Mastoid Reconstruction With Platelet-Rich Plasma and Bone Pate After Canal Wall Down Mastoidectomy: A Preliminary Report.

OBJECTIVES: Mastoid reconstruction principle had been described to overcome problems of chronic discharging cavity. Different materials were used; nonbiologic materials seem to be less preferred. Platelet-rich plasma (PRP) could promote the regeneration of mineralized tissues. In this work, the authors present a simple and easy technique for mastoid reconstruction with PRP and cortical bone pate. METHODS: The study design is a case series. Patients had mastoid reconstruction after canal wall down mastoidectomy using PRP and cortical bone pate. RESULTS: This study included 21 patients: 9 males, and 12 females. Sixteen patients had left side disease. All surgical procedures were conducted smoothly within 90 to 135 minutes with no stressful events had been reported. At 12 to 16 months of follow-up, external canal stenosis and mastoid fistulas were not reported. Good healing of the tympanic membrane was seen in 18 patients. No radiological signs suggestive of recurrence were detected and the reconstructed mastoid cavity was smooth and well aerated. Residual tympanic membrane perforations were detected in 3 patients. CONCLUSION: Autologous materials (PRP and bone pate pate) after canal wall down mastoidectomy appear to be a reliable and effective choice for mastoid reconstruction.

Free vascularized medial femoral condyle corticoperiosteal flap with non-vascularized iliac crest graft for the treatment of recalcitrant clavicle non-union.

Clavicle non-union is a challenging problem. Open reduction with internal fixation and autologous bone grafting is usually the first line treatment. In case of failure, the medial femoral condyle corticoperiosteal flap in association with a non-vascularized bone graft is one of the therapeutic options, which is well adapted to the clavicle anatomical characteristics. We performed a retrospective study of all patients treated with this technique in our department. Between 2014 and 2017, five patients with recalcitrant post traumatic clavicle non-unions received this surgical treatment. The average nonunion time period was 50.2 month (range 10 to 108 months), and the mean defect length was 3.4 cm (between 2 and 5 cm), defects were all located in the medial third of the clavicle Three patients achieved full consolidation with an average time of consolidation of 8,7 months (range 6 to12 months). Patients with radiological consolidation had better functional improvement and pain reduction with an average DASH score improved from 53,6 before surgery to 19,6 after consolidation (at the last follow up visit). There was one donor site complications (hematoma). The medial femoral condyle corticoperiosteal flap with non-vascularized iliac crest graft is a good option for the management of recalcitrant clavicle non-union, especially when the bone defect is small.

Evaluation of bone availability for grafts in different donor sites, through computed tomography.

OBJECTIVE: To quantify the bone volume that can be safely withdrawn from 3 donor sites: (1) the mandibular symphysis, (2) the oblique mandibular line and (3) the skullcap. METHODOLOGY: For the symphysis, 200 tomographic exams were evaluated by the extension of the anterior loop of mental foramen, by the nerve, by the distance of the foramens, by the distance between the vestibular cortical and the lingual plates and by the distance between the apexes, or lower anterior teeth, and the mandibular base, using the "distance" tool of the I-CAT Vision, in the panoramic and parasagittal reformations. For the oblique line, 70 TCFC exams were analyzed retrospectively in panoramic and parasagittal reformations, evaluating the thickness of the vestibular cortical and the distance between the cortical and the mandibular canal. For the cranial bone, a hexagonal donor site located in parietal area was considered. RESULTS: The average dimensions of the bone blocks that can be safely removed from the region of the mandibular symphysis are: 32.27 mm in length, 4.87 mm in height and 4 mm in thickness, providing a volume of 628.61 mm3 available for grafting. In the oblique line, the available bone volume for grafting was 859.61 mm3. In the region of the cranial vault, multiplying the average bone thickness by the area of the hexagon, an average volume of 2,499 mm3 was obtained. CONCLUSIONS: Comparing the donor sites, the bone availability in the cranial vault is 3 times greater than in the mandibular posterior region, and at least 2 times greater than in the mandibular symphysis.

Evaluation of bone availability for grafts in different donor sites, through computed tomography

Abstract Objective To quantify the bone volume that can be safely withdrawn from 3 donor sites: (1) the mandibular symphysis, (2) the oblique mandibular line and (3) the skullcap. Methodology For the symphysis, 200 tomographic exams were evaluated by the extension of the anterior loop of mental foramen, by the nerve, by the distance of the foramens, by the distance between the vestibular cortical and the lingual plates and by the distance between the apexes, or lower anterior teeth, and the mandibular base, using the "distance" tool of the I-CAT Vision, in the panoramic and parasagittal reformations. For the oblique line, 70 TCFC exams were analyzed retrospectively in panoramic and parasagittal reformations, evaluating the thickness of the vestibular cortical and the distance between the cortical and the mandibular canal. For the cranial bone, a hexagonal donor site located in parietal area was considered. Results The average dimensions of the bone blocks that can be safely removed from the region of the mandibular symphysis are: 32.27 mm in length, 4.87 mm in height and 4 mm in thickness, providing a volume of 628.61 mm3 available for grafting. In the oblique line, the available bone volume for grafting was 859.61 mm3. In the region of the cranial vault, multiplying the average bone thickness by the area of the hexagon, an average volume of 2,499 mm3 was obtained. Conclusions Comparing the donor sites, the bone availability in the cranial vault is 3 times greater than in the mandibular posterior region, and at least 2 times greater than in the mandibular symphysis.

Comparison of morphological quantitative characteristics of the newly formed alveolar bone after the application of demineralized bone matrix and cortical bone allografts / Comparación de las características morfológicas cuantitativas del hueso alveolar recién formado después de la aplicación de matriz ósea desmineralizada y aloinjertos de hueso cortical

The allografts were used to obtain sufficient alveolar bone tissue for proper dental implant placement. The objective of the present study was to evaluate the morphological and quantitative characteristics (cellular and collagen densities) of the newly formed alveolar bone with the application of cortical bone (CB) and demineralized bone matrix (DBM) allografts. Six samples of alveolar bone tissue from 5 patients (50 ± 6.3 years) were obtained after 6 months of application of the allografts and immediately before the placement of the dental implants. The samples were fixed (buffered formaldehyde, pH7.2), decalcified (EDTA 10 %) and histologically processed (HE and Picro-Sirius) for histologic analysis. Morphological analysis revealed presence of osteocytes and trabeculae in neoformed bone tissue near the allografts and absence of inflammatory and allergic cells; the remnants of CB were located mainly in the periphery of the bone tissue and the remnants of DBM were more incorporated into the tissue. Osteogenitor cells were observed around the remaining material. The cell density was not modified in newly formed bone tissue with the application of both allografts as compared to mature bone tissue. The density of the type I and III collagens present in the osteoids interspersed with the remainder of the materials showed a tendency to increase in the samples treated with DBM. It was concluded that by the histological characteristics observed both grafts were biocompatible, however the bone treated with DBM presented better incorporation and a tendency of increase of the collagen content in the remnant region of the allografts.

Los aloinjertos son utilizados para obtener tejido óseo alveolar apropiado para la colocación correcta del implante dental. El objetivo de este trabajo fue evaluar las características morfológicas y cuantitativas (densidades celulares y de colágeno) del hueso alveolar recién formado con la aplicación de aloinjertos de hueso cortical (CB) y matriz desmineralizada de hueso (DBM). Seis muestras de tejido óseo alveolar fueron obtenidas de 5 pacientes (50 ± 6,3 años) después de 6 meses de aplicación de los aloinjertos e inmediatamente antes de la colocación de los implantes dentales. Las muestras fueron fijadas (formaldehído tamponado, pH 7,2), descalcificadas (EDTA al 10%) y procesadas histológicamente (HE y Picro-Sirius) para el análisis histológico. El análisis morfológico reveló la presencia de osteocitos y trabéculas en el tejido óseo neoformado cerca de los aloinjertos y la ausencia de células inflamatorias y alérgicas; los remanentes de CB se ubicaron principalmente en la periferia del tejido óseo y los remanentes de DBM se incorporaron más en el tejido. Se observaron células osteogenitoras alrededor del material restante. La densidad celular no se modificó en el tejido óseo recién formado con la aplicación de ambos aloinjertos en comparación con el tejido óseo maduro. La densidad de los colágenos de tipo I y III presentes en los osteoides intercalados con el resto de los materiales mostró una tendencia a aumentar en las muestras tratadas con DBM. Se concluyó que, debido a las características histológicas observadas, ambos injertos fueron biocompatibles, sin embargo, el hueso tratado con DBM presentó una mejor incorporación y una tendencia al aumento del contenido de colágeno en la región remanente de los aloinjertos.

Combined Pedicled Vascularized and Wedge Nonvascularized Bone Graft for Treating Scaphoid Waist Nonunion With Humpback Deformity.

Pedicled vascularized bone graft (VBG) is a useful method in treating the scaphoid fracture nonunion, especially when the avascular necrosis exists. Humpback deformity is an important issue that we have to correct it during the treatment. We describe a method by using combined wedge non-VBG to correct the nonunion deformity when treating scaphoid nonunion with pedicled VBG. The wedge bone graft was harvested just proximal to the 2,3 intercompartmental supraretinacular artery VBG and was used as an inlay at the volar site to correct the humpback deformity, whereas the VBG was set at the dorsal site for bone bridging and blood supply. We also present our results of 10 patients with scaphoid fracture nonunion and humpback deformity treated with this method. Bone healing was achieved and the lateral intrascaphoid angles could be improved in all the 10 patients. Functional outcomes, including the Visual Analog Pain Scale for pain during activity, grip strength, the shortened Disabilities of the Arm, Shoulder, and Hand questionnaire (QuickDASH), and the modified Mayo Wrist Scores, were significantly improved.

Arthroscopic treatment of scaphoid nonunion with humpback deformity and DISI with corticocancellous bone grafting: Technical note.

For two decades, scaphoid nonunion has been treated arthroscopically. However, compressed cancellous bone graft does not have the same mechanical properties as corticocancellous bone graft for reducing the scaphoid humpback deformity and DISI tilt. Here, we describe an arthroscopic technique to treat Alnot stage IIB scaphoid nonunion. We treated a 27-year-old male patient for scaphoid waist nonunion with humpback deformity and DISI. A 8×8×10 mm cylindrical corticocancellous bone graft was harvested from the dorsal aspect of the radius using a single-use osteochondral autograft transfer system (OATS®, Arthrex Inc., Naples, USA). It was inserted in the nonunion site through an arthroscopic volar approach. Bone union was obtained at 3 months with lasting correction of the scaphoid humpback deformity and DISI. The functional result at 6 months was excellent. There were no complications. Scaphoid nonunion with humpback deformity and DISI may be treated arthroscopically with a corticocancellous bone graft.

The Author's Technique for the Management of Unstable Scaphoid Nonunions: Tips and Tricks.

This article presents historical aspects, rationale, indications, planning, and execution of anterior interpositional bone grafting technique for unstable scaphoid nonunions. The author's original technique considers four points: (1) preoperative planning based on comparative anteroposterior radiographs in maximal ulnar deviation was used to calculate resection zone, size of the graft, and scaphoid length; (2) a volar approach was used; (3) an iliac crest wedge-shaped corticocancellous graft was interposed; and (4) Kirschner wires were inserted for fixation. Contemporary refinements of the technique including a modification to treat nonunions with failed previous screw fixation with tricks and hints and results are shown.

Volar Radius Vascularized Bone Flaps for the Treatment of Scaphoid Nonunion.

Vascularized bone flaps (VBFs) improve union rates for scaphoid nonunions compared with nonvascularized grafts. Volar VBFs are indicated in cases of scaphoid nonunion with avascular necrosis and/or humpback deformity. Four volar VBFs are described in this article. The volar carpal artery and pronator quadratus VBFs are most commonly used. The pisiform VBF can be used for replacement of the proximal pole of the scaphoid; it is covered by articular cartilage. The ulna VBF has greater donor morbidity; the ulnar artery is harvested and a palpable donor site deformity results.

Induced membrane technique for clavicle reconstruction in paediatric patients: Report of four cases.

BACKGROUND: Clavicular reconstruction in paediatric patients is a rarely performed procedure that often raises complex technical challenges and produces unreliable outcomes. The induced membrane technique is an innovative two-stage procedure involving cement spacer placement into the defect to induce the development of a membrane, followed by the implantation of a cortical-cancellous bone graft. The primary objective of this study was to assess the medium- and long-term clinical and radiographic outcomes of clavicular reconstruction using the induced membrane technique in children and to highlight the advantages and drawbacks of this technique. The secondary objectives were to evaluate the fixation and the outcomes according to age and to the underlying diagnosis. HYPOTHESIS: Clavicular reconstruction using the induced membrane technique produces good outcomes in paediatric patients. PATIENTS AND METHODS: The induced membrane technique was used for clavicular reconstruction in 4 children with a mean age of 9.7 years (range, 7.4-12.3 years). The diagnosis was congenital pseudarthrosis of the clavicle in 3 patients and aneurysmal bone cyst in 1 patient. Shoulder pain and mobility were assessed at last follow-up. Radiological bone healing was evaluated using the total radiographic union score (RUS, range, 0-10). Complications and number of procedures per patient were recorded. RESULTS: Mean follow-up was 3.9 years (range, 1-8.4 years). None of the patients had pain or motion range limitation. After 6 months, the clavicle was healed with a RUS of 10 in all patients. The mean number of surgical procedures per patient was 3.75 (range, 3-5). Two patients required revision surgery for distal pin migration and another for a subcutaneous abscess under the pin. DISCUSSION: When used for clavicular reconstruction, the induced membrane technique is effective and associated with a low complication rate. The induced membrane technique therefore deserves to be viewed as an alternative to other methods. LEVEL OF EVIDENCE: IV, retrospective observational study.

[Accelerated orthodontic treatment using corticotomies: what are the minimally invasive alternatives?] / Traitement orthodontique accéléré par corticotomies : quelles sont les alternatives minimalement invasives ?

INTRODUCTION: The duration of orthodontic treatment in adults remains a barrier for some patients. Some surgical techniques have been developed in order to accelerate orthodontic tooth movement. The technique of corticotomies is effective in decreasing the orthodontic treatment time but remains invasive, leading to significant postoperative consequences. MATERIALS AND METHODS: Minimally invasive techniques without muco-periosteal flap elevation have been developed: corticision, micro-osteoperforations, piezopuncture and piezocision. RESULTS: The piezocision procedure seems to be the best compromise to accelerate orthodontic tooth movement while respecting a specific surgical and orthodontic protocol. The piezocision surgery allows the addition of biomaterials in cases of dehiscence and/or fenestration on the alveolar bone associated with moderate to severe overcrowding. CONCLUSION: According to current publications, minimally invasive corticotomy techniques can be viewed as a new therapeutic tool in the acceleration of orthodontic tooth movement.

Metacarpal bone reconstruction by a cementless induced membrane technique.

Gunshot wounds to the hand often produce complex injuries and large segmental bone defects. Bone reconstruction remains a challenge in this context. The induced membrane technique is a simple and effective procedure for reconstruction of segmental bone defects. The technique is straightforward but must be performed rigorously. Usually polymethylmethacrylate (PMMA) cement is required for the first stage of the surgery. We describe four cases of metacarpal bone reconstruction after gunshot wounds in a limited-resource setting. Two patients were treated using the induced membrane technique with a polypropylene syringe body instead of PMMA cement, which was unavailable in this situation. A thick membrane was observed 6 weeks after spacer implantation. Bone union was achieved in all cases.

Management of an extensive equine juvenile ossifying fibroma by rostral mandibulectomy and reconstruction of the mandibular symphysis using String of Pearls plates with cortical and cancellous bone autografts.

OBJECTIVE: To describe a surgical technique for rostral mandibulectomy and reconstruction of the mandibular symphysis. STUDY DESIGN: Case report. ANIMAL: One 5-month-old warmblood cross filly. METHODS: A preoperative diagnosis of a juvenile ossifying fibroma was made on the basis of clinical appearance and was later confirmed via histology. The tumor was large, rapidly growing and extending to the caudal aspect of the mandibular symphysis. Computed tomography was performed for surgical planning. The tumor was excised by performing a mandibulectomy caudal to the symphysis. The mandibular symphysis was reconstructed with String of Pearls (SOP) plates. Cortex screws placed in lag fashion, a cortical bone graft from one of the mandibles and a cancellous graft harvested from the tuber coxae. RESULTS: At 9 months of age there was no sign of tumor reoccurrence, the implants were removed because of infection and the mandible had formed a new stable symphysis. The horse was able to prehend food and masticate normally. The owner was pleased with the cosmetic and functional outcome. CONCLUSION: The described surgical technique is a viable option for mandibulectomy and reconstruction of the mandibular symphysis. The technique provided adequate stability for healing to occur in the face of infection. CLINICAL SIGNIFICANCE: Neoplasia and other conditions affecting the entire mandibular symphysis can be treated by complete surgical excision and reconstruction.

Management of the Posttraumatic Coronoid-Deficient Elbow.

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

Nasal Dorsal Augmentation with Freeze-Dried Allograft Bone: 10-Year Comprehensive Review.

BACKGROUND: The aim of this study was to evaluate freeze-dried cortical allograft bone for nasal dorsal augmentation. The 42-month report on 18 patients was published in 2009 in Plastic and Reconstructive Surgery with 89 percent success at level II evidence, and this article is the 10-year comprehensive review of 62 patients. METHODS: All grafts met standards recommended by the American Association of Tissue Banks, the U.S. Food and Drug Administration, and the Centers for Disease Control and Prevention. Objective evaluation of the persistence of graft volume was obtained by cephalometric radiography, cone beam volumetric computed tomography, and computed tomography at up to 10 years. Vascularization and incorporation of new bone elements within the grafts were demonstrated by fluorine-18 sodium fluoride positron emission tomography at up to 10 years. Subjective estimation of graft volume persisting up to 10 years was obtained by patient response to a query conducted by an independent surveyor. RESULTS: The authors report objective proof of persistence of volume alone or combined with proof of neovascularization in 16 of 19 allografts. The authors report the patient's subjective opinion of volume persistence in 37 of 43 grafts. The dorsal augmentation was assessed overall to be successful in 85 percent of 62 patients evaluated between 1 and 10 years, with a mean of 4.7 years. CONCLUSIONS: Freeze-dried allograft bone is a safe and equal alternative for dorsal augmentation without donor-site morbidity. Further studies are needed to (1) confirm these findings for young patients needing long-term reconstruction, and (2) partially demineralize allograft bone to allow carving with a scalpel. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Volar Vascularized Strut Graft for Avascular Scaphoid Nonunion Using the 1,2 Intercompartmental Supraretinacular Artery.

In this retrospective study, we report the preliminary results of a novel technique for volar vascularized strut grafting to treat avascular scaphoid nonunion by using the 1,2 intercompartmental supraretinacular artery through a single incision. Forty-three of 45 patients with avascular scaphoid nonunion healed at a mean of 13 weeks (range, 3 to 10 mo). Complications consisted of 1 pin tract infection that resolved with oral antibiotics and 4 cases of transient dysesthesia of the radial sensory nerve. In 4 patients with equivocal radiographs, computed tomography scans confirmed bony union. The 2 patients who remained unhealed subsequently underwent proximal row carpectomy. Two other patients had persistent pain with the progression of radiocarpal arthritis. Our technique provides good results for the treatment of avascular scaphoid fracture nonunion. Notable advantages include performance through a single incision, use of an already established vascularized bone graft, volar graft placement, and no requirement for microvascular free graft reconstruction. It also provides the surgeon with the ability to adjust the procedure intraoperatively in the event of unexpected avascularity, without requiring substantially longer operative time or additional equipment.

Bone Graft Options in Upper-Extremity Surgery.

Bone grafting in the upper extremity is an important consideration in patients with injuries or conditions resulting in missing bone stock. A variety of indications can necessitate bone grafting in the upper extremity, including fractures with acute bone loss, nonunions, malunions, bony lesions, and bone loss after osteomyelitis. Selecting the appropriate bone graft option for the specific consideration is important to ensure optimal patient outcomes. Considerations such as donor site morbidity and the amount and characteristics of bone graft needed all weigh in the decision making regarding which type of bone graft to use. This article reviews the options available for bone grafting in the upper extremity.

Horizontal Maxillary Osteotomy Stability Using Mandibular Outer Cortex Bone Grafts in Patients With Cleft Lip and Palate.

OBJECTIVE: To investigate horizontal maxillary osteotomy stability after using bone grafts for the treatment of patients with unilateral cleft lip and palate (UCLP). DESIGN: Retrospective cohort study. SETTING: Plastic surgery hospital. PATIENTS: Fifty-eight patients with UCLP and maxillary hypoplasia requiring a maxillary Le Fort I advancement of 6 to 9 mm. INTERVENTIONS: The test group (TG) was comprised of 28 patients who underwent mandibular outer cortex bone grafting in the gaps created by a modified Le Fort I osteotomy. The control group (CG) was comprised of 30 patients who underwent a Le Fort I osteotomy without bone grafts. MAIN OUTCOME MEASURES: Maxillary horizontal advancement (recorded during the operation using a Vernier caliper) and horizontal relapse at 12 months after surgery (based on a manual cephalometric analysis of pre- and postoperative lateral teleradiographs). RESULTS: In the TG, the mean maxillary horizontal advancement was 7.13 ±â€Š0.7 mm (range: 6.01-8.23 mm), and the mean postoperative horizontal relapse was 25.07 ±â€Š6.64%. In the CG, the mean maxillary horizontal advancement was 6.90 ±â€Š0.55 mm (range: 6.05-7.39 mm), and the mean postoperative horizontal relapse was 24.89 ±â€Š4.25%. There were no significant between-group differences in the mean horizontal relapses. CONCLUSION: The use of mandibular outer cortex bone grafts as physical barriers in patients with UCLP does not increase postoperative stability when the maxillary advancement is 6 to 9 mm.

Reconstructed the bone stock after femoral bone loss in Vancouver B3 periprosthetic femoral fractures using cortical strut allograft and impacted cancellous allograft.

AIMS: This study was performed to evaluate the efficacy of reconstructing bone stock in Vancouver B3 periprosthetic femoral fractures (PFFs) using an impacted cancellous allograft cortical or combined with cortical strut allograft. PATIENTS AND METHODS: We retrospectively assessed 39 Vancouver-type B3 periprosthetic fractures in 39 patients. Having different bone defects in the femur, 20 patients were treated with intramedullary impacted cancellous allograft, and 19 patients were treated with impacted cancellous allograft combined with cortical strut allograft. The median follow-up time was 58 months. RESULTS: Thirty-three patients completed the follow-up as scheduled, and three of them underwent re-operation (9.1%, 3/33). The last evaluated mean hip Harris score was 81.8; WOMAC pain, stiffness, and function scores were 82.3, 79.0, and 81.3, respectively. The satisfaction score was 86.6, and the SF-12 mental and physical scores were 40.4 and 51.1, respectively, for all patients. These outcomes were without significant difference between the two treatment groups (p > 0.05). The facture union was achieved in all the hips (100%). The stem was fixed with bone ingrowth in 24 patients and with fibrous fixation in eight, while stem fixation was not achieved for the remaining patient. The stem subsided less than 3 mm in 23 patients and 3-5 mm in nine patients. One patient had > 5 mm subsidence. The femoral bone stock was improved in 18 patients and remained unchanged in 14 patients; only one patient suffered a diminished bone stock. The radiographic assessment outcomes exhibited little difference between the two treatment groups (p > 0.05). Osseous union of the cortical strut to the host femur occurred in six patients with partial union and ten with complete union. There was moderate and mild graft resorption in three and 13 hips, respectively. CONCLUSIONS: The use of impacted cancellous allograft and cortical strut allograft to reconstruct bone stock can provide reliable options and satisfactory results.