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Objective: The present study described a modified technique of atlantoaxial arthrodesis in patients with atlantoaxial instability (AAI) along with the postoperative clinical and radiological results., Methods: Five patients underwent this method for their AAI concurrent with C1 arch hypoplasia and/or the development of odontoid pannus causing myelopathy. After thorough exposure of the posterior surface of the C1-2 complex, the bilateral C2 nerve roots were sectioned to allow for easier access to the C1/2 facet joints. To prepare a suitable grafting bed, the C1/2 facet capsule was opened, and then the articular cartilaginous and synovial tissues were thoroughly removed. After being properly fashioned to match the gap between the C1/2 facet joint spaces, the structural bone grafts from the iliac crest were directly inserted into the facet joint spaces. To alleviate cord compression caused by concomitant odontoid pannus and/or hypoplastic C1 arch, C1 laminectomy was necessitated in all cases. Subsequently, posterior screw-rod instrumental fixation was conducted., Results: All 5 patients underwent this procedure successfully. Clinical and radiological follow-up data of all patients indicated favorable relief of clinical symptoms and early rigid C1-2 stability. The sequelae of C2 nerve resection were not remarkable. No other neural or vascular damage associated with this technique was observed., Conclusions: Modified atlantoaxial arthrodesis via intraarticular autografting using the structural iliac bone combined with posterior instrumentation appears to be an efficient alternative treatment method for AAI patients with concurrent pathologies, even when the C1-2 posterior arches are unavailable for the grafting bed., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Large-volume autologous iliac cancellous bone grafting for alveolar cleft may lead to undesirable bone resorption and susceptible donor-site morbidity, whereas the addition of deproteinized bovine bone (DBB) could optimize outcomes. This study aimed to evaluate the effectiveness of combining autologous iliac bone with DBB using three-dimensional cone beam computed tomography (3D-CBCT) for better analysis of bone generation than conventional evaluation methods. Thirty-six patients with unilateral alveolar cleft were assigned into two groups. Group A (n = 21) underwent autogenous cancellous bone graft harvested from the anterior iliac crests, while Group B (n = 15) received a composite of autogenous iliac cancellous bone and DBB. Patients in Group B displayed higher bone filling rates (P < 0.0001) and lower bone absorption rates (P < 0.001) than those in Group A at both 6 months and 1 year postoperatively. Additionally, there were directional differences in bone absorption within the bone grafts, with more absorption observed on the alveolar crest and palatal sides than that on the nasal and labial sides (P < 0.001). This study demonstrates that employing a combination of DBB and autologous bone in alveolar cleft repair achieves better outcomes of bone grafting., (Copyright © 2024. Published by Elsevier Ltd.)

Wound dehiscence is a common complication after secondary alveolar bone grafting (SABG), leading to unfavourable surgical outcomes. Studies have shown that autologous platelet concentrates (APC) may enhance wound healing and improve outcomes. Therefore, this review aimed to evaluate in patients with alveolar clefts, whether using APC and iliac crest bone graft can mitigate the likelihood of wound dehiscence formation compared with those who underwent iliac bone grafting only following SABG. A comprehensive literature search was conducted using various electronic databases, including PubMed, Embase, Scopus, Web of Science, EBSCOhost, Ovid MEDLINE, LILACS, Cochrane Library, and grey literature, to include studies until July 31, 2023, without any restriction to language and time of publication. Only randomized (RCT) and controlled (CCT) clinical trials were included. Two independent reviewers screened the studies based on the predefined criteria, after which a qualitative and quantitative analysis was conducted. The search yielded 821 studies, of which seven were deemed eligible for systematic review. The risk of bias assessment done using "The Cochrane collaboration tool for risk of bias assessment" for six RCTs and the "Risk of Bias in Non-randomized Studies - of Interventions" for one CCT revealed a moderate to high risk of bias. The meta-analysis of five studies showed that the overall risk of developing wound dehiscence was lower in the APC group (RR = 0.33; 95% CI: 0.16, 0.71; p = 0.005; χ 2  = 0.82; I 2  = 0%). Subgroup analyses based on study design further supported these findings. Although the adjuvant use of APC for alveolar cleft reconstruction reduces the risk of wound dehiscence, more studies with increased scientific rigour and fewer confounding variables are warranted., Competing Interests: Declaration of competing interest All authors declare no conflicts of interest., (Copyright © 2024 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Background: Anterior cervical corpectomy and fusion achieves foraminal radicular and central medullary decompression and spinal stabilization in staged lesions. Many bone graft materials have been developed for the reconstruction of cervical lordosis and the restoration of intervertebral height after corpectomy. The PolyEtherKetoneEtherKetoneKetone (PEKEKK) is a semicrystalline thermoplastic polymer that can be reinforced with carbon fibers to create long and highly fenestrated rectangular cervical cages for corpectomy. This study aimed to evaluate the radiological outcomes of an innovative PEKEEKK cage compared with others grafting options., Methods: Forty-five consecutive patients who underwent surgery with PEKEKK cages between 2017 and 2019 at a spine institution, were matched with 15 patients with a titanium mesh cylindrical cage (TMC) and 15 patients with a tricortical structural iliac bone graft. The restoration of vertebral height and cervical lordosis postoperatively, and subsidence of the construct were evaluated. Complications were reported., Results: The minimal follow-up was 5.1±2years. A better, but nonsignificant, postoperative gain in height was observed for PEKEKK (+8.1 ± 20%) and TMC cages (+8.2 ± 16%) than for iliac crest autograft reconstruction (+2.3 ± 15%, P = 0.119). The mean subsidence at the last follow-up was greater for TMC cages (-10.2 ± 13%), but was not significant, with -6.1 ± 10% for PEKEKK cages and -4.1 ± 7% for iliac crest autografts (P = 0.223). The gain in segmental cervical lordosis was significant (P < 0.001) and remained stable in all the groups., Conclusions: Although an improvement in radiologic anatomical parameters can be achieved with all cage groups, the PEKEKK cage can be considered as a safe alternative for reducing subsidence., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Atrophic pseudoarthrosis is a serious complication with an incidence of 5-10 % of bone fractures located in the diaphysis of long bones. Standard treatments involve aggressive surgical procedures and re-interventions requiring the use of autografts from the iliac crest as a source of bone-forming biological activity (Standard of Care, SoC). In this context, regenerative ex vivo expanded osteogenic cell-based medicines could be of interest. Particularly, Mesenchymal Stromal Cells (MSC) offer new prospects to promote bone tissue repair in pseudoarthrosis by providing biological activity in an osteoconductive and osteoinductive environment., Methods: We conducted a phase IIa, prospective, randomised, parallel, two-arms, open-label with blinded assessor pilot clinical trial to compare SoC vs. a tissue-engineered product (TEP), composed of autologous bone marrow (BM)-derived MSCs loaded onto allogeneic decellularised, lyophilised spongy bone cubes, in a cohort of 20 patients with non-hypertrophic pseudoarthrosis of long bones. Patients were followed up for 12 months. Radiological bone healing was evaluated by standard X-ray and computed tomography (CT) scanning. Quality of life was measured using the EUROQOL-5D questionnaire., Results: Ten patients were randomized to TEP and 10 to SoC with iliac crest autograft. Manufacturing of TEP was feasible and reproducibly achieved. TEP implantation in the bone defect was successful in all cases and none of the 36 adverse events (AE) reported were related to the treatment. Efficacy analyses were performed in the Full Analysis Set (FAS) population, which included 17 patients after 3 patients withdrew from the study. The degree of consolidation, estimated by measuring Hounsfield units (HU) on CT, showed no significant differences between the two treatment groups at 12 months post treatment (main efficacy variable) (p = 0.4835) or at 6 months., Conclusions: Although only a small number of patients were included in our study, it is notable that no significant differences were observed between the experimental treatment and SoC, thus suggesting TEP as an alternative where autograft is not available or contraindicated., Competing Interests: Declaration of competing interest The authors declare there is no conflict of interests., (Copyright © 2024 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Introduction: Bone grafts for scaphoid nonunion with deformity include cortcicocancellous or pure cancellous bone grafts. This study compared the outcomes between two types of bone grafts when employing a volar locking-plate in patients with scaphoid nonunion with dorsal intercalated segmental instability (DISI)., Patients and Methods: This retrospective study included 34 patients with scaphoid nonunion and DISI due to humpback deformity treated between March 2017 and January 2022. Two types of bone grafts were obtained from iliac crest. Twenty of the corticocancellous (CC) group underwent a wedge-shaped graft, while 14 patients of the pure cancellous (C-only) group received graft chips. In both groups, a 1.5-mm anatomically pre-contoured locking plate was used for fixation. Radiographic evaluations included the union rate and carpal alignment including scapholunate angle (SLA), radiolunate angle (RLA), intrascaphoid angle (ISA) and scaphoid height to length ratio (HLR). Clinical assessments encompassed wrist range-of-motion, grip strength, and patient-reported outcomes., Results: Nineteen of the 20 patients in the CC group and 12 of the 14 patients in the C-only group respectively, achieving osseous union. The mean follow-up period in CC group was 14.7 (range, 12 ∼ 24) months and that in C-only group was 12.6 (range, 12 ∼ 15) months. Postoperatively, there were no significant intergroup differences of radiographic parameters including SLA (CC; 49.9° ± 6.7° vs. C-only; 48.9° ± 3.5°, P = 0.676), RLA (1.7° ± 6.4° vs. 2.4° ± 3.3°, P = 0.74), ISA (36° ± 7.5° vs. 36.6° ± 12.2°, P = 0.881), and HLR (0.54 ± 0.09 vs. 0.53 ± 0.05, P = 0.587). Clinical outcomes, including the flexion-extension arc (137° ± 30° vs. 158° ± 33°, P = 0.122), grip strength (93.4 % ± 15.4% vs. 99.5 % ± 16.7 %, P = 0.39), Quick Disabilities of the Arm, Shoulder, and Hand scores (11.2 ± 8.3 vs. 12.5 ± 7.7, P = 0.74) and Mayo Wrist Scores (81.2 ± 13.1 vs. 89 ± 11.4, P = 0.242) also showed no significant intergroup differences., Conclusions: Volar locking-plate fixation with pure cancellous bone grafts achieved outcomes comparable to those achieved with corticocancellous bone grafts in scaphoid nonunion with deformity, possibly due to the biomechanical advantages of the volar plate to provide structural supports., Competing Interests: Declaration of competing interest None., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Objective: Segmental mandibular defects can occur due to various etiologies, including trauma and tumor resection. Reconstruction should provide adequate support for subsequent dental rehabilitation and allow for proper occlusion. Nonvascularized bone grafts have been used for reconstructing mandibular defects in cases where vascularized grafts were not feasible. The objective of this study was to assess the success rate of these grafts in reconstruction of segmental defects of various sizes in the mandible., Study Design: Fifty patients were included in this retrospective chart review. Length of the grafts varied from 3 to 20 cm and patients were followed up from 4 to 80 months. Fifteen grafts were harvested from anterior iliac crest, 23 from posterior iliac crest, 9 grafts were a combination of either with costochondral graft, and 3 were solely allografts. Bone morphogenetic protein was utilized in 41 cases as an adjunct., Results: Success was defined as continuity of bone clinically and radiographically at a 4-month follow-up. Nonvascularized bone grafting was successful in 90% of cases. Complications were observed in 34% of cases, of which the most common were infection followed by wound dehiscence., Conclusions: Our study demonstrated substantial success rate with nonvascularized bone grafts in reconstruction of segmental mandibular defects., Competing Interests: Declaration of interests The authors declare no conflict of interest., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Purpose: Autologous bone grafts demonstrate osteoconductive, osteoinductive, and osteogenic properties. Hand surgeons commonly augment surgical fixation with autografts to promote fracture healing. This study compared the intrinsic stem cell-like properties of 2 commonly used autograft sources in hand surgery: the iliac crest and distal radius., Methods: A total of 9 subjects who received an iliac crest bone graft and distal radius bone graft harvest as a part of the standard care of distal radius malunion or nonunion correction or scaphoid nonunion open reduction and internal fixation were enrolled in the study. Cells were isolated by serial collagenase digestion and subjected to fibroblast colony-forming units, osteogenesis, and adipogenesis assays. The expression levels of genes involved in osteogenesis and adipogenesis were confirmed using quantitative polymerase chain reaction., Results: The cells isolated from the iliac crest bone graft compared with those isolated from the distal radius bone graft demonstrated significantly higher mean fibroblast colony-forming unit efficiency; increased osteogenesis, as measured using alizarin red quantification; increased adipogenesis, as measured using oil red O quantification; and higher expression levels of genes involved in osteogenesis and adipogenesis under the respective differentiation conditions., Conclusions: The cells isolated from the iliac crest bone graft demonstrated a higher fibroblast colony-forming unit capacity and an increased capability to undergo both osteogenesis and adipogenesis., Clinical Relevance: Limited evidence exists comparing the intrinsic stem cell-like properties of the iliac crest and distal radius despite the widespread use of each source in hand and wrist surgery. The information from this investigation may assist hand and wrist surgeons with the selection of a source of autograft., (Copyright © 2024 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Purpose: We hypothesised that traditional iliac tricortical bone grafts (no vascularised) still have a reasonable role in promoting satisfactory bony healing in non-union defects of certain sizes. Here, we report the clinical/radiological outcomes through a retrospective case series., Methods: We screened 74 patients with definitive non-union in the long bones of the upper extremities who visited the outpatient department from 2008 to 2018. Among these patients, 25 who met our inclusion/exclusion criteria were investigated., Results: The mean age was 51.92 years, and there were 12, 9, 1, and 3 lesions of the radius, ulna, clavicle, and humerus, respectively. The tools for primary fixations were plate and intramedullary nails in 24 and 1 patients, respectively. Six patients presented with atrophic non-union. The mean period from a previous surgery was 6.84 months. The mean defective bone sizes were 1.81 and 3.50 cm pre-debridement and post-debridement, respectively. All devices had locking plates longer than the previous plate, and the graft was concurrently fixed by screws in three patients. At a mean of 15.92 weeks after the revision surgery, all patients experienced union. At the final follow-up, the clinical outcomes were satisfactory. No significant differences in clinical outcomes were found according to the lesion, type of non-union, period from the previous surgery, or harvest length of the iliac bone., Conclusions: If the proper indications and some technical aspects are considered, a non-vascularised iliac bone graft longer than 3 cm could still be a reasonable option for treating diaphyseal non-union of the upper extremities., Level of Evidence: Level IV, retrospective case series., Competing Interests: Declaration of Competing Interest There are no conflicts of interest., (Copyright © 2023 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Purpose: To compare donor-site morbidity for alveolar bone grafting results following cartilage-preserving outer and inner cortico-cancellous iliac crest (OCIC and ICIC) bone block grafting in children., Materials and Methods: Patients were randomly divided into two groups and prospectively reviewed. In the OCIC and ICIC groups, cortico-cancellous bone blocks were harvested at outer and inner iliac crest respectively. Patient characteristics and surgical parameters were compared; pain intensity and duration, lateral femoral cutaneous nerve (LFCN) injury, gait disturbance, scar and contour satisfaction were analysed postoperatively., Results: Forty-nine consecutive patients (OCIC, 24; ICIC, 25) were included. There were no significant differences in patient characteristics or donor-site surgical parameters. The mean pain score on the first post-operative day was significantly lower in the OCIC group (3.75±1.70) than in the ICIC group (5.20±2.08) (p=0.012). The pain duration was similar in the two groups (median: 5 days). Temporary LFCN injury only occurred in 3 patients in the ICIC group. Postoperatively, the duck and circle gaits were observed in the OCIC and ICIC groups, respectively. There were no significant differences in the claudication duration, scar and contour satisfaction between the groups., Conclusion: OCIC bone graft harvesting is marginally advantageous in children due to less early postoperative donor-site pain and a lower risk of nerve damage., (Copyright © 2023 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Purpose: Screw fixation with iliac crest bone grafting (ICBG) is a well-studied treatment for pediatric scaphoid nonunions. Studies in adults, as well as in pediatric spine fusions, have demonstrated high rates of complications with ICBG, including longer-term donor site pain. We hypothesized that in pediatric patients undergoing ICBG for scaphoid nonunion, the donor site complication rate would be lower than that reported in other populations., Methods: Records of patients ages 0-18 years at a single institution undergoing surgical reconstruction for scaphoid nonunion from 1995 to 2016 were reviewed. Patient and surgical variables were recorded, including how ICBG was harvested. Donor site complications were recorded, including donor site pain beyond 30 days after surgery, infection, peri-incisional or lower extremity numbness at any point after surgery and reoperation at the donor site at any time point after surgery., Results: During the study period, 119 wrists in 117 patients underwent internal fixation and ICBG for scaphoid nonunion. The average age was 16 years; mean follow-up was 1 year. The majority of wrists (73, 62.9%) underwent harvest of both outer and inner tables of the iliac crest; 38 (31.9%) had only outer table harvested; 5 (4.3%) had only cancellous graft harvested. Ten wrists (8.4%) had a donor site complication. The most common donor site complication was donor site pain beyond 30 days after surgery (5, 4.2%), followed by numbness (4, 3.4%). No infections, seromas, or reoperations at the donor site occurred. In comparison to those subjects who did not experience complications, we found no difference based on the age at surgery or the type of graft used. Female patients were more likely to have a recorded complication than males., Conclusions: Donor site morbidity for iliac crest grafting in pediatric patients undergoing scaphoid nonunion surgery appears to be lower than that previously reported in adult patients., Type of Study/level of Evidence: Therapeutic IV., (Copyright © 2023 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Purpose: To present a radiographic follow-up study of the use of a nonvascularized iliac crest bone graft as a treatment for modified Blauth type IIIB thumb hypoplasia., Methods: From January 2015 to December 2019, nonvascularized iliac crest bone grafts were used to reconstruct the first metacarpal in 23 cases with type IIIB thumbs. The average follow-up duration was 1.9 years (range 1.0-3.9 years). We evaluated the patients' serial x-rays and measured the width and length changes of the reconstructed first metacarpals., Results: Survival of the graft, judged radiographically, was achieved in 20 cases (20/23, 87%), with an average reduction of 33% in the width of the graft. Shortening of the graft (average 2.3 mm, range 0.1-5.6 mm) was noted in 11 of the 20 cases, and an increase in the length of the graft (average 4.2 mm, range 0.7-8.6 mm) was observed in the other 9. Bone graft failure (3/23, 13%) occurred in 3 cases because of significant bone resorption., Conclusions: For type IIIB thumb hypoplasia, a nonvascularized iliac crest bone graft was a feasible method to reconstruct the first metacarpal, with a 13% risk of graft failure, 33% average reduction in graft width, and 55% reduction in graft length. However, in cultures that value the preservation of a 5-digit hand, this technique may provide an alternative to excision with index pollicization., Type of Study/level of Evidence: Therapeutic IV., (Copyright © 2023 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Metacarpal nonunion is a rare outcome of metacarpal injury, and little has been published about its management. Care typically includes open reduction and internal fixation with a possible bone graft, similar to the treatment of other nonunions. However, there is no literature guidance if traditional methods do not lead to union. To improve the treatment of these recalcitrant metacarpal diaphyseal nonunions, we proposed a new surgical technique using a "top hat" bone graft harvested from the iliac crest. The graft is carefully shaped to create a cancellous "crown," which is inserted into the nonunion site, and cortical "brims," which are used to secure the graft to the metacarpal. This has been successful in treating 2 cases of metacarpal nonunion that failed to heal with first-line intervention., (Copyright © 2022. Published by Elsevier Inc.)

The aim of this article is to evaluate the early and late morbidities of the donor- and recipient-site in patients undergoing mandibular reconstruction using either vascularized fibular flap (VFF) or vascularized iliac flap (VIF). Electronic databases, including PubMed, Web of Science, Cochrane Central and Embase, were explored for literature published until October 2020. A total of twenty-four articles reporting complications following mandibular reconstruction surgery with follow-up periods ranging from six to 63 months were selected based on the exclusion criteria. For each research, the JBI Critical Assessment Tool and the ROBINS-I Tool were used to analyze the methodological quality and the risk of bias. A single-arm meta-analysis was performed to have a synthesized analysis of the donor- and recipient-site early and late morbidities. Results showed that the early morbidities in VFF group ranged from 3% to 12%, and the late morbidities in VFF group ranged from 5% to 67%. In VIF group, the early morbidities ranged from 3% to 16%, and the donor-site late morbidities ranged from 6% to 43%. Complications with the top three morbidities in the VFF group were: chronic sensory disturbances at the donor-site (67%), malocclusion (22%) and chronic lower limb weakness (20%); and in the VIF group were: chronic sensory disturbances at the donor-site (43%), chronic pain at the donor-site (26%), chronic gait disturbance (20%). Further controlled clinical trials are needed to assess the long-term outcome of VFF or VIF grafting., (Copyright © 2021. Published by Elsevier Ltd.)

Background: A high incidence of osteonecrosis of the femoral head (ONFH), a commonly seen and intractable disease, has been reported. This retrospective study aims to compare the reconstructive outcomes by free vascularized iliac bone flap (FVIBF) with those by vascularized pedicled iliac bone flap (PIBF) to determine which one is better for ONFH patients., Methods: From January 2010 to December 2017, 35 patients (40 hips) were treated by PIBF grafting, and 32 patients (36 hips) were treated by FVIBF grafting. The two groups were then compared in terms of the preoperative baseline conditions, intraoperative data, and postoperative Harris hip score (HHS)., Results: In the PIBF group, the operating time was significantly longer than the FVIBF group (195.5 ± 26.4 vs 147.2 ± 17.7 min, respectively), and the intra-operative blood loss was significantly heavier (330.0 ± 63.9 vs 240.3 ± 37.5 ml, respectively). Meanwhile, the recipient site morbidity rate in the PIBF group outnumbered that in the FVIBF group (27.5% vs 8.3%, respectively), and a higher rate of lateral femoral cutaneous nerve (LFCN) injury was observed in the PIBF group than in the FVIBF group (27.5% vs 8.3%, respectively). No difference was found in postoperative HHS score between the two groups. In both groups, the recovery effect of the patients in stage II was better than that in stage III., Conclusion: While maintaining a similar clinical effect, the FVIBF grafting exhibited a distinct advantage over the PIBF grafting, in terms of shorter operative time, less blood loss, and lower risk of LFCN injury., Competing Interests: Declaration of Competing Interest The authors declare that they have no conflict of interest., (Copyright © 2020 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Background: Opinions vary regarding optimal treatment of unstable hangman's fractures. Recent technological advances have allowed short segment, motion preserving fixation, even in complex cases. The aim of the study was to demonstrate C1-C2 motion-preserving short-segment fusion in hangman's fracture and the evolution of technique from pedicle realignment to pedicle reformation in complex fractures with resorbed/destroyed C2 pedicles., Methods: This was a retrospective study. Patients operated by a single surgeon at a tertiary level center from 2012 to 2018 were included. The type of fracture, operating time, and blood loss was recorded. Neurologic deficits were recorded using the American Spinal Injury Association scale with regular clinicoradiologic follow-up., Results: Nine patients (8 male), with a mean age of 36 ± 16.9 years were included. In the initial 7 patients, C2 pedicle screw, C3-C4 lateral mass screw, and rod fixation was done. The last 2 patients were complex neglected injuries, with 1 having severe angulation and displacement and the other having spondyloptosis with C2 body placed anterior to C4 body. In both these patients, direct C2 body screw were placed and pedicle reconstruction was done. Mean follow up was 41.4 ± 29.8 months. All 5 patients with preoperative neurologic deficits had improvement in power. C1-C2 joint motion was preserved in all. All patients had bony fusion., Conclusions: Preservation of motion at the C1-C2 joint should be the goal in all surgically managed hangman's fracture patients. The technique of C2 pedicle reconstruction can be utilized for the same in old neglected hangman's fractures., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Introduction: To date, there is a lack of evidence related to the long-term evaluation of recipient-site functional outcomes following mandibular reconstruction with vascularized bone grafts. Therefore, the aim of this systematic review and meta-analysis was to evaluate the long-term recipient-site functional outcomes in oral oncology patients who require mandibular reconstruction with either vascularized fibular flap (VFF) or vascularized iliac flap (VIF)., Methods: An extensive electronic search was conducted in PubMed, Web of Science, Cochrane, and Embase databases for identifying articles published until April 2020. All papers were dual screened for eligibility in accordance with the Preferred Reporting of Systematic Reviews and Meta-Analyses and Meta-analysis of Observational Studies in Epidemiology guidelines. The risk of bias was assessed using the MINORS tool. A meta-analysis of functional outcome parameters was performed to estimate single incidence rates., Results: A total of 257 patients with a mean follow-up period of 38.6 ± 19.5 months were included in this meta-analysis, where 174 patients underwent VFF reconstruction and 83 patients involved reconstruction with VIF. The functional outcomes in patients reconstructed with VIF showed improved scoring for mastication, deglutition, diet, and speech. Speech showed highest score among all functional parameters, whereas, mastication was the most poorly recovered parameter in relation to reconstruction with both flaps. No significant difference in functional outcomes was observed between both flaps., Conclusion: Current evidence seems to indicate that VIF offers improved long-term recipient-site functional outcomes. Yet, considering a high level of data heterogeneity in published studies, future long-term standardized comparative studies should be conducted., Competing Interests: Declaration of Competing Interest None declared., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Background: Several bone grafting techniques for posterior atlantoaxial arthrodesis have been reported. The techniques of placing a cancellous morselized bone graft (MBG) on decorticated surfaces of the atlantoaxial complex and securing a structural iliac bone graft (SBG) between C1 and C2 have been used widely. The aim of the present study was to compare the outcomes of these 2 bone grafting techniques for atlantoaxial arthrodesis., Methods: The data from 64 patients with reducible atlantoaxial dislocation treated using posterior C1-C2 screw-rod fixation and fusion were retrospectively reviewed. The MBG technique had been used in 32 patients and the SBG technique in 32 patients. The time required for bone fusion was recorded. The outcomes were evaluated using the Japanese Orthopaedic Association scale score, Neck Disability Index, visual analog scale (VAS) score for neck pain, patient satisfaction, and neck stiffness and compared between the 2 groups. The donor site complications were also compared, and donor site pain was assessed using a VAS., Results: At the final follow-up, the bone fusion rate was 100% in both groups. No significant differences were found in the bone fusion time or donor site pain between the 2 groups (P > 0.05). Postoperatively, The Japanese Orthopaedic Association scale scores, Neck Disability Index, and VAS score for neck pain had improved significantly within both groups (P < 0.05), with no statistically significant differences between the 2 groups (P > 0.05). Additionally, no differences were found between the 2 groups in patient satisfaction and neck stiffness postoperatively (P > 0.05)., Conclusions: The MBG and SBG techniques were both effective for atlantoaxial arthrodesis, with the advantages of reducing the potential risk of catastrophic bleeding of the epidural venous plexus and C2 nerve root injury., (Copyright © 2020 Elsevier Inc. All rights reserved.)

In cases with difficult scaphoid screw placement due to small, fragile bone fragments, or transplants and insufficient space, the internal Kirschner wire fixation is a fallback option; however, controversy remains regarding its stability, safety, and outcome. Between 2001 and 2011, 95 patients were treated in our center (n = 80 with cannulated compression screws and n = 15 with Kirschner wires), and retrospectively analyzed. The outcome measurements included the analysis of patient data, union rate and analysis of functional measures, and quality of life. Bony reconstructions were performed with Vascularized Bone Grafts (VBG) based on the 1,2-Intercompartmental Supraretinacular Artery (ICSRA) , Medial Femoral Condyle (MFC)-VBG, cancellous bone, and iliac crest grafts. Bony healing and functional outcome showed no significant differences between Kirschner wire fixation and cannulated compression screws, although significantly more 1,2-ICSRA-VBG were treated with Kirschner wires. Although predominantly used as an intraoperative fallback option, our data demonstrate that Kirschner wire internal fixation can be safe and reliable, with comparable bony union rates and excellent functional outcomes., Competing Interests: Declaration of Competing Interest None., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Background: Preoperative prognostication of adverse events (AEs) for patients undergoing surgery for lumbar degenerative spondylolisthesis (LDS) can improve risk stratification and help guide the surgical decision-making process. The aim of this study was to develop and validate a set of predictive variables for 30-day AEs after surgery for LDS., Methods: The American College of Surgeons National Surgical Quality Improvement Program was used for this study (2005-2016). Logistic regression (enter, stepwise, and forward) and LASSO (least absolute shrinkage and selection operator) methods were performed to identify and select variables for analyses, which resulted in 26 potential models. The final model was selected based on clinical criteria and numeric results., Results: The overall 30-day rate of AEs for 80,610 patients who underwent surgery for LDS in this database was 4.9% (n = 3965). The median age of the cohort was 58.0 years (range, 18-89 years). The model with the following 10-predictive factors (age, gender, American Society of Anesthesiologists grade, autogenous iliac bone graft, instrumented fusion, levels of surgery, surgical approach, functional status, preoperative serum albumin [g/dL] and serum alkaline phosphatase [IU/L]) performed well on the discrimination, calibration, Brier score, and decision analyses to develop machine learning algorithms. Logistic regression showed higher areas under the curve than did LASSO methods across the different models. The predictive probability derived from the best model is uploaded on an open-access Web application, which can be found at: https://spine.massgeneral.org/drupal/Lumbar-Degenerative-AdverseEvents., Conclusions: It is feasible to develop machine learning algorithms from large datasets to provide useful tools for patient counseling and surgical risk assessment., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Locally aggressive vertebral body tumors of the axis must be treated with wide local excision for best outcome. Reconstruction of the load-bearing vertebra needs to be done after tumor resection in such a manner so as to give stable, long-term fusion in this young population., Methods: We describe the management strategy of a 25-year-old acutely quadriplegic patient, with respiratory distress, with a C2 giant cell tumor. The use of a novel iliac crest graft modification used for C2 reconstruction along with a modified mesh cage used as an anterior plate has been reported., Results: The patient had a good outcome at 18 months' follow-up, with neurologic improvement and a solid fusion., Conclusions: Iliac crest autograft is inexpensive and easy to harvest and can be considered as a C2 prosthesis, especially in a resource-constrained setting. Modified iliac crest graft can be used for load transmission from C1 lateral mass to C3 body, and the mesh cage can be modified according to need as a plate with good results in an emergency., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Clavicle non-union is a challenging problem. Open reduction with internal fixation and autologous bone grafting is usually the first line treatment. In case of failure, the medial femoral condyle corticoperiosteal flap in association with a non-vascularized bone graft is one of the therapeutic options, which is well adapted to the clavicle anatomical characteristics. We performed a retrospective study of all patients treated with this technique in our department. Between 2014 and 2017, five patients with recalcitrant post traumatic clavicle non-unions received this surgical treatment. The average nonunion time period was 50.2 month (range 10 to 108 months), and the mean defect length was 3.4 cm (between 2 and 5 cm), defects were all located in the medial third of the clavicle Three patients achieved full consolidation with an average time of consolidation of 8,7 months (range 6 to12 months). Patients with radiological consolidation had better functional improvement and pain reduction with an average DASH score improved from 53,6 before surgery to 19,6 after consolidation (at the last follow up visit). There was one donor site complications (hematoma). The medial femoral condyle corticoperiosteal flap with non-vascularized iliac crest graft is a good option for the management of recalcitrant clavicle non-union, especially when the bone defect is small., Competing Interests: Declaration of Competing Interest The authors certify that they have no financial and personal relationships with other people or organisations that could inappropriately influence their work., (Copyright © 2020 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Objective: To compare the radiologic union rates between autogenous iliac crest bone graft (ICBG) and local bone graft in 1- to 3-level lumbar fusion., Methods: We reviewed 178 consecutive patients who underwent 1- to 3-level lumbar fusion surgery because of lumbar spinal stenosis. Fusion status of the anterior or posterior column was evaluated by plain radiographs obtained at 24 months postoperatively. If at least either the anterior or posterior column was fused, that segment was regarded as having achieved fusion and was termed segment union. The definition of overall union was achieving union of all segments in a single patient., Results: For each ICBG group and local bone graft group, fusion rate of the anterior and posterior column, and rate of the segments and overall union at postoperative 2 years were not different between the groups, regardless of surgery level. In the overall union rate according to the fusion level, the ICBG group showed constant overall fusion rate according to the fusion level (i.e., 96.9%, 96.9%, and 93.1% for 1-, 2-, and 3-level fusion), but tended to decrease with increasing level in the local bone graft group (100%, 95.8%, and 85.7% for 1-, 2-, and 3-level fusion, respectively) without statistically significant differences., Conclusions: The union rate of 3-level fusion was not inferior to those of 1- or 2-level fusion in both ICBG and local bone graft patients. Local bone graft could be regarded as an adequate option for not only 1- or 2-level lumbar fusion but also 3-level lumbar fusion surgery., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: The management of traumatic composite bone and soft tissue loss (TCBSTL) requires a classification system and decision-making algorithm for the purpose of description, prognosis and choice of treatment method., Patients and Methods: between the year 2000 and 2017 a series of 254 cases of TCBSTL were treated using distraction histogenesis and external fixation techniques. The tissue loss was due to either the initial injury or debridement of infection. Adjunctive procedures included split thickness skin grafting and ICBG when indicated. A classification system was designed by the author. The classification is based on factors that influence management and prognosis; (1) stability of the host bone (intact tibia or a well-fixed fracture), (2) presence or absence of infection in the fracture site, (3) size of bone defect, and (4) contamination (infection) of the medullary cavity. A flowchart and decision-making algorithm was subsequently developed., Results: Ilizarov external fixator was used in all cases. Ten cases (4%) had combined Masquelet - Ilizarov technique. One hundred seventy five cases (68.9%) had gradual distraction-compression (GDC) technique; while 79 cases (31.1%) had acute shortening and re-lengthening (ASRL) technique. Seventy-two cases (28.3%) had autogenous iliac crest bone graft (ICBG). All cases (100%) had complete clinical and radiological fracture union. All patients completed the follow up that ranged from 24 to 118 months (mean 43.3 ± 23). The results were satisfactory in 212 cases (83.5%) and unsatisfactory in 42 (16.5%) cases due to residual leg length discrepancy, joint stiffness, and persistent pain., Discussion: the proposed classification is simple, applicable, recallable and includes most scenarios of reconstructable TCBSTL. The classification provides a basis for communication, description and evaluation of such cases. The algorithm, based on our classification, provides a guideline for management without over/under treatment., Competing Interests: Declaration Competing of Interest The authors declare no conflict of interest., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Background: To systematically evaluate the effect of bone morphogenetic protein-2 (BMP-2) and iliac cancellous bone graft (ICBG) on alveolar cleft bone grafting (ACBG) in cleft lip and palate., Method: Online databases were searched for case-control studies related to the application of BMP-2 and ICBG in ACBG., Result: Meta-analysis showed no significant statistical difference in the filling rate (OR = 4.1, 95% CI (0.06, 2.63)), the volume of bone graft area (OR=-0.42, 95% CI (-1.44, 0.60)), the height of bone graft area (OR = -21.38, 95% CI (-23.00, -19.76)), the density of bone graft area (OR = 0.43, 95% CI (-0.79, 1.64)), the failure rate of bone graft (OR = 0.02, 95% CI (-0.03, 0.06)), infection after operation, and the rate (OR = 0.20, 95% CI (0.05, 0.73)) and the incidence of postoperative oronasal fistula (OR = 4.1, 95% CI (0.06, 2.63)) between BMP-2 and ICBG in ACBG. However, there were obvious statistical differences in operative time (OR = -3.64, 95% CI (-7.35, 0.06)) and the length of hospital stay (OR = -1.97, 95% CI (-2.41, -1.53))., Conclusion: The meta-analysis shows that there is no significant difference between BMP-2 and ICBG in filling rate, volume, density, failure rate, and the occurrence of oronasal fistula after ACBG. There were significant differences between BMP-2 and ICBG in the operation time and hospitalization time of ACBG. Compared with ICBG bone graft, BMP-2 has more advantages in ACBG such as remaining area height, postoperative infection rate, operative time, and length of hospital stay., Competing Interests: Declaration of Competing Interest None of the listed authors have conflicts of interest or any disclosures., (Copyright © 2020. Published by Elsevier Ltd.)

Objective: The interlaminar fusion combination involving C1-C2 screwing fixation is one of the most effective techniques for atlantoaxial dislocation or subluxation, and the bone graft is usually stabilized by wiring constructs. However, some adverse events were reported during the insertion of sublaminar wiring, such as accidentally damaging the spinal cord or dura. Thus we used the miniplate to stabilize the harvest bone graft on the C1-C2 laminar, which led to a shorter operation time and prevented spinal canal violation. This study investigated the safety and efficacy of the novel surgical technique, namely miniplate-augmented interlaminar fusion., Methods: We retrospectively reviewed 43 patients who underwent posterior atlantoaxial fusion with the miniplate-augmented iliac crest autograft at our institute. Complications related to surgery were recorded and calculated. After operation, patients were followed up through routine radiography to examine whether the fusion of the atlantoaxial segment was achieved. Success of fusion was defined as follows: 1) the presence of bone bridging between the bone graft and both the atlas and axis; and 2) the absence of movement of the atlantoaxial spinous process on flexion-extension radiography, which meant that the variation of length measured in 2 views, respectively, was <1 mm. The first time when radiography showed successful fusion after surgery was termed as fusion time and was recorded individually. In addition, overall fusion rates and mean fusion times were analyzed., Results: Of 43 patients, long-term follow-up data were available for 31 patients, whereas the remaining 12 patients had dropped out (mean follow-up duration, 24.91 months; range, 6-72 months). Among 31 patients, 22 (70.96%) were women and 9 (29.03%) were men. The mean age was 63.33 years. Regarding the etiology, atlantoaxial dislocations or subluxations were caused due to degeneration, rheumatoid arthritis, odontoid fracture, trauma, and os odontoideum in 14 (45%), 3 (10%), 5 (16%), 8 (26%), and 1 (3%) patient(s), respectively. Successful fusion was achieved in 30 (96.77%) patients, with a mean fusion time of 6.23 months, whereas only 1 (3.23%) patient did not meet the fusion criteria. No complications related to the miniplate occurred. We noted vertebral artery rupture not requiring blood transfusion in 1 patient, aspiration pneumonia in 1 patient, urinary tract infection in 1 patient, anemia requiring transfusion in 1 patient, and leg dysesthesia in 1 patient. No neurologic deficit was found., Conclusions: Miniplate-augmented interlaminar fusion with C1-C2 screwing resulted in excellent fusion rates with a considerably low probability of complications. Hence this novel technique for bone graft fixation with atlantoaxial screwing has a good efficacy and safety and can serve as an alternative for bone graft fixation during C1-C2 fusion., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: The purposes of the present study were to introduce an indirect decompression using oblique lateral lumbar interbody fusion combined with anterolateral screw fixation (OLIF-AF) for the treatment of lumbar degenerative disc disease and examine the clinical efficacy and radiographic outcomes., Methods: A total of 65 patients had undergone single-level OLIF-AF at L2-L5 from December 2017 to August 2018. The cross-sectional area of the thecal sac was evaluated using magnetic resonance imaging. The disk height, foraminal height (FH), and degree of upper vertebral slippage were evaluated using computed tomography. The visual analog scale score and Oswestry disability index were recorded pre- and postoperatively., Results: The visual analog scale scores and Oswestry disability index had significantly improved after surgery (P < 0.001). At 3 days postoperatively, the cross-sectional area had improved from 93.2 ± 14.4 mm 2 to 124.2 ± 7.5 mm 2 (P < 0.001), the disk height had increased from 9.9 ± 1.7 mm to 12.7 ± 1.0 mm (P < 0.001), the left FH had increased from 16.6 ± 2.0 mm to 19.6 ± 2.0 mm (P < 0.001). In contrast, the right FH had increased from 16.7 ± 2.1 mm to 19.9 ± 2.0 mm (P < 0.001), and the degree of upper vertebral slippage had decreased from 14.2% ± 3.1% to 4.6% ± 2.8% (P < 0.001), respectively. At the 12-month follow-up examination, these parameters showed no statistically significant differences compared with the values at 3 days postoperatively (P > 0.05). Adverse events were observed in 15 patients (23.1%) patients and included pain at the iliac bone donor site in 1 (1.5%), left thigh pain/numbness in 2 (3.1%), quadriceps weakness in 2 (3.1%), psoas weakness in 3 (4.6%), intraoperative endplate injury in 2 (3.1%) and cage subsidence in 5 (7.7%)., Conclusions: Our results have shown that OLIF-AF surgery is a relatively safe and effective surgical option for LDDD at L2-L5. Cage subsidence was the most common operative complication., (Copyright © 2019 Elsevier Inc. All rights reserved.)

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., (Copyright © 2019. Published by Elsevier Ltd.)

Introduction: Bone grafting of alveolar clefts is routinely performed with cancellous bone harvested from the iliac crest. Graft site morbidity is frequently seen, with early postoperative pain being one of the most common complaints. Liposomal bupivacaine (LB) has been demonstrated to provide improvement in postoperative pain for patients undergoing bunionectomy or hemorrhoidectomy, which may translate to patients requiring iliac crest bone graft harvest., Methods: Thirty-eight patients undergoing iliac crest bone harvest were included in the study. Twenty-one patients underwent open iliac crest bone graft harvest with administration of 0.25% bupivacaine at the hip donor site, while 17 patients received local infiltration of 1.3% liposomal bupivacaine. Patient-reported pain scores, total narcotic use, length of stay, and postoperative steps were monitored., Results: There were no significant differences in age, weight, distribution of clefts, or choice of donor hip between the two groups. There were no significant differences in length of hospitalization stay. However, differences were noted in average postoperative pain scores at five of six time points in the first 24 h, total oral morphine equivalents administered (4.7 ± 5.3 vs. 14.3 ± 12.0), and steps at postoperative days one to three (p < 0.001, for all three days) for patients receiving 1.3% LB versus 0.25% bupivacaine, respectively., Conclusion: Reduced pain scores and increased postoperative activity highlight the potential of LB to improve postoperative pain management in children undergoing iliac crest bone harvest for alveolar bone grafting., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Intraoral anastomosis of free flaps was introduced to avoid extraoral scars. In addition, advances in vascularized iliac-crest flap have greatly facilitated jaw reconstruction. The primary aim of this study was to evaluate feasibility and outcomes of intraoral anastomosis of vascularized iliac-crest flaps used for jaw reconstruction. Methods: From December 2015 to June 2018, 10 (3 men and 7 women) patients aged 12-55 (median, 28) years were treated at the Peking University School and Stomatology Hospital, China. Six patients underwent maxillary reconstruction, and four patients underwent mandibular reconstruction with the intraoral anastomosis of vascularized iliac-crest flaps. Conclusion: In all cases, the facial artery was easily identified by intraoral Doppler ultrasound. The operative time for the preparation of facial vessels by the intraoral approach was 30-60 minutes. All DCIA flaps were successfully harvested. All intraoral anastomoses were successfully established and survived in 9 patients. However, one flap for maxillary reconstruction was lost because of arterial spasm. Nine patients with survived flaps had unrestricted mobilization and showed facial symmetry after surgery. No healing complications were reported in the transplant region in nine patients with survived flaps, and no serious donor site complications were observed during the follow-up period., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Objective: 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., Methods: 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 time <2 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., Results: 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)., Conclusions: Additional bone grafting of the atlantoaxial joint could increase the bone fusion rate of iliac crest autograft in posterior occipitocervical fusion., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Posttraumatic coronoid deficiency is one of the most challenging scenarios even for the most experienced elbow surgeon. Surgical options can be grouped into soft tissue reconstructions, autogenous corticocancellous bone graft reconstructions, osteochondral reconstructions, and prosthetic replacement. However, the literature is inconclusive with limited cases, short follow-up, and no conclusive clinical comparative studies of these techniques. This article provides a review of the current surgical options, and we offer the senior author's (S.W.O.) perspective after years of experience with many of these techniques., (Copyright © 2019 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Purpose: The Masquelet technique is a procedure increasingly utilized for addressing segmental bone defects. The technique involves staged procedures consisting of bone debridement and temporary spacer placement to induce membrane formation, followed by delayed bone grafting. This report summarizes our center's experience with the Masquelet technique to reconstruct bone loss exclusively in the forearm., Methods: We reviewed all cases in which the Masquelet technique was used to reconstruct segmental bone defects in the forearm resulting from acute trauma or nonunion, with or without infection, between 2014 and 2017 at a level-1 trauma center. Injury mechanism, prior surgeries, extent of bone defect, and demographic data were collected. Union was assessed along with treatment-related complications or reoperations., Results: We identified 9 patients with segmental bony defects in the forearm treated with the Masquelet technique. Among this cohort, 5 patients had bone defects associated with acute open fractures and 4 patients presented with nonunion (1 atrophic and 3 infected nonunions). The median bony defect was 4.7 cm (range, 1.7-5.4 cm) at the time of grafting. Second stage grafting was performed with Reamer Irrigator Aspirator autograft from the femur in 8 patients and iliac crest bone cancellous graft in 1 patient. Union was achieved in all 9 patients. Six patients achieved union by 3-month follow-up, 2 patients by 6 months, and 1 patient by 12 months. One patient required a reoperation for plate fracture prior to union treated with revision internal fixation and grafting., Conclusions: The Masquelet technique effectively reconstructed traumatic and posttraumatic segmental defects in the forearm with a low incidence of complication., Type of Study/level of Evidence: Therapeutic V., (Copyright © 2019 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Background: We have introduced a new operation for isthmic spondylolysis in adolescents and evaluated its clinical efficacy., Methods: A total of 30 adolescent patients with isthmic spondylolysis and chronic low back pain underwent "temporary" short-segmental pedicle screw combined with transverse device fixation and isthmic bone graft repair treatment. Radiograph and computed tomography images were evaluated during regular follow-up examinations to confirm successful bone graft fusion, after which the fixation was removed. Lumbar magnetic resonance imaging was performed before and 1 year after fixation surgery and 1 year after fixation removal. Modic and Pfirrmann grading standards were used to observe the effect of "temporary" fixation on the corresponding vertebral endplate and intervertebral disc., Results: All 30 patients had complete follow-up data available at 2 years postoperatively. The low back pain symptoms had disappeared completely, and radiographs and computed tomography showed that the isthmus in all patients had achieved bony fusion. With removal of the internal fixation, motion of the fixed segment recovered. "Temporary" rigid internal fixation did not increase the corresponding vertebral endplate or intervertebral disc degeneration., Conclusions: "Temporary" short-segmental pedicle screw combined with transverse device fixation is a simple and effective method for adolescent isthmic spondylolysis with rigid internal fixation and accelerated bone graft fusion., (Copyright © 2018. Published by Elsevier Inc.)

Introduction: In edentulous patients the form and size of the maxillary sinus vary greatly. Therefore sinus floor augmentation is a standard procedure for implantological purposes. As the sinus membrane cannot be characterized as periosteum, various augmentation materials are used., Hypothesis: an artificially generated space underneath the sinus membrane in the floor of the sinus will lead to spontaneous callus forming and a stable bony consolidation without augmentation material., Methods: Ten edentulous patients with highly atrophic maxillae were selected. Augmentation of the sinus floor was carried out in a split-mouth study design: On one side a combination of autogenous and xenogenous bone was used, and on the contralateral side a sinus membrane elevation was performed without using any substitutes. After a 6-month interval bone specimens from the test regions were harvested during implant placement., Results: Clear histological evidence of new bone formation was found in all human bone specimens. An active de-novo bone formation process could be proven by the presence of Haversian systems (osteons) displaying osteoblastic and osteoclastic activity., Conclusion: In the maxillary sinus of edentulous patients a spontaneous callus-derived de-novo bone formation is possible by elevating the sinus membrane without using augmentation materials., (Copyright © 2019 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Purpose: The aim of the present study was the histomorphometric and cephalometric comparison of autogenous bone grafting of the anterior iliac crest and the application of bovine bone substitute concerning new bone formation and postoperative stability in patients undergoing orthognathic Le Fort I osteotomy., Patients and Methods: Twenty-five patients requiring orthognathic surgery with Le Fort I osteotomy were included in this study. Patients were randomly divided into three groups receiving either autogenous iliac crest BONE grafting (BONE; n = 8) or xenogenic bovine bone grafting (Bio-Oss ® ) in INTER (n = 12) or in ONLAY (n = 5) position. Histomorphometric analysis was performed using trephine bone biopsies from the autogenous, respectively xenogenic bone grafting region. Postoperative stability was evaluated using teleradiographies of three different timepoints., Results: All groups showed comparable mineralized fractions in bone biopsies of 50.2% (±13.2%) INTER, 46.48% (±12.3%) ONLAY and 57.1% (±20.6%) BONE as well as comparable percentage of connective tissue. Patients in the INTER-group revealed the lowest relapse rate of 20.5% (INTER) compared to 30.3% (ONLAY) and 33.0% (BONE). All groups underwent comparable maxillary advancement and healing time., Conclusions: Present results indicate that block shaped bovine bone substitute is a promising alternative to autogenous bone grafting to bridge the Le Fort I osteotomy gap in orthognathic surgery., (Copyright © 2018 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Treatment of forearm nonunion associated with bone defects can be challenging. Restoring the correct length and rotation are two main principles for the management of these patients. Herein, we describe a patient with isolated radius nonunion already treated with an iliac crest autograft with no success. A free vascularized osteoseptocutaneous fibular autogenous graft was harvested as the final solution to managed long bone defect after previous multiple surgeries. At the 1- year follow-up, the patient gained full range of motion and was functioning well., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

An infected non-union is a major and potentially devastating complication following bone fractures. It is often debilitating for the patients, physically and psychologically, because of its long healing period and emotional toll on patient and caregivers. Different surgical procedures (in one or two stages) are described in literature for its treatment. These range from external fixation (axial or circular) to internal fixation (nails or plates) associated or not with different types of biological support/augmentation (iliac crest bone graft, platelet rich plasma, bone morphogenic protein, etc.). This case report is about a 19 y.o. man affected by an infected non-union of the femoral shaft, who had to undergo a revision surgery a year after his accident. The treatment chosen by the senior author was the following one stage procedure: external fixator removal, surgical debridement, reduction and fixation of the fracture with a locked plate (internal fixator), bone graft and antibiotic cement usage. The use of new iliac crest bone graft after three months was necessary to obtain radiographic and clinical healing with great patient's satisfaction. The autologous iliac bone graft was chosen because it was necessary to give the patient the highest chance of healing. Despite the great experimental and clinical efforts to stimulate the biological healing process through the use of growth factors, stem cells, tissue scaffolds and other methods, today the gold standard of bone graft is still the autologous cancellous bone from the iliac crest., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Purpose: The objective of the present study was to evaluate the outcome of surgical treatment of hand lesions in Ollier disease (OD) carried out during childhood., Methods: A retrospective review was carried out of 10 pediatric patients with hand involvement of OD, who had undergone surgery for metacarpal or phalangeal enchondromas. The technique comprised curettage and cortical bone reconstruction with corticoplasty, to restore a near-normal phalangeal volume. The range of finger motion (pulp-to-palm distance), the shortened Disabilities of the Arm, Shoulder, and Hand (QuickDASH) questionnaire score, cosmetic improvement, radiological findings (according to Tordai's classification), and recurrence were recorded after a mean follow-up of 7.5 years (range, 4-11.3 years)., Results: The mean age at surgery was 10.7 years (range, 6-14 years). Curettage was performed on 35 enchondromas, and 9 cavities were filled with a bone graft. The mean pulp-to-palm distance was significantly lower after surgery (from 1.5 cm to 0.25 cm; P < .05). The mean QuickDASH score was 3.84 (range, 0-11.4). A marked cosmetic improvement was noted for 83% of the hands. Three enchondromas recurred in 1 patient, requiring a second curettage. Fifty-seven percent of the cavities were completely filled with bone (Tordai stage 1) at last follow-up. The outcome did not depend on the presence or absence of a bone graft., Conclusions: Our results suggest that early surgical treatment comprising curettage and corticoplasty leads to good clinical, cosmetic, and radiological outcomes. Early surgical treatment of well-developed and/or symptomatic enchondromas of the hand in OD should be considered., Type of Study/level of Evidence: Therapeutic V., (Copyright © 2018 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Purpose: To describe the results of nonsurgical and surgical treatment of enchondromas of the distal phalanx of the hand., Methods: Eleven enchondromas of the distal phalanx were retrospectively reviewed. Five patients underwent surgery (curettage and autogenous cancellous bone graft from the iliac crest) and 6 patients were treated nonsurgically. Clinical records and radiographs were reviewed for each patient. We recorded complications and cosmetic and functional results. Radiographic healing in surgical patients was scored according to the classification of Tordai and to the criteria of Wilhelm and Feldmeier. The average follow-up of the nonsurgical and surgical cases was 45 and 62 months, respectively., Results: Eight patients were women. Average age at diagnosis was 40 years. Nine patients presented with a pathological fracture. The demographic characteristics of the surgical group and nonsurgical group were similar. Among the cases treated nonsurgically (6), 1 had 2 pathological fractures after diagnosis. At final follow-up, the average pain on a visual analog scale was 2.8. With the exception of 1 patient, the range of motion of the fingers was normal or minimally reduced. Among the surgical cases (5), there were no complications in the bone graft donor site, 2 patients developed infections in the operated finger, and no postoperative pathological fractures were found. At final follow-up, the average pain was 3.2. Joint mobility was normal in 3 patients. Postoperative radiological examination revealed complete bone healing in all patients (grade I in the Tordai classification). No local recurrence was seen. According to the criteria of Wilhelm and Feldmeier, there were 3 excellent, 1 good, and 1 satisfactory results in the surgical group, and 2 excellent, 3 good, and 1 satisfactory results in the nonsurgical group., Conclusions: Surgical and nonsurgical treatment in distal phalanx enchondromas appear to be associated with satisfactory results, although each has their own advantages and disadvantages., Type of Study/level of Evidence: Therapeutic IV., (Copyright © 2018 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Objectives: Surgical treatment of femoral neck fracture in young adults is clinically challenging due to the high incidence of avascular necrosis of femoral head and fracture nonunion. The objective of this study is to evaluate the effectiveness of cannulated screws with deep circumflex iliac artery bone grafting (DCIABG) by comparing to the routinely used method in the treatment of femoral neck fracture in young adults., Methods: From March 2006 to December 2012, a total of 185 patients with femoral neck fracture were admitted to the hospital for internal fixation surgery, 103 patients (61 males and 42 females, mean age of 39.1 years) were treated with three cannulated screws with DCIABG (group A), and 82 patients (49 males and 33 females, mean age of 35.5 years) were treated with three cannulated screws without DCIABG (group B)., Results: All patients were followed up for at least 24 months after the surgery. The patients in group A had a significantly higher Harris Hip Score (p < 0.001), shorter fracture healing time (p < 0.001), lower occurrence rate of avascular necrosis of femoral head (p = 0.008) and fracture nonunion (p = 0.012) compared to the patients in group B. However, the operation time and intraoperative blood loss were significantly lower in patients in group B than those in group A (p < 0.001)., Conclusions: Cannulated screws with DCIABG significantly reduced femoral head osteonecrosis and fracture nonunion. Therefore, it is a feasible and effective method in the treatment of young adult patients with femoral neck fracture., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

When combined with iliac bone, perforator flaps are more chimeric, and there is increased mobile skin island to reconstruct soft tissue defects in the oral and maxillofacial region. This study examined oromandibular defects reconstructed using deep circumflex iliac artery perforator flap with iliac crest (DCIAPF). We retrospectively reviewed records of 23 patients with mandibular defects received DCIAPFs after oncological resection for oromandibular reconstruction from November 2015 to August 2016. All perforators, identified before surgery by Doppler examination, were terminal perforators of DCIA. DCIAPFs were successfully harvested in all patients. The flap survival rate was 95.6% (22/23); one flap failed due to artery spasm. Three patients developed slight skinedge necrosis in the skin island. Anatomical reconstruction contour of the mandible and sufficient bone length and height were achieved, with no serious donor-site complications during the follow-up period. The results demonstrated that DCIAPF is a favorable single-flap option for oromandibular reconstruction after oncological resection with fewer donor-site complications because of its adequate bone tissue and satisfactory soft tissue, with a constant location of the perforator., (Copyright © 2018 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Human mesenchymal stromal cells (hMSCs) are the cellular source of new bone formation and an essential component of autologous bone grafts. Autologous bone graft harvesting is routinely conducted at the iliac crest, although alternative donor sites with lower complication rates are available. Thus, the aim of this study was to compare hMSCs harvested from the iliac crest and the proximal tibia regarding their proliferative and osteogenic differentiation capacity. Furthermore, we investigated the influence of donor age on these biological properties. HMSCs were isolated from iliac crest or proximal tibia bone grafts of 46 patients. Proliferative capacity was assessed by cumulative population doublings, population doubling time, colony forming units and cell proliferation assays. Osteogenic capacity was assessed by quantification of extracellular calcium deposition and marker gene expression levels. The number of hMSCs per gram harvested tissue was determined. Furthermore, the adipogenic and chondrogenic differentiation capacity were quantified using BODIPY and Safranin Orange staining, respectively. Additional analyses were carried out after grouping young (18-49 years) and aged (≥50 years) donors. HMSCs derived from the proximal tibia featured a comparable proliferative and osteogenic differentiation capacity. No significant differences were found for any analysis conducted, when compared to hMSCs obtained from the iliac crest. Furthermore, no significant differences could be revealed when comparing young and aged donors. This was equally true for hMSCs from both donor sites after comparison within the same age group. Our study demonstrates comparable biological properties of hMSCs derived from both donor sites, the iliac crest and the proximal tibia. Furthermore, aging does not alter proliferative and osteogenic differentiation capacity. Consequently, the proximal tibia should be considered more closely as an alternative donor site in patients of all age groups., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Background: Parathyroid hormone (PTH) (1-34) treatment reduces fracture risk in osteoporotic patients. Previously, we demonstrated in a rabbit model that low-dose PTH treatment resulted in increased fusion mass volume. As effects of PTH on bone are dose-dependent, we aimed to evaluate whether increasing dosage of PTH increases both volume and biomechanical stiffness of the resulting fusion masses and/or exhibits synergistic effects with low-dose bone morphogenetic protein 2 (BMP-2)., Methods: Posterolateral lumbar spinal fusion surgery was performed on 60 New Zealand White rabbits divided into 6 experimental groups: iliac crest autograft alone, autograft plus 20 μg/kg/day PTH, autograft plus 40 μg/kg/day PTH, BMP-2 alone, BMP-2 plus 20 μg/kg/day PTH, and BMP-2 plus 40 μg/kg PTH. Fusion was assessed at postoperative week 6 via manual palpation, volumetric computed tomography analysis, and 4-point bending biomechanical testing., Results: All groups treated with BMP-2 fused. Increasing doses of PTH resulted in increased fusion mass volume compared with autograft alone. Autograft plus 40 μg/kg/day PTH yielded fusion mass volumes comparable to BMP-2. When the autograft groups were considered alone, increased mechanical stiffness was observed only in the 20 μg/kg/day group. No significant stiffness differences were observed between BMP-2 groups., Conclusions: Treatment with the highest dose of PTH resulted in fusion mass volumes similar to those obtained with BMP-2. When the autograft groups were considered alone, significant increases in mechanical stiffness were observed at a dosage of 20 μg/kg/day, suggesting there may be an optimal dose of PTH in the rabbit model. Effects of BMP-2 on fusion were dominant., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Lateral inter-body fusion (LIF) using cages with a large bone grafting space can lead to a shortage of autologous grafting materials. The use of artificial bone is an option to increase the volume of grafting materials. However, the rate of bony fusion for these materials compared to that of autologous bone is unclear., Methods: The bone fusion rate for artificial bone (HAp/Col) and autologous iliac bone (IBG) graft among 23 patients who had undergone LIF (total 66 disc levels) combined with multilevel posterior corrective fusion for the treatment of adult spinal deformity was retrospectively evaluated. To allow comparison, one of the two separate bone grafting holes in each LIF cage was filled with HAp/Col and the other, with IBG. The change in Hounsfield units (HU) inside the implanted holes at 1-year post surgery (PO1Y) from baseline and immediately after surgery and bony fusion between adjacent vertebrae, defined by the extent of trabecular continuity at PO1Y, were evaluated using computed tomography. Differences between the convex and concave sides as well as effects of the side of approach were investigated., Results: HU values increased significantly for IBG, from 228.9 at baseline to 286.1 at PO1Y (p < 0.001), with no change for HAp/Col. The fusion rate was higher for IBG (71.2%) than for HAp/Col (19.7%; p < 0.001). A significant effect of the location of the holes on fusion rate was identified for HAp/Col but not IBG. No effects of the side of approach were identified., Conclusions: A higher rate of fusion in LIF cages was obtained with IBG than with HAp/Col, with no effect of location of implantation (convex or concave) for IBG. Therefore, exclusive use of artificial bone, particularly on the convex side, should be avoided during LIF., (Copyright © 2018. Published by Elsevier B.V.)

Purpose: To describe one center's experience with nonunion of one or both bones of the forearm and report on the functional recovery of patients treated for a single- or 2-bone forearm nonunion., Methods: We performed a retrospective analysis of 23 patients who presented to our institution over an 11-year period and underwent surgical repair of a forearm nonunion (radius, ulna, or both bones). The main outcome measurements included time to union, visual analog scale pain scores, range of motion, Short Musculoskeletal Function Assessment scores, and postoperative complications., Results: Of the 23 patients, 21 (91.3%) healed their nonunion after a single surgical procedure. All patients ultimately healed their nonunion; 7 patients were healed at 3-month follow-up, 11 healed at 6-month follow-up, and 5 healed at 12-month follow-up. Mean visual analog scale pain scores improved considerably from presentation to latest follow-up. The mean range of motion at the latest follow-up was as follows: elbow 130.9° flexion-extension arc, forearm 78.5° pronation/77.8° supination, and wrist 76.1° palmar flexion/74.3° dorsiflexion. Mean Short Musculoskeletal Function Assessment arm and hand index scores improved significantly from baseline to the latest follow-up. Mean Short Musculoskeletal Function Assessment function, activity, and bothersome indices demonstrated improvement, though this was not statistically significant. Two patients required further surgery to achieve osseous union. One patient sustained an iatrogenic posterior interosseous nerve palsy, which resolved spontaneously., Conclusions: Repair of forearm nonunion with compression plating and bone grafting provides reliable clinical and functional outcomes. Patients treated surgically for nonunion of one or both of the forearm bones can expect to heal with the potential for considerable improvements in pain and function postoperatively., Type of Study/level of Evidence: Therapeutic IV., (Copyright © 2018 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

The purpose of this prospective randomised study was to compare the clinical and radiological outcomes of injectable CaP bone cement with corticocancellous bone graft used to fill voids after corrective opening wedge osteotomies in the distal radius. 17 women/3 men, median age 56 (51.3; 61.0), underwent an open-wedge osteotomy of a dorsal malunion in the distal radius randomised to filling the defect either with bone graft (10) or CaP bone cement (10). Dorsal titanium locking plates were used and the wrist was plastered for 8 weeks. Follow-ups for 24 months included X-rays, CT scans, VAS on wrist and iliac crest, grip strength, ROM, Quick-DASH and Gartland & Werley scores. No difference was found between the 2 groups as to clinical outcome or radiological results with no loss of reduction. One bone graft patient developed a pseudarthrosis and one CaP patient suffered a plate fracture 6 months post-operatively. CaP bone cement is a good alternative to bone graft as a void filler in open-wedge osteotomies of the distal radius. The procedure is shorter, easier with the post-operative advantage of no donor site pain. Level of Evidence Randomised controlled trial. Level I evidence., (Copyright © 2017. Published by Elsevier Ltd.)