Harvesting Autogenous Cancellous Bone Graft from the Anterior Iliac Crest

[Research progress on biomechanics for internal fixation in tibial plateau fracture]

Objective

To review the biomechanical research progress of internal fixation of tibial plateau fracture in recent years and provide a reference for the selection of internal fixation in clinic.

Methods

The literature related to the biomechanical research of internal fixation of tibial plateau fracture at home and abroad was extensively reviewed, and the biomechanical characteristics of the internal fixation mode and position as well as the biomechanical characteristics of different internal fixators, such as screws, plates, and intramedullary nails were summarized and analyzed.

Results

Tibial plateau fracture is one of the common types of knee fractures. The conventional surgical treatment for tibial plateau fracture is open or closed reduction and internal fixation, which requires anatomical reduction and strong fixation. Anatomical reduction can restore the normal shape of the knee joint; strong fixation provides good biomechanical stability, so that the patient can have early functional exercise, restore knee mobility as early as possible, and avoid knee stiffness. Different internal fixators have their own biomechanical strengths and characteristics. The screw fixation has the advantage of being minimally invasive, but the fixation strength is limited, and it is mostly applied to Schatzker typeⅠfracture. For Schatzker Ⅰ-Ⅳ fracture, unilateral plate fixation can be used; for Schatzker Ⅴand Ⅵ fracture, bilateral plates fixation can be used to provide stronger fixation strength and avoid the stress concentration. The intramedullary nails fixation has the advantages of less trauma and less influence on the blood flow of the fracture end, but the fixation strength of the medial and lateral plateau is limited; so it is more suitable for tibial plateau fracture that involves only the metaphysis. Choosing the most appropriate internal fixation according to the patient's condition is still a major difficulty in the surgical treatment of tibial plateau fractures.

Conclusion

Each internal fixator has good fixation effect on tibial plateau fracture within the applicable range, and it is an important research direction to improve and innovate the existing internal fixator from various aspects, such as manufacturing process, material, and morphology.

Effectiveness and safety analysis of titanium mesh grafting versus bone grafting in the treatment of spinal Tuberculosis: a systematic review and meta-analysis

BACKGROUND

To systematically assess the safety and effectiveness of titanium mesh grafting compared with bone grafting in the treatment of spinal tuberculosis.

METHODS

Electronic databases, including PubMed, Embase, Web of Science, and Cochrane Library, were searched from their inception until April 2023. The outcome indicators for patients treated with titanium mesh grafting or bone grafting for spinal tuberculosis include surgical duration, intraoperative blood loss, graft fusion time, American Spinal Injury Association (ASIA) Spinal Cord Injury Grade E assessment, VAS score, lumbar pain score, post-graft kyphotic angle, and postoperative complications. The Newcastle-Ottawa Scale (NOS) and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach were used for quality assessment and evidence grading of clinical studies. Funnel plots and Begg's test were employed for bias assessment.

RESULTS

A total of 8 studies were finally included, comprising 523 patients, with 267 cases of titanium mesh fixation and 256 cases of bone grafting. The meta-analysis showed no significant statistical differences in surgical duration (Weighted Mean Difference (WMD) = -7.20, 95% Confidence Interval (CI): -28.06 to 13.67, P = 0.499), intraoperative blood loss (WMD = 16.22, 95% CI: -40.62 to 73.06, P = 0.576), graft fusion time (WMD = 0.97, 95% CI: -0.88 to 2.81, P = 0.304), ASIA Spinal Cord Injury Grade E assessment (Relative Risk (RR) = 1.03, 95% CI: 0.97 to 1.09, P = 0.346), and overall complications (RR = 0.87, 95% CI: 0.49 to 1.55, P = 0.643). Differences in VAS score, ODI lumbar pain score, and post-graft kyphotic angle between the titanium mesh grafting group and the bone grafting group were not significant within the 95% CI range. The rate of postoperative implant subsidence was slightly lower in bone grafting than in titanium mesh grafting (RR = 9.30, 95% CI: 1.05 to 82.22, P = 0.045).

CONCLUSIONS

Both bone grafting and titanium mesh grafting are effective and safe for the surgery, with no significant statistical differences in the results. Considering the limitations of the present study, large-scale randomized controlled trials are warranted to further verify the reliability of this finding.

Reconstruction After En Bloc Resection of a Distal Radius Tumor. An Updated and Concise Review

The distal radius is rarely affected by either primary or metastatic bone cancers. The most frequent tumors of the distal radius are giant cell tumors, which are benign tumors with the propensity to invade. En bloc excision of giant cell tumors of the distal radius achieves a low recurrence rate but compromises the wrist joint, necessitates a significant reconstruction, and has functional consequences. Reconstruction after en bloc resection of a distal radius bone tumor is challenging. Furthermore, orthopedic oncologists disagree on treating such long bone anomalies most effectively. The present article summarizes the various biological and non-biological reconstruction techniques performed after en bloc resection of a distal radius tumor, discusses the advantages and disadvantages of each reconstruction strategy, and summarizes several case studies and case reports.

Scooping Technique to Acquire Cancellous Bone for Grafting in the Masquelet Procedure: A Retrospective Study

Background

The Masquelet procedure is effective in overcoming large bone defects; however, the limited number of cancellous bone and donor site complications remains a challenge. We developed a scooping technique to harvest sufficient cancellous bone from iliac crests for grafting during the Masquelet procedure. We hypothesized that this method would be efficient and safe.

Methods

This retrospective study included 13 patients who underwent the Masquelet procedure with cancellous bone grafting using the scooping technique. The following parameters were observed: (1) duration and total volume of cancellous bone extraction; (2) amount of bleeding and drainage fluid, and Visual Analog Scale (VAS) score of pain at the donor site during different periods; and (3) complications and bone regeneration at the ilium at the final follow-up.

Results

The median follow-up duration was 17 months. There were 3 unilateral and 10 bilateral extraction sites. The mean total amount extracted, extraction duration, bleeding, and drainage were 39 mL, 23 min, 49 mL, and 44 mL, respectively. Only three patients felt pain (VAS score: 1 point) at the final follow-up. Postoperatively, one case each of hematoma and lateral femoral cutaneous nerve injury supervened, and no infections or other complications occurred. The last computed tomography examination showed varying degrees of bone regeneration in the ilium.

Conclusion

The scooping technique for the iliac crest produced a substantial amount of autogenous cancellous bone using a small incision. It retained the appearance and morphology of the ilium with few complications. We believe it is a successful and safe option for treating bone defects.

Autologous versus synthetic bone grafts for the surgical management of tibial plateau fractures: a systematic review and meta-analysis of randomized controlled trials

AIMS

Our objective was to conduct a systematic review and meta-analysis, to establish whether differences arise in clinical outcomes between autologous and synthetic bone grafts in the operative management of tibial plateau fractures.

METHODS

A structured search of MEDLINE, EMBASE, the online archives of Bone & Joint Publishing, and CENTRAL databases from inception until 28 July 2021 was performed. Randomized, controlled, clinical trials that compared autologous and synthetic bone grafts in tibial plateau fractures were included. Preclinical studies, clinical studies in paediatric patients, pathological fractures, fracture nonunion, or chondral defects were excluded. Outcome data were assessed using the Risk of Bias 2 (ROB2) framework and synthesized in random-effect meta-analysis. The Preferred Reported Items for Systematic Review and Meta-Analyses guidance was followed throughout.

RESULTS

Six studies involving 353 fractures were identified from 3,078 records. Following ROB2 assessment, five studies (representing 338 fractures) were appropriate for meta-analysis. Primary outcomes showed non-significant reductions in articular depression at immediate postoperative (mean difference -0.45 mm, p = 0.25, 95%confidence interval (CI) -1.21 to 0.31, I2 = 0%) and long-term (> six months, standard mean difference -0.56, p = 0.09, 95% CI -1.20 to 0.08, I2 = 73%) follow-up in synthetic bone grafts. Secondary outcomes included mechanical alignment, limb functionality, and defect site pain at long-term follow-up, perioperative blood loss, duration of surgery, occurrence of surgical site infections, and secondary surgery. Mean blood loss was lower (90.08 ml, p < 0.001, 95% CI 41.49 to 138.67) and surgery was shorter (16.17 minutes, p = 0.04, 95% CI 0.39 to 31.94) in synthetic treatment groups. All other secondary measures were statistically comparable.

CONCLUSION

All studies reported similar methodologies and patient populations; however, imprecision may have arisen through performance variation. These findings supersede previous literature and indicate that, despite perceived biological advantages, autologous bone grafting does not demonstrate superiority to synthetic grafts. When selecting a void filler, surgeons should consider patient comorbidity, environmental and societal factors in provision, and perioperative and postoperative care provision. Cite this article: Bone Jt Open 2022;3(3):218-228.

Minimally invasive treatment and internal fixation vs. extended lateral approach in calcaneus fractures of thalamic interest

The extended lateral side approach is a common technique in the surgical treatment of calcaneal fractures, with thalamic collapse offering a good exposure of the fractured site; however, it can be burdened with complications due to soft tissue trauma. The present study aimed to compare patients treated with minimally invasive osteosynthesis through a minimum lateral approach and internal fixation with patients that were treated using internal fixation with an extended lateral side approach in cases of intra-articular calcaneal fractures with thalamic fracture. Patients were evaluated preoperatively and postoperatively by performing clinical and imagistic examinations, with radiography scans of the anterior-posterior calcaneal profile and computer tomography. Furthermore, preoperative and postoperative analyses of the Böhler angle on the radiological profile, complications and duration of the hospital admission for both groups were performed. There were 36 patients (39 calcaneal fractures) in group 1 and 24 patients (29 calcaneal fractures) in group 2. The results demonstrated no statistically significant differences in the preoperative (P=0.72) and postoperative (P=0.20) Böhler angle values. The postoperative Böhler angle average values were 26.9 in group 1 and 29.3 in group 2. A total of 11 patients were treated with Kirschner wires inserted in the calcaneus, and in 2/ll cases, one of the brooches registered a migration movement. There were no cases of material migration in the fractures that were stabilized by inserting Kirschner brooches up to the astragalus and cuboid bones. Taken together, the results of the present study demonstrated no significant differences in the Böhler angle values between the minimally invasive and open reduction techniques. However, the antibiotic therapy period, as well as the infection rate were lower in patients that were treated using the minimally invasive technique, suggesting that this technique was superior with respect to lower complication rates and improved functional results.

Structural Bicortical Autologous Iliac Crest Bone Graft Combined with the Tunnel Bone Tamping Method for the Depressed Tibial Plateau Fractures

BACKGROUND

Clinically, autologous iliac crest bone grafts (ICBG) and bone tamping methods are often applied to manage depressed tibial plateau fractures (DTPFs). The purpose of this study was to describe and evaluate the technique of using structural bicortical autologous ICBG combined with the tunnel bone tamping method (TBTM) for treating DTPFs.

METHODS

All patients with DTPFs who underwent structural bicortical autologous ICBG combined with TBTM from January 2016 to February 2018 were prospectively analysed. Demographics, injury, surgery, postoperative complications, and clinical outcomes were recorded. All patients were followed up for more than 30 months. Postoperative radiography and CT were employed to assess fracture healing and the reduction quality.

RESULTS

Forty-three of the included patients completed the follow-up. No malreduction was observed. Based on the immediate postoperative imaging, the intra-articular step-off was significantly reduced (8.19 mm preoperatively vs. 1.30 mm immediate postoperatively, P < 0.001). From the immediate operation to the latest follow-up, the reduction was maintained significantly well, with a nonnegligible absolute difference (0.18 mm, P = 0.108). A remarkable secondary loss of reduction (intra-articular step off > 3 mm) was found in two elderly patients (2/43, 4.65%). The incidence of complications related to the bone-graft donor and bone-graft site was 2.33% and 4.65%, respectively. At the final follow-up, the mean Hospital for Special Surgery (HSS) score of the knee was 98.19 ± 2.89, and the mean 36-Item Short-Form Health Survey (SF-36) score was 95.65 ± 4.59.

CONCLUSION

Structural bicortical autologous ICBG combined with TBTM is radiologically effective and stable in terms of complications for the DTPFs.

An Extrudable Partially Demineralized Allogeneic Bone Paste Exhibits a Similar Bone Healing Capacity as the "Gold Standard" Bone Graft

Autologous bone grafts (BGs) remain the reference grafting technique in various clinical contexts of bone grafting procedures despite their numerous peri- and post-operative limitations. The use of allogeneic bone is a viable option for overcoming these limitations, as it is reliable and it has been widely utilized in various forms for decades. However, the lack of versatility of conventional allogeneic BGs (e.g., blocks, powders) limits their potential for use with irregular or hard-to-reach bone defects. In this context, a ready- and easy-to-use partially demineralized allogeneic BG in a paste form has been developed, with the aim of facilitating such bone grafting procedures. The regenerative properties of this bone paste (BP) was assessed and compared to that of a syngeneic BG in a pre-clinical model of intramembranous bone healing in critical size defects in rat calvaria. The microcomputed tridimensional quantifications and the histological observations at 7 weeks after the implantation revealed that the in vivo bone regeneration of critical-size defects (CSDs) filled with the BP was similar to syngeneic bone grafts (BGs). Thus, this ready-to-use, injectable, and moldable partially demineralized allogeneic BP, displaying equivalent bone healing capacity than the “gold standard,” may be of particular clinical relevance in the context of oral and maxillofacial bone reconstructions.

Cancellous Tibial Bone Graft for Malunion after Mandibular Reconstruction in Head and Neck Cancer

OBJECTIVES/HYPOTHESIS

While nonunion after mandibular reconstruction for head and neck surgery is rare, literature exploring management is scarce. Our primary objective was to determine success rates of tibial bone graft (TBG) in achieving mandibular union. Secondary objectives include determining factors that contribute to failure of TBG.

STUDY DESIGN

Retrospective Chart Review.

METHODS

Retrospective chart review between January 1, 2008 and December 31, 2018. Patients who underwent a mandibulotomy or mandibulectomy with osteocutaneous free flap reconstruction were identified. Patients who were pursuing dental rehabilitation, subsequently diagnosed with mandibular nonunion and received a cancellous TBG were assessed.

RESULTS

The 15 patients meeting inclusion criteria were mostly male (67%), white (87%), and nonsmokers (67%) with a median age of 64 (IQR = 60-73). Successful union occurred in 13 of 18 (72%) TBGs and the majority (63%) had a partial union documented at the time of surgery. Five patients (83%) who initially had a mandibulotomy achieved union compared to 78% of those with osteocutaneous reconstruction (P = 1.0). Postoperative radiation did not affect rates of union: 80% for both (P = 1.0). Patients with osteoradionecrosis (ORN) achieved union in 67% of cases compared to 75% of cases who did not have ORN (P = .86). There were similar rates of union for those who required perioperative antibiotics for infection and those without infection (67% vs. 75%, P = .86). Dental rehabilitation was achieved in 55% of patients, most commonly dentures.

CONCLUSIONS

This study shows that TBG can be used to achieve union for patients with malunion after head and neck cancer reconstruction. We show its successful use within the reconstructive algorithm for patients regardless of postoperative radiation for very small defects.

LEVEL OF EVIDENCE

3 Laryngoscope, 131:1291-1296, 2021.

Iliac Bone Harvesting Techniques for Bone Reconstruction. Comparative Study Between Tricortical Bone Harvesting vs Trapdoor Technique

Objective

To investigate the effects of trapdoor-procedure-based bone harvesting and tricortical iliac bone harvesting on the iliac bone-graft donor site pain experienced by patients and their clinical effects.

Methods

A retrospective analysis was performed using the clinical data of 65 patients with tibial plateau fractures who received autologous iliac bone-supporting grafts in two hospitals between January 2014 and January 2019. The patients who received trapdoor-procedure-based bone harvesting (34 cases) were in the experimental group, and those who received tricortical iliac bone harvesting (31 cases) were in the control group. This study compared differences in iliac bone-graft donor site incision length, intraoperative blood loss, amount of bones harvested, operation time, and postoperative complications between the two bone-harvesting methods. Subsequently, it evaluated the pain experienced by the two patient groups in their iliac bone-graft donor sites and their clinical effects.

Results

One week after surgery, the differences between the iliac bone-graft donor site pain score (measured using SF-MPQ-2) of the experimental group and the control group were not statistically different. However, 3 weeks, 5 weeks, and 3 months after surgery, the iliac bone-graft donor site pain scores of the experimental group were significantly lower than those of the control group. The iliac bone-graft donor site incision length and operation time of the experimental group were not significantly different from those of the control group. However, the iliac bone-graft donor site intraoperative blood loss, amount of bones harvested and the incidence of complications of the experimental group were significantly lower than those of the control group.

Conclusion

Trapdoor-procedure-based bone harvesting has lower donor site pain, intraoperative blood loss, and postoperative complications. However, for bone grafting in regions with significant bone loss, tricortical iliac bone harvesting remains the optimal option.

History of Spinal Fusion: Where We Came from and Where We Are Going

Spinal fusion surgery is performed all over the world to help patients with cervical and thoracolumbar pathology. As outcomes continue to improve in patients with spine-related pathology, it is important to understand how we got to modern day spinal fusion surgery. Scientific innovations have ranged from the first spinal fusions performed with basic instrumentation in the late nineteenth century to contemporary tools such as pedicle screws, bone grafts, and interbody devices. This article tracks this technological growth so that surgeons may better serve their patients in treating spine-related pain and disability.

Autologous Iliac Bone Graft Compared with Biphasic Hydroxyapatite and Calcium Sulfate Cement for the Treatment of Bone Defects in Tibial Plateau Fractures: A Prospective, Randomized, Open-Label, Multicenter Study

BACKGROUND

Bone-graft substitutes are commonly used for the augmentation of traumatic bone defects in tibial plateau fractures. However, their clinical performance compared with that of autologous bone-grafting, the gold standard in bone defect reconstruction, still remains under debate. This study investigates the differences in quality of life, pain, and radiographic outcomes in the treatment of tibial plateau fracture-associated bone defects with either autologous bone grafts or a bioresorbable hydroxyapatite and calcium sulfate cement (CERAMENT BONE VOID FILLER [CBVF]; BONESUPPORT).

METHODS

In this study, 135 patients with acute depression and split-depression fractures of the proximal part of the tibia (OTA/AO types 41-B2 and 41-B3) were enrolled in a prospective, controlled, randomized, multicenter trial including 20 hospitals in Germany. Patients were randomized to receive either autologous iliac bone graft or CBVF for reconstruction of the bone defect. The primary outcome measures were the Short Form (SF)-12 version 2 Physical Component Summary (PCS) score at week 26 (the study was designed to show noninferiority of the CBVF with regard to the PCS with a prespecified margin of -5 points) and the pain level at 26 weeks postoperatively measured by a visual analog scale (VAS). The secondary outcomes were the SF-12 version 2 Mental Component Summary (MCS) and SF-12 PCS scores at weeks 1, 6, and 12 and bone-healing on radiographs.

RESULTS

Age, sex, fixation methods, and fracture pattern were comparable in both groups. There were no significant differences (p > 0.05) in the SF-12 PCS or VAS scores at postoperative week 26. There was a significant reduction of blood loss (p = 0.007) and pain levels (p = 0.008) at postoperative day 1 in the CBVF group. The rates of fracture-healing, defect remodeling, and articular subsidence were not significantly different (p > 0.05) in both groups.

CONCLUSIONS

Bioresorbable CBVF was noninferior to autologous bone graft with regard to both patient-reported and radiographic outcomes in tibial plateau fractures of OTA/AO types 41-B2 and 41-B3.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.