better at 1 month after operation and the final follow‐up than those before the operation (P, Laminoplasty combined with ARCH plate

The degree of sutural closure between bones generally allows for the classification of skeleton maturity in tetrapods. In mammals, the sutural closure of skull bones was previously used as proxy to evaluate the ontogenetic stage of single individuals. However, due to temporal variation, this process can be only applied among mammalian subclades, but not for all mammals in general. In contrast, the process of sutural closures in bird skulls could be a more reliable ontogenetic proxy for this clade as adult birds commonly show a generally high degree of bone fusion. To test this, we studied the process of sutural closure in ontogenetic series of 18 extant bird species regarding the presence of an ontogenetic signal and compared the results with changes in skull size and proportions. Univariate analyses indicate that bone fusion happens faster in altricial than in precocial birds. However, the use of PCoA and multivariate regressions reveal that the skull bone fusion follows a common pattern among birds and thus can be used as proxy to identify different ontogenetic stages. In general, the process of sutural closure spreads from posterior to anterior and from ventral to dorsal. In contrast, skull measurements reflect rather interspecific allometry than ontogeny. The used of bone fusion as proxy will help to better identify and compare different stages of maturation in birds, including historical material from osteological collections.

Introduction Both bone morphogenetic protein 2 (BMP‐2) and teriparatide (parathyroid hormone [PTH] 1‐34) are used to enhance bone healing. There is still no established opinion regarding the optimum dose and administration method. We investigated the optimal administration method for the combination of BMP‐2 and PTH 1‐34 in a rat spinal fusion model. Methods Group I was implanted with a control carrier. Groups II, III, and IV were implanted with a carrier containing 3 μg of recombinant human BMP‐2 (rhBMP‐2). In addition, following implantation, PTH 1‐34 injections were administered to Group III thrice a week (total, 180 μg/kg/week) and Group IV six times a week (total, 180 μg/kg/week). The rats were euthanized after 8 weeks, and their spines were explanted; assessed by manual palpation, radiographs, and high‐resolution micro‐computed tomography (micro‐CT); and subjected to histological analysis. Serum markers of bone metabolism were also analyzed. Results Manual palpation tests showed that the fusion rates in Groups III and IV were considerably higher than those in Group I. They also had higher radiographic scores than Group I and II. Micro‐CT analysis revealed Tb.Th in the Group IV had higher values than that in the Group I, II, III with significant differences and Tb.Sp in the Group IV had lower values than that in the Group I, II, III with significant differences. Serum marker analysis revealed that Group IV had higher osteocalcin and lower tartrate‐resistant acid phosphatase‐5b than Group III. Histological analysis indicated that Group IV had enhanced trabecular bone structure. Conclusions Frequent administration of PTH may be better in making thicker and strengthening the trabecular bone structure in newly formed bone in the rat spinal fusion model using insufficient BMP‐2., The current study investigated the optimal administration method for the combination of BMP‐2 and PTH 1‐34 in a rat spinal fusion model. Frequent administration of PTH may be better in making thicker and strengthening the trabecular bone structure in newly formed bone in the rat spinal fusion model using insufficient BMP‐2

Background: Back pain is a common chief complaint within the United States and is caused by a multitude of etiologies. There are many different treatment modalities for back pain, with a frequent option being spinal fusion procedures. The success of spinal fusion greatly depends on instrumentation, construct design, and bone grafts used in surgery. Bone allografts are important for both structural integrity and providing a scaffold for bone fusion to occur. Method: Searches were performed using terms “allografts” and “bone” as well as product names in peer reviewed literature Pubmed, Google Scholar, FDA-510k approvals, and clinicaltrials.gov. Results: This study is a review of allografts and focuses on currently available products and their success in both animal and clinical studies. Conclusion: Bone grafts used in surgery are generally categorized into 3 main types: autogenous (from patient9s own body), allograft (from cadaveric or living donor), and synthetic. This paper focuses on allografts and provides an overview on the different subtypes with an emphasis on recent product development and uses in spinal fusion surgery.

Background Destruction of the spine is a huge complication of infectious spondylitis and surgical intervention is required. However, vertebral defect is a major problem after surgical intervention and numerous methods have been researched to solve this problem. There are known methods that use variously designed, patient-customized 3-dimensional (3D)-printed implants in various medical fields. The use of 3D-printed implants has also been attempted in treating defects in the spine. We present a case of failure of expandable titanium cage fusion after infection, treated using a 3D-printed implant. Case Description The patient had undergone reconstruction surgery with expandable titanium cage due to infectious spondylitis and needed reoperation owing to recurrence of infections and failure of bone fusion. The problem we faced in this operation was a large vertebral defect, for which we used a 3D-printed implant. After 3 years of follow-up, the implant and bone fusion were intact and infection or mechanical complications were not seen. Conclusions A 3D-printed implant could be an acceptable and alternative treatment option for replacing a large vertebral defect.

Interbody fusion surgery is often used to settle matters such as degenerative disc disease or disc herniation in clinical orthopedics. Considering the deficiencies of the current treatment methods, we developed an interbody fusion cage made of calcium silicate (CS)/polyetheretherketone (PEEK) and hoped that the bioactive cage could exhibit great fusion ability and maintain stable mechanical function. In the goat model of cervical interbody fusion, the CS/PEEK cage showed stronger interbody fusion at 12 and 26 weeks compared with pure PEEK cage based on the X-ray analysis. The micro-CT scanning and analysis indicated that the CS/PEEK cage induced more new bone ingrowth than the PEEK cage and led to nearly complete interbody fusion at 26 weeks. Moreover, the CS/PEEK group showed excellent mechanical stability and stiffness as evaluated by the spine kinematic assay at the time points. The histological assessment showed the rapid osseointegration and mineralized bone formation around the CS/PEEK cage. This study confirmed that the bioactive CS/PEEK cage is capable of inducing highly effective bone fusion and has high potential to be used in the clinics of spine surgery.

Laminectomy followed by posterolateral fusion (PLF) is a standard procedure for thoracic and thoracolumbar (TL) compressive lesions. However, it is challenging to apply sufficient bone chips as the spinal cord is exposed after the laminectomy. Therefore, we performed posterior thoracic cage interbody fusion (PTCIF) as an alternative technique. A total of 25 patients operated with PTCIF technique between 2012 and 2017 were analyzed in our study. These patients required a posterior decompression and fusion in thoracic and TL spine for traumatic injury or degenerative disease. To evaluate the outcome of bone fusion, computed tomography (CT) was performed at least 3–4 months after PTCIF. The surgery was performed through insertion of screws and cages packed with autologous bone chips in a similar fashion to the posterior lumbar interbody fusion technique. Among 25 patients who underwent PTCIF, 22 patients were involved in our study. The mean age and follow-up interval were 58.6 (28–78) years and 27.1 (6–60) months, respectively. Traumatic spinal injury was diagnosed in 6 patients and degenerative disease in 16 patients. One level PTCIF was performed in 12 patients and 2 levels in 8 patients. After the operation, patients with degenerative disease showed neurological improvement, and trauma cases showed no neurological aggravation. Successful bone fusion was confirmed on CT for all patients. PTCIF is an effective treatment thereby we suggest this approach to be considered as an alternative procedure to decompression and fusion surgery in the thoracic and TL spine.

Purpose: To compare the bone fusion of freeze-dried allograft alone versus freeze-dried allograft combined autograft in spinal instrumentation due to spondylodiscitis. Methods: A randomized prospective trial of patients with spondylodiscitis treated with surgical debridement and spinal fixation with freeze-dried bone allograft and autograft (Group 1) or freeze-dried bone allograft alone (Group 2) was performed. Patient follow-up was assessed with a CT-scan for bone fusion; consecutive serum inflammatory marker detection (C-reactive protein, [CRP], and erythrocyte sedimentation rate, [ESR]) and clinical assessment (pain, functional disability, and spinal cord injury recovery) were other outcome parameters. The primary outcome was the grade of bone allograft integration with the scale of Tan (which ranges from 1 to 4, with lower scores indicating a better fusion rate) at 1 year after surgery. Results: A total of 20 patients were evaluated, 13 (65%) men and 7 (35%) women with a mean age of 47.2 (±14.3) years. Homogeneous distribution of demographic data was observed. A similar satisfactory bone graft fusion grade was observed in both graft groups at 1 year after surgery (p = 1.0000). Serum inflammatory markers gradually decreased in both groups after surgical intervention (CRP, p < 0.001; ESR, p < 0.01). At one-year follow-up, gradual improvement of pain, functional disability, and neurological spinal injury recovery in both graft groups were achieved. Conclusion: Freeze-dried allograft alone could be a therapeutic option for spinal fixation surgery due to spondylodiscitis since it achieves a satisfactory graft fusion rate and clinical improvement. Level of Evidence: Level 1. Treatment register: NCT03265561

AIM To evaluate the clinical results of patients who underwent unilateral dynamic rod stabilization after unilateral facet joint excision during spinal surgery. MATERIAL AND METHODS Twenty patients who were diagnosed with degenerative spinal disease or spinal tumor, who were operated on using a unilateral approach, who underwent facet joint resection, and who were stabilized with a unilateral dynamic rod were examined. Visual analog scale (VAS) and Oswestry disability index (ODI) scores were used to clinically evaluate the cases during the preoperative and postoperative periods. Radiological examinations for sagittal alignment, segmental angle, and bone fusion were also conducted. RESULTS The mean preoperative VAS and ODI scores were 7.6 and 71.7, respectively, and the 12 th postoperative month scores were 1.1 and 12.8, respectively. The mean segmental angle measurements were 22.1° in the preoperative period and 21.6° at the postoperative 12 th month. No deterioration in sagittal alignment and no bone fusion were observed. CONCLUSION We can protect segmental movements and provide sufficient stability by applying unilateral dynamic rod stabilization after unilateral facetectomy. In addition, applying screws to one side can reduce operation time and cost as well as the possibility of complications.

Background There have been several reports of instrumentation failure after three-column resections such as total en bloc spondylectomy (TES) for spinal tumors; however, clinical outcomes of revision surgery for instrumentation failure after TES are seldom reported. Therefore, this study assessed the clinical outcomes of revision surgery for instrumentation failure after TES. Methods This study employed a retrospective case series in a single center and included 61 patients with spinal tumors who underwent TES between 2010 and 2015 and were followed up for > 2 years. Instrumentation failure rate, back pain, neurological deterioration, ambulatory status, operation time, blood loss, complications, bone fusion after revision surgery, and re-instrumentation failure were assessed. Data were collected on back pain, neurological deterioration, ambulatory status, and management for patients with instrumentation failure, and we documented radiological bone fusion and re-instrumentation failure in cases followed up for > 2 years after revision surgery. Results Of the 61 patients, 26 (42.6%) experienced instrumentation failure at an average of 32 (range, 11–92) months after TES. Of these, 23 underwent revision surgery. The average operation time and intraoperative blood loss were 204 min and 97 ml, respectively. Including the six patients who were unable to walk after instrumentation failure, all patients were able to walk after revision surgery. Perioperative complications of reoperation were surgical site infection (n = 2) and delayed wound healing (n = 1). At the final follow-up, bone fusion was observed in all patients. No re-instrumentation failure was recorded. Conclusion Bone fusion was achieved by revision surgery using the posterior approach alone.

Pedicle subtraction osteotomy (PSO) is an invasive surgical technique allowing the restoration of a well-balanced sagittal profile, however, the risks of pseudarthrosis and instrumentation breakage are still high. Literature studied primary stability and posterior instrumentation loads, neglecting the load shared by the anterior column, which is fundamental to promote fusion early after surgery. The study aimed at quantifying the load-sharing occurring after PSO procedure across the ventral spinal structures and the posterior instrumentation, as affected by simple bilateral fixation alone, with interbody cages adjacent to PSO level and supplementary accessory rods. Lumbar spine segments were loaded in vitro under flexion–extension, lateral bending, and torsion using an established spine tester. Digital image correlation (DIC) and strain-gauge (SG) analyses measured, respectively, the full-field strain distribution on the ventral surface of the spine and the local strain on posterior primary rods. Ventral strains considerably decreased following PSO and instrumentation, confirming the effectiveness of posterior load-sharing. Supplemental accessory rods considerably reduced the posterior rod strains only with interbody cages, but the ventral strains were unaffected: this indicates that the load transfer across the osteotomy could be promoted, thus explaining the higher fusion rate with decreased rod fracture risk reported in clinical literature.

RESUMEN La signatia es una rara malformación congénita en la que se encuentra una fusión ósea del maxilar con la mandíbula. Puede ser unilateral o completa y se caracteriza por la incapacidad de abrir la boca del recién nacido. Esta puede clasificarse de acuerdo con su presentación clínica. Las complicaciones de esta anomalía pueden ser muy graves: incompatibilidad con la vida, incapacidad de proteger la vía aérea, dificultades para la alimentación, así como alteraciones en el crecimiento. Se han referido casos con distintos abordajes, por lo que el protocolo terapéutico-quirúrgico estará dado según las particularidades de cada individuo. En el presente caso se hace referencia de un lactante femenino que se presentó con fusión del complejo cigomático-maxilar con la mandíbula unilateral, el abordaje y seguimiento. ABSTRACT Syngnathia is a rare congenital malformation in which a fusion of the mandible with the maxilla is found, it can be unilateral or complete and is characterized by the inability to open the mouth of the newborn, this can be classified according to its clinical presentation. The complications of this anomaly can be inability to protect the airway, difficulties for feeding, as well as alterations in growth. There have referred cases with different approaches, thus the therapeutic-surgical protocol will be given according to the particularities of each individual. In the present case reference is made of female infant with unilateral maxillo-mandibular-zygomatic fusion, diagnosis and follow-up.

BackgroundOccipitocervical and atlantoaxial instability in the pediatric population is a rare and challenging condition to treat. Variable surgical techniques have been employed to achieve fusion. The study aimed to assess bony fusion with rigid craniocervical fixation using an allograft bone block to serve as scaffold for bony fusion.MethodsThis is a single center case series from a tertiary referral neurosurgical center. The series includes 12 consecutive pediatric patients with rigid craniocervical fusion between 2006 and 2014. The primary outcome was bony fusion as assessed by computed tomography and flexion-extension radiographs. The authors did not receive external funding for this study.ResultsTwelve patients (age 1–15 years) were operated with a median imaging follow-up time of 22 months (range 6–69 m). A modified Gallie fusion technique with a tightly wired allograft bone block was used in 10 of 13 procedures. One patient underwent re-fixation due to screw breakage. Eleven out of 13 procedures resulted in a stable construct with bony fusion. All 10 patients operated with the modified Gallie fusion technique with sublaminar wiring of allograft bone block had bony fusion. No post-operative complications of the posterior fixation procedure were noted.ConclusionsThe modified Gallie fusion technique with allograft bone block without post-operative immobilization achieved excellent fusion. We conclude there is no need to use autograft or BMPs in craniocervical fusion in the pediatric population, which avoids related donor-site morbidity.Level of evidenceLevel IV—case series; therapeutic.

BACKGROUND Anterior cervical discectomy and fusion (ACDF) and anterior cervical corpectomy and fusion (ACCF) are effective treatments for cervical spondylotic myelopathy (CSM), but it is unclear which is better. In this study, we compared the biomechanical properties of 2-level ACDF and 1-level ACCF. MATERIAL AND METHODS An intact C3-C7 cervical spine model was developed and validated, then ACDF and ACCF simulation models were developed. We imposed 1.0 Nm moments and displacement-controlled loading on the C3 superior endplate. The range of motions (ROMs) of surgical and adjacent segments and von Mises stresses on endplates, fixation systems, bone-screw interfaces, and bone grafts were recorded. RESULTS ACDF and ACCF significantly reduced the surgical segmental ROMs to the same extent. ACCF induced much lower stress peaks in the fixation system and bone-screw interfaces and higher stress peaks on the bone graft. ACDF induced much lower stress peaks on the C4 inferior endplate and equivalent stress on the C6 superior endplate. There was no difference in the ROMs of surgical and adjacent segments and the intradiscal stress of adjacent levels between ACDF and ACCF. CONCLUSIONS Both ACDF and ACCF can provide satisfactory spinal stability. ACDF may be beneficial for subsidence resistance due to the lower stress peaks on the endplate. The ACCF may perform better in long-term stability and bone fusion owing to the lower stress peaks in the fixation system and bone-screw interfaces, and higher stress peaks in the bone graft.

Exfoliated carbon nanofibers (ExCNFs) are expected to serve as excellent scaffolds for promoting and guiding bone-tissue regeneration. We aimed to enhance the effects of ExCNFs using bone morphogenetic proteins (BMPs) and examined their feasibility and safety in clinical applications using a rat spinal fusion model. Group I (n = 15) animals were implanted with the control carrier; Group II (n = 16) animals were implanted with carrier containing 1 μg ExCNFs; Group III (n = 16) animals were implanted with carrier containing 1 μg recombinant human (rh) BMP-2; and Group IV (n = 17) animals were implanted with carrier containing 1 μg rhBMP-2 and 1 μg ExCNFs. The rats were euthanized after 4 or 8 weeks and their spines were explanted and assessed by manual palpation, radiographs, and high-resolution microcomputerized tomography (micro-CT); the spines were also subjected to histological analysis. The fusion rates in Group IV (25.0%: 4-week, 45.5%: 8-week) were considerably higher than in Groups I (0%: 4-week, 0%: 8-week), II (0%: 4-week, 15.0%: 8-week), and III (16.7%: 4-week, 30.0%: 8-week). These results demonstrated the enhancement of ExCNF bone fusion effects by BMP in a rat spinal fusion model. Our results suggest that the enhancement of ExCNFs effects by BMP makes this combination a possible attractive therapy for spinal fusion surgeries. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:2892-2900, 2018.

Background After interbody cage implantation for posterior or transforaminal lumbar interbody fusion (PLIF or TLIF) spinal fusion surgery, pseudoarthrosis can develop. However, there are several shortcomings of the posterior approach if the interbody cage requires removal. Therefore, an anterior approach may be useful. Methods We reviewed salvage anterior lumbar interbody fusion (ALIF) for pseudoarthrosis after PLIF or TLIF performed from December 2006 to December 2016. A total of 10 patients met inclusion criteria for the study. All preoperative and postoperative clinical and radiologic parameters were recorded. Results Salvage ALIF resulted in improvements in clinical and radiologic outcomes in all cases. In 9 cases, the previously inserted cage was successfully removed. In 1 case, only 1 of the 2 previously inserted cages could be removed, as the previously inserted cage exhibited a high subsidence and remained in a diagonal position in the vertebral body. No serious complications occurred in all cases. Bone fusion was successful in all cases. Conclusions ALIF is useful for salvage surgery to treat failed PLIF or TLIF. The advantages of salvage ALIF include improvements in clinical and radiologic outcomes and a low complication rate after surgery. To successfully remove a previously inserted cage, the vascular window of the anterior index level and the degree of subsidence of the cage should be well characterized through preoperative radiologic imaging.

Objective A three-dimensional reconstruction technique using the CustomBone (CB) prosthesis allows custom-made cranioplasty (CP) possessing osseointegration properties owing to its porous hydroxyapatite (HA) composition. This reconstruction technique has replaced less expensive techniques such as subcutaneously preserved autologous bone (SP). Our primary objective was to evaluate complications between CB and SP CP techniques. A secondary objective was to assess cosmetic results and osseointegration of CPs. Methods This single-center study comprised patients undergoing delayed CB or SP CP after craniectomy between 2007 and 2014. A prospective interview was conducted to collect all data, including 2-year follow-up clinical and radiologic data. Cosmetic results were assessed by a qualitative score, and osseointegration was assessed by measuring relative fusion at the CP margins. Results Of 100 patients undergoing CB or SP CP between 2007 and 2014, 92 (CB, n = 44; SP, n = 48) participated in the prospective interview. No significant difference in complication rates was observed between the 2 groups. The main complication specific to the CB group was fracture of the prosthesis observed in 20.8% patients. A higher rate of good cosmetic results was observed in the CB group (92.5% vs. 74.3%, P = 0.031). In the CB group, 51% of patients demonstrated no signs of bone fusion of the CP. Conclusions Although the CB prosthesis is associated with cosmetic advantages, the porous hydroxyapatite composition makes it fragile in the short-term and long-term, and effective osseointegration remains uncertain.

Study DesignRetrospective case series.PurposeTo examine the efficacy of platelet-rich plasma (PRP) for bone fusion in transforaminal lumbar interbody fusion (TLIF) using local bone grafting.Overview of LiteratureSeveral authors have reported the efficacy of PRP for bone union in animal models. However, the use of PRP for bone fusion in TLIF surgery has not been fully explored.MethodsTwenty patients underwent single-level TLIF surgery because of L4 spondylolisthesis. An interbody fusion cage and local bone were used in nine patients (control group) and an interbody fusion cage, local bone, and PRP were used in 11 patients (PRP group). PRP was prepared from the patients' blood samples (400 mL) immediately before surgery. The duration of bone union and postoperative bone fusion rate were assessed using plain radiography at every 3 months postoperatively and computed tomography at 12 or 24 months postoperatively, respectively. Lower back pain, leg pain, and leg numbness were evaluated using the visual analog scale preoperatively and at 3, 6, 12, and 24 months postoperatively.ResultsThe platelet count was 8.7 times higher in PRP than in blood. The bone union rate was significantly superior in the PRP group than in the control group (91% and 77%, respectively; p=0.035), whereas the average duration of bone union was not significantly different between the groups (7.7±0.74 and 10.0±2.00 months, respectively; p=0.131). There was no significant difference in lower back pain, leg pain, and leg numbness in both groups during follow-up (p>0.05).ConclusionsOur study suggests that the use of PRP in TLIF surgery increases bone fusion rate.

Porous interbody cages, manufactured using additive laser melting technology, have recently been used in lumbar fusion surgery. The major advantage of a porous cage is the presence of space inside the cage for bone ingrowth. However, the biomechanical effects of different porosities on the lumbar segment with and without bone fusion (ingrowth) are still unclear. Hence, the present study aimed to compare the biomechanical responses, including the stress and range of motion (ROM) of the lumbar L3-L4 segments with three different types of porous cages along with a posterior instrument (PI) with and without bone fusion using computer simulation. A lumbar L3-L4 segment model with a PI and porous cages was used in this study. Three different porosities, namely 12.5, 41.2, and 80.84% were used. The diameter of the pores of the porous cage was uniformly set to 0.5 mm. In addition, a traditional PEEK cage was used in this study. Two different bone statuses, with and without bone fusion (ingrowth into the pores of the porous cage and the inner space of the PEEK cage), were considered. The results indicated that although the contact pressure on the bone surface reduced, the cage stress increased with increasing cage porosity. Furthermore, cage stress and contact pressure also increased in cases with bone fusion compared with those without bone fusion. The contact pressure on the bone surface with a cage porosity of 80.8% decreased by 40% (from 943.1 to 575.5 MPa), 37.7% (from 133 to 82.9 MPa), 40.4% (from 690.8 to 412 MPa), and 34.2% (from 533 to 351.1 MPa), respectively, for flexion, extension, lateral bending, and rotation, respectively, compared with that with a cage porosity of 12.5%. The rotational ROM of the PEEK cage with bone fusion was clearly larger than those of the porous cages. Porous cages have recently become popular owing to improved manufacturing technology. This study provides scientific data on the strength and weakness of porous cages with different porosities for clinical use.

Bird skeletons exhibit remarkable modifications that allow for flight. The most distinguishable features are the fusion of the bones in the hand, feet, and pelvis into composite rigid and bony structures. However, the historical origins of these avian bone fusions remain elusive because of the rarity of transitional fossils and developmental studies on modern birds. Here, we describe an Early Cretaceous bird (120 Mya) that has fully fused alular-major metacarpals and pelvis. We discuss the manus and pelvis fusions across Paravian phylogeny and demonstrate that these features evolved independently across nonavian theropods, Enantiornithes, and Ornithuromorpha. The fusions of these bones are rare in known nonavian theropods and Early Cretaceous birds but are well established among Late Cretaceous and modern birds, revealing a complicated evolution pattern unrecognized previously. We posit that the developments of bone fusion were polymorphic close to the origin of birds, resulting in the varying degrees of fusion in Paraves. However, that development polymorphism appears to be fundamentally restricted along the line to modern birds by the Late Cretaceous, where all birds have a completely fused manus and pelvis. Such changes likely correspond to a refinement of flight capability. Alternatively, the degree of bone fusion in this primitive bird may have been related to modifications in genes or developmental paths. Future studies and fossil discoveries are required to clarify these hypotheses and pinpoint the developmental pathways involving the bone fusions in early avian evolution through to their modern pattern.

The effectiveness of subtalar arthrodesis has been well documented in treating degenerative subtalar joint disease. The arthroscopic subtalar approach for arthrodesis has also been proved to give excellent results in terms of bone fusion rates and reduction of wound-related pain and complications. To date, the main concerns about arthroscopy have regarded incision-related neurologic complications such as lesions of the tibial, fibular, and sural nerves. In this context, we present a 2-portal lateral (anterior and middle) approach to arthroscopic subtalar arthrodesis, recently documented in the literature, that provides similar excellent access to the joint with a lower risk of nerve damage.

OBJECTIVES: To evaluate the safety and efficacy of a novel bone cement-injectable cannulated pedicle screw augmented with polymethylmethacrylate in osteoporotic spinal surgery. METHODS: This study included 128 patients with osteoporosis (BMD T-score −3.2±1.9; range, −5.4 to -2.5) who underwent spinal decompression and instrumentation with a polymethylmethacrylate-augmented bone cement-injectable cannulated pedicle screw. Postoperative Visual Analogue Scale scores and the Oswestry Disability Index were compared with preoperative values. Postoperative plain radiographs and computed tomography (CT) scans were performed immediately after surgery; at 1, 3, 6, and 12 months; and annually thereafter. RESULTS: The mean follow-up time was 42.4±13.4 months (range, 23 to 71 months). A total of 418 polymethylmethacrylate-augmented bone cement-injectable cannulated pedicle screws were used. Cement extravasations were detected in 27 bone cement-injectable cannulated pedicle screws (6.46%), mainly in cases of vertebral fracture, without any clinical sequela. The postoperative low back and lower limb Visual Analogue Scale scores were significantly reduced compared with the preoperative scores (

A joint, the location between two bones, can be divided into two categories: immovable and movable. Immovable joints include skull seam by bone fusion and chimeric structure between the teeth and mandible. Once this kind of joints is injured, there is no joint transplantation available because bone or substitutes can used to repair the injury. Movable joints are further divided into amphiarthrodial and active ones. The former connects two bones by a ligament, such as the distal tibiofibular joint. Generally, there is no need to perform joint transplantation for injury to amphiarthrodial joints because their range of motion is very limited.

Arctocephalus australis y Otaria flavescens son las dos especies de otáridos que aparecen con mayor frecuencia en el registro zooarqueológico de sitios costeros de Sudamérica. La similitud en los huesos del esqueleto postcraneal en estos otáridos ha limitado la identificación específica, constituyéndose en una de las mayores dificultades encontradas para emprender estudios zooarqueológicos pormenorizados en estos animales. El objetivo de este trabajo es presentar criterios descriptivos claros que puedan ser empleados en la identificación de estas dos especies recuperadas en el registro zooarqueológico. La utilización de rasgos diagnósticos junto a otros abordajes existentes (estudios osteométricos, cronograma de fusión de huesos) permitirá investigar aspectos particulares que involucren el registro fósil de estos animales. A partir de una muestra de 24 individuos adultos actuales se revisaron los criterios propuestos previamente por otro autor y como resultado se presenta una nueva lista de 36 rasgos diagnósticos para huesos del esqueleto postcraneal, sólidamente sustentada. [DIAGNOSTIC TRAITS IN POST-CRANIAL ELEMENTS FOR THE IDENTIFICATION OF TWO OTARIIDS SPECIES IN THE ZOOARCHAEOLOGICAL RECORD. ABSTRACT: Arctocephalus australis and Otaria flavescens are the two species of otariids that frequently appear in the zooarchaeological record of South American coastal sites. The similarity between their postcranial bone elements has limited taxonomic identification, resulting in one of the greatest difficulties encountered to carry out detailed zooarchaeological analysis of these animals. The aim of this study is to present a clear descriptive criterion that can be used to identify these two species when recovered from the zooarchaeological record. The use of diagnostic traits along with other approaches (e.g., osteometric studies, bone fusion schedule), will allow investigating particular aspects of the fossil record of these animals. From a sample of 24 modern adult individuals, earlier proposed criteria were reviewed, and as a result, a new list of 36 diagnostic traits for postcranial skeleton bones is presented.] Arctocephalus australis and Otaria flavescens are the two species of otariids that frequently appear in the zooarchaeological record of South American coastal sites. The similarity between their postcranial bone elements has limited taxonomic identification, resulting in one of the greatest difficulties encountered to carry out detailed zooarchaeological analysis of these animals. The aim of this study is to present a clear descriptive criterion that can be used to identify these two species when recovered from the zooarchaeological record. The use of diagnostic traits along with other approaches (e.g., osteometric studies, bone fusion schedule), will allow investigating particular aspects of the fossil record of these animals. From a sample of 24 modern adult individuals, earlier proposed criteria were reviewed, and as a result, a new list of 36 diagnostic traits for postcranial skeleton bones is presented. Fil: Borella, Florencia. Universidad Nacional del Centro de la Provincia de Buenos Aires; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Conicet - Tandil. Investigaciones Arqueológicas y Paleontológicas del Cuaternario Pampeano. Universidad Nacional del Centro de la Provincia de Buenos Aires. Investigaciones Arqueológicas y Paleontológicas del Cuaternario Pampeano; Argentina Fil: Vales, Damián Gustavo. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Conicet - Centro Nacional Patagónico. Centro para el Estudio de Sistemas Marinos; Argentina Fil: Grandi, Maria Florencia. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Conicet - Centro Nacional Patagónico. Centro para el Estudio de Sistemas Marinos; Argentina Fil: Garcia, Nestor Anibal. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Conicet - Centro Nacional Patagónico. Centro para el Estudio de Sistemas Marinos; Argentina

Owing to the limited blood supply in the midfoot, multiple arthrodesis attempts in midfood joints may result in severe osteonecrosis, leading to a difficult scenario for bone reconstruction. This article describes the use of fibula flaps (two free and one pedicled flap) to reconstruct bone defects in three cases of persistent nonunion in midfoot joints. Before admission, all patients (aged 32-56 years old) had undergone multiple arthrodesis attempts (range 3-4) aimed at treating joint diseases associated with flatfoot or Muller-Weiss syndrome. All inserted flaps were stable, and bone fusion was confirmed by X-ray examination at month 4. After the follow-up period (range 1-4 years), all patients showed normal, painless gait. No foot deformities or further complications were observed. Our report suggests that fibula flap transfer may be a good alternative for treating persistent nonunion in midfoot joints involving bone loss, and may prevent the osteonecrosis associated with limited blood supply. © 2016 Wiley Periodicals, Inc. Microsurgery 36:430-434, 2016.

The article presents the estimates of the parameters of endoprosthesis, which allows to determine the advantages and dis- advantages of various implants as systems for reconstruction and stabilization of the spinal motion segment, and creating conditions for bone fusion of vertebrae adjacent to the resected one. The results obtained in studying characteristics of the cages allow their division into 4 groups depending on the combination of features necessary for performing surgeries on the anterior and middle columns of the spine. Based on these data, the authors developed a design of vertical cylindrical telescopic endoprosthesis LAS. The above information increases the possibility of an objective evaluation of the mechanisms of probable postoperative complications and may facilitate the selection of the optimal design, taking into account characteristics of the clinical situation in each particular case.

We sought to explore whether additional bone grafting of the atlantoaxial joint increases the bone fusion rate of iliac crest autograft in posterior occipitocervical fusion surgery.From January 2012 to January 2016, a total of 78 patients who had basilar invagination with occipitalization of the atlas came to our tertiary spine center. Except for those lost to follow-up (10 cases) or who had a follow-up time2 years (20 cases), there were 48 patients retrospectively included in this study. In the control group, a piece of autogenous iliac corticocancellous bone was placed between the occipital and C2 vertebral lamina for fusion. In the hybrid fusion group, besides posterior occipitocervical autograft, some granular bone harvested from the iliac crest was packed into the bilateral atlantoaxial joint. X-ray imaging and cervical computed tomography (CT) were performed during follow-up.The operations were completed successfully in all patients without intraoperative complications. Only 21 (87.5%) patients in the control group had confirmed posterior bony fusion on CT, while 24 (100%) patients in the hybrid fusion group had confirmed posterior bony fusion. There were postoperative implant-related complications in 2 patients. Both cases belonged to the control group (8.3%). Three patients (12.5%) complained of transient numbness in the posterior occipital region: 2 patients in the hybrid group and 1 patient in the control group. The mean duration to posterior occipitocervical fusion was 5.5 months in the hybrid fusion group versus 6.1 months in the control group (P = 0.757). Of note, in the hybrid fusion group, the process of atlantoaxial joint fusion was faster than that of posterior occipitocervical fusion (5.1 months vs. 5.5 months, P = 0.823).Additional bone grafting of the atlantoaxial joint could increase the bone fusion rate of iliac crest autograft in posterior occipitocervical fusion.

Prospective cohort study.To assess rate and degree of interbody bone fusion and evolution in Oswestry Disability index (ODI) and visual analog scale (VAS) of pain after minimally invasive far lateral lumbar interbody fusion.Twenty-three patients with single-level lumbar instability or degenerative disc were treated by this method and prospectively included. VAS of pain and ODI were evaluated preoperatively and at last follow-up. Computed tomography scan was performed 6 months after surgery to assess interbody fusion.Between preoperative and 2 years postoperative follow-up, mean VAS decreased by 2.4 points (Minimally invasive far lateral lumbar interbody fusion resulted in satisfactory clinical and radiological results.

This retrospective cohort study aimed to evaluate the clinical outcomes of posterior surgical treatment of ankylosing spondylitis (AS) with spinal tuberculosis (STB). This was a retrospective study including 12 patients treated between January 2004 and April 2014 for AS with STB at our department. All patients underwent 1-stage posterior internal fixation, debridement, and bone fusion. The patients were evaluated based on the American Spinal Injury Association (ASIA), kyphotic Cobb angle, and the visual analog score (VAS). All patients were followed up for an average of 42.7 ± 13.2 months after surgery and bone fusion was achieved 6.8 ± 1.3 months. According to ASIA, 2 cases were rated as Grade D, 10 cases were Grade E at last follow-up. The average preoperative Cobb angle was 26.7 ± 7.6° (range 15–36) and the average postoperative Cobb angle was 7.8 ± 1.2° (range 6–9). The mean latest follow-up Cobb angle was 9.1 ± 1.0° (range 6–10). Compared with the average preoperative Cobb angle, there were significant differences regarding the kyphotic Cobb angle measured postoperatively and at final follow-up (P

Introduction: Autologous iliac bone harvesting is associated with significant drawbacks and low fusion rates are noted in conditions such as osteoporosis. Bone Marrow Aspirate (BMA) is relatively inexpensive and contains mononuclear cells which can be utilised. Aim: To document the efficacy of concentrated Bone Marrow Mononuclear Cells (BM-MNC) in bone fusion and compare fusion rates with autologous Iliac Crest Bone Graft (ICBG) alone versus combined ICBG and BM-MNC. Materials and Methods: This prospective, non randomised study included study group and age matched control group (of previously operated craniovertebral junction anomalies) with 15 patients in each group. Combined autologous ICBG+BM-MNC (study group) was compared with autologous ICBG alone (control group). The BMA was processed in stem-cell laboratory to procure mononuclear cells. Morcelised graft pieces mixed with BM-MNC were applied over fusion site after instrumentation. Patients were assessed for fusion and neurological outcome. Qualitative data analysis was done using Fisher exact test. Results: Mean age, surgical procedures and complications were similar in both groups. Average duration for procurement of cells was 98 minutes. Average of 40.6 million cells were utilised. Higher fusion rates were noted in the study group both at three and six months which, however, was not statistically significant (p-value 0.06 and 0.26 respectively). Conclusion: To the best of our knowledge, this is the first study of its kind to utilise concentrated mononuclear cells combined with iliac graft which lead to higher proportion of fusion and was effective in all surgical procedures. It seems economical and might be suitable for patients who cannot afford expensive graft substitutes and with conditions like osteoporosis. Further prospective studies in larger numbers are needed to confirm these findings.

Recently, the one-stage posterior approach for treating spinal tuberculosis (TB) has gained popularity. However, large bony defects after debridement remain a major challenge in posterior surgery. The present retrospective study aims to compare the clinical outcomes of posterior-only surgical management by titanium mesh versus iliac bone grafts for treating lumbosacral TB. This was a retrospective cohort study. From January 2006 to April 2012, 36 patients with lumbosacral TB were treated at our department. The 36 cases were divided into 2 groups: 17 patients in Group A (titanium mesh) underwent one-stage posterior internal fixation, debridement, and titanium mesh bone fusion. The 19 patients in Group B (iliac bone graft) underwent posterior instrumentation, debridement, and iliac bone graft in a single procedure. The clinical and radiographic results for the 2 groups were analyzed and compared. The mean year of patients was 49.9 ± 15.4 months in group A and 55.5 ± 12.6 months in group B. All patients were followed up for an average of 47.3 ± 8.1 months (range 36–60 months). Spinal TB was completely cured and no intraspinal infection and central nervous system complications of TB infection occurred. Bone fusion was achieved 6.4 ± 1.9 months in group A and 7.8 ± 2.1 months in group B. There was no significant statistical difference in bone fusion between the 2 groups (P > .05). The Oswestry Disability Index score (ODI) significantly improved between the preoperative and the last visit in either group. However, no significant difference was observed between the 2 groups at last visit (P > .05). There were significant differences between groups regarding the postoperative lumbosacral angle and angle correction loss at the final follow-up (P

Complete syndactyly with bone fusion in patients with Apert syndrome was treated using perifascial areolar tissue (PAT) grafts via a two-stage surgery (i.e. bone separation using inter-bone PAT graft insertion followed by web separation and reconstruction with full-thickness skin grafts). This technique is easy and created nail folds for fingertips.

Objective The purpose of this study was to evaluate the therapeutic effects of combination therapy with curcumin and alendronate on spine fusion surgery in ovariectomized rats. Methods Thirty-two female Sprague-Dawley rats (12 weeks old) underwent bilateral ovariectomy (OVX). Eight weeks after surgery, animals underwent intertransverse spine fusion at L4-5. The rats were randomly distributed amongst 4 groups; untreated OVX group, curcumin administered group, alendronate administered group, and the combination therapy group. At 8 weeks after fusion surgery, the animals were sacrificed and the fusion mass was assessed by manual palpation, radiographic scan, and micro-computed tomographic scan. In addition, mechanical strength was determined by a 3-point bending test. Results Based on the results of manual palpation testing and 3-dimensional micro-computed tomography scanning, solid bone fusion rate was 50% (4 of 8) in the OVX group, 75% (6 of 8) in the alendronate-only and curcumin-only group, and 87.5% (7 of 8) in the combination therapy group, respectively. The combination therapy group had a higher fusion rate compared with the other treatment groups, though not statistically significantly (p>0.05). And the combination therapy group had a significant increase in fusion volume at 8 weeks after spine fusion surgery compared with curcumin-only group (p=0.039). The 3-point bending test showed that combination therapy group had a significantly greater maximal load value compared to that of curcumin-only group (p=0.024). Conclusion The present study demonstrated that additional treatment of curcumin and alendronate after spine fusion surgery in rat can promote higher fusion volume, and improve bone mechanical strength.

International audience; PURPOSE: The aim of this study was to assess the interbody fusion rate for patients treated by anterior cervical interbody fusion (ACIF) using polyetheretherketone (PEEK) cages filled with synthetic bone graft in acute cervical spine injury. MATERIALS AND METHODS: Twenty-nine patients (mean age: 49 years) with monosegmental instability due to cervical spine injury were followed. We assessed the rate of and time to interbody fusion at 1-year follow-up. In case of secondary displacement, we analysed its causes and surgical management. RESULTS: The rate of fusion was 86.2%. The mean time to fusion was 7.2 months. Interbody fusion was observed at 3 months in 4 patients, at 6 months in 14 and at 1 year in 7. Four patients had secondary displacement within 3 months. CONCLUSION: ACIF with a PEEK cage filled with synthetic bone graft seems to be an alternative to iliac crest bone graft with no morbidity related to the harvest site.

Spine arthrodesis is frequently performed in the treatment of spine trauma, deformity, and degenerative disorders. With an estimated 413,000 fusion procedures performed in the United States annually, the number of procedures performed has increased by 2.4-fold since 1998. Based on its prevalence, it is critical that spine surgeons have an adequate understanding of the basic science behind bone fusion. This chapter will review basic bone anatomy and histology, discuss the principles and process of bone healing, and explore the clinical applications of these topics.

The aim of this study was to examine the solid bone fusion rates between Plasmapore-coated titanium cages (PPC group) and non-Plasmapore-coated titanium cages (N-PPC group) in patients who received anterior cervical decompression and fusion (ACDF).Of 78 patients who received ACDF at the hospital, a follow-up period greater than 2 years was possible for 61 patients, including 30 in the PPC group and 42 in the N-PPC group. Evaluations were performed at 3, 6, 12, and 24 months after surgery. Radiological stabilization (RS) was defined as the restriction of spinous process movement to3 mm and the absence of a halo around the cages on flexion-extension radiographs. Solid bone fusion (SBF) was defined as the formation of bony bridges between the fixed vertebral bodies in sagittal computed tomography sections. The rates of RS and SBF were compared between both groups.The differences in RS were not significant between the 2 groups during the follow-up period. However, the SBF rates at 6 and 12 months were significantly higher in the PPC group (26.7% and 56.7%) than in the N-PPC group (5% and 21.4%). Moreover, 63.3% (19 of 30) of patients in the PPC group demonstrated RS at 3 months, and of these patients, SBF was observed in 100% (19 patients) after 24 months, respectively. In comparison, the SBF rates in the N-PPC group were 86%.Plasmapore-coated titanium cages enabled more rapid solid bone fusion. We suggest that these types of cages might help to reduce postoperative radiograms.

Objective To evaluate the outcome of knee fixation without bone fusion using an intramedullary modular nail and interposed cement. Materials and methods Retrospective study of 29 infected total knee arthroplasties with prospective data collection and a mean follow-up of 4.2 years (3–5). Results Complications included 2 recurrent infections, 1 peri-implant fracture, and 1 cortical erosion due to the tip of the femoral component. All of these were revised with successful results. The mean limb length discrepancy was 0.8 cm, with 24 Conclusions The Endo-Model Link nail is an effective method for knee fixation that restores the anatomical alignment of the limb with adequate leg length.

A patients with atlantoaixial instability and osodontoideum underwent atlantoaixial fusion (Harms and Melcher technique) with demineralized bone matrix. But, unfortunately, the both pedicle screws in C2 were fractured within 9 weeks follow-up periods after several suspected episode of neck hyper-flexion. Fractured screws were not contact to occipital bone in several imaging studies, but it could irritate the occipital bone when neck extension because the relatively close distance between the occipital bone and C1 posterior arch. The patient underwent revision operation with translaminar screw fixation with autologus iliac bone graft. Postsurgical course were uneventful except donor site pain, but the bony fusion was not satisfied after 4 months follow-up. The patient re-underwent revision operation in other hospital. Continuous complication after atlantoaixial fusion is rare, but the clinical course could be unlucky to patients. Postoperative immobilization could be important to prevent the unintended clinical course of patients.

A few methodologies and developments of potential medical and biomedical applications are described in this chapter, showing how shock wave research has extended. Some sections may encourage students and scientists to enroll in novel research topics. Shock wave-mediated drug delivery, needleless injection, thrombus ablation, pain release, and enhancement of bone fusion to treat skull bone defects are described in the first sections. This is followed by reporting promising studies dealing with gene transfection, i.e., the delivery of deoxyribonucleic acid (DNA) into cells, as well as with the enhancement of cytotoxic effects of drugs to treat oncological diseases. Genetic transformation of bacteria and fungi are other interesting topics that were included. Filamentous fungi play a crucial role in the food, chemical and pharmaceutical industry by producing amino acids, antibiotics, insulin, anticoagulants, vaccines, pesticides, biofuels, food preservatives, and acidulants; however, more efficient methodologies for delivering exogenous nucleic acid to fungi are still needed. As described in this chapter, a promising approach is the use of underwater shock waves. The final sections of the chapter deal with the bactericidal action of shock waves including their potential to disrupt dental biofilm, enhancing the efficiency of antibiotics. Other research topics in dentistry are shock wave-induced bone regeneration and reduction of tooth mobility after active orthodontic treatment.

BACKGROUND CONTEXT Occipitocervical fusion can be utilized to correct joint instability caused by trauma, rheumatological conditions, infection, neoplasm, or congenital conditions. Bone-graft-related complication was relatively frequent during occipitocervical fusion surgery. In previous studies, the reported fusion rates were ranged from 83.6% to 100%; and the rate of instrumentation failure after nonunion was as high as 7% during occipitocervical fusion. PURPOSE To explore whether additional bone grafting of atlantoaxial joint increase the bone fusion rate of iliac crest autograft in posterior occipitocervical fusion surgery. STUDY DESIGN/SETTING A retrospective, controlled study with a 2-year follow-up. PATIENT SAMPLE Between January 2014 and January 2016, a total of 48 consecutive patients underwent posterior occipitocervical fusion with a screw-rod fixation system in a tertiary spine center. OUTCOME MEASURES In the postoperatively follow up, patients underwent computed tomography (CT) scan at every interval until bone fusion was confirmed. The related complications were also recorded. METHODS In the control group, we only placed a piece of autogenous iliac corticocancellous bone between the occipital and C2 vertebral laminae for fusion. In the hybrid fusion group, besides posterior occipitocervical autograft, we additionally pack some granular bone harvested from the iliac crest into bilateral atlantoaxial joint. RESULTS Only a piece of autogenous iliac corticocancellous bone was placed between the occipital and C2 in 24 patients to perform posterior occipitocervical fusion. In the other 24 cases, besides posterior occipitocervical autograft, we additionally pack some granular bone harvested from the iliac crest into bilateral atlantoaxial joint. All patients were followed for at least 24 months. Only 21 (87.5%) patients in the control group had confirmed posterior bony fusion on CT imaging while 24 (100%) patients in the hybrid fusion group had confirmed posterior bony fusion. There were postoperative implant-related complications in 2 patients; screw loosening was visible in one case, pullout and breakage of internal fixation was observed in another case. All two cases were belong to the control group (8.3%). Mean duration to posterior occipitocervical fusion was 5.5 months in the hybrid fusion group versus 6.1 months in the control group (P=.037). Of note, in the hybrid fusion group, the process of atlantoaxial joint fusion was faster than that of posterior occipitocervical fusion (5.1 months vs. 5.5 months, p=.103). CONCLUSIONS Additional bone grafting of atlantoaxial joint could increase the bone fusion rate of iliac crest autograft and promote the process of bone fusion in posterior occipitocervical fusion.