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To assess the outcomes of patients after rib nonunion reconstruction.Retrospective case series.Level 1 trauma center.Between January 2007 and August 2019, 25 consecutive patients with 51 nonunions with disabling pain or chronic instability were treated for nonunited rib fractures.Rib nonunion reconstructions performed using plate and screw fixation, recannalizing the medullary canal and augmented with autogenous iliac crest bone graft.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.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.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.Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

The purpose of this study is to determine the reliability of standard magnetic resonance imaging (MRI) evaluation of AIIS morphology compared with three-dimensional (3D) computerized tomography (CT) (reference standard).Sixty hips in 30 patients met the inclusion criteria. The images were reviewed and classified by two fellowship-trained orthopedic surgeons. A second imaging viewing session was conducted in the same manner for validation of AIIS evaluation. The agreement and accuracy indices between the two raters were calculated for each imaging modality (inter-rater agreement) as well the agreement across the imaging modality for each rater (intermethod agreement).The inter-rater agreement for the morphological evaluation of the AIIS for the first session according to 3D CT was .553 (P.05) and by means of MRI was .0163 (P.05). The inter-rater agreement for the second session by means of 3D CT was .449 (P.05) and according to MRI was 0 (P.05). The inter-method agreement for rater 1 for the first session was .04 (P0.05), while the agreement for rater 2 was .016 (P.05). The intermethod agreement for rater 1 on the second session was .35 (P0.05), while that of rater 2 was .297(P.05). The overall accuracy of MRI compared to 3D CT for rater 1 for the first session was .531, .490, and .959 for types I, II, III respectively and .551, .531, and .980 for the second session for types I, II, and III respectively. The overall accuracy of MRI compared to 3D CT for rater 2 for the first session was .551, .469, and .918 for types I, II, III respectively and .633, .592, and .918 for the second session for types I, II, and III, respectively.MRI evaluations and subsequent classifications of AIIS morphology demonstrated a poor to slight correlation compared with that of the reference standard of 3D CT.Level II, retrospective diagnostic study.

The aim of this study was to answer the question: which analgesic protocol is most efficient and most effective in overcoming pain and promoting functional recovery after iliac bone grafting in cleft alveolus patients? A systematic review of the literature was performed. The population consisted of cleft lip and alveolus patients with or without cleft palate undergoing iliac crest bone grafting; the outcomes analysed were represented by the duration of hospital stay, subjective pain rating, and degree of impaired mobility. A total of 15 articles were selected for review. The following protocols were subject to comparison in this review: simple classic intravenous/per-oral analgesia, local anaesthetic infiltration in the donor site, anaesthetic-soaked sponge, neural blocks and continuous infusion at the donor site. The results of the included studies were individually reported identifying trends in the efficiency of the different pain-management techniques. Although hospital stay varied from same-day discharge to almost a week, other factors besides pain influenced this outcome. School was resumed after an average of 12.6 days and sport activities after maximum one month regardless of the used protocol. Even though the age of patients had a statistically significant influence on hospital stay durations, it did not determine the latter. The pain management protocols after iliac bone grafting of alveolar clefts selected for analysis have their advantages and drawbacks. All protocols seem effective meaning they reach adequacy in managing pain at the donor site. The efficiency of the protocols could not be assessed due to the lack of data and inconsistency in pain assessment scales. Further investigation through randomized controlled studies is required.

Background Alveolar cleft grafting is a necessary procedure to restore bone defects. Randomized clinical trials (RCTs) are regarded as a golden standard for investigating the efficacy of treatments. Nevertheless, risk of bias (RoB) can still affect the validity of these trials. We aimed to conduct a systemic review of all control trials (CTs) using regenerative materials for alveolar cleft reconstructions to evaluate their RoB and perform a meta-analysis of new bone formation. Methods Cochrane Oral Health Group's Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (PubMed), EMBASE AND Google Scholar were searched up to October 2020. Thereafter, the articles underwent quality assessment (according to the Jadad scale and the Delphi list) for the evaluation of the RoB. Results A total of 15 trials met the inclusion criteria, none of which reached a full score. Of these, 20% didn't randomize the trails, 73,33% failed to describe the way of randomization, and none reported the double-blinded criteria. Furthermore, allocation concealment (99.9%), intention to treat (100%), and patient awareness (100%) were inadequately described. The meta-analysis found no significant difference between regenerative materials and iliac crest graft. Conclusion This review showed high RoB in CTs implying quality improvement of CTs is necessary. Meta-analysis showed no significant difference between the regenerative materials and autogenous grafts.

We report the case of a 68-year-old man who was placed on heparin as bridge therapy and subsequently developed an iliacus haematoma with associated femoral nerve palsy. His team involved the orthopaedic surgery team in delayed fashion after his symptom onset. Due to his active medical conditions, he did not undergo surgical decompression of his haematoma until late into his hospital course. Unfortunately, this patient did not regain meaningful function from his femoral nerve deficit. We believe this case highlights the high index of suspicion necessary for making this diagnosis as well as the repercussions of an untimely decompression for this acute, compressive neuropathy. Although we are surgeons and this is a surgical case, we hope to publish this case in a medical journal to raise awareness that surgical decompression does have a role in this diagnosis and should ultimately be pursued early in its course for optimal patient benefit.

The objective of this study was to assess the efficacy of tissue engineered (TE) constructs compared to the standard autogenous anterior iliac crest (AIC) bone graft in secondary maxillary alveolar cleft reconstruction. This clinical trial was registered on (clinical trials.gov); the trial registry number is: NCT03563495. Patients with unilateral alveolar clefts were allocated on the basis of simple randomization. Selected patients were randomly divided into two equal groups: the AIC group (control) received autogenous particulate bone graft from anterior iliac crest, whereas the TE group received tissue engineered construct. Assessment included the newly formed bone volume and density at the grafted cleft sites, which were measured immediately, 6 and 12 months postoperatively on axial computed tomograms. The study population included 10 patients; each group comprised 5 patients. There was no statistically significant difference between the 2 groups regarding the mean volume of the newly formed bone (p = 0.91 at 6 months, p = 0.994 at 1 year) and the mean density of the newly formed bone (p = 0.364 at 6 months, p = 0.073 at 1 year). However, there was a significant increase of TE graft density from 6 months to 1 year (p = 0.048). Within the limitations of the study it seems that the tissue engineered construct (collagen/osteogenically differentiated bone marrow−derived mesenchymal stem cells) might be an alternative to autogenous bone for unilateral secondary alveolar cleftgrafting.

Background Cage implantations and autologous pelvic bone grafts are common surgical procedures to fuse the spine in cases of spinal disorders such as traumatic fractures or degenerative diseases. These surgical methods are designed to stably readjust the spine and to prevent late detrimental effects such as pain or increasing kyphosis. Benefits of these surgical interventions have been evaluated, but the long-term well-being of patients after the respective treatments has not yet been examined. This study was designed to evaluate the clinical outcome for patients who received iliac crest or cage implantations. Material and Methods Forty-six patients with traumatic fractures after they obtained an anterior fusion in the thoracic or lumbar spine (12 cages; mean age: 54.08 years; 34 pelvic bone grafts; mean age: 42.18 years) were asked to participate in the survey using a precast questionnaire according the Visual Analog Scale (VAS) Spine Score. Twenty-nine of them provided the data requested. Results Evaluation of the VAS scores of the patients, reporting at least 1 year after the surgery, revealed that cage implantations led to significantly better results with respect to all aspects of their daily life such as pain sensing, capability to undertake physical activities and exercise as compared with patients with autologous pelvic bone graft. Patients with autologous pelvic bone graft treatment reported a particularly poor overall satisfaction level concerning their long-term well-being. Conclusions Patients with cage implantation reported a higher degree of long-term well-being. The data provide evidence for a positive impact on the postsurgery quality of life after cage implantation.

Percutaneous iliosacral screw fixation and transsacral fixation are challenging procedures requiring extensive knowledge of sacral anatomy to avoid damaging nearby neurovascular structures. Greater knowledge of anatomical screw trajectory and size allowances would be helpful to guide surgical placement. An anatomical study of 40 cadaveric sacra in specimens ages 18-65 was performed. Three-dimensional surface scans were obtained, and computer modeling software was used to simulate a 7.3 mm diameter screw with 1 mm buffer inserted orthogonal to the sacroiliac joint in the pelvic inlet and outlet views. Transsacral screws were also inserted into S1 and S2 vertebrae. For screws orthogonal to the sacroiliac joint, the overall mean screw insertion angle was 4.1° ± 7.5° (range, -18.3° to 22.0°) in the inlet view in the posterior to anterior direction, and 21.7° ± 5.1° (range, 8.2°-36.3°) in the outlet view in the caudal to cranial direction. Before breaching the sacrum, the range of sacral tunnel lengths was between 31.1 and 70.1 mm with a range of diameters between 9.3 and 13.3 mm. Transsacral screws inserted into either the S1 or S2 vertebrae did not breach the sacrum in 40% (16/40) at each level. 30% (12/40) of sacra could not safely accommodate both S1 and S2 transsacral screws. There is an initial screw insertion angle range of -4° to 12° in the inlet view and 16°-27° in the outlet view. There was always adequate size to accept a 7.3 mm or larger screw.

Objective The purpose of this study is to determine whether a Transversus Abdominis Plane (TAP) block can reduce donor site morbidity among pediatric patients undergoing iliac crest bone grafting for repair of their alveolar cleft. Design This retrospective cohort study was carried out at the Division of Dentistry at the Montreal Children's Hospital. Medical charts of patients who underwent alveolar cleft bone grafting between January 2011 and January 2021 were reviewed and they were divided into two groups, intraoperative TAP block and intraoperative local anesthesia infiltration (control group). The outcomes measured were patients’ post-operative pain at the donor site, in-hospital narcotics requirements and length of stay. Results A total of 66 patients were included. There were no significant differences in pain scale among the TAP group and control group [1.9 (SD 2.5) and 1.3 (SD 2.1), respectively ( p = 0.23)]. The mean length of stay for both groups was 1 day. Interestingly, there was a significant higher proportion of patients who required in-hospital opioids (morphine) in the TAP block group when compared to the control group ( p = 0.03). Conclusions The results of our study suggest there may be no role for a TAP block in reducing pain and improving opioid stewardship.

We aimed to investigate the impact of long corrective fusion to the ilium on the physical function in elderly patients with adult spinal deformity and its correlation with spinopelvic parameters and health-related quality of life outcomes.We included 60 female patients who underwent long corrective fusion from T9 or T10 to the pelvis for adult spinal deformities (mean age of 69.8 years, range 55-78 years). The radiographic parameters, health-related quality of life outcomes using the Scoliosis Research Society Outcome Instrument-22 and physical function assessments were reviewed preoperatively and at 1-year postoperatively.All spinopelvic parameters, except for thoracolumbar kyphosis, and all domains of the Scoliosis Research Society Outcome Instrument-22 significantly improved at 1-year postoperatively (p 0.0001). Physical function results, including those for one-leg standing time, timed up-and-go test, and 6-min walk tests, significantly improved at 1-year postoperatively (p 0.005). Based on forward stepwise multivariate logistic regression, the predicted timed up-and-go test and 6-min walk test outcomes at 1-year postoperatively were as follows: timed up-and-go test, 7.8 + 0.47 × preoperative timed up-and-go test - 0.21 × 1-year postoperative grasping power +0.015 × 1-year postoperative C1 sagittal vertical axis (R2 = 0.6209, p 0.0001); 6-min walk test, 309.2-9.1 × body mass index + 11.6 × 1-year postoperative grasping power + 3.3 × 1-year postoperative thoracolumbar kyphosis - 0.59 × 1-year postoperative C1 sagittal vertical axis (R2 = 0.4409, p 0.0001).Corrective long fusion surgery for adult spinal deformity in normalizing sagittal alignment improves trunk balance and gait performance. Postoperative physical function depends on the preoperative physical performance status and skeletal muscle status; thus, preoperative interventions for improved physical function are recommended.

Background The term non-invasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP) was recently proposed as a non-malignant thyroid lesion with indolent behavior that does not require post-operative radio-iodine treatment. We are reporting a case of NIFTP with bone metastasis that is the second case reported so far. Case presentation We describe a 38-year-old woman who presented with an indeterminate thyroid nodule and underwent total thyroidectomy with the finding of NIFTP on careful pathologic examination. However, her initial follow-up evaluation revealed a serum thyroglobulin level of > 300 ng/ml and a diagnostic whole body 131I scan demonstrated a focus of increased uptake in the left hemipelvis, confirmed on CT scan to be a lytic lesion in the left iliac bone. She was treated with 7.4GBq (200 mCi) of 131I and her follow-up 1 year later revealed an undetectable serum thyroglobulin and a negative whole body 131I scan with no visible uptake in the iliac bone indicating an excellent response. Conclusion This case presentation reminds us to be alert to the rare occurrence of distant metastasis in NIFTP and the need for a case by case analysis and continuing post-operative follow-up for detection of residual or recurrent disease.

Background Five different sacral fracture fixation methods were compared using finite element (FE) analysis to study their biomechanical characteristics. Methods Denis type I sacral fractures were created by FE modeling. Five different fixation methods for the posterior pelvic ring were simulated: sacroiliac screw (SIS), lumbopelvic fixation (LPF), transiliac internal fixator (TIFI), S2-alar-iliac (S2AI) screw and S1 pedicle screw fixation (S2AI-S1) and S2AI screw and contralateral S1 pedicle screw fixation (S2AI-CS1). Four different loading methods were implemented in sequence to simulate the force in standing, flexion, right bending and left twisting, respectively. Vertical stiffness, relative displacement and change in relative displacement were recorded and analyzed. Results As predicted by the FE model, the vertical stiffness of the five groups in descending order was S2AI-S1, SIS, S2AI-CS1, LPF and TIFI. In terms of relative displacement, groups S2AI-S1 and S2AI-CS1 displayed a lower mean relative displacement, although group S2AI-CS1 exhibited greater displacement in the upper sacrum than group S2AI-S1. Group SIS displayed a moderate mean relative displacement, although the displacement of the upper sacrum was smaller than the corresponding displacement in group S2AI-CS1, while groups LPF and TIFI displayed larger mean relative displacements. Finally, in terms of change in relative displacement, groups TIFI and LPF displayed the greatest fluctuations in their motion, while groups SIS, S2AI-S1 and S2AI-CS1 displayed smaller fluctuations. Conclusion Compared with SIS, unilateral LPF and TIFI, group S2AI-S1 displayed the greatest biomechanical stability of the Denis type I sacral fracture FE models. When the S1 pedicle screw insertion point on the affected side is damaged, S2AI-CS1 can be used as an appropriate alternative to S2AI-S1.

Objective To compare the difference of anterior inferior iliac spine (AIIS) and subspine hypertrophic deformity between symptomatic and asymptomatic hips in patients traditionally diagnosed with femoroacetabular impingement (FAI), and investigate the correlation of subspine decompression with AIIS variation and subspine hypertrophic deformity. Methods We retrospectively reviewed 70 patients with unilateral symptomatic FAI who underwent hip arthroscopy. The operative hips and contralateral hips naturally formed the symptomatic groups and asymptomatic control groups, respectively. The morphometric comparison of the hip joint was performed between the operative and contralateral sides of each patient. Radiological assessment was performed by two observers (an experienced musculoskeletal radiologist and an experienced surgeon). Three‐dimensional (3D)‐CT images of each patient were blindly reviewed to determine the AIIS variation and subspine hypertrophic deformity. Reformatted two‐dimensional (2D)‐CT images and anterior–posterior (AP) pelvic plain radiographs were blindly reviewed to determine FAI‐related morphological measurements. Moreover, the surgical assessment was reviewed by one experienced surgeon to interpret whether subspine decompression was performed. The correlation of subspine decompression with AIIS variation and subspine hypertrophy was analyzed. Results Out of 70 patients with unilateral symptomatic FAI, 37 were males (52.9%) and 23 (32.9%) had symptoms involving the left hip. The mean age was 39.3 ± 10.4 years and the mean BMI was 24.3 ± 3.6. The distribution of AIIS variants in symptomatic hips did not differ significantly from that in asymptomatic hips (χ2 = 3.092, P = 0.213). Twenty‐nine hips in the symptomatic group (41.4%) and 12 hips in the asymptomatic group (17.1%) were identified as positive for subspine hypertrophy. The incidence of positive subspine hypertrophy was significantly higher in the symptomatic hips compared to the asymptomatic hips (χ2 = 9.968, P = 0.002). FAI‐related morphological parameters including α angle, lateral center‐edge angle, acetabular anteversion, crossover sign, and Tonnis grade were highly symmetrical and did not show significant differences between symptomatic and asymptomatic hips. Fifty‐four of 70 hips (77.1%) had labral tears extended to the acetabular rim corresponding to the AIIS. Forty‐seven hips of 70 hips (67.1%) underwent subspine decompression, which was significantly correlated with AIIS variation and subspine hypertrophic deformity (P = 0.019 and 0.001, respectively). Conclusion Subspine hypertrophic deformity was found to be more common in symptomatic side vs asymptomatic side in patients with unilateral symptomatic femoroacetabular impingement. Subspine hypertrophy may be considered as an underlying indication for subspine decompression besides low‐lying AIIS., Subspine hypertrophy is a common but underlying deformity in patients with unilateral symptomatic femoroacetabular impingement. Subspine hypertrophy may be considered as a potential indication for subspine decompression besides low‐lying AIIS.

Objective To describe in detail the variability of the attachments of the iliopectineal fascia (IPF) and its relation to the external iliac vessels to inform surgical approaches and help prevent injury to the adjacent vascular structures. Methods A cadaveric study was performed on 16 specimens. The IPF was identified from the lateral and medial perspectives of the II and anterior intrapelvic approaches, respectively, and its anatomic characteristics were described. Results The IPF originates in the fascia of the psoas muscle, it has variable attachments in the pelvic brim, and it inserts in the medial surface of the iliac bone where it is continuous with the obturator internus fascia. Two variants were found in relation to the external iliac vessels. In one variant found in 4 cadavers, the IPF formed a sail-like structure that surrounds the external iliac vessels. In the other variant observed in 4 cadavers, the IPF overlaid the iliac fossa, under the external iliac vessels which laid free in the iliac fossa. Conclusions The anatomic variants of the attachment of the IPF to the pelvic brim and its variants in relation to the external iliac vessels must be accounted for when performing acetabular surgery to prevent vascular injury and attain adequate exposure.

BackgroundHistologically normal appendices resected for right iliac fossa pain in children demonstrate immunohistochemical markers of inflammation. We aimed to establish if subclinical inflammation was present in histologically normal appendices resected from adults with right iliac fossa pain.MethodsImmunohistochemistry was performed on formalin-fixed paraffin-embedded appendices for tumour necrosis factor (TNF)-α, interleukin (IL)-6, IL-2R and serotonin in four groups: Group I (n = 120): uncomplicated appendicitis, Group II (n = 118): complicated appendicitis (perforation or gangrene), Group III (n = 104): histologically normal appendices resected for right iliac fossa pain and Group IV (n = 106) appendices resected at elective colectomy. Expression was quantified using the H-scoring system.ResultsMedian, interquartile range expression of TNF-α was increased in Groups I (5.9, 3.1–9.8), II (6.8, 3.6–12.1) and III (9.8, 6.2–15.2) when compared with Group IV (3.0, 1.4–4.7,p p p p ConclusionHistologically normal appendices resected from symptomatic patients exhibited increased proinflammatory cytokine expression on immunohistochemistry suggesting the presence of an inflammatory process not detected on conventional microscopy.

Background The primary aim of this systematic review and meta-analysis was to compare postoperative pain, analgesic consumption, and complications after fascia iliaca block (FIB) versus control for patients undergoing primary total hip arthroplasty (THA). Second, we compared the outcomes of FIB versus placebo. Finally, we sought to evaluate pain and analgesic consumption after preoperative and postoperative FIB. Methods We performed a systematic literature search in MEDLINE, Embase, Scopus, Web of Science, Google Scholar, ClinicalTrials.gov, and CENTRAL through February 2021 to identify randomized controlled trials (RCTs) that evaluated the efficacy of FIB versus control for patients undergoing primary THA. All analyses were conducted on intent-to-treat data with a random-effects model. Results Twelve RCTs with a total of 815 patients were included. There was no difference in postoperative pain (P = 0.64), analgesic consumption (P = 0.14), or complication rate (P = 0.99) between FIB and control groups. Moreover, no difference in postoperative pain (P = 0.26), analgesic consumption (P = 0.06), or complication rate (P = 0.71) was found between FIB and placebo. Moreover, sensitivity analysis suggested that no significant difference in postoperative pain, analgesic consumption, or complication rate was present between FIB and control in studies that used preoperative and postoperative FIB. Conclusion FIB was not found to be superior to placebo or various anesthetic techniques for patients undergoing primary THA, as measured by postoperative pain, analgesic consumption, and complications.

Nondisplaced and minimally displaced sacral insufficiency fractures are increasingly being recognized as a cause of immobilizing low back pain in the elderly. These insufficiency fractures are most accurately diagnosed by visualizing sacral bone marrow edema on magnetic resonance imaging, which is the radiologic imaging modality with the highest sensitivity for identifying these fractures. Successful treatment options range from nonsurgical (eg, bed rest, pain medication, mobilization, antiosteoporotic medication, low-intensity-pulsed ultrasound, etc.) to surgical management (ie, sacroplasty and/or osteosynthesis with iliosacral screws or lumbosacral hinge fixation with or without application of reinforcing bone cement). The appropriate surgical treatment for frail subjects requires a less-invasive technique that establishes full weight-bearing stability for successful early remobilization of affected elderly and multimorbid individuals. Iliosacral screw osteosynthesis with a single C-arm is a common surgical technique for stabilizing the posterior pelvic ring after traumatic instabilities or fractures of the sacrum. Bilateral injuries are generally addressed from both sides of the pelvis. This article describes the surgical technique of 3D image-guided transsacral screw fixation for unilateral and bilateral nondisplaced sacral insufficiency fractures in the elderly using a single-sided approach, and specifies the associated preoperative and postoperative management. The procedure is illustrated in an instructional video that demonstrates step-by-step, how the navigated surgical procedure is performed.

STUDY DESIGN This was a retrospective cohort review. OBJECTIVE The objective of this study was to determine the rate of fusion associated with an expandable cage and iliac crest bone graft in minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) surgery. SUMMARY OF BACKGROUND DATA MI-TLIF is a commonly performed procedure, but challenges inherent in MI-TLIF technique can make achieving an interbody fusion difficult. METHODS A retrospective review was performed on consecutive patients treated with an MI-TLIF for degenerative lumbar pathology. Patients that completed patient-reported outcome measures and 1-year computed tomography (CT)-scans for fusion analysis were included. Fusion morphology was analyzed by evaluating CT scans for location of bridging trabecular bone in relation to the cage. Patients with bridging bone were considered fused. Preoperative and postoperative health-related quality of life scores were compared. A Kolmogrov-Smirnoff test was used to determine normality of health-related outcome scores. A Friedman 2-way analysis of variance by ranks with pairwise comparisons to determine statistical significance of differences between the date of a follow-up examination and preoperative examination was done. RESULTS Of 75 patients evaluated 23 patients were excluded due to loss to follow-up, adjacent segment degeneration, inability to obtain a CT scan, or reoperation for nonfusion related symptoms. Of 61 disk spaces that were included, 55 had bridging bone through the intervertebral cage, resulting in an overall fusion rate of 90.2%. There was a higher rate of fusion at L5-S1 as compared to L4-L5. There was mean improvement in patient-reported outcome measures for Oswestry Disability Index, Short Form-12 Physical Component Score, Visual Analog Scale Back/Leg pain, and Patient-Reported Outcome Measurement Information System Physical Function. There were no complications associated with iliac crest bone graft harvesting. CONCLUSION Combining an expandable cage with iliac crest autograft bone harvested through a minimally invasive technique can allow for improved fusion rates without graft-site complications in MI-TLIF surgery.

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.

Purpose Stability of the dorsal pelvic ring is important for patient mobilisation and can be restored using several surgical procedures after fracture. Placement of percutaneous iliosacral screws is a reliable and minimal-invasive technique to achieve stabilisation of the dorsal pelvic ring by placement of two screws in the first sacral vertebra. Aim of this study was to evaluate 3D CT scans regarding the anatomical possibility to place two 7.3 mm iliosacral screws for fixation of the dorsal pelvic ring. Methods 3D CT datasets of 500 consecutive trauma patients with 1000 hemipelves of a mid-european level I trauma centre with or without pelvic injury were evaluated and measured bilaterally in this retrospective study. Results One thousand hemipelvic datasets of 500 patients (157 females, 343 males) with a mean age of 49.7 years (18 to 95) were included in this study. Only 16 hemipelves (1.6%, 11 in females, 5 in males) in 14 patients (2.8%, 9 females = 5.73%, 5 males = 1.5%) showed too narrow corridors so that 7.3 mm screw placement would not be possible (p = 0.001). In women, too narrow corridors occurred 3.9 times as often as in men. Only two females showed this bilaterally. Conclusion The evaluation of 3D CT scans of the pelvis showed the importance of planning iliosacral screw placement, especially if two 7.3 mm screws are intended to be placed in the first sacral vertebra.

OBJECTIVE To determine the influence of plating systems on the clinical outcomes in dogs treated for ilial fractures. DESIGN Retrospective study. ANIMALS Fifty-nine dogs (63 hemipelves). METHODS Radiographs and medical records of dogs with ilial fractures presented to Iowa State University between 2003 and 2019 were reviewed. After fracture reduction, fractures were fixed with a locking plate system (LPS) or non-locking plate system (NLS). Perioperative, long-term complications, and follow-up data were recorded. The frequency of implant failure and pelvic collapse were compared using a logistic and linear regression analysis, respectively. Where the univariate test was statistically significant, a multivariate analysis across categories was performed to identify statistically different categories. RESULTS LPS and NLS implants were used in 25/63 and 38/63 hemipelves, respectively. Median follow-up time was 8 weeks (3-624 weeks). Implant failure occurred in 18/63 (29%) of fracture repairs, consisting of 17 with NLS and 1 with LPS. Revision surgery was recommended in five cases of implant failure, all with NLS. The probability of implant failure was higher when fractures were fixed with NLS (p = .0056). All other variables evaluated did not seem to influence outcome measures. CONCLUSION The variable with the most influence on the outcomes of dogs treated for ilial fractures consisted of the fixation method (NLS vs. LPS). Fractures repaired with NLS were nearly 20 times more likely to fail than those repaired with LPS. CLINICAL RELEVANCE Surgeons should consider repairing ilial body fractures in dogs with LPS to reduce the risk of short-term implant failure.

© 2021, The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.Purpose: The primary aim of this study is to prove that reconstructing the anterior glenoid defect with iliac crest graft arthroscopically using double-barrelled cannula through the rotator interval is safe and prevents both recurrence of instability and the neurovascular injury because subscapularis muscle is not split and procedure is far away from important structures. Methods: Thirteen patients with anterior shoulder instability and engaging Hill-Sachs lesion were reviewed after arthroscopic reconstruction of the anterior glenoid with iliac crest autogenous graft. Patient satisfaction and Western Ontario İnstability Score (WOSI) were evaluated on clinical examination. Computed tomography was used to analyse graft position on sagittal and axial planes. Results: The mean follow-up was 28.7 months (SD 7.1), and age at surgery was 31 years (21 to 64 years). Post-operatively there was only one dislocation due to trauma. There was statistically significant improvement of WOSI scores (p: 0.001). There was not any neurological injury. Graft position on the axial plane was described as flush in 5 cases (41%), lateral in 2 (16%), too lateral in one (8%) and medial in 4 of the cases (33%). Graft position could be accepted as high in only three patients (23%). Conclusion: Arthroscopic reconstruction of glenoid defect using autogenous iliac bone graft, through rotator interval, without splitting subscapularis is safe and effective without any neurological injury, producing substantial graft position and good functional outcomes in patients.

Several authors have suggested that implants can be placed simultaneously with onlay bone grafts without affecting outcomes. Therefore, the purpose of this study was to answer the following clinical questions: (1) What are the outcomes of implants placed simultaneously with autogenous onlay bone grafts? And (2) is there a difference in outcomes between simultaneous vs delayed placement of implants with autogenous onlay bone grafts? Databases of PubMed, Embase, and Google Scholar were searched up to 15 November 2020. Data on implant survival was extracted from all the included studies (single arm and comparative) to calculate point estimates with 95% confidence intervals (CI) and pooled using the DerSimonian–Laird meta-analysis model. We also compared implant survival rates between the simultaneous and delayed placement of implants with data from comparative studies. Nineteen studies were included. Five of them compared simultaneous and delayed placement of implants. Dividing the studies based on follow-up duration, the pooled survival of implant placed simultaneously with onlay grafts after

Osteoporosis is characterized by an imbalance between bone formation and resorption rates, resulting in bone loss. For ethical reasons, effects of antiosteoporosis drugs are compared against patients receiving vitamin D and calcium supplementation which is a mild antiresorptive regimen. Bone formation may be resolved into two phases: the initial formation of mineral crystals (primary nucleation) and the subsequent mineral accumulation (secondary nucleation and mineral growth) on them. In this study, we used Raman microspectroscopic analysis of iliac crest biopsies from healthy females (N = 108), postmenopausal osteoporosis patients receiving vitamin D and calcium supplementation (PMOP-S; N = 66), and treatment-naive postmenopausal osteoporosis patients (PMOP-TN; N = 12) to test the hypothesis that at forming trabecular surfaces, mineral maturity / crystallinity of the youngest crystallites associates with the amount of subsequent mineral accumulation. The surfaces of analysis were chosen based on the presence of fluorescent double labels, defining three distinct tissue ages. The results indicated that when adjusted for age and tissue age, there were no differences in amount of mineral formed between healthy females and either PMOP-S or PMOP-TN, while both PMOP-S and PMOP-TN had larger crystallites compared to healthy females. Moreover, significant differences existed between PMOP-S and PMOP-TN in size of initial crystals formed as well as rate of mineral accumulation and maturation. These findings suggest an additional mechanism that may contribute to the decreased mineral content evident in PMOP, and provide a potential target for the development of new interventions. Statement of Significance We used Raman microspectroscopic analysis of iliac crest biopsies from healthy females and postmenopausal osteoporosis patients (PMOP) receiving placebo to test the hypothesis that at forming trabecular surfaces, mineral maturity / crystallinity (MMC) of the youngest crystallites associates with the amount of subsequent mineral accumulation. This can affect bone mechanical properties as larger crystallites have been shown to result in compromised mechanical attributes; and larger crystallites grow slower compared to smaller ones. The results of the present analysis indicate that increased MMC of the youngest formed mineral may contribute to the bone mineral loss evident in PMOP and the accompanying increased fracture risk independently of bone turnover rate.

This study aims to analyze the outcomes of subtalar distraction arthrodesis (SDA) for calcaneal malunion using structural freeze-dried iliac allograft (FDIA) compared to using autologous iliac bone (AIB).We retrospectively evaluated 57 consecutive cases (51 patients) of calcaneal malunion between March 2006 and December 2017. All patients were followed for an average of 22.8 months. All cases were treated by SDA using structural FDIA (17 cases, group 1), or AIB (40 cases, group 2). The outcome measures included the American Orthopaedic Foot and Ankle Society ankle-hindfoot (AOFAS) scores, visual analog scale (VAS) pain scores, and radiographic measurements.The mean postoperative 3, 6, and 12 months of AOFAS scores and VAS pain score were significantly better in group 2 than those in group 1 (p0.05, for all). There were 3 cases (17.6%) of nonunion in the group 1, whereas the group 2 had 2 cases (5.0%), which did not shown significant difference between two groups (p = 0.492). Although the mean pre-, postoperative, and final follow-up radiologic parameters in both groups were similar, (p0.05, for all) the difference of talocalcaneal height, talocalcaneal angle, and talar declination angle from postoperative to final follow-up were significantly bigger in the group 1. (p0.05, for all).Although union rate was not significantly different between the two groups, we obtained more favorable clinical and radiologic outcomes in the autologous iliac bone group. Using FDIA without any orthobiological agent for SDA, there were significant more loss of radiological parameters due to inferior incorporation and biomechanical properties. When considering the SDA for calcaneal malunion, routine use of FDIA without any orthobiological agents as an interpositional graft for SDA is not recommended.

External fixation has been widely implemented as a resuscitation strategy in combination with pelvic packing for high energy, hemodynamically unstable, pelvic ring injuries. The primary aim of this study is to compare urgent iliac crest (IC) versus supraacetabular (SA) external fixation in the setting of haemodynamic instability. This is a retrospective review of a prospectively gathered registry at an urban level one trauma centre comparing placement of pelvic external fixator by SA or IC technique. Outcomes assessed were accuracy of pin placement, duration of procedure, and the effect on true pelvic circumference depending on type of fracture by Young and Burgess Classification system. Ninety-three haemodynamically unstable patients with a pelvic fracture included. Pin malpositioning was more common with IC than SA groups (proportional difference, − 40%; 95% CI, − 57 to − 20%; p

Purpose To evaluate the clinical, functional, and radiological midterm outcomes of the all-arthroscopic modified Eden-Hybinette procedure in patients with recurrent anterior shoulder instability. Methods A retrospective, single-center case series with prospectively collected data was conducted. The inclusion criterion was traumatic recurrent anterior shoulder instability with significant glenoid bone loss; patients with atraumatic or multidirectional instability were excluded. An all-arthroscopic modified Eden-Hybinette procedure using iliac crest autograft and double-pair button fixation was carried out. All patients were postoperatively assessed for recurrence and apprehension. Shoulder range of motion values and functional scores, including American Shoulder and Elbow Surgeons Score, Oxford instability, Rowe instability, and Walch-Dupplay, were recorded. Graft positions, healing, and absorption were evaluated with computed tomography. Comparisons of values were performed with paired t tests for normally distributed differences and with nonparametric Wilcoxon’s signed rank test otherwise. Results The final study cohort included 28 patients, mean age 36 ± 10 years, and mean follow-up period 43 ± 6 months (range 36 to 53). Median glenoid bone loss was 12.4% (range 8% to 33%). No recurrence occurred, no subjective shoulder instability was reported, and no major complications were documented through the last follow-up. Postoperative shoulder range of motion had no significant differences compared with the healthy side. All final postoperative functional scores significantly increased to show excellent results compared with preoperative values. All grafts were positioned and healed optimally, and none was completely reabsorbed. Conclusions The all-arthroscopic modified Eden-Hybinette procedure is safe, leading to excellent clinical and radiological midterm outcomes in patients with recurrent anterior shoulder instability. This technique restores glenoid bone defects and preserves the normal shoulder anatomy. Level of Evidence IV, therapeutic, retrospective case series

SUMMARY: The osteomyocutaneous iliac crest free flap is a reconstructive option for segmental mandibular or complex palatomaxillary defects. Familiarity with the radiographic appearance of free flaps such as the iliac crest is necessary for the postoperative evaluation of patients after mandibular, maxillary, or palatal reconstructions because it allows radiologists to properly monitor and interpret the appearance of the flap over time. This study presents a retrospective review of 5 patients who underwent palatomaxillary reconstruction with an iliac crest free flap at our institution. The imaging appearances of the 5 patients were analyzed to determine the key radiographic characteristics of a healthy and successful iliac crest free flap. Radiographic fluency with the imaging appearance of the iliac crest free flap, as well as the new anatomy of the region in the postoperative period, will allow for better interpretation of the flap appearance on imaging and will prevent false identification of tumor recurrence.

Purpose Instability of the posterior pelvic ring may be stabilized by lumbopelvic fixation. The optimal osseous corridor for iliac screw placement from the posterior superior iliac spine to the anterior inferior iliac spine requires multiple ap- and lateral-views with additional obturator-outlet and -inlet views. The purpose of this study was to determine if navigated iliac screw placement for lumbopelvic fixation influences surgical time, fluoroscopy time, radiation exposure, and complication rates. Methods Bilateral lumbopelvic fixation was performed in 63 patients. Implants were inserted as previously described by Schildhauer. A passive optoelectronic navigation system with surface matching on L4 was utilized for navigated iliac screw placement. To compare groups, demographics were assessed. Operative time, fluoroscopic time, and radiation were delineated. Results Conventional fluoroscopic imaging for lumbopelvic fixation was performed in 32 patients and 31 patients underwent the procedure with navigated iliac screw placement. No differences were found between the groups regarding demographics, comorbidities, or additional surgical procedures. Utilization of navigation led to fluoroscopy time reduction of more than 50% (3.2 vs. 8.6 min.; p 2; p p = 0.002) despite the necessity of additional surface referencing. Conclusion For iliac screws, identifying the correct entry point and angle of implantation requires detailed anatomic knowledge and multiple radiographic views. In our study, additional navigation reduced operative time and fluoroscopy time resulting in a significant reduction of radiation exposure for patients and OR personnel.

Bone location is uncommon in both sarcoidosis and in neck cancer (HNC). Diagnosis of a bone lesion is therefore challenging to distinguish its nature in a patient suffering from both diseases. We report the case of a 69-years-old woman referred for P16 positive HPV-HNC. Magnetic Resonance Imaging (MRI) showed T2 hypo-signal on iliac crest and spine. 18FDG-PET demonstrated radiotracer uptake on these locations suggesting bone metastasis. However, bone biopsy showed epithelioid granuloma without malignant cells compatible with sarcoidosis location. The diagnosis of both localized advanced HPV-HNC and systemic sarcoidosis (bone, central nervous system) were retained. The patient received corticosteroid regimen at 0.5 mg/kg/day and Methotrexate for sarcoidosis and radiation and chemotherapy with platins for carcinoma. As granulomatous bone marrow infiltration may have an uptake on 18FDG-PET, bone sarcoidosis can mimic metastatic disease. In addition, MRI often fails to distinguish sarcoidosis lesions from metastatic lesion in bones. As no reliable imaging test can decipher both diseases, the description of our case reinforces the necessity to perform bone biopsy in a patient suffering from both conditions to expertise the nature of bone lesions.

With the help of a J-shaped bicortical iliac crest bone graft, the morphology of the glenoid can be augmented without having to use screws to achieve glenohumeral stability. The aim of this retrospective clinical study was to evaluate the clinical stability and function of the shoulder joint as well as the radiological remodelling process and arthropathic outcomes following the J-bone graft technique. 34 patients with recurrent shoulder dislocations and bony glenoid defects were treated with the J-bone graft technique between 2010 and 2018 at our level-I trauma centre. 15 patients (18 shoulders) could be recruited for the study. Pain levels, ASES, UCLA, SST, DASH, Rowe and WOSI Scores were collected using questionnaires. In 13 patients (16 shoulders) the Constant Score, ROM, CT with 3D reconstruction of the glenoid to assess the graft remodelling and X-rays were performed additionally. None of the patients suffered subluxations or recurrent dislocations during the follow-up period. The overall complication rate was 11%. The evaluation using objective and subjective shoulder function scores yielded good-to-excellent results. Radiological assessment at follow-up showed a low rate of moderate-to-severe arthritis (12%) and a high rate of shoulders without any signs of arthritic degeneration (53%). The CT scans all revealed an almost complete restoration of the glenoid with none of the grafts being resorbed. A rise in the average glenoid circumference and glenoid area could be demonstrated between preoperative measurements (81.6 and 82.4%, respectively) and follow-up measurements (104 and 102.5%, respectively). The results of this study show a successful stabilisation of the shoulder joint and a low complication rate following the J-bone graft technique. Remodelling of the bone graft could be demonstrated, which in turn led to an almost perfect glenoid surface area of 100%.

Objectives This study aims to evaluate the early- and mid-term shoulder and elbow functions and compare the union rates after the application of single plate and double plate for the treatment of humerus shaft nonunions. Patients and methods This retrospective study included 56 patients (36 males, 20 females; mean age 53.8±9.5; range, 28 to 68 years) treated with double plate (n=25) and single plate (n=31) osteosynthesis between October 2012 and January 2016. Surgical treatment of the nonunion was applied in the fourth month after the fracture at the earliest. Autograft taken from the iliac bone was applied during the surgery in all patients. Evaluation was performed using The University of California at Los Angeles (UCLA) Shoulder Score, Mayo Elbow Performance Score (MEPS), Visual Analog Scale (VAS), Constant Shoulder Score, and Disabilities of the Arm Shoulder and Hand (DASH) questionnaire. Results The mean postoperative follow-up time was 40.7±9.6 (range, 25 to 58) months. No statistically significant difference was determined in respect of time to union, follow-up time, DASH questionnaire score, UCLA Shoulder Score, VAS, MEPS and Constant Shoulder Score after union in the comparison of the two groups (p>0.05). In the examination of postoperative early (three months) recovery phase of shoulder and elbow functions, statistically significant superior scores were obtained in the double plate group for MEPS (double plate median=85 [min 75-max 90], single plate median=75 [min 70-max 85]) and Constant Shoulder Score (double plate median=89 [min 85-max 92], single plate median=81 [min 75-max 90]) (p

Recently, the number of adult spinal deformity surgeries including sacroiliac joint fixation (SIJF) by using an S2 alar iliac screw or iliac screw has increased to avoid the distal junctional failure. However, we occasionally experienced patients who suffered from hip pain after a long instrumented spinal fusion. We hypothesized that long spinal fusion surgery including SIJF influenced the hip joint as an adjacent joint. The aim of this paper was to evaluate the association between spinal deformity surgery including SIJF and radiographic progression of hip osteoarthritis (OA). This study was retrospective cohort study. In total, 118 patients who underwent spinal fusion surgery at single center from January 2013 to August 2018 were included. We measured joint space width (JSW) at central space of the hip joint. We defined reduction of more than 0.5 mm/year in JSW as hip OA progression. The patients were divided into two groups depending on either a progression of hip osteoarthritis (Group P), or no progression (Group N). The number of patients in Group P and Group N was 47 and 71, respectively. Factor that was statistically significant for hip OA was SIJF (p = 0.0065, odds ratio = 7.1, 95% confidence interval = 1.6–31.6). There were no other significant differences by the multiple logistic regression analysis. This study identified spinal fixation surgery that includes SIJF as a predictor for radiographic progression of hip OA over 12 months. We should pay attention to hip joint lesions after adult spinal deformity surgery, including SIJF.

Bone marrow aspirate (BMA) is an emerging therapy that is gaining popularity for orthoplastic reconstruction. The stem cells collected are multipotent and regenerative in nature. In addition to stem cells, other biological components collected augment the mitogen of local cells, proliferation, and angiogenesis, and inhibit proinflammatory cytokine and bacteria to optimize an environment to heal. The most common site for harvest is the iliac crest. Techniques for harvesting BMA are simple to perform, financially modest, and associated with low morbidity. Additional research is needed to evolve and standardize the technology; however, BMA is proven to be advantageous for tissue repair.

Objective We simulated the trajectory for an L5/S1 percutaneous endoscopic transforaminal discectomy (PETD) to guide decision-making for the surgery approach. Methods Twenty-three patients with L5/S1 lumbar disc herniation were included in the study. The patients all underwent thin-section computed tomography scans, after which data were collected for 3-dimensional reconstruction. Simulations of the trajectory for the L5/S1 PETDs were generated and the hindrance of surrounding anatomic structures was evaluated. Results Preoperative simulation showed that 14 patients were considered suitable for lumbar PETD. Nine patients were not considered suitable for PETD surgery according to the simulation. Factors affecting the trajectory included high iliac crest in 5 patients, L5 transverse process in 3 patients, and hypertrophic L5-S1 facet joint in 1 patient. Conclusions Preoperative simulation of the trajectory for L5/S1 PETD was helpful in the decision-making for the surgical approach.

Category: Ankle; Ankle Arthritis Introduction/Purpose: End-stage ankle arthritis may be managed with ankle arthrodesis or total ankle replacement (TAR). Failure of these procedures results in a challenging clinical situation. Revision in these scenarios is technically demanding, and if associated with subtalar degeneration, conversion to tibiotalocalcaneal (TTC) arthrodesis may be required. Bone grafting may be necessary to maintain length and reduce disability, and fibular strut grafting in form of ‘pillars’ or ‘columns’ may be used in association with intramedullary TTC nailing. In our experience, fibular column autograft may be supplemented with tricortical and cancellous iliac crest graft and stabilised with cannulated screws and either an intramedullary nail or a lateral plate. In this technical note, we review the history of this technique and report indications, surgical approach, results and complications. Methods: A distal J-shaped lateral approach is performed over the posterior edge of the distal fibula. An oblique fibular cut is made with a saw at 8- 12 cm from the fibular tip. Careful removal of the implant, previous cement spacer or metalwork is performed then articular surfaces are prepared. After assessment of the articular gap, the autograft is prepared by removing the tip of the fibula from the fibular block, then sectioning it in to either three or four columns which are positioned into the gap and stabilised either in a press-fit fashion or using 1.6mm K-wires. Six patients (4M, 2F; mean age: 69.8 years (range, 51 to 83)) were treated between December 2018 and March 2019 (5 failed TAR and 1 was symptomatic tibiotalar non-union) at our institution. Fixation was achieved in 5 cases with a locked intramedullary nail and in 1 case with a lateral locking plate. Results: At a mean follow up of 10 months (range, 6 to 11 months), 4 patients had clinically and radiologically united and were satisfied with the outcome of surgery. Two patients remained dissatisfied having not united: one patient with a background of chronic kidney disease had raised inflammatory blood markers at 10 months and is undergoing investigation to exclude infection whilst one other patient with no obvious risk factors for non-union has started low intensity pulsed ultrasound treatment at 6 months. No other complications were observed. Conclusion: Tibiotalocalcaneal fusion augmented with fibular columns and iliac crest autograft is an option to treat combined ankle and the subtalar joint pathologies with significant talar bone loss. However larger studies with longer follow-up are required to define the rates of success and failure with future research directed to better understand which factors may predict the outcome.

The purpose of this study was to evaluate long-term three-dimensional graft resorption following reconstruction of the severely atrophic maxilla with anterior iliac crest bone grafting.Twenty-two patients (13 males), who underwent autogenous bone grafting and implant placement to their severely atrophic maxillary alveolar ridges were identified and included in the study. Pre- and postoperative cone-beam computed tomography (CBCT) scans of 40 recipient grafting sites were evaluated to calculate volumetric changes over time. CBCT scans were performed preoperatively (V0) and one week (V1), three months (V2), one year (V3), and three years (V4) following the augmentation operation.The average graft resorption from V1 to V2, V1 to V3, and V1 to V4 was 31.42%, 33.96%, and 37.96%, respectively. Initial graft volume reduction within the first three months was statistically higher compared to other postoperative periods (P0.013). The rate of resorption reduced slightly from the third month of the surgery (V2) (P0.013). There was no statistical difference between resorption volume and gender, type of prosthesis, the presence of vestibuloplasty, or patient age (P0.05).The overall success rate of the iliac bone block grafts was found to be high. The volumetric resorption rates associated with the graft were favourable for the reconstruction of the maxilla and for permitting the placement of dental implants three months after augmentation. The highest graft resorption was found at the third postoperative month. Placement and loading of the implants reduced the resorption rate slightly over time.

BACKGROUND CONTEXT Although autogenous iliac crest bone graft (AICBG) is considered the gold-standard graft material for spinal fusion, new bone substitutes are being developed to avoid associated complications and disadvantages. By combining autologous bone marrow mesenchymal stromal cells (MSCs) expanded ex vivo and allogenic cancellous bone graft, we obtain a tissue-engineered product that is osteoconductive and potentially more osteogenic and osteoinductive than AICBG, owing to the higher concentration of MSCs. PURPOSE This study aimed to evaluate the feasibility and safety of implanting a tissue-engineered product consisting of expanded bone marrow MSCs loaded onto allograft bone (MSC+allograft) for spinal fusion in degenerative spine disease, as well as to assess its clinical and radiological efficacy. STUDY DESIGN/SETTING A prospective, multicenter, open-label, blinded-reader, randomized, parallel, single-dose phase I-II clinical trial. PATIENT SAMPLE A total of 73 adult patients from 5 hospitals, with Meyerding grade I-II L4–L5 degenerative spondylolisthesis and/or with L4–L5 degenerative disc disease who underwent spinal fusion through transforaminal lumbar interbody fusion (TLIF). OUTCOME MEASURES Spinal fusion was assessed by plain X-ray at 3, 6, and 12 months and by computed tomography (CT) at 6 and 12 months post-treatment. An independent radiologist performed blinded assessments of all images. Clinical outcomes were measured as change from baseline value: visual analog scale for lumbar and sciatic pain at 12 days, 3, 6, and 12 months posttreatment, and Oswestry Disability Index and Short Form-36 at 3, 6, and 12 months posttreatment. METHODS Patients who underwent L4–L5 TLIF were randomized for posterior graft type only, and received either MSC+allograft (the tissue-engineered product, group A) or AICBG (standard graft material, group B). Standard graft material was used for anterior fusion in all patients. Feasibility was measured primarily as the percentage of randomized patients who underwent surgery in each treatment group. Safety was assessed by analyzing treatment-emergent adverse events (AEs) for the full experimental phase and appraising their relationship to the experimental treatment. Outcome measures, both radiological and clinical, were compared between the groups. RESULTS Seventy-three patients were randomized in this study, 36 from the MSC+allograft group and 37 from the AICBG group, and 65 were surgically treated (31 group A, 34 group B). Demographic and comorbidity data showed no difference between groups. Most patients were diagnosed with grade I or II degenerative spondylolisthesis. MSC+allograft was successfully implanted in 86.1% of randomized group A patients. Most patients suffered treatment-emergent AEs during the study (88.2% in group A and 97.1% in group B), none related to the experimental treatment. X-ray-based rates of posterior spinal fusion were significantly higher for the experimental group at 6 months (p=.012) and 12 months (p=.0003). CT-based posterior fusion rates were significantly higher for MSC+allograft at 6 months (92.3% vs 45.7%; p=.0001) and higher, but not significantly, at 12 months (76.5% vs 65.7%; p=.073). CT-based complete response (defined as the presence of both posterior intertransverse fusion and anterior interbody fusion) was significantly higher at 6 months for MSC+allograft than for AICBG (70.6% vs 40%; p=.0038), and remained so at 12 months (70.6% vs 51.4%; p=.023). Clinical results including patient-reported outcomes improved postsurgery, although there were no differences between groups. CONCLUSIONS Compared with the current gold standard, our experimental treatment achieved a higher rate of posterior spinal fusion and radiographic complete response to treatment at 6 and 12 months after surgery. The treatment clearly improved patient quality of life and decreased pain and disability at rates similar to those for the control arm. The safety profile of the tissue-engineered product was also similar to that for the standard material, and no AEs were linked to the product. Procedural AEs did not increase as a result of BM aspiration. The use of expanded bone marrow MSCs combined with cancellous allograft is a feasible and effective technique for spinal fusion, with no product-related AEs found in our study.

Purpose To describe evaluation and physical therapy treatment for an athlete who is male and 13 years old with healing bilateral rectus femoris avulsion fractures. Summary of key points Fractures of the anterior inferior iliac spine may be linked to poor abdominal stability in soccer athletes who are male and an adolescent. The development and use of an abdominal stability screening tool could be an efficient and effective way to determine fracture risk and guide prevention programs. Conclusions and recommendations for clinical practice Following 8 weeks of conservative physical therapy treatment, the athlete met all goals and returned to pain-free soccer activities without residual impairments. Four months following discharge, he reported full participation in soccer competition without complications. This case illustrates that abdominal weakness is a potential risk factor for anterior inferior iliac spine avulsion fracture. Screening for abdominal weakness and incorporating preventative programs into training regimens is recommended to prevent anterior inferior iliac spine injuries in this population.

Pelvic incidence (PI) is assumed to be fixed, yet studies have reported PI changes after long fusions to the pelvis. In a cohort of ASD patients undergoing surgery with S2-alar-iliac (S2AI) screws, we sought to: (1) report the magnitude of PI changes, and (2) evaluate subsequent pelvic parameter changes. A retrospective case series of ASD patients undergoing surgical correction with S2AI screw placement and sagittal cantilever correction maneuvers was conducted. Patients were categorized based on preoperative PI: High-PI (H-PI) (PI ≥ 60°); Normal-PI (N-PI) (60° > PI > 40°); Low-PI (L-PI) (PI ≤ 40°). PI was measured preoperatively and immediately postoperatively. A significant PI change was established a priori at ≥ 6.0. PI, pelvic tilt (PT), lumbar lordosis (LL), and PI-LL mismatch were analyzed. In 68 patients (82.3% female, ages 22–75 years), the average change in PI was 4.6° ± 3.1, and 25 (36.8%) had a PI change ≥ 6.0° with breakdown as follows: H-PI 12 (66.7%) patients, 9 (25.87%) patients, and 4 (33.3%) patients. Of 25 patients with PI changes, 10 (14.7%) had a PI increase and 15 (22.1%) had a PI decrease. Significant improvements were seen in PT, LL, PI-LL mismatch in all patients with a PI change ≥ 6.0°, in addition to both subgroups with an increase or decrease in PI. PI changes of ≥ 6.0° occurred in 36.8% of patients, and H-PI patients most commonly experienced PI changes. Despite PI alterations, pelvic parameters significantly improved postoperatively. These results may be explained by sacroiliac joint laxity, S2AI screw placement, or aggressive sagittal cantilever techniques.

Adult forearm nonunion should be investigated prior to developing a treatment strategy: "Why did the fracture not heal?" Optimizing the patient's biology and the stability at the nonunion site are critical for a successful outcome. This review concisely discusses the initial work-up, including history, physical examination, imaging, and laboratory testing, as well as available surgical techniques-irrigation and debridement with deep cultures, revision open reduction internal fixation with or without biological adjuvant therapies, cancellous autograft, tricortical iliac crest, reamer/irrigator/aspirator, allograft, vascularized free-fibula and induced-membrane technique.

Neuromuscular scoliosis (NMS) is often associated with rapid progressive spinal deformities. Indications, when to extend the instrumentation to the pelvis for pelvic obliquity are not generally accepted at this time. This study reports on the indications, surgical technique and results using pedicle screw instrumentation exclusively with or without pelvic fixation for spine fusion in patients with NMS.Thirty-seven NMS patients were treated with pedicle screw instrumentation (PSI) between 2007 and 2013 with a minimum follow-up of 24 months. The mean age at the time of operation was 14.91 ± 2.03 years (range, 11.17-18.58). Posterior spine fusion (PSF) was conducted in 33 patients; 4 patients underwent a combined anterior spinal release followed by PSF during one-stage surgery. Pelvic fixation was achieved by ilium screws combined with S-1 screws in 4 cases and by sacral-alar-iliac (SAI) technique by Sponseller in 9 cases, respectively.The mean primary Cobb angle was 65.5° (range, 14-103°) and improved significantly to 19.8° (range, 1-50°, p 0.001) after surgery and 20.5° (range, 3-57, p = 0.47) at 2 years FU, respectively. Besides, an improvement of pelvic obliquity and T1 tilt angle could be detected. Major complications occurred in 19% and minor complications in 32%.Pedicle screw fixation only for spine fusion in patients with NMS can be applied safely with reasonable complication rates. An excellent correction in all planes, a significant improvement of the pelvic obliquity and almost no loss of correction at 2 years FU were observed.

An 18-year-old male patient was diagnosed pelvic chondrosarcoma histopathologically. Hip joint involvement was detected. No metastasis or neurovascular invasion was seen. Type I+II pelvic resection and hip reconstruction were planned with pedestal cup (LUMiC®) and proximal femur tumor prosthesis. Surgery was performed in lateral decubitus position with extensive triradiate incision. Pelvic wide resection was performed. At the second year of follow-up, implant failure was detected and patient was revised with same pedestal cup. Axial stability was supported by a L5 screw and connector from L5 vertebrae to LUMiC® prosthesis. Except the implant failure, no oncological complication or infection was observed during the final 36th month follow-up.

Lumbosacral instrumentation continues to be challenging due to complex biomechanical force distributions and poor sacral bone quality. Various techniques have therefore been established. The aim of this study was to investigate the outcome of patients treated with S2-alar-iliac (S2AI), S2-alar (S2A), and iliac (I) instrumentation as the most caudal level. Sixty patients underwent one of the 3 techniques between January 2012 and June 2017 (S2AI 18 patients, S2A 20 patients, I 22 patients). Mean age was 70.4 ± 8.5 years. Screw loosening (SL) and sacroiliac joint (SIJ) pain were evaluated during the course at 3-month and maximum follow-up (FU). All patients completed 3-month FU, the mean FU period was 2.5 ± 1.5 years (p = 0.38), and a median of 5 segments was operated on (p = 0.26), respectively. Bone mineral density (BMD), derived opportunistically from computed tomography (CT), did not significantly differ between the groups (p = 0.66), but cages were more frequently implanted in patients of the S2A group (p = 0.04). SL of sacral or iliac screws was more common in patients of the S2A and I groups compared with the S2AI group (S2AI 16.7%, S2A 55.0%, I 27.3% of patients; p = 0.03). SIJ pain was more often improved in the S2AI group not only after 3 months but also at maximum FU (S2AI 61.1%, S2A 25.0%, I 22.7% of patients showing improvement; p = 0.02). Even in shorter or mid-length lumbar or thoracolumbar constructs, S2AI might be considered superior to S2A and I instrumentation due to showing lower incidences of caudal SL and SIJ pain.

Provision of a natural scaffold, good quality cells, and growth factors in order to facilitate the replacement of the complete osteochondral unit with matching talar curvature for large medial primary and secondary osteochondral defects of the talus.Symptomatic primary and secondary medial osteochondral defects of the talus not responding to conservative treatment; anterior-posterior or medial-lateral diameter10 mm on computed tomography (CT); closed distal tibial physis in young patients.Tibiotalar osteoarthritis grade III; multiple osteochondral defects on the medial, central, and lateral talar dome; malignancy; active infectious ankle joint pathology.A medial distal tibial osteotomy is performed, after which the osteochondral defect is excised in toto from the talar dome. The recipient site is microdrilled in order to disrupt subchondral bone vessels. Then, the autograft is harvested from the ipsilateral iliac crest with an oscillating saw, after which the graft is adjusted to an exact fitting shape to match the extracted osteochondral defect and the talar morphology as well as curvature. The graft is implanted with a press-fit technique after which the osteotomy is reduced with two 3.5 mm lag screws and the incision layers are closed. In cases of a large osteotomy, an additional third tubular buttress plate is added, or a third screw at the apex of the osteotomy.Non-weight bearing cast for 6 weeks, followed by another 6 weeks with a walking boot. After 12 weeks, a CT scan is performed to assess consolidation of the osteotomy and the inserted autograft. The patient is referred to a physiotherapist.Ten cases underwent the TOPIC procedure, and at 1 year follow-up all clinical scores improved. Radiological outcomes showed consolidation of all osteotomies and all inserted grafts showed consolidation. Complications included one spina iliaca anterior avulsion and one hypaesthesia of the saphenous nerve; in two patients the fixation screws of the medial malleolar osteotomy were removed.OPERATIONSZIEL: Wiederherstellung des natürlichen Knochengerüsts mit gesunden Zellen und Wachstumsfaktoren zur Rekonstruktion von großen primären und sekundären Knochendefekten an der medialen Talusrolle, mit Einsatz einer kompletten osteochondralen Einheit mit passendem Radius entsprechend der Talusrolle.Symptomatische primäre und sekundäre mediale osteochondrale Defekte am Talus nach fehlgeschlagener Physiotherapie; anteroposteriorer und/oder mediolateraler Durchmesser10 mm in der Computertomographie (CT); bei jüngeren Patienten: geschlossene Wachstumsfuge der distalen Tibia.Generalisierte Osteoarthrose im gesamten Sprunggelenk; multiple Osteochondraldefekte; aktive Infektion; Malignität.Zunächst wird eine mediale Osteotomie der distalen Tibia durchgeführt, anschließend der Osteochondrale Defekt vollständig aus dem Talus entfernt. Der Defekt wird angebohrt, um die subchondralen Blutgefäße zu öffnen. Das Transplantat wird am ipsilateralen Beckenkamm mit der oszillierenden Säge entnommen und in den Defekt unter Beachtung der korrekten Wiederherstellung von Form und Radius der Talusrolle eingepasst. Dann wird das Transplantat mittels Press-Fit-Technik fixiert. Anschließend erfolgen die Reposition der Tibiaosteotomie und die Fixation mit zwei 3,5-mm-Zugschrauben sowie der Wundverschluss.Unbelastete Mobilisation im Unterschenkelgips für 6 Wochen, danach Vollbelastung in einer Unterschenkelorthese (Walker) für weitere 6 Wochen. Nach 12 Wochen Kontroll-CT zur Analyse der Knochenheilung sowohl der medialen Tibiaosteotomie als auch der Integration des Transplantates in den Talus. Danach beginnen mit Physiotherapie.In einer prospektiven Studie wurden 10 konsekutive Patienten mit der TOPIC-Technik behandelt. Nach einem Nachuntersuchungszeitraum von 12 Monaten verbesserten sich alle klinischen Werte der Patienten. Als Komplikationen sind bisher eine Avulsionsfraktur der Spina iliaca anterior und eine Hypästhesie des N. Saphenus aufgetreten. Bei 2 Patienten traten leichte Druckschmerzen über dem medialen Malleolus auf, die nach Entfernen der Zugschrauben wieder verschwanden.

Purpose The purpose of this study was to evaluate the number of colony-forming units (CFUs) derived from concentrated bone marrow aspirates (BMAs) that were processed following arthroscopic harvest from either the proximal humerus or the body of the ilium during biologic augmentation of the rotator cuff and acetabular labral repairs. Methods Between November 2014 and January 2019, BMA was harvested from the proximal humerus (n = 89) and the body of the ilium (n = 30) during arthroscopic surgery. Following concentration of the aspirate, a 0.5-mL aliquot was further processed and the number of nucleated cells (NC) was counted. Each aliquot was cultured until CFUs were quantifiable. Fluorescence-activated cell sorting analysis and quantitative polymerase chain reaction was performed to confirm presence of mesenchymal stem cells. BMA harvest sites were prospectively assessed and evaluated for differences in age, sex, volume of aspirated BM, and CFUs per milliliter of BMA. Results The prevalence (38.57 ± 27.92ilium vs. 56.00 ± 25.60humerus CFUs per 106 nucleated cells) and concentration (979.17 ± 740.31ilium vs. 1,516.62 ± 763.63humerus CFUs per 1.0 mL BMA) of CFUs was significantly higher (P .05, respectively). Conclusion Both proximal humerus and the body of the ilium can be considered reliable sources of bone marrow aspirate for the use in biologic augmentation during their respective arthroscopic surgery. Samples of bone marrow aspirate from the proximal humerus yielded a significantly higher amount of CFUs when compared with samples of BMA obtained from the ilium. Level of Evidence: Level II- prospective laboratorial study.

The approach to the sciatic plexus and lateral part of the sacrum is difficult. A subperitoneal anterolateral approach can be extended by sectioning the iliac bone above the acetabulum and lowering it toward the external part of the iliac wing and buttock. This transiliac anterolateral approach exposes the lumbosacral trunk, first sacral foramina and sciatic plexus to the origin of the sciatic trunk. Exposure can be extended upward by subperitoneal lumbotomy, downward by opening the ischiorectal fossa, or outward by trochanterotomy. This approach was used 18 times by one of the authors (FHD) for resection of 13 malignant tumors and 5 plexus releases. Procedure time was 3-6hours, with 500-4,000ml blood loss. The approach systematically enabled surgical objectives to be met. There was 1 septic complication that healed after debridement.

Summary 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.

Percutaneous iliosacral screw fixation is an essential osteosynthesis technique for pelvic fractures and requires precise imaging tools to assist correct screw placement. 3D imaging coupled to navigation has significantly improved this technique. Several possibilities exist, depending on the instrument set used, with varying degrees of difficulty and very variable risk of error. The techniques traditionally described use a guide to navigate a drill bit, where a one-degree difference in trajectory can alter screw tip placement by several millimeters. The present article proposes a standardization of the procedure by using navigated pedicular screw instruments that have the advantage of navigating the instrument itself and not a projection. In a series of 90 screws implanted in 62 patients using this technique, only one path had to be repeated in the light of intraoperative control. No improperly positioned screws were found on postoperative control.

Background Transiliac–transsacral (TITS) screw fixation might be necessary in some cases involving the vertical shearing injuries with transforaminal fracture and bilateral posterior ring injuries. However, the possibility of S1 TITS screw should be preoperatively assessed because the pelvic ring injuries with sacral dysmorphism had the insufficient osseous corridors. Hypothesis AxWS2 may predict the possibility of TITS screw fixation and be used as the new indicator to discriminate the sacral dysmorphism. Materials & methods The conventional CT images of eighty-two cadaveric pelvis imported into Mimics® software to reconstruct three-dimensional (3D) models. A 7.0 mm-sized screw was processed into a 3D model using a 3D-sensor at actual size and virtually implanted as S1 and S2 TITS screw using Mimics® software. The cortical violation around screw path was evaluated using 3D biplanar and conventional CT images. The osseous corridor widths around TITS screws were measured in the axial plane images and defined as AxWS1 and AxWS2, respectively. Results Despite no cortical violation in S2 of all models, cortical violation of S1 TITS screw was found in 20 models. Of them, 14 models (impossible models) were identified in the 3D biplanar images, and all 20 models (CT-violation models) were identified only in CT axial plane images. AxWS1 was Discussion By using AxWS2, the possibility of S1 TITS screw fixation could be predicted and safely placed without cortical violation, if AxWS2 was less than 13 mm. Considering the negative relationship with AxWS1, AxWS2 should be used as a new indicator to predict safe S1 TITS screw fixation. Level of evidence III, controlled laboratory study.