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Background: The aim of this study was to investigate whether using an innervated vascularized iliac bone flap could effectively prevent bone resorption and maintain sensory function in the lower lip., Methods: In the innervated group, the deep circumflex iliac artery and recipient vessels were anastomosed, with simultaneous microanastomosis of ilioinguinal nerve, mental nerve, and inferior alveolar nerve. Conversely, the control group underwent solely vascular anastomosis. Computed tomography was used to assess bone quality. Sensory recovery of the lower lip was recorded using 2-point discrimination and current perception threshold testing., Results: The study comprised a total of 40 subjects, with each group accounting for 20 participants, equally distributed in terms of gender. Hounsfield unit loss was significantly lower in the innervated group (13.26% ± 8.65%) as compared with the control group (37.98% ± 8.60%) ( P < 0.001). Moreover, 2-point discrimination values were lower in the innervated group (15.11 ± 8.39 mm) when compared with the control group (21.44 ± 7.24 mm) ( P = 0.02). The current perception threshold values for the innervated group were 176.19 ± 31.89, 64.21 ± 19.23, and 42.29 ± 18.96 at 2 kHz, 250 Hz, and 5 Hz, respectively, whereas in the control group, the current perception threshold values were 204.47 ± 36.99, 82.26 ± 27.29, and 58.89 ± 25.38 at 2 kHz, 250 Hz, and 5 Hz ( P = 0.02, P = 0.02, and P = 0.03, respectively)., Conclusion: The innervated vascularized iliac bone flap represents a safe and effective novel approach to preserving lower lip sensation and preventing bone resorption through functional mandibular reconstruction., Clinical Question/level of Evidence: Therapeutic, I., (Copyright © 2024 by the American Society of Plastic Surgeons.)

Study Design: Assessment of bone formation in an ovine interbody fusion study., Objective: To compare OsteoAdapt SP, which consists of AMP-2, a modified variant of recombinant human bone morphogenetic protein (rhBMP-2) bound to a tricalcium phosphate-containing carrier, to autologous iliac crest bone graft (ICBG) in a lumbar interbody fusion model., Summary of Background Data: Treatment of lumbar disk degeneration often involves spinal fusion to reduce pain and motion at the affected spinal segment by insertion of a cage containing bone graft material. Three graft materials were compared in this study-ICBG and OsteoAdapt SP (low or high dose)., Methods: The sheep underwent lateral lumbar fusion surgery with PEEK or Titanium interbody cages packed with OsteoAdapt SP (low or high dose) or ICBG. Outcomes were evaluated at 8-, 16- and 26- weeks. Newly formed bone quality, bone mineralization, and fusion were assessed by manual palpation, qualitative and semi-quantitative histopathology, histomorphometry, computed tomography (CT), and micro-CT (mCT) analysis., Results: OsteoAdapt SP was implanted into 43 animals and ICBG into 21 animals (L3-L4). No group showed evidence of systemic toxicity by multiple assessments. All levels were fused by manual palpation at 26 weeks. Serial CT scans showed increasing fusion scores over time. Both doses of OsteoAdapt SP resulted in robust new bone formation and progression of fusion in the interbody cage. Range of motion tests for treatment groups was lower compared with ICBG at 8- and 16 weeks. Similarly, histology at eight weeks demonstrated more robust new bone formation for both OsteoAdapt SP groups compared to autograft., Conclusion: We have demonstrated the preclinical safety and efficacy of OsteoAdapt SP in a clinically relevant large animal model, supporting faster and more robust new bone formation within the interbody cage, comparable to or better than the gold standard, ICBG, in all measures., Competing Interests: The authors report no conflicts of interest., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc.)

Chronic ankle pain significantly impairs daily activities and athletic performance with osteochondral lesions of the talus (OLT) in Hepple stages IV and V, which are often causative factors. This study aimed to assess the efficacy and safety of autologous osteochondral transplantation (AOT) for the treatment of these conditions. This retrospective study was conducted from May 2020 to May 2023 at Cangzhou Traditional Chinese and Western Medicine Combined Hospital, including patients with a diagnosis of Hepple stage IV or V OLT confirmed by magnetic resonance imaging (MRI) and arthroscopy. Surgical interventions involved arthroscopic debridement, followed by AOT or limited arthrotomy based on the location and size of the lesion. Preoperative and postoperative evaluations used the Visual Analog Scale, American Orthopedic Foot and Ankle Society Ankle-Hindfoot Scale, MRI-Based Cartilage Repair Tissue Scoring, and the International Knee Documentation Committee Knee Evaluation Form. Statistical analysis was conducted using paired-sample t tests to compare the preoperative and postoperative data. Twenty patients were included, revealing significant postoperative improvements in Visual Analog Scale, American Orthopedic Foot and Ankle Society, and MRI-based cartilage repair tissue scores (P < .05). The radiographic findings suggested effective cartilage regeneration. No adverse effects were observed in the donor knee sites, as confirmed by the stable pre- and postoperative International Knee Documentation Committee Knee Evaluation Form scores. Recovery of physical abilities was achieved on average within 7.3 weeks for daily activities and 13.4 weeks for sports activities. AOT effectively treats Hepple stage IV-V OLT, improves ankle function, promotes cartilage regrowth, and allows quick resumption of daily and athletic activities without compromising donor-site integrity., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc.)

Background: The induced membrane technique is now widely used for pediatric diaphyseal bone loss due to various etiologies. Although consolidation rates remain satisfactory, complications, and healing delays may occur requiring additional procedures. We studied a series of induced membrane bone reconstructions in which the second stage included an embedded endomembranous non vascularized fibular shaft, in addition to iliac bone grafts. The purpose of this study was to analyze the results in terms of bone consolidation and complications., Methods: This is a retrospective comparative and multicentric study of 32 children with large bone loss treated with the induced membrane reconstruction technique. Patients were divided into 2 groups according to the graft used during the second stage. The first group (G1) of 16 patients had a nonvascularized fibula embedded inside the membrane in addition with the corticocancellous grafts from the iliac crest. The second group (G2) of 16 patients underwent reconstruction using the original technique, with iliac crest graft only., Results: The 2 groups were similar in terms of etiologies of bone loss and follow-up (mean: 44 mo for G1 and 49 mo for G2). Mean bone losses were 15.4 cm (range: 2 to 25; SD: 5.6) for G1 and 10.6 cm (range: 3 to 19; SD: 5.2) for G2. In the first group, all patients healed primarily, with a mean time of 5.9 months (range: 4 to 8; SD: 1.6). In the second group, 2 of 16 patients did not healed; for the others 14, healing mean time was 6.9 months (range: 3 to 12; SD: 2.7). The short-term and long-term complications rates were 38% to 19% for G1 and 50% to 31% for G2, respectively. Regarding the donor site, the fibulas reconstructed spontaneously with a mean time of 4.8 months (range: 3 to 6; SD: 1.2)., Conclusions: The integration of a nonvascularized fibula during the second stage of the induced membrane technique appears to improve the consolidation rate in the pediatric population., Level of Evidence: Level III-Retrospective comparative study., Competing Interests: Each author certifies that there are no funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article related to the author or any immediate family members. The authors declare no conflicts of interest., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc.)

Video Available at: https://ota.org/education/ota-online-resources/video-library-procedures-techniques/anterior-iliac-crest-bone-0., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Video Available at: https://ota.org/education/ota-online-resources/video-library-procedures-techniques/lateral-tibial-plateau., Competing Interests: Dr. S. R. Konda is a consultant for Stryker. The remaining authors report no conflict of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Abstract: Metacarpal bone loss presents a challenging reconstructive dilemma for hand surgeons. While multiple bone grafting techniques have been described, complications including nonunion, graft resorption, fixation requiring prolonged immobilization, stiffness, and the need for multiple procedures are well-documented. We present a technique for managing metacarpal bone loss utilizing a tri-cortical iliac crest graft and an intramedullary metacarpal nail for the treatment of metacarpal fractures and nonunions that is technically simple, fast, and allows for early initiation of motion to decrease postoperative complications., Level of Evidence: Level IV- Therapeutic., Competing Interests: Conflicts of Interest and Source of Funding: The authors report no conflicts of interest and no source of funding., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

The objective of this article is to propose a technique for mandibular reconstructions of up to 17 cm, in order to obtain anterior iliac crest grafts smaller than those required, and then lengthen them using corticotomies. This technique has been performed in 5 patients with an indication for reconstruction after partial mandibulectomy due to pathology. Reconstruction of the body of the mandible, including the angle in some cases, was performed using nonvascularized anterior iliac crest grafts. These were elongated using corticotomies and fixed to cover the defect using reconstruction plates and screws (2.4 system). The wedge spaces that were formed by lengthening the bone block were grafted with autologous medullary bone and platelet-rich plasma. There was no loss of any of the grafts and there was no need for second surgical times to place more grafts. All cases were able to be rehabilitated with removable prostheses or dental implants. This method optimizes the amount of graft obtained, favors revascularization of the graft, reduces hypoxia times and allows the placement of osteoconductive and/or osteoinductive grafts directly on the exposed medullary areas, with the aim of promoting integration and reducing the resorption rate in large grafts., Competing Interests: The authors report no conflicts of interest., (Copyright © 2022 by Mutaz B. Habal, MD.)

Background: Alveolar bone grafting is an important component of cleft lip and palate treatment, with iliac crest as the most common donor site. Although studies have attempted to quantify alveolar bone graft resorption, few have directly compared the outcomes of graft techniques. This study compared the long-term success rates of corticocancellous block to trephine cancellous-only alveolar bone grafting from the iliac crest., Methods: A retrospective review of all cleft lip and palate patients undergoing alveolar bone grafting over 14 years was performed. Power analysis was performed to determine sample size. Data including patient demographics, surgical technique, need for repeated grafting, complications, length of hospitalization, and follow-up were collected. Statistical analyses of outcomes were performed based on initial graft technique., Results: A total of 106 initial operations met criteria, with 73 using trephine technique, 30 using corticocancellous block, and three undergoing open cancellous harvest. The overall regraft rate was 40 percent, with an average follow-up of 43.5 months. Patients with corticocancellous block grafting had significantly lower rates of repeated grafting compared to trephine technique (16.7 percent versus 47.9 percent; p < 0.001). There was no significant difference in complication rates or length of admission between treatment groups., Conclusions: The use of corticocancellous block alveolar bone grafting demonstrated significantly higher success rates when compared to cancellous-only trephine techniques, with no difference in complication rates. Although this must be weighed against the minor disadvantages of open iliac harvest, surgeons should consider incorporating en bloc corticocancellous bone to optimize outcomes in alveolar bone grafting., Clinical Question/level of Evidence: Therapeutic, III., (Copyright © 2022 by the American Society of Plastic Surgeons.)

Summary: Secondary alveolar bone grafting is one of the key surgical procedures performed to restore dental arch continuity and facilitate tooth eruption in patients with cleft lip and palate. Harvest of cancellous bone graft from the iliac crest has become the gold standard; however. there is no consensus regarding the ideal technique. An optimal bone harvest technique must be aimed at producing minimal donor-site morbidity and patient discomfort. The success of the bone grafting procedure depends largely on the surgical technique. To restore cleft alveolar defects, one must be able to conceptualize the different underlying aspects of the problem to perform an effective surgical repair. It is important for surgeons-in-service to adopt newer techniques that significantly enhance the overall outcome. This article describes two techniques of iliac bone harvest and the principles involved in execution of the alveolar bone grafting procedure. The accompanying four-part video series depicts the bone harvest, flap design, dissection of the recipient cleft alveolus, and bone grafting in a step-by-step manner., (Copyright © 2022 by the American Society of Plastic Surgeons.)

Objective: To assess the outcomes of patients after rib nonunion reconstruction., Design: Retrospective case series., Setting: Level 1 trauma center., Patients/participants: Between January 2007 and August 2019, 25 consecutive patients with 51 nonunions with disabling pain or chronic instability were treated for nonunited rib fractures., Intervention: Rib nonunion reconstructions performed using plate and screw fixation, recannalizing the medullary canal and augmented with autogenous iliac crest bone graft., Main Outcome Measurements: Patient demographics, mechanism of injury, number of rib nonunions, and postoperative radiographs were assessed. Satisfaction, patient-reported complications, return to occupation and activity, and general health measures were captured using patient questionnaires., Results: In 25 patients, 51 painful rib nonunions were surgically treated. The average length from injury to surgical rib reconstruction was 25.1 months (range = 3-118 months; median = 12 months). Follow-up was obtained in 18 of 25 patients (72%) with a mean of 46.1 months (range = 13-139 months). All ribs achieved radiographic union at an average of 12.3 weeks (range = 8-24 weeks) after surgery. Sixteen of 18 patients (89%) reported satisfaction with surgery and 15 patients (83%) reported mild to no pain at final follow-up. Five patients had complications that all resolved after subsequent treatment., Conclusions: Successful treatment of symptomatic rib nonunion is possible using rib plates in conjunction with bone grafting and has high union rates, satisfactory results, and limited complications., Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: The authors report no conflict of interest. P. A. Cole is currently receiving institutional grant support from Stryker Inc., Depuy-Synthes, AOTrauma, AONA, COTA, OMeGA, honoraria from AOTrauma, and is a stockowner in Bonefoams, Inc. Funding sources did not play a role in this investigation. The remaining authors report no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: To compare blood loss and transfusion rates among reamer irrigator aspirator (RIA), iliac crest bone graft (ICBG), and proximal tibial curettage (PTC) for autograft harvest., Design: Retrospective comparative study., Setting: Level 1 trauma center., Patients/participants: The study included 139 adult patients treated between 2011 and 2018., Interventions: Nonunion repair of the femur or tibia using either RIA (n = 64), ICBG (n = 59), or PTC (n = 16) for autograft., Main Outcome Measurements: Estimated blood loss and transfusion rates., Results: Patient demographics, surgical indications, and medical comorbidities that affect bleeding did not differ among the groups. Estimated blood loss (mL) was significantly higher in the RIA group [RIA: 388 ± 368 (50-2000), ICBG: 286 ± 344 (10-2000), PTC: 196 mL ± 219 (10-700), P < 0.01]. The transfusion rate was also significantly higher in the RIA group (RIA 14%, ICBG 0%, PTC 0%, P < 0.01). The amount of graft obtained was higher in the RIA group (RIA = 48.3 mL, ICBG = 31.0 mL, PTC = 18.8 mL, P < 0.01), and the operative time (hours) was longer in the RIA group (RIA = 2.8, ICBG = 2.6, PTC = 1.9, P = 0.04)., Conclusion: Estimated blood loss and transfusion rates were significantly higher in patients undergoing RIA compared with those in patients undergoing ICBG and PTC; however, the incidence of transfusion after RIA (14%) was considerably lower than previous reports. These findings suggest that the risk of transfusion after RIA is present and clinically significant but lower than previously believed, and it is likely affected by the amount of graft obtained and complexity of the nonunion repair. The risk of transfusion should be discussed with patients and the choice of RIA carefully evaluated in patients who have anemia or risk factors of bleeding., Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: H.C. Sagi receives royalties and is a paid consultant of Acumed and Stryker, is on the editorial board for the Journal of Orthopaedic Trauma, and is a board member of the Orthopaedic Trauma Association. J.D. Wyrick is a paid presenter for Nuvasive and Smith & Nephew. M.T. Archdeacon receives royalties, is a paid consultant for Stryker and SLACK incorporated, and is a board or committee member of the Orthopaedic Trauma Association, Ohio Orthopaedic Society, and Journal of the American Academy of Orthopaedic Surgeons. The remaining authors report no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: There is no consensus in regard to grafts used after pelvic osteotomy in developmental dysplasia of the hip in the literature. The aim of this study was to compare iliac and femoral autografts used after Pemberton pelvic osteotomy (PPO)., Methods: In this prospective, randomized study, 60 hips with dysplasia of the hip were included. All patients underwent open reduction, PPO, and femoral shortening osteotomy. Iliac autograft (group I; n=30 hips; mean age, 39.07; range, 18 to 72 mo) and femoral autograft (group II; n=30 hips; mean age, 42.53; range, 19 to 70 mo) were used to fill the iliac osteotomy. The height and width of the iliac and femoral autografts were measured intraoperatively. Anteroposterior pelvic radiographs were obtained on the 45th day, and in the 2nd, 3rd, 6th, and 12th months postoperatively. Acetabular index angle, height of the graft, loss of graft position, graft resorption, operative time, blood loss, and union time were compared between the groups., Results: There was a significant difference in each group in terms of loss of graft height between the intraoperative measurement and the postoperative measurement at the 6th week and 3rd month. The intraoperative width of the grafts was significantly greater, loss of graft height was significantly less, and the amount of bleeding was significantly lower in group II (P<0.001 for all 3). However, time to union was significantly shorter in group I (P<0.001). There was no significant difference between the groups in terms of acetabular index angle at the last controls. There were loss of graft position in 2 cases and graft resorption in 1 case for group I, but no such cases occurred for group II., Conclusions: Graft height and position loss, donor site morbidity, and graft resorption were less in the femoral autografts group compared with the iliac autografts group in the treatment PPO with femoral shortening osteotomy., Level of Evidence: Level II.

Rationale: Adolescent wrist trauma can cause epiphyseal dysplasia and even distal radius deformity malunion. At present, there is no uniform treatment standard for the malunion of the distal radius of adolescents. Osteotomy and autologous bone grafting are currently one of the effective ways to treat the disease. We treated an adolescent patient with distal radius deformity malunion, and used this surgical method to treat the patient and achieved satisfactory results., Patient Concerns: A 16-year-old boy suffered from a serious distal radius deformity after trauma of the left wrist 8 years ago., Diagnoses: Physical examination, X-rays examination, high-resolution computed tomography scan, and 3-dimensional reconstruction images of the affected limb helped us diagnose the distal radius fracture malunion., Interventions: The fracture malunion was treated by osteotomy and autologous iliac bone grafting., Outcomes: At the 2-year follow-up, wrist flexion returned to 68°, wrist dorsiflexion to 55°, radial deviation to 14°, ulnar deviation to 12°, forearm pronation to 75°, supination to 67°. Grip strength increased to 35.1 kg after 2 years of operation, recovered to 87% of the uninjured side. Quick DASH score at 2-year follow-up was 9. No complication, such as nonunion or infection, was observed., Lessons: This rare case provides valuable insights for hand surgeons. High-resolution computed tomography scan and 3-dimensional reconstruction can help us effectively diagnose wrist diseases. Small lesions on the articular surface of the distal radius will change the position and function of the wrist joint, and cause traumatic arthritis of the wrist joint. Therefore, it is very important to reconstruct the normal structure of the distal radius articular surface. Osteotomy and autologous iliac bone grafting are effective treatments for serious distal radius fracture malunion in the adolescent patient. During the operation, care should be taken to protect the osteoepiphysis to avoid bone dysplasia.

Giant cell tumor of the distal radius is a rare, locally destructive, and frequently recurrent tumor. We present a case of Campanacci Grade III giant cell tumor of the distal radius with pathologic fracture and cortical destruction which was treated with neoadjuvant denosumab. This facilitated en-bloc resection of the entire distal radius, including the articular surface, while minimizing tumor contamination. Reconstruction was accomplished using a vascularized ulnar transposition flap to facilitate radioulnoscapholunate fusion, which was fixated using a long-stem contralateral variable angle locking volar distal radius plate in a dorsal position. This case illustrates multidisciplinary management of a challenging reconstructive problem and demonstrates a novel strategy for fixation which repurposes familiar and readily available hardware to provide optimal osteosynthesis.

Congenital pseudarthrosis of the tibia is defined as a non-union of a tibial fracture that develops in a dysplastic bone segment of the tibial diaphysis. Pathologically, a fibrous hamartoma surrounds the bone at the congenital pseudarthrosis of the tibia site. The cases of 25 children, who have congenital pseudarthrosis of the tibia, were included in this study. Their ages ranged from 15 months to 15 years at the time of treatment. Neurofibromatosis-1 was present in 24 children. They were managed according to our classification system and treatment protocol. The treatment for mobile pseudarthrosis (types 1 and 2) included complete excision of the pathological periosteum, insertion of autogenous iliac crest bone graft, and combined fixation using intramedullary rod and Ilizarov external fixator. For type 3 pseudarthrosis (stiff pseudarthrosis), a pre-constructed Ilizarov fixator was applied for simultaneous distraction of the pseudarthrosis and deformity correction without open surgery. Evaluation of results was mainly radiological and included achievement of union, leg length equalization, deformity correction and prevention of refracture. Consolidation of the pseudarthrosis and osteotomies was achieved in all cases (100%). Refracture occurred in one case (4%) at the site of previous pseudarthrosis. Residual limb length discrepancy more than 2.5 cm occurred in two cases (8%). Valgus deformity of the ankle was present in 12 cases (48%) and was treated by supramalleolar osteotomy. Follow-up ranged from 24 to 48 months (average 36.9 months) after fixator removal. The results of our treatment protocol, based on our classification system, have been consistently good and predictable in all cases of congenital pseudarthrosis of the tibia. Mobility of the pseudarthrosis is an important factor in choosing the type of interference.

Study Design: Multicenter, prospective randomized study., Objective: Evaluate the impact of weekly teriparatide (WT) and bone contact (BC) status of grafted bone in patients recovering from multilevel lumbar interbody fusion (M-LIF)., Summary of Background Data: WT has been reported to significantly improve bone fusion following posterior or transforaminal interbody fusion in osteoporosis patients., Methods: Patients older than 50 years and osteoporotic were recruited. We defined the fusion of two or more consecutive intervertebral levels as M-LIF. All patients were instrumented with pedicle, iliac, or S-2 alar iliac screws after transplanting cages and autogenous bone between vertebral bodies. After surgical indication for M-LIF, the subjects were randomly allocated to receive either subcutaneous WT from 1 week to 6 months postoperatively (WT arm, N = 50) or a bisphosphonate (BP; BP arm, N = 54). Blinded radiological evaluations were performed using computed tomography (CT). Evaluation of bone fusion was performed at the intervertebral disc located at the bottom of the fixed range. The degree of bone fusion was calculated as a score from 2 to 6 points, with 2 defined as complete fusion. Bone fusion rate was also compared at 6 months postoperatively based on BC status of the grafted bone on CT immediately after surgery., Results: Mean bone fusion score at 6 months postoperatively was 3.9 points in the WT group and 4.2 points in the BP group. The bone fusion rate at 6 months postoperatively tended to be higher in the WT group (46.8% vs. 32.7% in the BP group). The 6-month postoperative fusion rate of immediately postoperative of BC+ patients was significantly higher than that of BC- patients (47.4% vs. 9.5%)., Conclusion: In M-LIF, there were no significant differences in bone fusion score between WT- and BP-treated patients. In contrast, BC status immediately postoperatively had a major impact on 6-month bone fusion., Level of Evidence: 1.

Osteomyelitis of the finger presents a challenging problem. Although there are multiple treatments described in the literature, the infection often results in eventual amputation. The authors present a case of an open fracture of the index finger complicated by nonunion, infection, and osteomyelitis. This was successfully treated by the placement of an antibiotic cement spacer and subsequent reconstruction with iliac crest bone graft, after the 2-stage Masquelet technique, using intravenous and oral antibiotics. They show that this technique, although infrequently described in the hand and fingers, can be a successful option for the treatment of phalangeal osteomyelitis and phalangeal reconstruction., Competing Interests: Conflicts of Interest and Source of Funding: The authors report no conflicts of interest and no source of funding., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Study Design: This is a systematic literature review and meta-analysis., Objective: We aimed to evaluate the efficacy and safety of recombinant human bone morphogenetic protein (RhBMP) and autologous iliac crest bone graft (ICBG) in lumbar fusion., Summary of Background Data: RhBMP has been emphasized in lumbar fusion due to high fusion success rate. However, ICBG remains the criterion standard graft approach for lumbar fusion. The safety and effectiveness of rhBMP are controversial., Methods: Prospective randomized controlled trials were searched from PubMed, EMBASE, and Cochrane Central Register of Controlled Trails by using Medical Subject Headings terms "bone morphogenetic protein,' "bone transplantation,' and "spinal fusion.' Two independent investigators screened eligible studies, assessed the bias of original articles, extracted data including fusion success, Oswestry disability index improvement, improved short form 36 questionnaire scores, adverse events and re-operation, and a subgroup analysis. The GRADE approach was used to grade quality of evidence., Results: Twenty randomized controlled trials (2185 patients) met the inclusion criteria. There were higher fusion success rate (odds ratio [OR] 3.79, 95% confidence interval [CI] 1.88-7.63, P = 0.0002), better improvement of Oswestry Disability Index (mean difference 1.54, 95% CI 0.18-2.89, P = 0.03), and lower re-operation rate (OR 0.59, 95% CI 0.43-0.80, P = 0.0007) in rhBMP group. Heterogeneity was obvious in fusion success rate (I = 58%); hence, a subgroup analysis, based on protein type (rhBMP-2 or rhBMP-7), was performed, which suggested that only rhBMP-2 was better than ICBG for lumbar fusion. There was no difference in the incidence of adverse events between rhBMP and ICBG (OR 0.91, 95% CI 0.70-1.18, P = 0.47)., Conclusion: In lumbar fusion, rhBMP-2 exhibited a higher fusion success rate and reduced the risk of re-operation. No difference in complication rate is between rhBMP (rhBMP-2 and rhBMP-7) and ICBG. We suggest rhBMP especially rhBMP-2 as an effective substitute for ICBG for lumbar fusion., Level of Evidence: 1.

In the management of scaphoid fractures, nonunion is an important complication that can lead to carpal instability and early-onset arthritis. Various techniques have been described to treat scaphoid nonunions, yet a clear consensus on the superiority of one method is not yet established. The use of compression staple fixation has been described in the literature and may be a viable alternative to other fixation techniques. Volar Nitinol staple fixation avoids damage to the trapezium during retrograde fixation with a screw. It also avoids damage to the proximal dorsal cartilage, which occurs during anterograde screw fixation. Because of its shape and position on the volar aspect of the scaphoid, staple fixation provides compression, prevents graft extrusion, and avoids taking up space in the medullary canal of the scaphoid. Moreover, it may be technically easier than screw fixation. Despite these advantages, this technique has not been widely adopted. We describe the technique for utilizing Nitinol compression staples and bone grafting in the treatment of scaphoid nonunion., Competing Interests: Conflicts of Interest and Source of Funding: The authors report no conflicts of interest and no source of funding., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Unicameral bone cyst (UBC) is a benign fluid-filled lesion, mainly located in the metaphyses of long bones in children and adolescents. Elastic stable intramedullary nail (ESIN) is adopted in our institute for UBCs since 2010, and bone grafting was performed simultaneously. This study aims to evaluate the efficacy of ESIN decompression combined with different bone graft materials.All patients with the diagnoses of UBCs of the humerus, treated with ESINs and bone grafting between January 2010 and June 2018, were analyzed retrospectively. The bone grafting included injectable calcium sulfate, a mixture of the autologous iliac bone and allogeneic bone. All patients were categorized into 2 groups: ICS (injectable calcium sulfate) group and MIX (a mixture of the autologous iliac bone and allogeneic bone, ratio: 1:3) group. All the information was collected from the Hospital Database.In all, 17 patients (8.8 ± 2.3-year-old, male 8, female 9) in the ICS group and 19 patients (8.9 ± 1.9-year-old, male 10, female 9) in the MIX group were included in this study. Patients in both groups were followed up for more than 2 years (average, 3.4 ± 1.3 years). No recurrence was observed in either group. There was no significant difference between the two groups concerning the patient's demographic parameters, including sex, age, and affected side. All patients in both groups displayed excellent and good shoulder function, and there was no significant difference between the 2 groups (P = .29). As for the Capanna classification, there was no significant difference between these 2 groups (P = .78).Intramedullary nailing has the advantage of a minimally invasive procedure, immediate stability, and continuous decompression. ICS showed similar results as a mixture of the autologous iliac bone and allogeneic bone.

Rationale: The iliac bone graft procedure is one of the treatment options for individuals with extremely resorbed alveolar bones. An autogenous block bone graft can allow the use of an implant-supported fixed dental prosthesis, rather than conventional removable dentures, by completely edentulous patients. However, the iliac bone graft technique is an invasive procedure and should be carefully selected based on its long-term clinical results. This case report describes 11-year long-term outcomes for implant-supported complete denture on the grafted iliac bone., Patient Concerns: A 68-year-old Asian man was referred for oral rehabilitation with fixed dental prostheses. The patient had been unsatisfied with his removable dental prostheses in masticatory performance., Diagnosis: Radiographical examination revealed severely atrophied maxilla., Interventions: The atrophied maxilla was reconstructed with an iliac block bone graft, after which an implant-supported fixed complete denture was placed., Outcomes: During 11 years of follow-up, several prosthetic and mechanical complications were encountered. Nevertheless, no biological complications were observed. Marginal bone levels around the implants were well-maintained on the radiographs after 11 years of prosthetic use., Lessons: Iliac bone graft can be chosen as a predictable treatment option that allows patients with extremely atrophic maxilla to use a fixed dental prosthesis instead of a removable denture.

An accurate volumetric analysis method for evaluating the outcomes of different types of alveolar cleft reconstruction is essential because it can help determine which graft material is more effective, confirm favorable times for alveolar bone grafting, and improve surgical techniques. This study aimed to introduce a novel method of precisely calculating the bone formation ratio using computer-aided engineering after surgery. A patient with a unilateral alveolar cleft who was treated with anterior iliac crest bone grafting was enrolled in this study. Helical computed tomography scans were performed preoperatively and 12 months postoperatively. The Digital Imaging and Communications in Medicine (DICOM) data were reconstructed as three-dimensional images and saved in the STL format by using Mimics software. STL data were processed by Geomagic Wrap 2017, using the Boolean operation, the newly formed bone of the alveolar was segmented by identifying the differences between the preoperative and the postoperative three-dimensional images. For this patient, the mean volume of the newly formed bone was 0.387 cm, the morphology was clear, the bone formation ratio was 41.4%, the mean time required for calculating the newly formed bone volume was 23 minutes, and the bone survival ratio was 38.7%. This method is a clinically practical, accurately measurement and time-saving method to evaluate the outcome of alveolar cleft reconstruction. Both the volumetric assessment and morphological analysis of the newly formed bone could be determined in a precise manner.

Introduction: Currently, vascularized autologous bone transplantation is considered the gold standard for large mandibular continuity defect reconstruction. Donor site morbidity is a major concern. Therefore, bone tissue engineering (BTE) seems to be the ideal solution. Fresh-frozen bone allograft is the closest material to autologous bone. The purpose of this clinical report is to show a new technique of large mandibular continuity defect reconstruction using a fresh-frozen humeral allograft seeded with autologous iliac bone marrow aspirate and vascularized with a radial forearm flap., Methods: A 33-year-old man presented with severe cranio-facial trauma resulting in several fractures of the facial skeleton including a comminuted mandibular fracture from left parasymphysis to left angle, which caused a large continuity defect., Results: Result at 6 months was aesthetically and functionally satisfactory with osseointegration of the bone graft., Discussion: The authors chose to use iliac bone marrow aspirate to seed the allograft scaffold since hematopoietic stem cells and mesenchymal stem cell are able to differentiate into osteoblasts, ease of harvest of the iliac crest and its low rate of morbidity. Contemporary biomaterials used for BTE are bioceramic but bone is still the better scaffold to engineer bone and only allografting avoids donor site morbidity. Vascularization is one of the main challenges of BTE; insertion of autologous vascular bundles from pedicle or free flaps is 1 solution. The authors chose the radial forearm flap since the pedicle is long and the authors did not need a great amount of soft tissue.

Study Design: Basic Science., Objective: To determine if locally delivered simvastatin can enhance bone formation in a rat spinal fusion model., Summary of Background Data: The bone-anabolic properties of statins in fracture healing are well established, however, few studies have evaluated the impact of locally delivered statins in spinal fusion., Methods: We formulated poly(lactic-co-glycolic acid) (PLGA) nanoparticles by adapting previously published techniques. Two types of nanoparticles were created: simvastatin nanoparticles (SimNP) and nanoparticles without simvastatin (BlankNP). Drug elution from SimNP was characterized. Osteoblastic differentiation was analyzed using MC3T3-E1 cells cultured in differentiation medium containing SimNP or BlankNP. Forty male 12 week old outbred Wistar rats underwent uninstrumented posterolateral fusion using iliac crest bone graft and BlankNP, SimNP or simvastatin drug. X-rays to assess bone formation were obtained at 4 weeks and 9 weeks post-operatively. Spines were explanted at 9 weeks for micro-CT analysis, and a blinded manual assessment of fusion (MAF)., Results: SimNP achieved a release efficiency of 74.1% with ∼50% release occurring in the first day. Simvastatin and SimNP treated cells showed significantly greater expression of osteopontin (OPN) and osteocalcin (OCN). On micro-CT analysis, SimNP animals had higher bone volume and percent bone volume (bone volume/total volume) than control animals. SimNP rats had higher X-ray scores at 4 weeks (p=0.010) and 9 weeks (p<0.001) relative to BlankNP. MAF showed that SimNP had a higher fusion rate than BlankNP (42.9% vs. 0%, p=0.006)., Conclusion: We were able to validate that sustained release of simvastatin via a PLGA nanoparticle. SimNP was able to induce an increase in mineralization as well as an increase in markers of bone formation. X-ray analysis, micro-CT quantification, and MAF assessment of SimNP treated rats showed significantly greater bone formation and fusion mass strength relative to vehicle treated animals. Simvastatin may be a safe, cost-effective bone anabolic agent for use in spinal fusion., Level of Evidence: N/A.

Immediate mandibular reconstruction is always necessary for the patients receiving segmental mandibulectomy to recover the facial contour and function of occlusion. When 3D modeling is unavailable, temporary external fixator is necessary to maintain the occlusion relationship and facial contour. In this study, we introduce the clinical application of temporary external fixator for immediate mandibular reconstruction in patients receiving segmental mandibulectomy, which consists of 2 anchor claws, 2 all-round retentive arms, and 1 central locking structure. From August 2016 to September 2017, temporary external fixator was applied in 13 patients. Clinical data of gender, age, surgical procedure, duration of operation, and clinical outcomes were recorded and analyzed. Among the 13 patients, there were 4 men and nine women whose ages ranged from 21 to 64 (mean 47.7) years old. There were 9 benign and 4 malignant lesions. All lesions expended at the buccal side of mandible. 12 fibular flaps and 1 vascularized iliac bone graft were used. The mandibular defect ranged from 6 to 14 (mean 10) cm. The operation duration of surgery ranged from 5 to 10 (mean 7) hours. All flaps survived with primary healing. The occlusion and facial contour were good, without significant changes of the length of mandibular body and width of mandible before and after surgery. No functional sequelae were noted at the donor sites. From these results, the temporary external fixator is easy to operate; the surgical procedure is simple and time-saving for surgeon when 3D modeling is unavailable. The indication for temporary external fixator usage is the mandibular lesion growing outward to cheek soft tissue.

The aim of this study is to evaluate donor- and recipient-site complications of iliac bone grafting for the reconstruction of atrophic jaws.Our study includes 86 consecutive patients with atrophic jaws who underwent iliac bone grafting surgery. At the donor site, hematoma, infection, paresthesia, chronic pain, prolonged gait disturbance, fracture of the ilium, and esthetic concerns; at the recipient site, hematoma, infection, prolonged pain, graft exposure, graft loss, and loss of the implants were evaluated.Grafting was successfully performed in all patients. The mean follow-up period was 35 months. Prolonged gait disturbance (20.9%) and paresthesia (9.3%) were the most frequently observed donor-site complications. At the recipient site, hematoma (8.1%), infection (12.8%), prolonged pain (11.6%), partial graft exposure (33.7%), total graft exposure (7%), partial graft loss (17.4%), and total graft loss (5.8%) were observed.Reconstruction of atrophic jaws can be achieved successfully with iliac bone grafting. However, there are possible donor- and recipient-site complications that have to be taken into consideration.

Study Design: A multicenter, randomized, intrapatient controlled trial., Objective: This study investigated whether lumbar fusion patients blinded to the harvest site (A) can identify the iliac crest used for bone harvesting and (B) whether this iliac crest is more painful than the contralateral side., Summary of Background Data: Spinal fusion with iliac crest autograft is a frequently performed surgical procedure. A widely reported disadvantage of the harvesting procedure is potential donor site morbidity. This has driven the development of many bone graft substitutes. However, more recently the incidence and severity of donor site pain is debated, especially in lumbar fusion surgery., Methods: Ninety-two nontraumatic adult patients underwent a posterolateral (thoraco)lumbar fusion. Iliac crest bone graft was harvested unilaterally through the primary midline incision. At 6 weeks, 3 months, 6 months, and 1 year follow-up, patients were asked to identify the donor site and to rate pain in their back, left iliac crest and right iliac crest on a Visual Analogue Scale (VAS)., Results: Ninety patients, 44 males and 46 females with a mean age of 54 years, were analyzed. The left/right distribution of the iliac crest donor site was 50/50 and 89% of the patients underwent a lumbar fusion below L3. Only 24% patients identified the harvest site correctly. Moreover, the VAS pain scores for the donor site and contralateral iliac crest did not differ and were at each timepoint lower than the scores for back pain., Conclusion: This study showed that, during the first year after lumbar fusion surgery via a single midline incision approach, patients could not reliably identify the iliac crest used for bone graft harvesting and this iliac crest was not more painful than the untouched contralateral iliac crest. Therefore, donor site pain should not be the main reason to use bone graft alternatives for lumbar spinal fusion., Level of Evidence: 2.

Ameloblastoma is the most common odontogenic tumor of epithelial origin. These tumors are benign in nature but have a high rate of recurrence and possible malignant development when treated inadequately. However, recurrent ameloblastomas in bone grafts are rare. This article presents a rare case of a multiple recurrent ameloblastoma, with the last recurrence in a nonvascularized free iliac bone graft of the mandible, reconstructed with vascularized deep circumflex iliac artery free flap for the surgical defect. Furthermore, an updated review of the literature on recurrent ameloblastomas affecting the bone graft is provided.

Background: Harvesting the sartorius muscle and the iliac bone with a superficial circumflex iliac artery (SCIA) perforator flap can be a challenging procedure. The aim of this study was to describe the anatomical topology of the deep branch of the SCIA in fresh cadavers, which has not been reported in detail., Methods: Twenty groin regions from 10 fresh cadavers were dissected. The characteristics and landmarks of the SCIA system, including branches to the sartorius muscle and the iliac bone, were examined. Perfusion of the sartorius muscle and the iliac bone by means of the deep branch of the SCIA was evaluated with indocyanine green angiography and computed tomographic angiography., Results: The superficial and the deep branches were identifiable in all specimens. In 85 percent of the specimens, the bifurcation point could be seen within 2 cm from a fixed site: 6 cm from the pubic tubercle to the anterior superior iliac spine, and 3 cm caudal from that point. The deep branch in each case gave off branches to the sartorius muscle and the iliac bone. The cephalad portion of the sartorius muscle (up to 8 cm from the anterior superior iliac spine) and the superficial portion of the iliac bone (up to 1.5 cm from the iliac crest) were perfused by the deep branch of the SCIA., Conclusions: In all specimens, both the superficial branch and the deep branch of the SCIA were found. The deep branch was found consistently to give off perfusing branches to the sartorius muscle and the iliac bone.

Oral rehabilitation with osseointegrated implants is frequently the best alternative for replacement of lost teeth. Several techniques and materials allow achievement of excellent function and esthetics. In the case of maxillary or mandibular atrophy, extensive grafting may be necessary before implants can be properly placed. This is a case of maxillary reconstruction with autogenous iliac crest bone grafts, followed by placement of guided implants. After integration of the grafts, planning and insertion of implants allowed installation of an implant-supported prosthesis, recovering the morphology, function, and esthetics.

Study Design: Retrospective Analysis OBJECTIVE.: The aim of this study was to determine whether an association between increased acute pain, postoperative time, and direct hospital costs exists between the use of iliac crest bone grafting (ICBG) and bone morphogenic protein (BMP)-2 following a primary, single-level minimally invasive transforaminal lumbar interbody fusion (MIS TLIF)., Summary of Background Data: ICBG has been associated with enhanced fusion rates. Concerns have been raised in regards to increased operative time and postoperative pain. The advantages of ICBG compared to other spinal fusion adjuncts have been debated., Methods: Prospective, consecutive analysis of patients undergoing primary, single-level MIS TLIF with ICBG was compared to a historical cohort of consecutive patients that received BMP-2. Operative characteristics were compared between groups using χ analysis or independent t test for categorical and continuous variables, respectively. Postoperative inpatient pain was measured using the Visual Analog Scale, and inpatient narcotics consumption was quantified as oral morphine equivalents. Outcomes were compared between groups using multivariate regression controlling for preoperative characteristics., Results: A total of 98 patients were included in this analysis, 49 in each cohort. No significant differences were noted between cohorts with exception to sex (Females: ICBG, 53.06% vs. BMP-2, 32.65%, P = 0.041). There was a significant increase in operative time (14.53 minutes, P = 0.006) and estimated blood loss (16.64 mL, P = 0.014) in the ICBG cohort. Narcotics consumption was similar between groups on postoperative days 0 and 1. ICBG was associated with decreased total direct costs ($19,315 vs. $21,645, P < 0.001) as compared to BMP-2., Conclusion: Patients undergoing MIS TLIF with ICBG experienced increases in operative time and estimated blood loss that were not clinically significant. Furthermore, iliac crest harvesting did not result in an increase in acute pain or narcotics consumption. Further follow-up is necessary to determine the associated arthrodesis rates and long-term outcomes between each cohort., Level of Evidence: 3.

Background: The standard of care for patients with alveolar cleft deformities is autologous bone grafting using iliac crest bone graft (ICBG). The combination of demineralized bone matrix with recombinant human bone morphogenetic protein-2 (DBX/rhBMP-2), as a substitute for ICGB, has been shown to have similar bony incorporation within the maxilla without donor-site morbidity. It has been argued that one of the drawbacks of using DBX/rhBMP-2 is the higher cost. The aim of this study was to compare the cost, operative time, and hospital length of stay associated with these two treatment modalities., Methods: A chart review was conducted for 71 patients who underwent secondary alveolar cleft reconstruction. Forty patients received ICBG and 31 patients underwent reconstruction using DBX/rhBMP-2. Operative costs, operative time, and hospital length of stay were compared between the two groups., Results: The average total operative cost was $6892 in the ICBG surgery population versus $4836 in the DBX/rhBMP-2 population (p < 0.01). Statistically significant decreases in anesthesia, pharmacy, and operating room costs were found in patients who underwent the DBX/rhBMP-2 surgery. Operative time decreased from an average of 97.3 minutes to 67.0 minutes (p < 0.01), and length of inpatient stay decreased from an average of 29.8 hours to 9.3 hours (p < 0.01)., Conclusion: In the treatment of alveolar cleft deformities, operative material costs were greater in the DBX/rhBMP-2 group but-secondary to decreased hospital, anesthesia, pharmacy, and operating room costs-DBX/rhBMP-2 was more cost-effective than ICBG.

Longstanding humeral shaft nonunion is uncommon because humeral shaft fractures often respond well to conservative and surgical treatments. However, when it occurs, the treatment of longstanding humeral shaft nonunion is challenging. This study is a retrospective analysis of the clinical and radiographic findings in a consecutive series of patients with longstanding humeral shaft nonunions who underwent locking compression plate (LCP) fixation and autogenous iliac crest bone grafting.Six patients were surgically treated at Xi'an Hong Hui Hospital for longstanding humeral shaft nonunions between February 2011 and June 2015. Four patients were of synovial pseudarthrosis, 1 was atrophic, and 1 was hypertrophic. Follow-up was for at least 12 months after intervention. Standardized treatment included a thorough debridement, LCP and screw fixation, and autogenous iliac crest bone grafting. In 3 patients, a single plate was applied, and in the other 3 patients, double plates were used. The main outcome measurements were shoulder and elbow function (Constant and Murley scale, and Mayo elbow performance index [MEPI]) and the visual analog scale (VAS) for pain. In addition, all complications were documented.Our series included 6 male patients with an average age of 56.3 years and an average nonunion duration of 19.5 years. All patients had previously undergone at least 1 operation. At a mean of 26 months follow-up, all fractures had achieved solid union and none of the implants had evidence of loosening or breakage. Postoperative alignment was within 10° of anatomic in 4 patients, 1 patient had 23° of valgus angulation, and 1 patient had a posterior angulation of 12°. Mean humeral shortening was 2.8 cm. The mean Constant and Murley joint function score was 88.3 points, the mean MEPI was 96.7 points, and the mean VAS was 0.7. All patients reported significant improvement in shoulder and elbow function, and each patient was able to resume work and was satisfied with the treatment.Plate fixation combined with autogenous iliac crest bone grafting is an excellent option for the treatment of longstanding humeral shaft nonunion.

Aim: To describe the treatment of ameloblastoma involving the mandibular body and condyle in 3 patients., Methods: This report describes 3 patients with large ameloblastomas (2 were second recurrences) treated by partial mandibular resection. Involvement of the mandibular condyle in these 3 patients made the reconstruction more challenging. Reconstruction included immediate temporomandibular joint replacement by a custom-made alloplastic total joint and mandibular body (Zimmer-Biomet, Jacksonville, FL). These devices were designed using virtual surgical planning software. The 3 patients underwent concomitant bone graft reconstruction using autogenous-free corticocancellous block bone grafts from the iliac crest. This facilitated later dental implant placement and full dental rehabilitation. Direct inferior alveolar nerve repair or nerve graft reconstruction with allograft was also carried out for all 3 patients. Maxillomandibular fixation was not used in all 3 patients., Results: All the 3 patients underwent successful surgery and recovery. Mandibular function was preserved. The concomitant bone graft allowed successful dental implant placement for subsequent planned restorative dentistry., Conclusion: Ameloblastoma involving the mandibular condyle can be successfully treated by resection and concomitant total joint replacement with an alloplastic device. This technique shows promise in that there is rapid return to excellent function thanks to rigid fixation of the construct. Mirroring software used in the prosthesis design facilitates excellent cosmetic outcomes.

The authors performed a cantilever iliac bone graft for the secondary correction of severe cleft lip-nose deformities after the completion of growth. For the purpose of clarifying effects of the cantilever iliac bone grafts and the adverse events with regard to their time course changes after this procedure, the authors retrospectively surveyed long-term morphologic changes in 65 cleft lip, alveolus, and palate patients in whom cleft lip-nose deformities were treated with a cantilever iliac bone graft (age at surgery: 14-45 years old). All postsurgical documents of facial photographs and radiologic images were reviewed to evaluate the effects and adverse events. The main adverse events were deviations of the apex of the nose, excess resorption of the grafted iliac bone, protruding deformations of the grafted iliac bone at the root of the nose, and fracture of the grafted iliac bone. Additional surgery was necessary in 10.7% of patients. Postsurgical changes in facial profiles became favorable, measured on lateral view of cephalometric radiography, achieving morphologic improvements. A cantilever iliac bone graft was effective for improving nasal deformities in cleft lip, alveolus, and palate patients, although the counter measures should be taken to these adverse events.

The purpose of this study was to evaluate the efficiency of platelet-rich fibrin usage in the treatment of alveolar cleft with iliac bone graft by means of volumetric analysis. In this study, 22 patients with alveolar clefts-including 13 unilateral and 9 bilateral-were treated with anterior iliac crest bone grafts. Patients were divided into 2 groups as control (group A) and platelet-rich fibrin (group B) groups. Cone beam computed tomography (CBCT) scans were obtained preoperatively and 6 months postoperatively. Three-dimensional reconstructions of CBCT images were created by using Mimics software. Preoperative alveolar cleft volume and postoperative newly formed bone volume were assessed volumetrically. The percentages of preoperative alveolar cleft volume ranged from 0.51 to 2.04 cm, with a mean volume of 0.98 ± 0.33 cm. The percentages of newly formed bone in group B ranged from 50.70% to 80.09%, with a mean percentage of 68.21 ± 10.80%. In Group A, the percentages of bone formation ranged from 47.02% to 79.23%, with a mean percentage of 64.62 ± 9.49%. Platelet-rich fibrin can be used in the treatment of alveolar cleft with corticocancellous bone graft harvested from the anterior iliac crest, but in this study, there was no statistically significant difference between the groups for postoperative newly formed bone volume (P > 0.05).

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 < .05). The average operative complication rate of Group A was less than that of Group B. Both iliac bone and titanium mesh can effectively construct anterior column defects in posterior surgery. The titanium mesh has the advantage of minor surgical invasion, effective reconstruction of large defects, and ideal sagittal alignment in lumbosacral TB for patients with osteoporosis and poor iliac bone quality., (Copyright © 2017 The Authors. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Rationale: Familial gigantiform cementoma (FGC) is a rare benign autosomal dominant fibrocemento-osseous lesion generally limited to the facial bones, typically in the anterior portion of the mandible; it is often associated with abnormalities of the long bones and prepubertal pathologic fractures. Owing to the small number of such patients, a uniform treatment criterion has not been established. This paper presents a patient with FGC who was treated in our department, and offers a systematic review of the patients reported in the literature. Our aim was to explore the treatment strategy for patients with FGC., Patient Concerns: Our patient, a 13-year-old boy, presented with a painless enlargement of the mandible first noted 2 years earlier. It had grown rapidly over the preceding 8 months, affecting both his appearance and ability to chew., Diagnosis: Based on the pathologic, clinical, and radiographic features, FGC was diagnosed., Interventions: Mandibuloectomy was performed. The mandibular defect was immediately reconstructed with his right vascularized iliac crest flap. At the same time, a PubMed search was conducted to identify studies reporting on other patients with FGC., Outcomes: A 3-dimensional computed tomography (3D-CT) scan demonstrated appropriate height of the new alveolar bone. Follow-up results showed recovery of the patient's appearance and mandibular function. He was free of recurrence at 4-year follow-up., Lessons: FGC is a rare benign fibrocemento-osseous lesion of the jaws that can cause severe facial deformity. Incomplete removal leads to more rapid growth of the residual lesion. Therefore, extensive resection is a suitable strategy to avoid recurrence. Defects of the facial bones found intraoperatively should be repaired with resort to an appropriate donor site. However, it is important to be aware that patients with FGC always have concomitant abnormalities of skeletal metabolism and structure, as well as a vulnerability to fractures of the long bones of the lower extremity. Therefore, the optimal management strategy should include a review of treatment options for other patients as reported in the literature. An optimal protocol can not only provide sufficient high-quality bone suitable for the reconstruction of bone defects, but also minimize complications and maximize quality of life., (Copyright © 2017 The Authors. Published by Wolters Kluwer Health, Inc. All rights reserved.)

The reconstruction of mandible is a challenge with regard to aesthetic and reconstructive demands. The etiology of mandibular fractures is variable, trauma, pathology, bone infections. There are many materials that provide an excellent form of rehabilitation for these defects, where the autogenous graft presents important characteristics that favor a greater success rate. Furthermore, the rapid prototyping method is quite interesting, because it brings a series of advantages to the surgeon, like reducing the operative time, among others. The purpose of the present article is to describe a clinical case of a patient with mandible bone defect caused by gunshot perforation, treated through iliac crest bone graft with planning through rapid prototyping. The mandibular reconstruction can present a real challenge for the surgeon. Biomodels should be required in complex cases because they help to decrease surgical time and to increase the predictability of the procedure.

Background: Recent studies indicate that recombinant human bone morphogenetic protein-2 (rhBMP-2) in a demineralized bone matrix scaffold is a comparable alternative to iliac bone autograft in the setting of secondary alveolar cleft repair. Postreconstruction occlusal radiographs demonstrate improved bone stock when rhBMP-2/demineralized bone matrix (DBM) scaffold is used but lack the capacity to evaluate bone growth in three dimensions. This study uses cone beam computed tomography to provide the first clinical evaluation of volumetric and density comparisons between these two treatment modalities., Methods: A prospective study was conducted with 31 patients and 36 repairs of the alveolar cleft over a 2-year period. Twenty-one repairs used rhBMP-2/DBM scaffold and 14 repairs used iliac bone grafting. Postoperatively, occlusal radiographs were obtained at 3 months to evaluate bone fill; cone beam computed tomographic images were obtained at 6 to 9 months to compare volumetric and density data., Results: At 3 months, postoperative occlusal radiographs demonstrated that 67 percent of patients receiving rhBMP-2/DBM scaffold had complete bone fill of the alveolus, versus 56 percent of patients in the autologous group. In contrast, cone beam computed tomographic data showed 31.6 percent (95 percent CI, 24.2 to 38.5 percent) fill in the rhBMP-2 group compared with 32.5 percent (95 percent CI, 22.1 to 42.9 percent) in the autologous population. Density analysis demonstrated identical average values between the groups (1.38 g/cc)., Conclusions: These data demonstrate comparable bone regrowth and density values following secondary alveolar cleft repair using rhBMP-2/DBM scaffold versus autologous iliac bone graft. Cone beam computed tomography provides a more nuanced understanding of true bone regeneration within the alveolar cleft that may contribute to the information provided by occlusal radiographs alone., Clinical Question/level of Evidence: Therapeutic, II.

The management of long bone defects continues to be associated with significant challenges for optimum and timely bone repair. When bone grafting is needed, essential parameters to be addressed include adequate volume, optimum density, and structural capacity as well as potent biological properties. Although the autologous iliac crest bone graft remains the gold standard, its reduced availability and donor site morbidity have made the clinicians to seek for other alternative options. Reamer irrigator aspirator graft with materials used as graft expanders along with inductive molecules and cellular augmentation constitute the current trend for optimum bone regeneration. This article presents the contemporary thinking of the biological facet of segmental bone loss reconstruction.

Purpose: Fracture nonunion is a common problem for today's orthopaedic surgeon. However, many techniques are currently available for the treatment of long-bone nonunion. This video demonstrates the use of iliac crest bone graft and plate stabilization in the setting of a hypertrophic femoral nonunion., Methods: Treatment of femoral nonunion after intramedullary nail fixation using compression plating and bone grafting is a reliable technique for reducing pain, improving function, and achieving radiographic union. Furthermore, the use of autologous bone graft, in particular iliac crest bone graft, has provided reliable clinical results., Results: In this video, we present the case of a hypertrophic femoral nonunion treated with supplemental bone grafting in addition to plate and screw fixation., Conclusions: Although femoral nonunions are a relatively rare occurrence, they can be reasonably treated using stabilization and supplemental bone grafting. Iliac crest bone graft provides for excellent results when used for treatment of a fracture nonunion.

Purpose: Rib fractures are a common chest injury that can typically be treated nonoperatively. However, a percentage of these will go on to nonunion, either because of unique characteristics of the fracture itself or because of a variety of poor healing factors of the host. If a patient has continued symptomology beyond 3 months, surgeons may consider operative management., Methods: Although isolated resection of fibrous scar tissue from the nonunion site may be sufficient in some cases, it may also be necessary to provide additional structural integrity to the rib depending on the extent of the fracture pattern and resection. This goal can be achieved operatively with rib plating and bone grafting to promote healing., Results: This video demonstrates the use of plating in the treatment of rib nonunion. It begins with relevant background information on rib fractures and nonunions, then details the approach, open reduction and internal fixation of 3 ribs using plates and bone graft aspirate. Pearls and pitfalls are included during the surgical technique aspect of the video to both help guide surgeons new to the procedure and provide potentially advantageous technical details to more experienced surgeons.

Introduction: This video demonstrates the technique of posterolateral bone grafting with iliac crest bone graft for a distal tibial nonunion., Methods: The patient is a 42-year-old man who is 6 months status post an open distal tibia-fibula fracture treated surgically, and presents complaints of persistent right ankle pain. The fracture site was tender to palpation, and 3 consecutive plain radiographs spaced 6 weeks apart demonstrated no evidence of callus formation., Results: This patient was indicated for posterolateral bone grafting of his tibia and fibula nonunion with autogenous iliac crest bone graft. The plan was to create a synostosis between the fibula and tibia. Atrophic and oligotrophic nonunions have poor biology at the fracture site to promote bone growth and would therefore benefit from autogenous iliac bone graft, as this technique is osteoinductive, osteoconductive, and osteogenic stem cells. Indications for posterolateral bone grafting of the tibia include atrophic or oligotrophic nonunions, an ipsilateral same level tibia and fibula nonunion, or a tibial nonunion with a large anteromedial soft-tissue injury., Conclusion: The technique of posterolateral bone grafting with iliac crest bone graft for distal third tibia and fibula atrophic nonunion provides a reliable method for achieving union. If patients with injuries at high risk of nonunion are followed closely and intervention is performed in a timely manner, additional fixation or revision of fixation is not necessary if the addition of appropriate osteoinductive, osteoconductive, and osteogenic material to the nonunion is performed.

Background: Alveolar cleft reconstruction using iliac crest bone graft is considered standard of care for children with complete cleft lip and palate at the time of mixed dentition. Harvesting bone may result in donor-site morbidity and additional operating time and length of hospitalization. Recombinant human bone morphogenetic protein (rhBMP)-2 with a demineralized bone matrix is an alternative bone source for alveolar cleft reconstruction. The authors investigated the outcomes of rhBMP-2/demineralized bone matrix versus iliac crest bone graft for alveolar cleft reconstruction by reviewing postoperative surgical complications and cleft closure., Methods: A retrospective chart review was conducted for 258 rhBMP-2/demineralized bone matrix procedures (mean follow-up, 2.9 years) and 243 iliac crest bone graft procedures (mean follow-up, 4.1 years) on 414 patients over a 12-year period. The authors compared complications, canine eruption, and alveolar cleft closure between the two groups., Results: In the rhBMP-2/demineralized bone matrix group, one patient required prolonged intubation because of intraoperative airway swelling not thought to be caused by rhBMP-2, 36 reported facial swelling and one required outpatient steroids as treatment, and 12 had dehiscence; however, half of these complications resolved without intervention. Twenty-three of the 228 rhBMP-2/demineralized bone matrix patients and 28 of the 242 iliac crest bone graft patients required repeated surgery for alveolar cleft repair. Findings for canine tooth eruption into the cleft site through the graft were similar between the groups., Conclusions: The rhBMP-2/demineralized bone matrix appears to be an acceptable alternative for alveolar cleft repair. The authors found no increase in serious adverse events with the use of this material. Local complications, such as swelling and minor wound dehiscence, predominantly improved without intervention., Clinical Question/level of Evidence: Therapeutic, III.

Rationale: Precise bony reduction and reconstruction of optimal contour in treating comminuted mandibular fractures is very difficult using traditional techniques and devices. The aim of this report is to introduce our experiences in using virtual surgery and three-dimensional (3D) printing technique in treating this clinical challenge., Patient Concerns: A 26-year-old man presented with severe trauma in the maxillofacial area due to fall from height., Diagnosis: Computed tomography images revealed middle face fractures and comminuted mandibular fracture including bilateral condyles., Interventions and Outcomes: The computed tomography data was used to construct the 3D cranio-maxillofacial models; then the displaced bone fragments were virtually reduced. On the basis of the finalized model, a customized titanium mesh tray was designed and fabricated using selective laser melting technology. During the surgery, a submandibular approach was adopted to repair the mandibular fracture. The reduction and fixation were performed according to preoperative plan, the bone defects in the mental area were reconstructed with iliac bone graft. The 3D-printed mesh tray served as an intraoperative template and carrier of bone graft. The healing process was uneventful, and the patient was satisfied with the mandible contour., Lessons: Virtual surgical planning combined with 3D printing technology enables surgeon to visualize the reduction process preoperatively and guide intraoperative reduction, making the reduction less time consuming and more precise. 3D-printed titanium mesh tray can provide more satisfactory esthetic outcomes in treating complex comminuted mandibular fractures.

Background: The posterior screw fixation in atlas via posterior arch and lateral mass, also called C1 "pedicle" screw, combined with C2 pedicle screw fixiation has shown better biomechanical stability in unstable atlantoaxial fractures. However, its popularization has to fulfill the limitation imposed by anatomical characteristics. The aim of this study was to explore the manipulation, effect, and safety of the atlantoaxial transpedicular screw fixation under "direct vision" for the treatment of unstable atlantoaxial fracture., Methods: All the patients diagnosed with unstable atlantoaxial fracture, who received surgery treatment of C1,C2 internal fixation from January 2012 to December 2014 were reviewed. Only these patients that were diagnosed with atlantoaxial unstability secondary to trauma and were treated with atlantoaxial transpedicular screw fixation under "direct vision" and iliac autograft were included. The safety of transpedicular screw placement, postoperative outcome, atlantoaxial stability, autograft fusion, and complications was observed and analyzed retrospectively. The pain visual analog scale (VAS) and the Japanese Orthopedic Association (JOA) score were used as surgical curative effect evaluation standards., Results: We reviewed a total of 92 patients diagnosed with unstable atlantoaxial fracture, who received surgery treatment of C1,C2 internal fixation from January 2012 to December 2014, and 87 patients were treated with atlantoaxial transpedicular screw fixation under "direct vision" and were included this analysis. A total of 306 transpedicular screws in atlas and axis were placed successfully. All cases were followed-up >12 months. The overall breach rate was 11.36%. None of the breaches resulted in new-onset neurological sequela. The neurological status in cases with bilateral upper extremities numbness and lower extremities weakness had improved after surgery. At the latest follow-up, the neck VAS and JOA scores were significantly improved (P < .01) than those preoperatively. No cases demonstrated implantation failure and bone graft absorption on the postoperative x-ray films and CT scans., Conclusion: Atlantoaxial transpedicular screw fixation under "direct vision" and iliac autograft for the treatment of unstable atlantoaxial fracture has shown simple manipulation and efficient performance. Thus, the technique of C1-C2 fixation is feasible in treating unstable atlantoaxial fracture.

The most common causes of mandibular defects are ablative surgery of benign or malignant tumors, severe trauma, inflammatory diseases, and osteoradionecrosis. War injuries are another cause for mandibular defect. Reconstruction of the mandible is considered a challenge to the maxillofacial surgeon due to the accompanying functional and cosmetic importance. The object of this article was to show the role of nonvascularized bone graft in the reconstruction of segmental defect of the mandible resulted from projectiles and its snags. Seventeen patients underwent reconstruction of defect in the body of the mandible using non-vascularized iliac bone graft,in sixteen patients the grafts were fixed by reconstruction plate and in one by stainless-steel wire. In the emergency phase in which life-saving measures were done, in the immediate phase, treatments of associated facial and systemic injuries were carried out. The delayed phase includes the reconstruction of the residual defects and rehabilitation. A total of 17 male patients with a mean age of 34.5 years underwent reconstructive surgery, the time lapse between the injury and the delayed phase of treatment ranged from 20 days to 3 months. The size of the defects ranged from 4 to 7 cm. Treatment was considered successful in 15 patients (88.2%) in whom the grafts were incorporated to mandible with improvement of facial contour and symmetry and satisfactory occlusion of the remaining teeth. Nonvascularized bone graft is considered a feasible option for the reconstruction of a relatively small mandibular defect, especially in ascetic conditions for its role in improving facial appearance and to less extent functional benefit and more advanced method for the reconstruction needed to be introduced especially in war injuries.