Association of the Inlay Structure Used in the Modified Bristow Procedure With Accelerated Bone Union: Comparing the Cuistow and Modified Bristow Procedures.

Background: The Chinese unique inlay Bristow (Cuistow) procedure is a modified Bristow surgery in which an inlay (mortise-and-tenon) structure is added to the contact surface between the coracoid tip and the glenoid. Patients who have undergone the Cuistow procedure have had satisfying clinical performance and excellent postoperative bone healing rates (96.1%). Purpose: To compare the clinical and radiographic outcomes after the arthroscopic Cuistow procedure and the arthroscopic Bristow procedure. Study Design: Cohort study; Level of evidence, 3. Methods: A total of 91 patients who underwent either the Cuistow or Bristow procedure between January 2017 and March 2018 were selected, and 69 patients (70 shoulders; 35 in the Cuistow group and 35 in the Bristow group) were included. Clinical assessment at minimum 24 months postoperatively, including the visual analog scale for pain and instability, American Shoulder and Elbow Surgeons score, Rowe score, subjective shoulder value score, and active range of motion, was completed by independent observers and compared with values collected preoperatively. Assessment with 3-dimensional computed tomography scans was performed preoperatively; immediately after the operation; at 3, 6, and 12 months postoperatively; and at the final follow-up. Results: A total of 69 patients (70 shoulders) were included, with a mean follow-up duration of 34.41 ± 5.99 months (range, 24-50 months). Both groups saw significant improvement in visual analog scale for pain and instability, American Shoulder and Elbow Surgeons, Rowe, and subjective shoulder value scores at the final follow-up compared with the preoperative values (P < .001 for all), with no significant between-group differences on any clinical outcomes at the final follow-up. The 3-month postoperative graft union rate on computed tomography was significantly higher in the Cuistow group compared with the Bristow group (82.9% vs 51.4%, respectively, P = .003), although the graft union rate at the final follow-up was not significantly different (94.3% vs 85.7%, respectively; P = .449). Conclusion: Patients receiving the Cuistow procedure had equivalent clinical outcomes and a significantly higher bone union rate at 3 months postoperatively than those in the Bristow group. The inlay structure used in the Cuistow procedure was found to be associated with accelerated bone union.

Ilizarov Distraction for Congenital Pseudoarthrosis of the Tibia in Adults.

OBJECTIVE: The clinical evidence on the management for congenital pseudoarthrosis of the tibia (CPT) in adults is limited. The aim of this study is to assess the functional and radiological outcomes of Ilizarov distraction for treating CPT in adults. METHODS: A retrospective analysis was conducted. Between 2013 and 2022, an Ilizarov distraction technique was performed on 14 adults (14 limbs) with CPT in our limb deformity center. There were seven females and seven males with a mean age of 33.7 (range, 18 ~ 53) years. The diagnosis of NF-1 was confirmed in seven (50.0%) patients. Eight patients had a history of previous surgical failure. The pseudoarthrosis occurred in the middle and lower tibia in all limbs (six left and eight right). The CPT was classified by Crawford classification and Paley classification. The surgical procedures, external fixation time (EFT), and all outcomes and complications were recorded. The Kolmogorov-Smirnov test was performed to test the normality of the data. The American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot score at the preoperative and final follow-up was compared by using the Wilcoxon's signed-rank test. The limb-length discrepancy (LLD) and a self-made exercise capacity score at the preoperative and final follow-up were compared by using the student's t-test. The clinical and radiological outcomes were assessed by the Inan scale. RESULTS: The mean EFT of Ilizarov fixator was 19.5 months (range, 7.3 ~ 39.1). At a median follow-up of 26.8 months (IQR, 20.2 ~ 34.3), bone union of the pseudarthrosis and consolidation of the distraction zone were achieved in all patients. The mean LLD was decreased from 11.3 cm (range, 3.4 ~ 17.3) preoperatively to 1.1 cm (range, 0.3 ~ 3.7) (p < 0.05). The mean or median AOFAS ankle-hindfoot score was improved from 53.5 (IQR, 26.5 ~ 60.5) preoperatively to 63.9 (range, 53 to 73) at final follow-up (p < 0.05). The mean score for exercise capacity were improved from 4.9 (range, 1 to 8) preoperatively to 9.6 (range, 7 ~ 12) at final follow-up (p < 0.05). According to the criteria described by Inan et al., the clinical results were classified as good in 10 and fair in 4, while the radiological results were classified as excellent in three, good in 8, and fair in 2. The success rate was 92.9%, as refracture was defined as treatment failure and occurred in one patient. CONCLUSION: Ilizarov distraction provided a suitable treatment option for the CPT in adults, as it could achieve a high rate of bone union, a good correction of secondary deformity, a low risk of refracture, and consequently restore a relatively functional limb.

A Novel Method to Assess Healing of Segmental Bone Defects using the Induced Membrane Technique.

OBJECTIVE: Clinical concerns exist regarding the quality of bony consolidation in the context of the induced membrane technique. This study evaluates the clinical process of bone grafting in the second stage of induced membrane bone union in patients with tibial bone defects to infer the possibility of non-union and establish a reliable and effective evaluation method combined with computed tomography (CT) to assess fracture healing. METHODS: Patients with tibial bone defects who underwent the induced membrane technique at our hospital between February 2017 and February 2020 were retrospectively analyzed. The Hounsfield unit (HU) values of the patients were evaluated at different times during the second stage of bone grafting. Bone healing at the boundary value of the 120 HU output threshold (-1024 HU-3071 HU) was directionally selected, and the changes in the growth volume of union (new bone volume [selected according to HU value]/bone defect volume) were compared with analyzing individual class bone union. Method 1 involved X-rays revealing that at least three of the four cortices were continuous and at least 2 mm thick, with the patient being pain free. For Method 2, new bone volume (selected according to HU value/bone defect volume) at the stage was compared with analyzing individual class healing. Receiver operating characteristic curve analysis was used for Methods 1 and 2. RESULTS: A total of 42 patients with a segmental bone defect with a mean age of 40.5 years (40.5 ± 8.3 years) were included. The relationship between bone graft volume and time variation was analyzed by single factor repeated variable analysis (F = 6.477, p = 0.016). Further, curve regression analysis showed that the change in bone graft volume over time presented a logarithmic curve pattern (Y = 0.563 + 0.086 × ln(X), Ra2 = 0.608, p = 0.041). ROC curve analysis showed that Method 2 is superior to Method 1 (AUC: 86.3% vs. 68.3%, p < 0.05). CONCLUSION: The induced membrane technique could be used to treat traumatic long bone defects, with fewer complications and a higher healing rate. The proposed imaging grading of HU (new bone volume/bone defect volume) can be used as a reference for the quality of bony consolidation with the induced membrane technique.

Postoperative onset lateral hinge fracture is a risk factor for delayed union of the tibial tuberosity in medial opening wedge distal tibial tuberosity osteotomy.

Background: This study aimed to evaluate bone union of the tibial tuberosity in patients undergoing medial opening wedge distal tibial tuberosity osteotomy (OWDTO). It was hypothesized that bone union of the tibial tuberosity could be associated with lateral hinge fractures (LHFs), but not thickness of the tibial tuberosity osteotomy. Methods: Data of 61 consecutive patients who underwent OWDTO were retrospectively reviewed. Radiographic parameters of the lower limb and LHFs were evaluated. Thickness of the tibial tuberosity osteotomy and bone union of the tibial tuberosity were assessed at 1, 2, 3, 4, and 5 cm distal to the most proximal part of the tibial tuberosity on computed tomography. Bone union was assessed. Factors related to bone union of the tibial tuberosity were analyzed. Results: There were 13 postoperative onset LHFs: all healed with conservative treatments within 6 months after surgery. The total score of bone union of the tibial tuberosity was 8.4 ± 2.1 points, which correlated with age, postoperative medial proximal tibial angle (MPTA), correction angle, and postoperative onset LHF (r = 0.307, 0.388, 0.275, and -0.624, respectively; p = 0.016, 0.002, 0.033, and <0.001, respectively). Regression coefficient for postoperative onset LHF, postoperative MPTA, and body mass index were -0.619 (p < 0.001), 0.285 (p = 0.003), and -0.227 (p = 0.021), respectively. Conclusion: Postoperative onset LHFs, but not thickness of the tibial tuberosity osteotomy, were a risk factor for delayed union of the tibial tuberosity following OWDTO. Furthermore, to prevent delayed union of the tibial tuberosity, postoperative onset LHFs should be prevented. Level of evidence: LEVEL III, Case-control study.

Improvement of coracoid process union rates: a comparative study of conventional open and arthroscopic-assisted Bristow procedures for treating anterior shoulder instability in rugby players.

BACKGROUND: The Bristow coracoid transfer procedure is a reliable technique for treating anterior shoulder instability in patients with large glenoid bone loss or those involved in collision sports. However, its success is marred by its inferior bone union rate of the coracoid process as compared to the Latarjet procedure. This study aimed to evaluate whether arthroscopic confirmation of the secured coracoid fixation during the Bristow procedure improves the bone union rate and clinical outcomes as compared to the open procedure. METHODS: We retrospectively reviewed 104 rugby players (n = 111 shoulders) who underwent an open (n = 66 shoulders) or arthroscopy (AS)-assisted (n = 45 shoulders) Bristow procedure at our center from 2007 to April 2019. In the AS-assisted group, the screw fixation and coracoid stability and contact were confirmed under arthroscopic visualization. Graft union was evaluated through computed tomography at 3 months, 6 months, and 1 year postoperatively. Patient-reported outcome measures were assessed based on the American Shoulder and Elbow Surgeons score, Rowe score, and satisfaction rate. Recurrence, the rate of return to play (RTP), and the frequency of pain after RTP were also assessed. RESULTS: The mean follow-up period was 73.5 (range: 45-160) months for the open group and 32.3 (range: 24-56) months for the AS-assisted group. In the former, the rates of bone union were 50%, 72.7%, and 88.9% at 3 months, 6 months, and 1 year, respectively. In contrast, the AS-assisted group had significantly greater bone union rates-88.9%, 93.3%, and 95.6% at 3 months, 6 months, and 1 year, respectively. Both groups showed significant improvement in the American Shoulder and Elbow Surgeons and Rowe scores compared to preoperative values as well as high satisfaction rates (open: 92%; AS-assisted: 95.7%). There were no statistically significant differences in the recurrence and RTP rates as well as the frequency of pain after RTP between the 2 groups. CONCLUSION: The AS-assisted procedure allows early and high bone healing without compromising the clinical outcomes.

Bone union-promoting effect of romosozumab in an ovariectomized rat posterolateral lumbar fusion model.

Spinal fixation surgery has been increasingly performed in patients with osteoporosis. Romosozumab, a drug that was introduced in Japan recently, is known to possibly promote bone healing. However, few studies have reported the therapeutic effects of romosozumab in clinical practice in Japan. Therefore, here, we investigated the effects of romosozumab dosage on bone fusion promotion using an ovariectomized rat spinal fusion model. Eight-week-old female Sprague-Dawley rats were matched by body weight and divided into three groups: 1.0 romosozumab (R) group (Evenity®, 25 mg/kg), 1/10R group (Evenity®, 2.5 mg/kg), and control (C) group (saline). Subcutaneous injections were administered twice a week for 8 weeks postoperatively. Computed tomography scans were performed every 2 weeks from the time of surgery till 8 weeks postoperatively. The mean fusion rates in terms of volume were significantly higher in the R groups [1/10R, 1.0R] than in the C group from 4 weeks postoperatively. The rate of increase was significantly higher in the 1.0R group from 4 weeks postoperatively and in the 1/10R group from 6 weeks postoperatively, than in the C group. The proportion of trabecular bone area was approximately 1.5 times higher in the R groups than in the C group. No significant differences were observed between the R groups. Our results suggest that romosozumab stimulates bone growth at the graft site, and similar effects were achieved at 1/10 of the standard dosage.

Faster Bone Gap Union in Medial Opening Wedge High Tibial Osteotomy With 3D-Printed Synthetic Bioresorbable Polycaprolactone and Tricalcium Phosphate Osteotomy Gap Fillers Compared to Allogeneic Osteotomy Gap Fillers: A Retrospective Matched-Pair Cohort Study.

OBJECTIVE: The use of synthetic bone substitute material (BSM) as osteotomy gap fillers have been reported to improve outcomes in medial opening wedge high tibial osteotomy (MOWHTO). This study aims to evaluate the early radiological outcomes (bone union) and complication rates of the novel patient-specific 3D-printed honeycomb-structured polycaprolactone and tricalcium phosphate (PCL-TCP) synthetic graft compared to allogeneic bone grafts as an osteotomy gap filler in MOWHTO. METHODS: A retrospective matched-pair analysis of patients who underwent MOWHTO with either PCL-TCP synthetic graft or allogenic femoral head allograft as osteotomy gap filler was performed. The osteotomy gap was split into equal zones (Zone 1-5), and bone union was evaluated on anteroposterior radiographs based on the van Hemert classification at 1, 3, 6, and 12 months postoperatively. Postoperative complications including infection, lateral hinge fractures, and persistent pain was measured. The study and control group were matched for age, smoking status, diabetes mellitus, and osteotomy gap size. RESULTS: Significantly greater bone union progression was observed in the PCL-TCP group than in the allograft group at 1 month (Zones 1-3), 3 months (Zones 1-4), 6 months (Zones 1-2, 4), and 12 months (Zones 2-3, 5) postoperatively (P < 0.05). No significant difference in complications rates was noted between the two groups at 1 year. CONCLUSIONS: Bone union rates observed in patients who underwent MOWHTO with the PCL-TCP synthetic graft osteotomy gap filler were superior to those in the allograft group at 1 year postoperatively, with no significant difference in complication rates (postoperative infection, lateral hinge fractures, and persistent pain).

Outcomes of Ulnar Shortening Osteotomy with an Intramedullary Bone Graft for Idiopathic Ulnar Impaction Syndrome.

Background: Although several techniques for the treatment of ulnar impaction syndrome (UIS) have been introduced, there have still been reports on various complications such as delayed union, nonunion, refracture, wrist pain, plate irritation, and chronic regional pain syndrome. This study aimed to compare the differences in radiological and clinical outcomes of patients in which intramedullary bone grafting was performed in addition to plate stabilization with those without additional bone grafting during ulnar shortening osteotomies (USOs). Methods: Between November 2014 and June 2021, 53 wrists of 50 patients with idiopathic UIS were retrospectively reviewed. Patients were divided into 2 groups according to whether intramedullary bone grafting was performed. Among the 53 wrists, USO with an intramedullary bone graft was performed in 21 wrists and USO without an intramedullary bone graft was performed in 32 wrists. Demographic data and factors potentially associated with bone union time were analyzed. Results: There was no significant difference between the 2 groups when comparing postoperative radioulnar distance, postoperative ulnar variance, amount of ulnar shortening, and postoperative Disabilities of the Arm, Shoulder and Hand score. Compared to the without-intramedullary bone graft group, bone union time of the osteotomy site was significantly shortened, from 8.8 ± 3.0 weeks to 6.7 ± 1.3 weeks in the with-intramedullary bone graft group. Moreover, there were no cases of nonunion or plate-induced symptoms. Both in univariable and multivariable analyses, intramedullary bone grafting was associated with shorter bone union time. Conclusions: USO with an intramedullary bone graft for idiopathic UIS has favorable radiological and clinical outcomes. The advantage of this technique is the significant shortening of bone union time.

Fracture gap and working length are important actionable factors affecting bone union after minimally invasive plate osteosynthesis for the treatment of simple diaphyseal or distal metaphyseal tibia fractures.

INTRODUCTION: Indirect reduction of minimally invasive plate osteosynthesis (MIPO) can often result in delayed union in tibia fractures. This study evaluated several factors in MIPO in relation to bone union. HYPOTHESIS: We hypothesized that the fracture gap, plate - tibia distance, or working length would have a substantial effect on the tibia union rate. MATERIALS AND METHODS: Forty-one patients with simple diaphyseal or distal metaphyseal tibia fractures who underwent internal fixation surgery using the MIPO technique were divided into two groups: patients with delayed union and patients without delayed union. Non-actionable factors involving AO/OTA classification, fibula fracture and actionable factors including postoperative fracture gap, plate - tibia distance, working length in relation to parameters of bone union were compared between the two groups. Also cumulative rates of bone union and risk factors of delayed union according to variables of interest were investigated. RESULTS: AO/OTA classification, site of fibula fracture, postoperative fracture gap, working length, and bone union rate of the two groups significantly differed (p<0.05). The cumulative rate of bone union during 1-year follow-up according to 43A tibia fracture, distal fibula fracture, fracture gap, and working length significantly differed between the two groups (p<0.05). By univariate Cox proportional hazards model, 43A tibia fracture, distal fibula fracture, facture gap, and short working length were risk factors for delayed union (p<0.05). DISCUSSION: Non-actionable factors involving AO/OTA classification, distal fibula fracture and actionable factors including postoperative fracture gap, working length were significant factors affecting bone union after MIPO. The present study indicated that small fracture gap and long working length during MIPO might facilitate bone healing in tibia fracture. LEVEL OF EVIDENCE: IV; single-center retrospective cohort study.

The effect of teriparatide on patients with atypical femur fractures: a systematic review and meta-analysis.

INTRODUCTION: Bisphosphonates (BPs) are one of the most often used drugs to lower fracture risk in osteoporosis patients; nonetheless, BPs have been linked to atypical femoral fracture (AFF). Teriparatide (TPTD) is a parathyroid hormone analogue and anabolic drug that may accelerate fracture repair. TPTD has been considered as a possible treatment for AFF, particularly those caused by BP use. We evaluate the effect of TPTD on AFF in this systematic review and meta-analysis. MATERIALS AND METHODS: A thorough search of: Web of Science, Scopus, PubMed, and Cochrane was conducted on August 2, 2023. Trials evaluating the effect of TPTD on the incidence of: complete bone healing, non-union, early and delayed bone union, progression of incomplete AFF to complete AFF, and time to bone union were included. Using Review Manager (RevMan) version 5.4, the risk ratio (RR) and mean difference (MD) with the corresponding 95% confidence interval (CI) were estimated for dichotomous and continuous outcomes, respectively. The Newcastle-Ottawa Scale was used to assess the quality of studies. RESULTS: Eight studies met the eligibility criteria and were included in our analysis. TPTD significantly increased the incidence of early bone union (RR = 1.45, 95% CI [1.13, 1.87], P = 0.004) and time to bone union (MD = -1.56, 95% CI [-2.86, -0.26], P = 0.02) compared to the control group. No significant differences were observed in terms of complete bone healing (RR = 1.09, 95% CI [0.99, 1.13], P = 0.12), non-union (RR = 0.48, 95% CI [0.22, 1.04], P = 0.06), and progression of incomplete AFF to complete AFF (RR = 0.27, 95% CI [0.04, 1.97], P = 0.19). CONCLUSIONS: TPTD is an effective therapy for enhancing and hastening healing following AFF, particularly in postoperative settings. Future large randomized clinical trials are needed to confirm or dispute the results.

No Superior Bone Union Outcomes with Allografts Compared to No Grafts and Autografts Following Medial Opening Wedge High Tibial Osteotomy: A Retrospective Cohort Study.

OBJECTIVE: There has been long-standing debate about whether a medial opening wedge high tibial osteotomy (MOWHTO) gap should be filled with autologous bone graft or any other filler to expedite the healing process. The main purpose of this study was to compare the clinical and radiological outcomes of MOWHTO with an opening gap ≥10 mm, utilizing autograft, allograft, or no graft at 1 year postoperatively. METHODS: A total of 68 patients were included in this retrospective study and divided into three treatment groups: Group A (no bone graft), Group B (autologous iliac crest graft), and Group C (allogenous tibia plateau graft). At postoperative 1-year follow-up, the area of callus filling in the most medial side of the knee was measured using anteroposterior radiographs, and a modified van Hemert scoring system was used to evaluate bone union outcomes in five mediolaterally divided zones. Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores and relevant complications were assessed. The correlations between the gap width and bone union scores were evaluated. RESULTS: Patients in the autograft group demonstrated better bone union progression (p = 0.031) and higher bone union scores (p < 0.01) compared to patients in the allograft or no graft groups. There were no significant differences in terms of postoperative WOMAC scores and incidence of complications among the three groups. No discernible linear relationships between the width of the opening gap and the bone union score were found. CONCLUSION: For MOWHTOs with an average gap opening width of 12.1 mm, autografts resulted in superior bone union outcomes compared to allografts and no graft at 1 year postoperatively. However, no bone graft achieved similar outcomes to allografts, suggesting that routine use of allografts should not be recommended.

Effect of lateral hinge fractures for bone union and clinical outcomes following opening-wedge distal tibial tubercle osteotomy in comparison with opening-wedge high tibial osteotomy.

PURPOSE: Although the effects of lateral hinge fractures (LHF) on bone union and clinical outcomes after opening-wedge high tibial osteotomy (OWHTO) have been established, the effects of LHF after opening-wedge distal tibial tubercle osteotomy (OWDTO) are unclear. We hypothesised that LHF after OWDTO would be associated with delayed bone union and result in poorer clinical outcomes than expected for LHF after OWHTO. METHODS: This study enrolled 100 patients, with 50 OWDTO patients (18 men; mean age, 63.2 years) and 50 OWHTO patients compared based on the propensity score matched analysis. The effect of LHF on bone union was compared between the groups. Clinical outcomes were assessed using the Lysholm score and the Knee Injury and Osteoarthritis Outcome Score (KOOS) at the mean follow-up of 28 months. RESULTS: There was no between-group difference in the incidence rate of LHF. However, the rate of bone union at the anterior flange in the presence of an LHF was significantly lower in the OWDTO (26%) than in the OWHTO (80%) 3 months postoperatively (p < 0.05), but no difference was observed 12 months postoperatively. The Lysholm score was significantly lower for patients with LHF following OWDTO than for OWDTO patients without LHF or OWHTO patients with/without LHF 3 and 12 months postoperatively (p < 0.001); Lysholm score and KOOS were not different at the final follow-up. CONCLUSIONS: LHF after OWDTO was associated with delayed bone union and poor clinical outcomes until 12 months. This information can guide decisions regarding the indications and the management of patients after OWDTO. LEVEL OF EVIDENCE: IV.

The Duration of Bone Healing and Nonunion Ratio After Ulnar Shortening Osteotomy Using a 5-Hole Forearm Compression Plate With Transverse Osteotomy.

BACKGROUND: Ulnar shortening osteotomy using various osteotomy sites, osteotomy methods, and surgical techniques with a variety of implants has been reported, but nonunion rates and the duration of bone healing are not uniform by the authors. The purpose of this study was to investigate the duration of bone healing and nonunion ratio in patients who underwent ulnar shortening osteotomy by a 5-hole nonlocking plate with a simple transverse osteotomy for ulnar impaction syndrome and to determine the correlation between the gap length of the osteotomy site and the duration of bone healing. METHODS: We assessed patients who underwent ulnar shortening osteotomy for ulnar impaction syndrome using a 5-hole nonlocking plate fixation followed by a simple transverse osteotomy between July 2012 and October 2021. This study was a case series study, and the level of evidence was IV. RESULTS: A total of 80 patients were included. The mean age of the patients was 46.7 years, and 46 patients were men. The average bone union period was 41.8 ± 18.7 weeks. The correlation between the gap length of the osteotomy site and the duration of bone union of the osteotomy site was not significant. The nonunion ratio of our method was 2.5%. CONCLUSION: The nonunion rate of our ulnar shortening osteotomy with a simple transverse osteotomy and a 5-hole nonlocking plate was comparable to that in previous reports, but our method required slightly longer periods for bone union. There was no correlation between the gap length of the osteotomy and the duration of bone union. LEVEL OF EVIDENCE: Level IV (Case series).

Comparing Bone Fusion Rates Between Novel Unidirectional Porous Tricalcium Beta-Phosphate and Autologous Bone in Lumbar Lateral Interbody Fusion: A Two-Year Radiographic Outcome Study.

This retrospective cohort study aims to examine the potential differences in bone fusion between autologous bone and artificial bone in the lumbar lateral interbody fusion at 2two years post-surgery. The bone fusions performed in 15 cases and at 34 intervertebral levels were compared to assess the differences between the artificial bone, Affinos® (Kuraray Co., Tokyo, Japan), and autogenous bone. Two years post-surgery, we evaluated computed tomography (CT) multi-planar reconstruction images in the coronal and sagittal planes. One year after surgery, out of the 24 windows, 17 (70.8%) windows transplanted with autologous bones showed bone fusion. Additionally, out of the 38 windows, 18 (47.4%) windows transplanted with Affinos® showed bone fusion. Two years post-surgery, out of the 24 windows, 19 (79.2%) windows transplanted with autologous bones showed bone fusion. Additionally, out of the 38 windows, 30 (79.0%) windows transplanted with Affinos® showed bone fusion, and no difference was observed in the fusion rate at two years post-surgery (P = 0.238). In cases using Affinos® for transplanted bone, the bone fusion rate increased between one and two years. The rate of bony fusion using Affinos® in lateral lumbar interbody fusion (LLIF) cages is at par with that of autologous bone grafts at two years post-surgery. Affinos® is a promising candidate for graft material in LLIF surgery.

The early posterior cortex pixel value ratio: a novel reliable indicator for distraction osteogenesis.

Aims: We aimed to explore the associations of the early PVR in four cortices with Healing Index (HI), Lengthening Index (LI), and External Fixator Index (EFI) in the bone union and non-union groups. Methods: A total of 52 patients, including 39 bone union and 13 bone non-union subjects, were recruited in this study. The general characteristics and PVR in four cortices in each group were explored. Afterward, the early PVR in four cortices, including medial, lateral, anterior, and posterior sides, were compared. Finally, the associations of the early PVR in four cortices with HI, LI, and EFI were also investigated. Results: The general characteristics of these patients were consistent, except for HI (31.54 ± 12.24 vs. 45.08 ± 27.10, P = 0.018) and EFI (57.63 ± 18.15 vs. 71.29 ± 24.60, P = 0.046). The growth of regenerated callus was asymmetrical in the bone union group (the posterior PVR seems to grow faster), whereas no statistical difference was obtained in the bone non-union group. Furthermore, the posterior PVR in the bone union group was significantly higher than that in the bone non-union group (the first month: 0.96 ± 0.17 vs. 0.86 ± 0.06, p = 0.047; the second month: 0.98 ± 0.14 vs. 0.89 ± 0.09, p = 0.041; the third month: 1.00 ± 0.12 vs. 0.92 ± 0.09, p = 0.039). Most importantly, the posterior PVR was inversely associated with HI, LI, and EFI (the first month: r = -0.343, p = 0.041; r = -0.346, p = 0.042; r = -0.352, p = 0.041; the second month: r = -0.459, p = 0.004; r = -0.277, p = 0.101; r = -0.511, p = 0.002; the third month: r = -0.479, p = 0.003; r = -0.398, p = 0.018; r = -0.551, p = 0.001) in the bone union group, respectively. However, this finding was lost in the bone non-union group. Conclusion: The early posterior cortex PVR seems to grow faster than the medial, lateral, and anterior sides in the bone union group, which represents an asymmetrical development pattern. Moreover, the posterior cortex PVR was negatively associated with HI, LI, and EFI, respectively. The posterior cortex PVR may be a novel and reliable detection index in the process of DO.

A novel technique of managing an irreducible posteriorly displaced type 2 odontoid fracture: A case report.

Background: Type 2 odontoid fractures with posterior displacement are rare. Most acute cases reported in the literature are readily reduced with traction alone. Here, we reviewed the management of a chronic, posteriorly displaced odontoid fracture that was managed with a unique posterior reduction maneuver. Case Description: A 58-year-old male with a chronic type 2 retro-odontoid displaced fracture was managed with traction and an anterior force applied to the displaced odontoid fragment using rods attached to bilateral C1 lateral mass screws. Notably, this included a simultaneous cantilever maneuver using a lever placed between the C1 and C2 facet joints. Following reduction, an atlantoaxial fusion was performed. The postoperative course of the patient was uneventful and the bone union was achieved in 1 year. Conclusion: Closed reduction is rarely successful in chronic posteriorly displaced type 2 odontoid fractures. These cases require meticulous open reduction and fixation.

Unique Characteristics of New Bone Formation Induced by Lateral Lumbar Interbody Fusion Procedure.

Introduction: Despite the absence of bone grafting in the area outside the cage, lateral bridging callus outside cages (LBC) formation is often observed here following extreme lateral interbody fusion (XLIF) conversely to conventional methods of transforaminal lumbar interbody fusion and posterior lumbar interbody fusion. The LBC, which may increase stabilization and decrease nonunion rate in treated segments, has rarely been described. This study aimed to identify the incidence and associated factors of LBC following XLIF. Methods: We enrolled 136 consecutive patients [56 males, 80 females; mean age 69.6 (42-85) years] who underwent lumbar fusion surgery using XLIF, including L4/5 level with posterior fixation at a single institution between February 2013 and February 2018. One year postoperatively, the treated L4/5 segments were divided into the LBC formation and non-formation groups. Potential influential factors, such as age, sex, body mass index, bone density, height of cages, cage material (titanium or polyetheretherketone [PEEK]), presence or absence of diffuse idiopathic skeletal hyperostosis (DISH), and radiological parameters, were evaluated. Multivariate logistic regression analysis was performed for factors significantly different from the univariate analysis. Results: The incidence of LBC formation was 58.8%. Multivariate logistic regression analysis showed that the length of osteophytes [+1 mm; odds ratio, 1.29; 95% confidence interval, 1.17-1.45; p<0.0001] was significant LBC formation predictive factors. Receiver operating characteristic curve analysis demonstrated that the cut-off value for osteophyte length was 14 mm, the sensitivity was 58.8%, the specificity was 84.4%, and the area under the ROC curve for this model was 0.79. Conclusions: The incidence of LBC formation was 58.8% in L4/5 levels one year after the XLIF procedure. We demonstrated that the length of the osteophyte was significantly associated with LBC formation.

Arthrodesis of the interphalangeal joints of the hand by two-dimensional intraosseous wiring.

BACKGROUND: Numerous techniques for arthrodesis have been described to fix interphalangeal (IP) joints, and the fixation method should be considered on a case-by-case basis. This study aimed to investigate the availability of IP joint arthrodesis of the hand, using a two-dimensional intraosseous wiring (two-DIOW) method. METHODS: A total of 43 joints (19 thumb IP joints, 9 proximal finger interphalangeal (PIP) joints and 15 distal interphalangeal (DIP) joints in 29 patients with a mean age of 66 years (range, 24-85 y) were retrospectively analyzed. All operations were performed with two-DIOW method. We evaluated the bone union rate, correction loss, presence of any surgical complications, and oral steroid use in cases of joint fixation using the two-DIOW method. RESULTS: Of these 43 digits, 42 achieved bone union (97.7%). Non-union was seen in a thumb IP joint of mutilans rheumatoid arthritis. Mean correction loss of deviation was 1.0°, and flexion or extension angulation was 1.6° in the direction of extension. Surgical complications included mild nail deformity in 2 digits and wire irritation necessitating wire removal in 2 digits. Oral steroids were used for 18 of the 43 digits, including 2 digits complicated by nail deformities. There was no infection and skin necrosis in all digits with or without steroid use. CONCLUSIONS: The two-DIOW method appears to offer an effective method of IP joint fixation, but caution should be exercised in digits of severe joint destruction and in the treatment of wire knot.

Effects of Spina Bifida Occulta on Bone Union in Fifth Lumbar Spondylolysis.

Introduction: The effect of spina bifida occulta (SBO) on bone union in lumbar spondylolysis is controversial. The study aim was to assess the effect of SBO on bone union after conservative treatment of L5 spondylolysis, the most common level. Methods: The study included 191 lesions in 145 patients (mean age, 14.0 years) with conservatively treated L5 spondylolysis. We examined the relationships between bone union after conservative treatment and the number of SBOs, levels, and single or multilevel status. Fisher's exact probability test, chi-square test, and Welch's T test were performed. Results: The SBO incidence was 53%, with at least one SBO at any vertebral level. SBO at S1 (p=0.034) or S2 (p=0.0003), two SBOs (p=0.0018), and three SBOs (p=0.011) were associated with a lower bone union rate. The bone union rate was significantly lower for lesions with SBOs at both S1 and S2 than without (42% vs. 79%; p<0.0001). Conclusions: The SBO incidence in L5 spondylolysis was 53%. SBO at S1 or S2 and a higher number of SBOs were associated with lower bone union rates. In particular, the bone union rate of lesions with SBOs at both S1 and S2 was <50%.

Outcomes Following Type C Distal Humeral Fracture Fixation Using Two Different Osteosynthesis Techniques.

BACKGROUND: Distal humeral fractures are notorious injuries, and they require surgical fixation. The reliability of reconstruction devices has been a subject of debate. Our primary outcome was to detect differences, if any, between two different groups of patients using the patient-reported outcomes measurement information system (PROMIS) Global-10 form and to compare it with the Mayo elbow performance score (MEPS) results. Other secondary outcomes included the difference in union time between patients who received a reconstruction plate vs those who received a pre-contoured anatomical plate. MATERIAL AND METHODS: It is a prospective randomised study which included a total of 30 cases equally distributed into two groups. RESULTS: The mean PROMIS and MEPS scores for group A were 31.5 SD 6.6 and 77.7, respectively, compared to 33.7 SD 6.66 and 73, respectively, for the other group. Time to union was 13.4 weeks for group A and 12.6 weeks for the other group. There was no statistically significant difference between the groups regarding union and function. However, reconstruction plates were more cost effective. The correlation between the MEPS and PROMIS G scores in both groups was statistically significant. CONCLUSION: 1. Recon plates continue to be a cost-effective method of treatment in simple intra-articular fractures. 2.PROMIS is a valuable tool to be used along with other scores in future studies.