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Bone graft granules are valuable tools for ridge area bone grafting owing to their ease of manipulation and interconnected porous structure. Guided bone regeneration (GBR) using barrier membranes is commonly used for alveolar ridge augmentation; however, the surgical procedures are technically complicated. In this study, we fabricated bioresorbable mesh domes (BMDs) using two types of Vicryl mesh (woven and knitted types) containing carbonate apatite granules. BMD samples were prepared in three groups: upper sides made from the woven type (UW) and lower sides made from the woven type (LW) (the UW/LW group), upper sides made from the woven type (UW) and lower sides made from the knitted type (LK) (the UW/LK group), and upper sides made from the knitted type (UK) and lower sides made from the knitted type (LK) (the UK/LK group). The samples were subsequently implanted into rabbit calvaria, and radiomorphometric and histological analyses were conducted. The UK/LK group exhibited enhanced appositional bone formation because the knitted mesh on the skin side prevented the infiltration of a substantial amount of fibrous tissue. This increase in bone formation could be attributed to the interaction between granules and osteoprogenitors that pass through the mesh from the host bone. Conversely, the UW/LW and UW/LK groups presented limited appositional bone formation. Compared with knitted mesh, woven mesh might tend to be absorbed over a short span, allowing fibrous tissue invasion and inhibiting new bone formation. Additionally, BMDs could retain granules in a targeted location and avoid displacement of the granules to unintended locations., (© 2024. The Author(s).)

Background: Autologous bone dust can be filled in bone defects to promote effective bone healing but typically it is lost when using suction during surgery. The aim of this study was to develop a novel bone collector that can be used to collect bone chips/dust of varying sizes without changing current surgical procedures., Research Design and Methods: This collector was designed to connect to a surgical continuous suction system and comprised a plate filter with a 3 mm hole and featured a taper filter with a mesh size of 0.27 mm for the separation and collection of both coarse and fine bone chips/dust. The bone collector was manufactured using nylon 3D printing and plastic injection with biocompatible materials., Results: The bone collector functional test revealed high bone chip collection efficiency (93%) with automatic size separation function. Low (3.42%) filtration errors showed that most of the water can be drained smoothly from the bone collector. In clinical usability testing, bone collectors can provide functions demonstrated in in vivo spinal fusion and femoral fracture surgeries with different bone grafting size requirements., Conclusions: The novel bone collector has been validated as a viable and effective surgical device, offering surgeons an additional option to enhance patient outcomes.

Anterior spine decompression and reconstruction with bone grafts and fusion is a routine spinal surgery. The intervertebral fusion cage can maintain intervertebral height and provide a bone graft window. Titanium fusion cages are the most widely used metal material in spinal clinical applications. However, there is a certain incidence of complications in clinical follow-ups, such as pseudoarticulation formation and implant displacement due to nonfusion of bone grafts in the cage. With the deepening research on metal materials, the properties of these materials have been developed from being biologically inert to having biological activity and biological functionalization, promoting adhesion, cell differentiation, and bone fusion. In addition, 3D printing, thin-film, active biological material, and 4D bioprinting technology are also being used in the biofunctionalization and intelligent advanced manufacturing processes of implant devices in the spine. This review focuses on the biofunctionalization of implant materials in 3D printed intervertebral fusion cages. The surface modifications of implant materials in metal endoscopy, material biocompatibility, and bioactive functionalizationare summarized. Furthermore, the prospects and challenges of the biofunctionalization of implant materials in spinal surgery are discussed. Fig.a.b.c.d.e.f.g As a pre-selected image for the cover, I really look forward to being selected. Special thanks to you for your comments., (© 2021. The Author(s).)

Background: Usually, the two-stage Masquelet induced-membrane technique for extremity reconstruction begins with a polymethylmethacrylate (PMMA) cement spacer-driven membrane, followed by an autologous cancellous bone graft implanted into the membrane cavity to promote healing of large bone defects. In exceptional cases, spacers made of polypropylene disposable syringes were successfully used instead of the usual PMMA spacers because of a PMMA cement shortage caused by a lack of resources. However, this approach lacks clinical evidence and requires experimental validation before being recommended as an alternative to the conventional technique., Questions/purposes: To (1) develop and (2) validate a critical-sized femoral defect model in rats for two stages of the Masquelet technique and to (3) compare the biological and bone healing properties of polypropylene-induced membranes and PMMA-induced membranes in this model., Methods: Fifty male Sprague Dawley rats aged 8 weeks old received a 6-mm femur defect, which was stabilized with an external fixator that was converted into an internal device. In the development phase, the defect was filled with PMMA in 16 rats to determine the most favorable timing for bone grafting. Two rats were excluded since they died of anesthetic complications. The other 14 were successively euthanized after 2 weeks (n = 3), 4 weeks (n = 4), 6 weeks (n = 4), and 8 weeks (n = 3) for induced membrane analyses. In the validation phase, 12 rats underwent both stages of the procedure using a PMMA spacer and were randomly assigned to two groups, whether the induced membrane was preserved or removed before grafting. To address our final objective, we implanted either polypropylene or PMMA spacers into the defect (Masquelet technique Stage 1; n = 11 rats per group) for the period established by the development phase. In each group, 6 of 11 rats were euthanized to compare the biological properties of polypropylene-induced membranes and PMMA-induced membranes using histological qualitative analysis, semiquantitative assessment of the bone morphogenic protein-2 content by immunostaining, and qualitative assessment of the mesenchymal stromal cell (MSC; CD31-, CD45-, CD90+, and CD73+ phenotypes) content by flow cytometry. Quantitative measurements from serum bone turnover markers were also performed. The five remaining rats of each group were used for Masquelet technique Stage 2, in which rat bone allografts were implanted in the induced membrane cavity after the polypropylene or PMMA spacers were removed. These rats recovered for 10 weeks before being euthanized for microCT quantitative measurements and bone histology qualitative assessment to evaluate and compare the extent of bone regeneration between groups., Results: Induced membrane analyses together with serum bone turnover measurements indicated that a 4-week interval time between stages was the most favorable. Removal of the induced membrane before grafting led to almost constant early implant failures with poor bone formation. Four-week-old rats with polypropylene-triggered induced membranes displayed similar histologic organization as rats with PMMA-driven induced membranes, without any difference in the cell density of the extracellular matrix (4933 ± 916 cells per mm2 for polypropylene versus 4923 ± 1284 cells per mm2 for PMMA; p = 0.98). Induced membrane-derived MSCs were found in both groups with no difference (4 of 5 with polypropylene versus 3 of 3 with PMMA; p > 0.99). Induced membrane bone morphogenic protein-2 immunolabeling and serum bone turnover marker levels were comparable between the polypropylene and PMMA groups. MicroCT analysis found that bone regeneration in the polypropylene group seemed comparable with that in the PMMA group (29 ± 26 mm3 for polypropylene versus 24 ± 18 mm3 for PMMA; p > 0.99). Finally, qualitative histological assessment revealed a satisfactory endochondral ossification maturation in both groups., Conclusion: Using a critical-sized femoral defect model in rats, we demonstrated that polypropylene spacers could induce membrane encapsulation with histologic characteristics and bone regenerative capacities that seem like those of PMMA spacers., Clinical Relevance: In a same bone site, polymers with close physical properties seem to lead to similar foreign body reactions and induce encapsulating membranes with comparable bone healing properties. Polypropylene spacers made from disposable syringes could be a valuable alternative to PMMA. These results support the possibility of a cementless Masquelet technique in cases of PMMA shortage caused by a lack of resources., 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. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request., (Copyright © 2021 by the Association of Bone and Joint Surgeons.)

Background: Large, malignant bone tumors and revision limb salvage procedures often result in the resection of extensive lengths of the involved bone segment, leaving a residual segment of bone that may be too short to support a standard intramedullary stem for endoprosthetic reconstruction. Telescope allografting, in which an allograft is used to augment the remaining bone segment by telescoping it into the residual bone segment, was described for situations in which residual bone stock is insufficient after tumor resection or prosthetic revision. Apart from one study that first described the procedure [15], there are no other studies reporting the outcome of this telescopic concept for restoring bone stock., Questions/purposes: For patients younger than 18 years who underwent the telescopic allograft technique to augment a short segment of the proximal femur after resection of bone sarcomas who also underwent endoprosthesis reconstruction of the distal femur, we asked: (1) What is the survivorship free from removal of the telescopic allograft and the endoprosthetic stem at 7 years after surgery? (2) What proportion of these reconstructions will heal to the host bone without delayed union or nonunion? (3) What is the functional outcome based on the Musculoskeletal Tumor Society (MSTS) score?, Methods: We retrospectively studied our institutional database and identified 127 patients younger than 18 years who underwent surgery for a primary malignant bone tumor of the distal femur between December 2008 and October 2018. After excluding 16 patients undergoing amputation and rotationplasty and 57 patients undergoing recycled autograft/allograft reconstruction, 54 patients who underwent primary or revision distal femur endoprosthesis reconstruction were identified. Among these patients, we considered 15 patients who underwent telescopic allograft augmentation of the femur for analysis. One patient was lost to follow-up before 2 years but was not known to have died, leaving 14 for analysis at a median (range) 49 months (24 to 136 months) of follow-up. The indications for telescopic allograft augmentation of the femur in our institution were a proximal femur length of less than 120 mm after resection or resection of more than two-thirds of the total length of the femur. Ten of 14 patients underwent telescopic allograft augmentation as a revision procedure (distal femur resorption in five patients, endoprosthesis stem loosening in three patients, implant fracture in one patient, and infection in one patient), and the remaining four patients underwent telescopic allograft augmentation as a primary limb salvage procedure for large malignant bone tumors of the distal femur. The histologic diagnosis in all patients was osteosarcoma. At the time of telescopic allograft augmentation and reconstruction, the median age of the patients was 14 years (7 to 18 years). The size and the type of bone allograft to be used (femoral shaft or proximal femur) was planned before surgery, with consideration of the extent of resection, level of osteotomy, diameter of the host bone at the osteotomy site, and approximate diameter of the endoprosthesis stem to be used. The segment of the cylindrical allograft used for telescoping was thoroughly washed, prepared, and impacted onto the native femur to achieve telescoping and overlap. Serial digital radiographs were performed once a month for the first 6 months after the procedure, every 2 months until 1 year, and then every 6 months thereafter. Two surgeons in the department (at least one of which was involved in the surgery) retrieved and reviewed clinical notes and radiographs to determine the status of the telescopic allograft and endoprosthesis stem. We defined delayed union as radiological union at the osteotomy site more than 6 months after the procedure without additional surgery; we defined nonunion as no radiological evidence of callus formation at the osteotomy site 9 months after the procedure, necessitating additional surgery. The reviewers did not disagree about the definition of healing time. None of the patients missed radiographic follow-up. Kaplan-Meier survivorship free from removal of telescopic allograft and the endoprosthesis stem at 7 years after surgery was estimated. Patient function was assessed using the 1993 version of the MSTS [9], as determined by chart review of the institutional database performed by one of the surgeons from the department., Results: The survivorship free from removal of the telescopic allograft and endoprosthesis stem at 7 years after surgery was 80% (95% confidence interval 22% to 96%). The allograft united with the host bone in 100% (14 of 14) of the patients. Though 21% (3 of 14) had delayed union, no nonunions were seen. The median (range) MSTS score at the final follow-up interval was 27 (22 to 30)., Conclusion: Although this is a small group of patients, we believe that allograft segments help augment short bone stock of the proximal femur after long-segment resections, and the telescopic technique seems to be associated with a low proportion of nonunion or delayed union, which is one of the most common complications of allografts. Maintaining an adequate length of the proximal femur is important in preserving the hip, and this technique may be especially useful for young individuals who may undergo repeated revision procedures., Level of Evidence: Level IV, therapeutic study., Competing Interests: All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request. Each author certifies that neither he, nor any member of his immediate family, has 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., (Copyright © 2021 by the Association of Bone and Joint Surgeons.)

The process of bone regeneration in bone grafting procedures is greatly influenced by the physicochemical properties of the bone graft substitute. In this study, porous phosphate glass (PPG) morsels were developed and their physicochemical properties such as degradation, crystallinity, organic content, surface topography, particle size and porosity were evaluated using various analytical methods. The in vitro cytotoxicity of the PPG morsels was assessed and the interaction of the PPG morsels with Dental Pulp Stem Cells (DPSCs) was studied by measuring cell proliferation and cell penetration depth. The cell-material interactions between PPG morsels and a commercially available xenograft (XG) were compared. The PPG morsels were observed to be amorphous, biocompatible and highly porous (porosity = 58.45%). From in vitro experiments, PPG morsels were observed to be non-cytotoxic and showed better cell proliferation. The internal surface of PPG was easily accessible to the cells compared to XG.

The quadrilateral anterior cervical plate (ACP) is used extensively in anterior cervical discectomy and fusion (ACDF) to reconstruct the stability of the cervical spine and prevent cage subsidence. However, there have been no comparison studies on the biomechanical performance of quadrilateral ACP and triangular ACP. The objective of this study is to investigate the functional outcomes of quadrilateral ACP and triangular ACP usage in ACDF surgery. In this study, a finite element model of intact C1-C7 segments was established and verified. Additionally, two implant systems were built; one using triangle anterior cervical plates (TACP) and another using quadrilateral orion anterior cervical plate (QACP). Both models were then compared in terms of their postoperative biomechanical performance, under normal and excessive motion. Compared to QACP, the peak stress of the TACP screws and plates occurred at 359.2 MPa and 97.2 MPa respectively and were the highest during over extension exercises. Alternately, compared to TACP, the endplate peak stress and the cage displacement of QACP were the largest at over extension, with values of 7.5 MPa and 1.2 mm, respectively. Finally, the average stress ratio of bone grafts in TACP was relatively high at 31.6%. In terms of biomechanical performance, TACP can share the load more flexibly and reduce the risks of cage subsidence and slippage but the screws have high peak stress value, thereby increasing the risk of screw slippage and fracture. This disadvantage must be considered when designing a TACP based implant for a potential patient., Competing Interests: The authors have declared that no competing interests exist.

Summary: The vascularized fibular flap has been the mainstay for mandibular reconstruction for over 30 years. Its latest evolutionary step is the jaw-in-a-day operation, during which the fibula flap and dental prosthesis restoration are performed in a single stage. Computer-aided design and manufacturing technology in mandibular reconstruction has gained popularity, as it simplifies the procedure and produces excellent outcomes. However, it is costly, time-consuming, and limited in cases that involve complex defects, including bone and soft-tissue coverage. Moreover, it does not allow for intraoperative changes in the surgical plan, including defect size and recipient vessel selection.The authors describe their approach, including a conventional technique for fibula osteoseptocutaneous flap harvest without the need for a premanufactured cutting guide, using bundled wooden tongue spatulas instead, a stereolithographic model to customize commercially ready-made reconstruction plates, and two pieces of resin to maintain occlusive alignment of the remaining jaw segments during mandibular osteotomy. Dental implants are inserted free-hand. Vector guides are then connected to the implants following insertion into the fibula to confirm acceptable alignment and subsequently replaced with scan sensors. An intraoperative digital scan is used to design and to produce a dental prosthesis by in-house milling of a polymethylmethacrylate block. From our 10-case experience over the past 3 years, we have found that our approach offers a reliable method that matches the excellent outcomes seen using full computer-assisted design and manufacturing technology. It is time- and cost-effective, not limited to relatively simple jaw defects, and can readily accommodate intraoperative changes of surgical plan., Competing Interests: Disclosure:The authors have no conflict of interest to declare., (Copyright © 2021 by the American Society of Plastic Surgeons.)

The aim of this study was to evaluate the influence of the intensity of the biomimetic hydroxyapatite (HA) coating of α-tricalcium phosphate (α-TCP) on biomaterial degradation and bone formation. Twenty-four female NZW rabbits of approximately 12 weeks of age were used. Critical size defects were randomly treated with 3%:97% HA:α-TCP (BBCP1), 12%:88% HA:α-TCP (BBCP2), and 23%:77% HA:α-TCP (BBCP3), respectively or sham. All defects were covered with a resorbable collagen membrane. Animals were euthanized after 3 and 12 weeks of healing and samples were investigated by micro-CT and histologic analysis. Ingrowth of newly formed woven bone from the original bone at 3-week healing period was observed in all samples. At the 12-week healing period, the new bone in the peripheral area was mainly lamellar and in the central region composed of both woven and lamellar bone. New bony tissue was found on the surface of all three types of granules and at the interior of the BBCP1 granules. Samples with 3% HA showed significantly less residual biomaterial in comparison to the other two groups. Furthermore, BBCP1 significantly promoted new bone area as compared to other three groups and more bone volume as compared to the control. Within its limitations, this study indicated the highest degradation rate in case of BBCP1 concomitant with the highest rate of bone formation. Hence, formation of new bone can be affected by the level of biomimetic HA coating of α-TCP.

Background: Treatments for unicameral bone cysts (UBCs) have high documented failure rates (27% to 63%) because of recurrence or persistence of the cyst, similar to nonoperative management. Recent evidence suggests that filling of the defect with a synthetic bone graft substitute (SBGS) supports the weakened cortex and promotes new bone growth. A calcium sulfate, brushite, calcium phosphate, composite graft material (PRODENSE, Wright Medical, Memphis, TN) has been evaluated as a substitute for autogenous or allogenous graft in animal and human studies. The purpose of this study was to compare the rates of revision surgery in patients treated for UBCs with an SBGS compared with historical treatments with allograft or autologous bone marrow aspirate., Methods: The authors reviewed 27 of 33 patients (age, 6 months to 21 years) an average of 121 months (range, 32 to 228) after filling of a UBC with an injection of SBGS (n=18) versus allograft or autologous bone marrow aspirate (n=9) between June 2008 and December 2017. Six patients with no follow-up were excluded. Groups did not differ in age at surgery, sex (19/27 male), history of pathologic fracture (22/27), or previous treatments (11/27). The primary outcome was the rate of revision surgery. Secondary outcomes included revision surgery-free survival as evaluated by the log-rank test, rate of postoperative fracture, persistent cysts, continued pain, and/or growth disturbance at the final follow-up., Results: Seven of 9 patients treated with allograft or autograft underwent revision surgery for postoperative pathologic fracture (n=2) or resorption of the graft (n=5) compared with 2 of 18 patients injected with the SBGS, both treated for graft resorption. The use of SBGS was associated with a decreased need for revision surgery over all time periods (hazard ratio, 0.14; 95% confidence interval, 0.03-0.05). There was no significant difference between postoperative fracture (2/18 vs. 2/9), persistent cyst (7/18 vs. 5/9), pain (0/18 vs. 2/9), or growth disturbance (1/18 vs. 3/9)., Conclusions: Treatment of UBCs with SBGS may decrease reoperation rates. Initial radiographic appearance after SBGS treatment shows solid structural support, followed by new bone formation. This appearance may lead to a less aggressive approach in considering revision surgery., Level of Evidence: Level III-retrospective comparative study investigating the results of treatment.

Objectives: This study aims to define the simultaneous prophylactic fixation indications of benign tumors and tumor-like lesions located in long bones that were treated by curettage and grafting/cementing., Patients and Methods: Fifty-six patients (33 males, 23 females; mean age 30.9±15.9; range, 15 to 65 years) who were treated by curettage and grafting or cementation for their benign tumors or tumor-like lesions in long bones between January 2013 and June 2016 were retrospectively analyzed. Age, sex, anamnesis and physical examination findings, histopathologic diagnosis, lesion localization, pre- and postoperative imaging results and follow-up data were all analyzed. The patients were divided into two groups as those with and without postoperative fracture., Results: The most common localization was femur (38%). The mean tumor diameter was 6.8±2.2 (range, 2.6 to 12.6) cm and volume was 58.3±45.0 (range, 6 to 177) cm³. Postoperative fracture occurred in 14 patients. The lesion diameter and volume of the patients in postoperative fracture group were significantly higher compared to group without postoperative fracture (p=0.034 and p=0.004, respectively). A volume value greater than 67 cm³ and ages over 35 years were found to be associated with a higher rate of fracture for all lesions., Conclusion: In the postoperative period, patients with benign tumors or tumor-like lesions of long bones had a higher fracture risk if the volume value was greater than 67 cm³ and the age was over 35 years. Prophylactic fixation may be suggested for these patients.

Periodontally affected teeth with periapical lesion indicated for periapical surgery have a poor prognosis. Using Er:YAG lasers to perform simultaneous surgery on both defects may increase their survival rate. Preparing a retrograde cavity on affected teeth and obturating it is still a matter of debate among clinicians. The purpose of this case report was to describe the simultaneous use of Erbium-doped Yttrium Aluminium Garnet Er:YAG (2,940 nm) laser in the treatment of periapical granuloma and infraossal defect and the achieved results. The Er:YAG laser was used to perform flap dissection, granulation tissue removal, osteotomy and root-end resection except for initial flap incision and reflection. The cystic cavity was filled with Bio-Oss Collagen® xenograft. Results were followed up for 18 months with the help of radiographic orthopantomographic images. The outcome of this clinical case indicates that the use of Er:YAG laser could be considered a suitable method to perform simultaneous periodontal and endodontic surgery., (This is an open access article distributed under the terms of the Creative Commons Attribution License (CC BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: For focal cartilage defects, biological repair might be ineffective in patients over 45 years. A focal metallic implant (FMI) (Hemi-CAP Arthrosurface Inc., Franklin, MA, USA) was designed to reduce symptoms. The aim of this study was to evaluate the effects of a FMI on the opposing tibial cartilage in a biomechanical set-up. It is hypothesized that a FMI would not damage the opposing cartilage under physiological loading conditions., Methods: An abrasion machine was used to test the effects of cyclic loading on osteochondral plugs. The machine applied a compressive load of 33 N and sheared the samples 10 mm in the anteroposterior direction by 1 Hz. Tibial osteochondral plugs from porcine knees were placed in opposition to a FMI and cycled for 1 or 6 h. After testing each plug was fixed, stained and evaluated for cartilage damage., Results: After 1 h of loading (n = 6), none of the osteochondral plugs showed histologic signs of degradation. After 6 h of loading (n = 6) three samples had histologic signs of injury in the tangential zone (grade 1) and one had signs of injury in the transitional and deep zones (grade 2). Exploration for 6 h resulted in significant more cartilage damage compared to the shorter exploration time (p = 0.06). However, no significant difference between saline and hyaluronic acid was evident (p = 0.55)., Conclusion: Under physiologic loading conditions, contact with a FMI leads to cartilage damage in the opposing articular cartilage in six hours. In clinical practice, a thorough analysis of pre-existing defects on the opposing cartilage is recommended when FMI is considered.

A single-mode-multimode-single-mode (SMS) optical fiber-based displacement sensing system mounted on an Ilizarov transverse tibial bone transport device for microcirculation reconstruction is reported. Wide-range displacement is approximated as a uniform extension of a spring that is connected to an SMS optical fiber structure acting as the displacement sensor and allowing full displacement characterization. Transmission spectrum changes are measured, providing a displacement range of 24 mm with a sensitivity of $ - {55.42}\;{\rm pm/mm}$-55.42pm/mm and a resolution of 45.2 µm. The experimental results are characterized using a polynomial response curve for measuring the displacement due to transverse distraction of the Ilizarov device. The SMS fiber interrogation system is based on a macrobending fiber edge filter-based ratiometric measurement system. The use of SMS fibers together with the macrobending fiber-based interrogation system eliminates the influence of temperature on the displacement measurement. The implementation of the all-fiber sensing system of this investigation has uniquely facilitated a smart clinical device with a wide displacement range as well as operating in real-time monitoring when attached to the Ilizarov transverse tibial bone transport device. It also means that this fiber-optic sensing device can be made more cost-effective, simpler in construction, and more versatile while providing a high degree of measurement accuracy and resolution.

The development of tissue scaffolds able to provide proper and accelerated regeneration of tissue is a main task of tissue engineering. We developed a nanocomposite gel that may be used as an injectable therapeutic scaffold. The nanocomposite gel is based on biocompatible gelling agents with embedded nanoparticles (iron oxide, silver, and hydroxyapatite) providing therapeutic properties. We have investigated the microstructure of the nanocomposite gel exposed to different substrates (porous materials and biological tissue). Here we show that the nanocomposite gel has the ability to self-reassemble mimicking the substrate morphology: exposition on porous mineral substrate caused reassembling of nanocomposite gel into 10× smaller scale structure; exposition to a section of humerus cortical bone decreased the microstructure scale more than twice (to ≤3 μm). The reassembling happens through a transitional layer which exists near the phase separation boundary. Our results impact the knowledge of gels explaining their abundance in biological organisms from the microstructural point of view. The results of our biological experiments showed that the nanocomposite gel may find diverse applications in the biomedical field.

Background: Limb salvage surgery is becoming increasingly popular after tumor resection in the lower extremity. Biological reconstruction and use of megaprosthesis are main methods for malignant bone tumors of the proximal femur, which remain controversial due to short- and long-term complication in the proximal femur. Tumor-bearing bone treated by liquid nitrogen is one of biological reconstruction. This study aimed to evaluate the mid- and long-term functional outcomes and complications in patients treated with frozen autograft-prosthesis composite (FAPC) reconstructions in the proximal femur., Methods: This retrospective study included 19 patients (10 women, 9 men) with malignant tumors of the proximal femur who underwent tumor-wide resection and FAPC reconstruction (mean age, 46 years; range, 9-77 years). The mean follow-up period of 69 months (range, 9-179 months). Functional outcomes, oncological outcome and complications were evaluated by Musculoskeletal Tumor Society score, clinical and radiological examinations., Results: The overall survival rate was 68.4%, and the mean Musculoskeletal Tumor Society functional score was 26.4 points (88%). FAPC survival rates were 100 and 50% at 5 and 10 years, respectively. Five of the 19 patients (26%) had complications: 2 required prosthesis removal and 2 developed a deep infection around acetabular. Wear of the acetabulum occurred in 2 cases, while disease recurrence was occurred in 1 case. There were no cases of greater trochanter avulsion, obvious absorption around frozen bone, prosthesis loosening or leg length discrepancy., Conclusions: Due to without femoral osteotomy, this technique features satisfactory functional outcome and provide biomechanical stability that is comparable to those of other methods of biological reconstruction or megaprosthesis.

Background: Recommendations for soft tissue management associated with customized bone regeneration should be developed. The aim of this study was to evaluate a new protocol for customized bone augmentation in a digital workflow., Methods: The investigators implemented a treatment of three-dimensional bone defects based on a customized titanium mesh (Yxoss CBR®, ReOSS, Filderstadt, Germany). Patients and augmentation sites were retrospectively analysed focussing on defect regions, demographic factors, healing difficulties and potential risk factors. An exposure rate was investigated concerning surgical splint application, A®- PRF and flap design., Results: In total, 98 implants could be placed. Yxoss CBR® was removed after mean time of 6.53 ± 2.7 months. Flap design was performed as full flap preparation (27.9%), full flap and periosteal incision (39.7%), periosteal incision (1.5%), poncho/split flap (27.9%) and rotation flap (2.9%). In 25% of the cases, exposures of the meshes were documented. Within this exposure rate, most of them were slight and only punctual (A = 16.2%), like one tooth width (B = 1.5%) and complete (C = 7.4%). A®- PRF provided significantly less exposures of the titanium meshes (76.5% no exposure vs. 23.5% yes, p = 0.029). Other parameters like tobacco abuse (p = 0.669), diabetes (p = 0.568) or surgical parameters (mesh size, defect region, flap design) did not influence the exposure rate. Surgical splints were not evaluated to reduce the exposure rate (p = 0.239). Gender (female) was significantly associated with less exposure rate (78,4% female vs. 21.6% male, p = 0.043)., Conclusions: The results of this study suggest that the new digital protocol including patient-specific titanium meshes, resorbable membranes and bone grafting materials was proven to be a promising technique. To improve soft tissue healing, especially A®-PRF should be recommended.

Background: Precise, expensive individual saw guides are used with increasing frequency for the reconstruction of mandibular defects with fibular grafts. In this report, an alternative is presented - the Multiuse Cutting Jig (MUC-Jig, proprietary development). It is reusable, suitable for all patients, requires simple planning based on conventional CT imaging, and is more economical., Methods: To investigate its precision, we conducted a nonblinded experimental study, with ten participating craniomaxillofacial surgeons. Osteotomies of four different fibula segments were carried out at the same angulation, with groups defined according to the proximal and distal fixed angulation: 45°, 30°, 15°, or 0°. The sagittal cut was performed proximally, with the coronal cut performed distally. The resulting 40 segments (n = 40) were analyzed with their Tx length (primary endpoint) and osteotomy angles, and compared to the original planning., Results: The mean (SD) relative deviation of all grafts from the original planning was -0.08 mm (1.12) in length and -0.71° (3.15) for the angle. Only 45° (-2.04 ± 3.71°) and 30° (-1.07 ± 2.52°) cuts differed significantly (p < 0.05) from smaller angle grafts. The mean (SD) absolute deviation was 0.81 mm (0.27) in length and 2.13° (0.93) in graft angles. For individual transplants, 45° cuts (1.28 ± 1.03 mm) differed significantly (p < 0.005) from others. We observed no differences in relative length or absolute angle deviation., Conclusions: The MUC-Jig is precise and cost-effective for osteotomies with medium angles and smooth reconstructions of template-guided procedures., (Copyright © 2019 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Objectives: This study aims to evaluate the long-term results of osteochondral autograft transfer (OAT) of talar lesions performed using a modified osteotomy technique., Patients and Methods: This retrospective study included 20 consecutive patients (11 males, 9 females; mean age 33.5±11 years; range, 15 to 56 years) (21 ankles) with osteochondral lesions of the talus (OLT) treated with the OAT system between August 2002 and October 2008. We performed a modified sulcus groove osteotomy, which provides better exposure of medial and central lesions. After a minimum duration of 10 years following surgery, patients' clinical functions were evaluated according to the American Orthopaedic Foot and Ankle Society (AOFAS) ankle- hindfoot scale and visual analog scale (VAS). The Tegner-Lysholm scoring system was used to determine the levels of knee activity., Results: The mean follow-up period was 143.5 (range, 120 to 186) months. The mean AOFAS scores significantly improved from 60.4±7.4 (range, 48 to 70) preoperatively to 86.2±9.2 (range, 60 to 94) at the last follow-up (p≤0.05). The mean ankle VAS score significantly decreased from 6.3±0.4 (range, 5 to 7) preoperatively to 2.0±1.4 (range, 0 to 4). The mean Tegner-Lysholm score for this group was 89.7±11.7 (range, 68 to 100). Revision surgery was performed in only two patients because of impingement and arthritis. Recurrent knee pain at the donor site of the osteochondral autograft was observed in three (14%) patients., Conclusion: In the present study, good to excellent results were obtained in the treatment of OLT with OAT for a minimum follow-up duration of 10 years. This novel technique can also simplify the steep learning curve, which is challenging for surgeons.

Background: Lateral locking plate (LLP) fixation has gained popularity for the treatment of proximal humeral fractures (PHFs); however, complications can occur due to loss of the medial cortical buttress from fracture comminution., Materials and Methods: We designed a novel intramedullary anatomical medial strut with allograft bone (IAMSAB) using MIMICS software to specifically fill the intramedullary canal of the proximal humeral bone. We used finite element analysis to evaluate the biomechanical characteristics of a LLP, LLP-intramedullary fixation system (IFS), LLP-anatomical medial locking plate (AMLP), or the combined application of a LLP and IAMSAB (LLP-IAMSAB) fixation construct in patients with a PHF and an unstable medial column., Results: For axial or rotational loads, under (normal) Nor or osteoporotic (Ost) bone conditions, the LLP-IAMSAB fixation construct was significantly stiffer than the LLP-IFS fixation construct, and displacement at the fracture site after LLP-IAMSAB fixation was significantly less than after LLP or LLP-IFS fixation (P < 0.05). Stiffness of the LLP-IAMSAB and LLP-AMLP fixation constructs and displacement at the fracture site after LLP-IAMSAB and LLP-AMLP fixation were not significantly different. The IFS, AMLP, and IAMSAB shared the load in the LLP and decreased the risk of implant failure. There were no significant differences in von Mises stress and stress distribution after fixation with the LLP-IFS, LLP-AMLP, and LLP-IAMSAB constructs., Conclusion: These data suggest that the IAMSAB can provide direct medial support or resistance to rotation and augment the biomechanics of the LLP. The combined application of the IAMSAB and LLP may achieve functional outcomes that are similar to the LLP-AMLP fixation construct., (Copyright © 2019 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.)

Background: The use of metallic screws for graft fixation during the Latarjet procedure is not devoid of complications. The purpose of the present cadaver study was to determine the initial strength of coracoid graft fixation using suture anchors and compare it to that of the traditional screw fixation of the graft using a fresh frozen human shoulder cadaver model., Materials and Methods: Twelve unpaired fresh frozen cadaver shoulders were utilized. In the first group, suture anchor fixation of the graft was used, while 3.75-mm cannulated screws were used in the second group. The specimens were then cyclically loaded from 5 to 150 N at a speed of 0.05 mm/s for 100 cycles. After cyclic loading, each specimen was then loaded at a constant rate of 0.5 mm/s until 7 mm of displacement. Cyclic elongation, peak-to-peak displacement, stiffness and maximum load were measured., Results: There were no significant differences between the traditional screw fixation and fixation using suture anchors in elongation, peak-to-peak displacement, stiffness and maximum load., Conclusions: In this study, traditional screw fixation and fixation using suture anchors did not significantly affect biomechanical performance in a classic Latarjet procedure.

Objective : To observe the clinical effect of anterior debridement, decompression, bone grafting, and instrumentation for cervical spinal tuberculosis in four hospitals. Materials and Methods : This research retrospectively analyzed 146 patients with cervical spinal tuberculosis who were treated by anterior debridement, decompression, bone grafting, and instrumentation in four institutions between January 2000 and January 2015. There were 68 males and 78 females with an average age of 31.32 ± 11.69 years. All patients received chemotherapy for 18 months after surgery, and fixed by brace for 3 months. Clinical outcome, laboratory indexes and radiological results were analyzed to evaluate the efficacy of anterior approach surgery in the treatment of cervical spinal tuberculosis. Results : All cases were followed up about 18 to 52 months later (average 24 months). At the last follow-up, all patients obtained bone fusion, pain relief and neurological recovery. There was no recurrence in any of the patients, and no complications related to internal fixation. There were statistically significant differences before and after treatment in terms of Visual analog scale (VAS), Neck disability index (NDI) and Japanese Orthopedic Association (JOA)(P < 0.05). During the last follow-up examination, in 83 patients with neurological deficit, 78 patients improved. The kyphosis was significantly improved postoperatively (P < 0.05). At the last follow-up, the Cobb angle had some degree of correction loss, but the difference was not statistically significant. Conclusion : Our study suggests that one-stage anterior debridement, decompression, bone grafting, and instrumentation are safe and effective methods in the surgical management of cervical spinal tuberculosis. Abbreviation: VAS: Visual Analog Scale; JOA: Japanese Orthopaedic Association; NDI: Neck Disability Index; ESR: Erythrocyte Sedimentation Rate; ASIA: American Spinal Injury Association; TB: Tuberculosis.

Background: Severe acetabular bone defects is a complex problem in revision hip arthroplasty, cage is one of the reconstruction options. The purpose of this study is to report the mid-long term clinical and radiographic results of Paprosky type III acetabular bone defects revised with reconstructional cage and morselized allogeneic cancellous bone graft without impaction., Methods: We retrospectively analyzed 28 patients who underwent revision hip arthroplasty with reconstructional cage and allogeneic cancellous bone graft between January 2007 and January 2016. There were 13 Paprosky type IIIA bone defect patients and 15 Paprosky type IIIB bone defect patients and 4 patients of the 15 were also with pelvic discontinuity. Clinical assessment included Harris Hip Score (HHS) and Short Form-12 (SF-12). Radiographic assessment included center of rotation, cage migration, and bone graft incorporation., Results: All patients were followed up with a mean follow-up of 79.5 months (range 38-141), HHS improved from 31.4 (13-43) points preoperatively to 84.6 (55-94) points at last follow-up and SF-12 also improved significantly. There was 1 re-revision for the cage loosening and screw breakage at 61 months after surgery, and 2 patients had nonprogressive radiolucency in zone III and the junction of zone II and zone III at the bone implant interface., Conclusion: The reconstructional cage combining with morselized allografts without impaction achieves a good result with a high complete allograft incorporation rate in Paprosky type III acetabular bone defects.

Purpose: To report the results of a guided arthroscopic Eden-Hybbinette procedure, using suture button for iliac crest bone graft fixation, in a series of patients with a prior failed Latarjet and persistent glenoid bone loss., Methods: Seven consecutive patients (5 males, 2 females, mean age: 30.7 years [range, 17-47 years]) with recurrent anterior dislocations and glenoid deficiency greater than 20% underwent the all-arthroscopic revision procedure. The iliac crest bone graft and suture-button device (Bone-Link) were shuttled through the rotator interval. Specific drill guides were used and a suture tensioning device allowed bone graft compression. Previous broken screw shafts (3 patients) were left in situ. Graft placement and healing was assessed postoperatively with computed tomography imaging., Results: No neurologic injury or hardware problems occurred, and no patient required further surgery. On computed tomography scan, optimal positioning (flush and under the equator) and healing of the bone graft was observed in all patients. At a mean follow-up of 21 months (range, 12-39 months), all but one patient were satisfied and had a stable shoulder; 5 returned to sports. The Constant score increased from 32 to 81 points, and the subjective shoulder value from 31% to 87% (P < .001). The Walch-Duplay and Rowe scores averaged 85.7 (range, 65-100) points and 86.4 (range, 70-100) points, respectively., Conclusion: Recurrence of anterior shoulder instability after a failed Latarjet procedure can be successfully treated by an all-arthroscopic Eden-Hybbinette procedure. Suture-button fixation is reliable and permits optimal positioning and predictable healing of the new bone graft; in addition, it is an appropriate fixation option in the setting of retained broken hardware., (Copyright © 2019 The Authors. Published by Elsevier Inc. All rights reserved.)

Glenohumeral arthrodesis is a salvage procedure in the shoulder with few indications. However, in young patients with flail shoulder, shoulder arthrodesis is a durable, functional option. Allograft or autograft can be used to reconstruct the defect during glenohumeral arthrodesis. Autografts be vascularized or nonvascularized. The use of vascularized autograft can increase operative time and is associated with substantial donor-site morbidity. The reamer-irrigator-aspirator, a system that irrigates and aspirates reamed bone and medullary contents, including mesenchymal stem cells, isolating bone graft with little donor-site morbidity, is a potential solution. We used this system for glenohumeral arthrodesis in a 22-year-old man with massive proximal humeral bone loss, axillary nerve injury, deltoid muscle atrophy, and soft-tissue coverage needs complicated by infection. Isolated graft was placed in the bony defect, and the arthrodesis was stabilized with a 16-hole plate. There were no intraoperative or postoperative complications. At 3 months after surgery, his bone graft had incorporated, with no evidence of instrumentation loosening or breakage. Six months after surgery, he had good function of the operative extremity with consolidation of the fusion mass and no loss of fixation. This patient's outcome highlights that this method has low donor-site morbidity, allows for rapid osseointegration and union, and preserves functional outcomes, despite necessary humeral shortening.

Nacre (mother of pearl) is a natural biomaterial used to prepare orthopedic devices. We have implanted screws and plates made with nacre in five sheeps. Bone were harvested after two months and embedded in poly(methyl methacrylate). Blocks were saws and the thick slabs were grinded, polished and surface stained. Sections were photographed at an ×1000 magnification. Giant cells were found in contact with nacre in eroded areas and true osteoclasts were found at distance in the neighboring bone in Howship lacunae. A texture analysis of the nuclei of giant cells and osteoclasts was done using the run-length method of the MaZda freeware. The size of the nuclei was reduced in osteoclast and their mean gray level appeared reduced. Texture analysis revealed that chromatin had a completely different pattern in giant cells when compared to osteoclasts. Giant cells had a fine repartition of the chromatin with large clear areas around prominent nucleoli. On the contrary, osteoclast nuclei had chromatin blocks evenly dispersed in the nuclei. This reflects the different origin of these cells expressing different functions.

Background: The aims of this study were to discuss the principle, therapeutic effect and influencing factors of multiple wrapped cancellous bone graft methods for treatment of segmental bone defects., Methods: This study retrospectively analyzed the therapeutic effect of different wrapped autologous cancellous bone graft techniques on 51 patients aged (34.5 ± 11.5) years with segmental bone defects. Cancellous bones were wrapped with titanium mesh (n = 9), line mesh (n = 10), line suturing or line binding cortical block, (n = 13), or induced membrane (n = 19). The bone defeats were as follows: tibia (n = 23), radial bone (n = 10), humerus (n = 8), ulnar bone (n = 7), and femur (n = 3). The defect lengths were (5.9 ± 1.1) cm. The functionary recovery of adjacent joint was evaluated by the Paley's method and DASH, respectively., Results: The incision healed by first intention in 48 cases and secondary healing in 3 cases. All patients were followed up for 19.1 ± 7.1 (12-48) months. Other than one patient with nonunion who received a secondary bone graft, all the patients were first intention of bone healing (the healing rate was 98.0%). The healing time was 6.1 ± 2.1 (3-15) months. There were no significant differences in the healing time among the 4 groups (χ 2  = 1.864, P = 0.601). The incidence of complications in the grafted site was 11.8%, whereas it was 21.6% in the harvest site. At the last follow-up, all the patients had recovered and were able to engage in weight-bearing activities. The functional recovery was good to excellent in 78.4% of cases, there were no significant difference among the 4 groups (χ 2  = 5.429, P = 0.143)., Conclusions: Wrapped cancellous bone grafting is a modified free bone graft method that can be used in the treatment of small and large segmental bone defects as it prevents loosening and bone absorption after bone grafting. The effect of bone healing is related with the quality and quantity of grafted bone, stability of bone defects, property of wrapping material and peripheral blood supply.

The reamer-irrigator-aspirator (RIA) autograft provides large volumes of autogenous graft that exhibit excellent osteogenic, osteoinductive, and osteoconductive properties. These features, combined with the relative ease of graft harvest and low donor site morbidity when compared with the gold standard iliac crest bone graft (ICBG), have made RIA autograft a viable alternative to ICBG. Some suggest RIA autograft is superior to ICBG, particularly in the setting of large segmental bone defects managed with the induced membrane technique. Although significant complications such as fracture and cortical perforation have been reported, they are preventable if proper surgical strategy and tactics are used., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Total wrist arthrodesis, fusion of the carpus to the radius, is a well-established and commonly performed procedure for the management of pancarpal degenerative arthritis, trauma, and other severe diseases of the wrist. A well-known complication of this is radiocarpal nonunion, with a rate of 4.4%. Commonly, bone grafting is done at the time of the surgery using local bone, iliac crest bone graft, or cancellous allograft bone. The Synthes Reamer-Irrigator-Aspirator (RIA) is a flexible reamer originally designed as a single-pass intramedullary reamer that can be used in reaming of long bone fractures prior to insertion of an intramedullary nail. Recently, its use has been expanding to the harvesting of bone graft. We present a case study of 2 patients who had total wrist arthrodesis after severe trauma to the wrist resulting in severe bone loss, in whom we used an RIA to obtain bone graft, and both patients went on to union. The first patient is a 17-year-old male who sustained a blast injury from a firework resulting in a mangling injury to the wrist with soft tissue and severe bone loss of his carpus. After being treated with multiple debridements with an external fixator, he was definitively treated with a wrist fusion with RIA bone graft. He went on to osseous union by his 4-month follow-up. Our second patient is a 53-year-old woman who sustained a gunshot wound to the wrist resulting in massive bone loss of the distal radius. After being initially treated with multiple debridements and external fixation, she was treated with a wrist fusion with RIA bone graft and went on to osseous fusion by her 3-month follow-up. Neither patient had complications from the RIA procedure., (Copyright © 2019 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

The CranioFix ® titanium clamp was developed for fixing bone flaps after craniotomy. In this case, to prevent cosmetic problems, the bone flaps were trimmed with a beveled edge, and a CranioFix clamp was used for bone flap fixation. As the brain swelled, the CranioFix clamp became loosened. If brain swelling is anticipated and bone margins have been trimmed, it may be better to consider other fixation methods.

Background: Controversy exists regarding surgical treatment of high-grade spondylolisthesis (HGS) in terms of decompression with surgical reduction or in situ fusion. In situ fusion has the advantage of being less technically demanding. However, the residual bone graft area is extremely limited, and posterolateral bone grafting is complex as the transverse process of the slipped vertebrae is located anterior to the sacral ala, which correlates with high rates of pseudoarthrosis., Methods: Four cases of L5/S1 HGS complaining of low back pain were treated using our new bone graft technique with an exposed osseous end plate. Transdiskal screw holes were made from the S1 pedicle, and bone chips were packed into the L5/S disk space through the screw holes. The slipped L5 vertebra was fixed with a combination of L5/S1 transdiskal and L5 pedicle screws., Results: All cases exhibited good bony fusion, and the low back pain disappeared in all patients up to the 12-month follow-up. This technique involved packing the bone into the closed space, relieving any concerns regarding bone graft migration., Conclusions: Transpedicular bone graft via transdiskal screw holes is an easy and practical technique for raising the fusion rate in surgical treatment of HGS., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Recent improvements in additive manufacturing technologies may facilitate the use of customized 3D printed grafts for horizontal and vertical augmentation of the atrophic alveolar ridge. The accurate fit of such grafts could reduce the clinical treatment time and contribute optimal bone regeneration. The aim of this in vitro study was to evaluate the marginal and internal fit of 3D printed resin grafts as they could be used for alveolar ridge augmentation. Alveolar ridge morphologic data were derived from the Cone Beam Computed Tomography (CBCT) scans of six patients with alveolar bone defects. These data were transferred to a segmentation program to produce virtual 3D reconstructions of the alveolar ridge models. Using a Computer Aided Design (CAD) program, the alveolar bone defects were defined and customized grafts were designed and both the defects as well as the grafts generated (CAM) as 3D projects. These projects were imported into a 3D printer and were manufactured in resin. Hereafter, the grafts were fitted to the defect sites of the corresponding models and new CBCT scans were performed. Based on these scans, measurements were made at the marginal and internal part of the fitted grafts to evaluate the marginal and internal fit, respectively. The statistical analysis revealed that the mean marginal fit was significantly better (P < 0.05) than the mean internal fit. The fit of the grafts was dependent on the shape and on the size of the grafts. Specifically, the total void surface between the fitted graft and the corresponding defect site was significantly larger in the large-defect grafts than the small-defect grafts (P < 0.05). Within the limitations of the study, it could be demonstrated that it is possible to fabricate 3D printed resin grafts with acceptable fit in customized shapes, when combining CBCT scans and computer aided design and 3D printing techniques., Competing Interests: The authors have declared that no competing interests exist.

Onlay graft bone augmentation is a standard practice to restore the loss of height of the alveolar ridge following loss of a tooth. Cranial grafts, lifted from the parietal bone, are sandwiched and used to bridge the bony defect in the jaw by means of small screws. During the elevation of the covering gum and subsequent screw placement, care has to be taken in order to preserve underlying nerves. Therefore, to avoid harm to the patient, a solid education of surgeons is essential, which requires training and experience. A simulator for cranial graft-lift training was already developed and shall be expanded to train the augmentation of the lifted implants. Therefore, in this study, synthetic bones for onlay block graft screw placement with realistic haptics for the screw application training were evaluated and compared with human specimens. Six different polyurethane based bone surrogate composites, enriched with varying amounts of calcium-based mineral fillers and blowing agents, were developed. The haptical properties of these synthetic bones were validated for screw placement and compared with human parietal bone specimens. For that, bones were pre-drilled, screws were automatically inserted using a customized testbench and the slope of the screw-insertion torques were analyzed. The slope of the screw insertion torques of the human reference bones was 56.5 ± 14.0 * 10 -3 Nm/deg, Surrogates with lower amounts of mineral fillers and blowing agents showed lower torques than the human bone. Synthetic bones, validated for drilling, milling and sawing in an earlier study, also achieved significantly lower torques, which were only the half of the human parietal bones. Two intermediate stages of the aforementioned material compositions, consisting of 75% mineral filler with 0.75% blowing agent and 100% mineral filler with 1.00% blowing agent revealed results comparable with human bone (57.4 ± 10.2 *10 -3 Nm/deg, p = 0.893 and 54.9 ± 11.1 *10 -3 Nm/deg, p = 0.795, respectively). In conclusion, our findings suggest that, two newly developed polyurethane-based materials mimicking the haptical properties of an onlay bone graft screw fixation, have been identified. Thus, these surrogates are capable of mimicking real bone tissue in our simulator for the education of novice surgeons., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

The next frontier of orthopedic implants are resorbable devices. Tissue engineering advances have created a demand for scaffolds that can facilitate biologic regeneration. Scaffolds that will degrade over time with the infiltration of host cells are of particular interest. Several principles have been identified as desirable design features for such scaffolds. Furthermore, the era of 3D printing has ushered new possibilities for scaffold production that brings this technology closer to market use. This article explores the future of the design and manufacture of resorbable scaffolds.

Pediatric cranioplasty poses a reconstructive challenge because of children's developing anatomy and dynamic growth. Although several studies have advocated the use of autologous bone over synthetic material in pediatric population, the full coverage of the cranioplasty defect can be not fulfilled in the majority of the cases due to the size of the defect and the limited bone stock. There is an ongoing research for the development of alloplastic bone substitutes that avoid rigid fixation and promote graft transformation into viable tissue to improve outcomes in alloplastic pediatric cranioplasty. The aim of this study is to offer a detailed review on evolution, evaluation, planning, materials, and outcomes of cranioplasty in pediatric patients.

To preserve the continuity of the mandible after resection or traumatic bone loss, the defect is usually reconstructed with a bone graft fixed by a reconstruction plate. The fate of these plates is the objective of this study. Twenty-three patients (4 females and 19 males) required a reconstructive procedure to restore the discontinuity defect in the mandible by a mandibular reconstruction plate. Postoperative follow-up was performed to assess the outcomes of these plates. The mean age of the patients was 28.22 years. The most common cause of the discontinuity defect was bullet injury. The mean follow-up period was 3.65 years. The most common postoperative complication was the surgical site infection. The reconstruction plate of the mandible is associated with long-term success and body acceptance in the hands of an experienced surgeon.

Introduction: The management of segmental bone loss poses a significant clinical challenge. The purpose of this study was to conduct a retrospective evaluation of our experience in treating segmental bone loss, using Reamer-Irrigator-Aspirator (RIA)-harvested autologous bone graft., Materials and Methods: Between June 2008 and March 2015, 81 patients were treated with the RIA technique for multiple purposes. Inclusion criteria for this study were skeletal mature patients with segmental bone loss, due to acute trauma or non-union, who were treated with RIA-harvested bone graft. Exclusion criteria were skeletal immaturity, pathological fractures and indications for the RIA system other than bone graft harvesting. The primary outcome parameter was clinical and radiographical bone healing., Results: During the study period, 72 patients met the inclusion criteria. In total, 39 patients (54.2%) were classified as having clinical and radiographical bone healing. Although univariate analysis could not reveal any significant influence of specific risk factors to predict the outcome, there was a trend towards statistical significance for defect volume. Further analysis indeed revealed that smaller defect volumes (< 8 cm 3 ) had a lower risk of non-union., Conclusions: In approximately half of our study population, the use of the RIA technique for autologous bone graft harvesting in cases of segmental bone loss resulted in a successful outcome with bone healing. Defect size seems to be a critical issue regarding the outcome. Although our results are less promising than previously published, the RIA technique has its place in the treatment algorithm of segmental bone defects.

Objective: The objective of this study was to compare the clinical outcomes and complications between the locking compression plate (LCP) and LCP with fibular allograft in the treatment of patients with displaced proximal humerus fracture (PHF) in elderly people., Material and Methods: Between January 2010 and December 2013, a total of 97 elderly patients with displaced PHF were treated by LCP or LCP with fibular allograft, and finally 89 patients were included in our study. All the patients were divided into Group I (patients treated by LCP) and Group II (patients treated by LCP with fibular allograft). Function results were assessed by the disability of the arm, shoulder, and hand (DASH) score and Constant-Murley score (CMS), and complications were also recorded in each group., Results: The average follow-up was 35.2 months (range, 24-48 months) in Group I and 33.5 months (range, 24-48 months) in Group II. DASH in patients of Group I was significantly higher than that in patients in Group II and patients of Group I had CMS scores significantly lower than patients in Group II (P<0.05). The rates of varus malunion, screw perforation, and loss of reduction>5mm were significantly higher in Group I than in Group II (P<0.05)., Conclusions: The present results showed that that patients treated by LCP with fibular allograft had a better functional outcome and a lower complication rate compared to patients treated by LCP alone. Suitable void filler in the proximal humerus for supporting the head fragment, medial cortical bone, and greater tuberosity might play a key role in reducing the incidence of the complications in elderly patients, especially with osteoporosis.

Background: To compare the clinical efficacy of single posterior debridement, bone grafting and instrumentation with that of single-stage anterior debridement, bone grafting and posterior instrumentation for treatment of adult patients with thoracic and thoracolumbar spinal tuberculosis (TB)., Methods: We performed a retrospective analysis of 64 adult patients with thoracic and thoracolumbar spinal TB who underwent surgery between January 2011 and December 2014. Of the 64 patients, 34 patients were treated using a single posterior-only approach (posterior debridement, bone grafting and instrumentation; Group A). Thirty patients were treated with a combined anterior and posterior approach (single-stage anterior debridement, bone grafting and posterior instrumentation; Group B). Clinical manifestations, laboratory and imaging results were subjected to statistical analysis., Results: The mean (±standard deviation) duration of follow-up was 16.8 ± 1.4 months (range, 10-34). Bony fusion was achieved in all the bone grafts with no loosening or breakage of internal fixation. In both of the groups, the visual analog scale (VAS) pain score, ESR and CRP at 6 weeks after operation and at the most recent follow-up were significantly lower than the preoperative level (p < 0.05). The operation time, intraoperative blood loss and length of hospital stay in group A were significantly less than those in group B (P < 0.05). As of most recent follow-up, no significant between-group difference was observed with respect to the American Spinal Injury Association classification status (p > 0.05). Furthermore, no significant between-group difference was observed with respect to preoperative kyphosis angle, and postoperative angle correction and angle correction rate (P > 0.05). One patient in group A relapsed 20 months after operation, and was successfully treated with debridement using the combined anterior and posterior approach., Conclusion: Single posterior debridement, bone grafting and instrumentation for treatment of thoracic and thoracolumbar spinal TB can achieve similar curative effect as that with single-stage anterior debridement, bone grafting and posterior instrumentation, and is associated with additional advantages of shorter operation time, less bleeding and shorter length of hospital stay.

Background: Pelvic ring reconstruction after resection of pelvic malignancies or aggressive benign tumors remains challenging, especially when the tumor invades periacetabular bone, resulting in a Type II resection as classified by Enneking and Dunham (removal of part or all of the acetabulum). Although numerous treatment approaches are in use, none is clearly superior to the others. An alternative involving use of the ipsilateral proximal femur as an autograft has not been well characterized, so we present our preliminary experience with this approach., Questions/purposes: (1) What were the oncologic outcomes after using an ipsilateral proximal femur autograft for reconstruction after Type II pelvic resection in a small series of patients who underwent this reconstructive approach? (2) What were the Musculoskeletal Tumor Society (MSTS) scores after this reconstruction? (3) What complications were observed?, Methods: Between October 2006 and May 2016, we treated 67 patients with Type II malignant or aggressive benign tumors of the ilium. Of those, we used an ipsilateral proximal femur and a prosthesis as a reconstruction method for 11 patients with pelvic tumors. In general, we performed this approach in young or middle-aged patients with primary malignant or aggressive benign tumors involving pelvic area II and in whom the tumor did not invade the hip. The method used for resection of pelvic tumors included osteotomy of the femoral shaft, harvesting the proximal femur as a graft. The length of the femoral graft was determined by the extent of the pelvic defect. The proper placement was selected after a comparison of the proximal femur and the pelvic defect. A curved reconstruction plate and cancellous bone screws were used for pelvic fixation. The operative duration and total blood loss were recorded. Of the 11 patients who underwent this approach, all but one had at least 2 years of followup unless death occurred earlier, and all but one have been seen within the last year for evaluation. Functional outcomes were assessed using the MSTS scoring system. Local recurrence, metastases, and deaths were recorded as were complications including infection, bone nonunion, mechanical failure and sciatic nerve palsy., Results: The followup was a mean of 37 months (range, 13-96 months). One patient was lost to followup. Three patients died of disease owing to local recurrence or lung metastasis. The other seven patients lived without evidence of tumor. The main complications included mechanical failure in two patients, nonunion in one patient, infection in two patients, and sciatic nerve palsy in one patient. The median MSTS function score was 70% (21 of 30 points; range, 11-25 points)., Conclusions: Our preliminary results show that this technique of using the ipsilateral proximal femur may be an alternative method for reconstruction of pelvic bone defects after tumor resection. Even with this short followup, complications were common, but short-term function appears to be comparable to studies of other options. Longer term followup with more patients is necessary to confirm our results., Level of Evidence: Level IV, therapeutic study.

Background: Pasteurized autograft is regarded as a biologic reconstructive option for managing bone defects after tumor resection; however, reports on long-term outcomes from large patient series are scarce. Contrary to previous favorable reports, we have observed many patients with failures, in particular as the duration of followup increased. Because pasteurized autografts are used in many countries as a reconstruction option, we wished to formally evaluate patients who underwent this approach at one specialty center., Questions/purposes: (1) What is the graft survival and what proportion of patients achieved union when pasteurized autografts were used for bone defects after tumor resection? (2) What are the complications and causes of graft removal? (3) What factors are related to the likelihood of union and graft survival? (4) What is the survival and cause of failure by type of pasteurized autograft reconstruction?, Methods: Over a 26-year period from 1988 to 2013, we performed 1358 tumor resections in our center. Of these, 353 were reconstructed with pasteurized autograft. Other reconstructions included endoprostheses (508 patients), instant arthrodesis using an intramedullary nail and bone cement (286 patients), allografts (97 patients), and resection only (114 patients). During the period in question, we generally used this approach when tumor showed an osteoblastic pattern and less than one-third cortical destruction in osteolytic tumor. We generally avoided this approach when the tumor showed an extensive osteolytic pattern. We excluded 75 (21% [75 of 353]) patients, 21 (6% [21 of 353]) for incomplete clinical data and 54 (15% [54 of 353]) with a followup < 2 years or those lost to followup leaving 278 autografts eligible. The mean followup was 113 months (range, 25-295 months). Of these 278 patients, 242 patients had primary bone sarcomas, 22 patients had soft tissue tumor invading bone, seven patients had metastatic carcinoma, and seven patients had aggressive benign bone tumors. From a chart review, we obtained the age, sex, location, tumor volume, histologic diagnosis, use of chemotherapy, graft length, fixation modality, type of pasteurized bone used, proportion of union, complications, and oncologic outcome of the patients. In total, 377 junctional sites were assessed for union with serial radiographs. We defined junctions showing union < 2 years as union and > 2 years as delayed union. We grouped our patients into type of pasteurized bone use: pasteurized autograft-prosthesis composites (PPCs) were performed in 149, intercalary grafts in 71, hemicortical grafts in 15, osteoarticular in 12, and fusion of a joint in 31 patients. The endpoint of interest included removal of the autograft with implant loosening, infection, fracture of the graft, or any reoperation resulting in removal. Survival of the graft was determined by Kaplan-Meier plot and intergroup differences were determined using log-rank test., Results: Five, 10-, and 20-year survival of 278 autografts was 73% ± 5.5%, 59% ± 6.7%, and 40% ± 13.6%, respectively. Of 278 autografts, 105 (38%) were removed with complications. Cause of removal included infection in 13% (33 patients), nonunion in 7% (18 patients), fracture of graft in 6% (16 patients), resorption of the graft in 5% (14 patients), and local recurrence in 4% (11 patients). Univariate survival analysis revealed that patient age ≤ 15 years (p = 0.027; hazard ratio [HR], 1.541), male sex (p = 0.004; HR, 1.810), and pelvic location (p = 0.05; HR, 2.518) were associated with graft removal. The 20-year survival rate of osteoarticular and hemicortical methods was 92% (95% confidence interval, -15.6% to +8.3%) and 80% ± 20%, respectively. For intercalary and fusion, it was 46% ± 15% and 28% ± 22%, respectively, although for PPC, it was 37% ± 22%. Log-rank survival analysis showed the osteoarticular and hemicortical groups had better graft survival compared with other types of reconstruction (p = 0.028; HR, 0.499). The most prevalent cause of graft removal in three major types of reconstruction was as follows: (1) PPC type was infection (30% [17 of 56]); (2) intercalary graft was infection, nonunion, and local recurrence in even proportions of 29% (86% [24 of 28]); and (3) fusion was infection (35% [six of 17]). Two hundred ten (56%) of 377 junctional sites showed union within 2 years (average, 14 months), 51 (13%) junctions showed delayed union after 2 years (average, 40 months), and the remaining 116 (31%) junctions showed nonunion. Diaphyseal junction (p = 0.029) and male sex (p = 0.004) showed a higher proportion of nonunion by univariate analysis., Conclusions: Compared with the favorable short-term and small cohort reports, survival of pasteurized autograft in this long-term large cohort was disappointing. We believe that pasteurized autograft should be used with caution in children and adolescents, in the pelvic region, and in PPC form. When bone stock destruction is minimal, it is worth considering this approach for small intercalary or distal long bone reconstruction. We believe this procedure is best indicated after hemicortical resection of long bone., Level of Evidence: Level III, therapeutic study.

Introduction: Orofacial clefts are congenital malformations characterized by an incomplete shaping of structures that separate the nasal from the oral cavity and can affect the right, left, or both sides. The aim of the present study is to assess, with clinical, radiographical, and histological evaluations, the efficacy of piezoelectric devices compared to traditional rotating instruments in the bone harvesting in patients with history of cleft., Materials and Methods: We have conducted a retrospective analysis on 20 patients with a history of orofacial clefts that were operated on from February 2014 to June 2017. The patients were divided into two groups: Group R in which bone graft was harvested using a burr and Group P in which the bone graft was obtained by a piezoelectric device. After a healing period of 8 months from the grafting procedure, clinical and radiographic evaluations were performed., Results and Discussion: The use of the piezoelectric devices in bone harvesting allows a slight improvement in the final volume. This supports a faster integration into the receiving site., Conclusions: The use of piezoelectric device in patients with history of orofacial cleft that needed bone graft represents a method to be taken into consideration because it has interesting advantages.

The reconstruction of mandibular defects using particulate grafts is a proven technique that restores the osseous anatomy effectively. Secondary osseous reconstruction can be accomplished with endoscopic assistance and reduced-access incisions if an intermediate spacer is placed during resection. Two patients required reconstruction after resection of mandibular ameloblastomas. We used a modified protocol that involved the implantation of a graft of particulate corticocancellous bone after removal of the spacer, and prepared the recipient site under endoscopic guidance with small extraoral incisions. The grafts healed uneventfully and matured into ossicles suitable for the placement of osseointegrated implants., (Copyright © 2018 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.)

Background: Achieving glenoid fixation with anterior bone loss can be challenging. Limited guidelines have been established for critical defect sizes that can be treated without supplemental bone graft when performing reverse shoulder arthroplasty., Methods: We quantified the impact of two sizes of anterior glenoid defects on glenoid baseplate fixation in a composite scapula using the ASTM F 2028-14 reverse shoulder glenoid loosening test method., Results: All glenoid baseplates remained well-fixed after cyclic loading in composite scapula without a defect and in scapula with an 8.5 mm anterior glenoid defect; however, one of seven baseplates loosened in a scapula with a 12.5 mm defect. No difference was observed between pre- and post-cyclic baseplate displacements in scapula with 8.5 mm or 12.5 mm defects or in the control group scapula. However, baseplate displacement in scapula with 12.5 mm anterior defects was significantly greater after cyclic loading than that of baseplates in 8.5 mm defects (superior-inferior displacement, p = 0.0004; anterior-posterior displacement, p < 0.0001), where baseplate displacement in 8.5 mm (superior- inferior displacement, p = 0.0003; anterior-posterior displacement, p = 0.0014) and 12.5 mm (superior-inferior displacement, p < 0.0001; anterior-posterior displacement, p < 0.0001) defects after cyclic loading was significantly greater than that of baseplates in scapula without a defect., Discussion: Adequate and stable fixation can be achieved in scapula with anterior glenoid defects of at least 8.5 mm in this biomechanical model using an established testing methodology; however, supplemental bone grafting should be utilized for anterior glenoid defects of 12.5 mm and larger using the reverse shoulder prosthesis tested in this study.

Background: Cranial vault reconstruction (CVR) is the gold standard in the operative treatment of craniosynostosis. Full thickness osseous defects (FTOD) of the calvaria have been observed in 5% to 15% patients after CVR, with higher rates cited in the fronto-orbital advancement (FOA) subset. Particulate bone graft (PBG) harvested manually has been shown to decrease FTOD after FOA from 24% to 5.5%. The authors used a modified technique using a powered craniotome, with the hypothesis that the technique would also improve outcomes., Methods: A retrospective review was performed of patients who underwent CVR for craniosynostosis between 2004 and 2014. Patient demographics, diagnosis, age, operative details, and postoperative care were reviewed in detail. Categorical, nonparametric variables were compared by Fisher exact tests., Results: A total of 135 patients met inclusion criteria. The most common diagnoses were metopic (n = 41), sagittal (n = 33), and unilateral coronal craniosynostosis (n = 31); 65% (n = 88) underwent FOA, 29% (n = 39) underwent single-stage total vault reconstruction, and 6% (n = 8) had a posterior vault reconstruction. CVR was performed without PBG in 95 patients and with PBG in 40 patients. Without PBG, FTOD were discovered on clinical examination in 18% of patients (n=17): 11 presented with subcentimeter defects, while 6 had larger defects requiring revision cranioplasty (6% operative revision rate). Among those receiving PBG, 1 patient presented a subcentimeter FTOD (2.5% FTOD incidence and 0% operative revision rate)., Conclusion: Particulate bone graft harvested with a powered device decreases the rate of FTOD and reoperation rate after CVR for craniosynostosis.

Background: We report the successful use of allograft-prosthesis composite (APC) and structural femoral head allografting in the bilateral reconstruction of large femoral and tibial uncontained defects during revision total knee arthroplasty (RTKA)., Case Presentation: A 67-year-old female with degenerative arthritis underwent bilateral total knee arthroplasty (TKA) using the Press Fit Condylar (PFC) modular knee system at our clinic in March, 1996. At 8 years postoperatively, the patient presented with painful, bilateral varus knees, with swelling, limited passive range of motion (ROM), and severe instability. We treated to reconstruct both knee using a femoral head allograft at the tibial site, a structural distal femoral allograft at the femoral site, and a varus-valgus constrained (VVC) prosthesis with cement. At the 10-year follow up, we found no infection, graft failure, loosening of implants, in spite of using massive bilateral structural femoral head allografts in RTKA., Conclusion: The use of APC enabled a stable and durable reconstruction in this uncommon presentation with large femoral bone deficiencies encountered during a RTKA.

Background: Wedge-shaped bone grafts that are internally fixed by a Herbert-type screw are a well-established surgical treatment for scaphoid nonunion. A procedure using cylinder-shaped bone grafts was also reported, but preoperative wrist functions were not assessed. In addition, it was not reported whether the humpback deformity of the scaphoid nonunion was corrected. The purpose of the current study was to compare preoperative wrist functions in cases of scaphoid nonunion with those observed at final follow-up, using cylinder-shaped bone grafts The humpback deformity of the scaphoid nonunion was also evaluated., Methods: We conducted a retrospective study to examine operative outcomes from 2008 to 2015. Twelve wrists in 12 patients (average age, 41 years; range, 17-67), with a mean follow-up of 19 months, were included in the current study. Cylinder-shaped bone grafts were obtained from the iliac crest with a newly designed trephine and fixed with a Herbert-type screw. We reviewed both the preoperative wrist functions and those obtained at final follow-up., Results: Union was achieved in 11 of 12 nonunion cases. Preoperative wrist functions, except for the range of wrist motion, significantly improved by final follow-up., Conclusions: We conclude that the use of cylinder-shaped bone grafts improves preoperative wrist functions in cases of scaphoid nonunion.

The aim of this study was clinical and radiographic evaluation of sinus floor lifting from the alveolar crest with trephine bur and autogenous bone graft. In this research, a press-fit dowel bone technique with application of an autogenous bone block was used for elevating the sinus floor. Ten closed sinus lift surgeries were performed on 10 patients; all patients possessed atrophic ridges in an edentulous maxilla. Bone height of the ridge ranged between 3 and 5 mm. Surgery included forming a bony cylinder with a trephine bur to reach the sinus cortical floor and then elevating the sinus floor bone with anosteotom and placing an autogenous bone block at the site and fitting it with strikes of a hand mallet. The amount of an osteotom sinus floor height gain was measured during implant placement and via radiography before surgery and four months postsurgery. Average height of the sinus floor bone after surgery was 8.33 mm with SD = 1.39 mm. Mean bone height gain after surgery in evaluated patients was 3.47 mm with SD = 1.4 mm. As a result, bone sinus floor height following surgery was significantly increased (P value = 0.044), with a significant difference between sinus floor bone height before and after surgery (P value = 0.041). No significant difference was observed between sinus floor bone height gain and sex, age, and smoking before and after the operation. The sinus floor lift method by trephine and autogenous bone graft is a practical and simple way to reduce the time needed for implantation in patients with moderate atrophy of the posterior maxilla.