Severe Complications Following Maxillary Sinus Augmentation Using Poly L-lactide-co-ε-caprolactone-Coated Bovine Bone: A Retrospective Study.

PURPOSE: To describe the postoperative complications following lateral wall sinus augmentation using (poly L-lactideco-ε-caprolactone; PLCL) and natural polysaccharides polymers-coated bovine bone (PBB). The secondary aims were to examine histologic findings and to propose complication management alternatives. MATERIALS AND METHODS: This retrospective study included 61 subjects who underwent 67 lateral wall sinus augmentation procedures using PBB in the standard protocol. In cases that presented complications, treatment included additional antibiotic therapy, implant removal, or sinus reentry and total removal of the grafting material. In three cases, biopsy specimens were taken from the sinuses, and histologic analyses were performed. RESULTS: The prevalence of postoperative complications was 32.8% (22 of 67 cases) in 18 of the patients (29.5%). The most prevalent symptoms were persistent pain (68.2%), swelling (63.6%), and oroantral fistula (54.5%). Radiographic signs appeared in 45.5% of the complications. A total of 24 implants failed; thus, an overall 80.3% survival rate was established at 19 months. The vast majority of complications (86.4%) were treated eventually with reentry surgery and revealed that the sinus was full with granulation tissue surrounding pieces of a nonossified rubber-like material. In cases where implants were placed, nonosseointegrated implants were surrounded by soft tissue. The sinus was cleaned thoroughly; the graft material remnants were removed together with inflamed parts of the sinus membrane, followed by chlorhexidine and saline lavages. In the biopsy specimens taken from the sinus cavity, there were no histologic features of new bone formation around the grafted material. CONCLUSION: Lateral wall maxillary sinus augmentation using PBB was associated with an acute sinus infection histologic appearance and with a 7-times-higher failure rate compared with previous reports. This serious adverse event suggests that PBB cannot be recommended for maxillary sinus augmentations.

Orbital reconstruction - applied materials, therapeutic agents and clinical problems of restoration of defects.

Reconstruction of large cavities in the skull and facial regions is important not only to restore health but also for the correction of facial distortions. Every visible deformity in the facial region of the patient affects their mental wellness and perception by society, entailing both, deterioration of health, but also a decrease in the performance in society, which translates into its productivity. With the progressive degradation of the natural environment, cancer, in the coming years, will be on the leading causes of morbidity and mortality. The review focuses on two main aspects: (i) the causes of injuries leading to the necessity of removal of orbital cavities occupied by the tumor and then their reconstruction, with the focus on the anatomical structure of the orbital cavity, (ii) the materials used to reconstruct the orbital cavities and analyze their advantages and disadvantages. The manuscript also underlines the not yet fully met challenges in the area of facial- and craniofacial reconstruction in people affected by cancer.

Comparison of post-operative outcomes of graft materials used in reconstruction of blow-out fractures.

BACKGROUND: Trauma to the face caused by assault or impact may cause internal orbital fracture. Increased intraorbital pressure without disruption of soft tissue integrity or causing a fracture line in orbital rims or orbital floor fractures described as 'orbital blow-out fracture'. Such fractures have been categorized as 'pure blow-out fractures' in which only the orbital floor is affected, and 'impure blow-out fractures' in which other maxillofacial bones such as zygoma, maxilla and nasoethmoid are also affected. Physical examination reveals periorbital edema and ecchymosis, subconjunctival hemorrhage, limitation of eye globe movements, diplopia, enophthalmos, dystopia, and infraorbital hypoesthesia. Reconstruction of the orbital bony structures is the most important issue to preserve the standard orbital functions and providing an aesthetic view. Although many surgical approaches have been defined in the literature regarding the attitude and timing of treatment, no consensus exists. In literature; many autogenous and alloplastic biomaterials have been recommended to correct orbital bone defects. METHODS: This study aims to compare postoperative outcomes of patients presenting with pure and impure blow-out fractures repaired with cartilage, bone grafts, titanium mesh or porous polyethylene implant. Sixty-four orbital floor fractures of 62 cases were included in this research who admitted to our clinic with maxillofacial trauma between 2011 and 2018. All patients underwent maxillofacial radiological examination; Waters radiography and also axial-coronal plane maxillofacial and orbital computerized tomography. RESULTS: Permanent, post-operative, vertical diplopia in extreme gazes was detected in 3 of 14 patients in whom the orbital floor was reconstructed with an iliac bone graft. Two of nineteen cases who underwent reconstruction using auricular conchal cartilage graft had vertical diplopia in extreme gazes four months after the operation. The implant extruded and became palpable in 2 of 15 patients in the porous polyethylene implant group. None of the patients in the iliac bone and conchal cartilage autograft groups was presented late postoperative enophthalmos according to the graft resorption. In titanium mesh group, 1 of eleven patients had permanent, post-operative vertical diplopia in extreme gazes. None of the patients in this group developed any donor area complications, infection, or implant extrusion. CONCLUSION: Results show that the auricular conchal cartilage graft was the best biomaterial used to repair defects smaller than 4 cm², where as titanium mesh was a good option to repair defects larger than 4 cm². However, selection of the optimal biomaterial to be used to repair orbital blow-out fractures should be made according to patient characteristics and preoperative findings, the severity of the injury, the cost of the biomaterial to be used, and surgeon's expertise.

Iatrogenic risk of osteonecrosis of the jaw? Bone substitutes for dental implants: a warning from Japan.

Commercial bone substitutes that are widely used for bone augmentation for dental implants are predisposing factors in the development of osteonecrosis of the jaw (ONJ), overlooking this situation may lead to serious problems. Most of these materials are supplied as inorganic porous granules of calcium phosphate, which have characteristics that exceed the bone resorption ability of normal osteoclasts; therefore, they can be equally regarded as existing antiresorptive necrotic bony granules in the body, i.e., micro-ONJs. In addition, because dental implants directly contact the surrounding bone without the periodontium with immunoprotective functions, the mucosal penetration of the dental implant itself predisposes the underlying bone to the risk of infection, latent osteomyelitis, and ONJ. Therefore, the remaining porous granules surrounding the dental implant pose an additional iatrogenic risk, even though the tissue may appear superficially healthy. In an aging society, an individual who was systemically healthy at the time of implantation with bone augmentation could develop osteoporosis or cancer bone metastasis later in life. ONJ can occur more easily if an antiresorptive agent such as bisphosphonates or denosumab is administered without sufficiently recognizing an intraoral situation. If the latent risk is known in advance, the selection or use of medicines could be restricted. Such restrictions can result in other crucial issues that are beyond the discretion of the dentists; however, dentists have not been warned about such possibilities. The use of antiresorptive agents and bone substitutes for dental implants should be reconsidered to avoid numerous adverse events such as ONJ.

High failure rate after Beta-tricalcium phosphate grafting for the treatment of femoral head osteonecrosis: a retrospective analysis.

BACKGROUND: Non-vascularized bone grafting is a promising head-preserving technique for younger patients diagnosed as non-traumatic osteonecrosis of the femoral head (NONFH). Among the various types of bone grafting techniques, "light-bulb" procedure grafting with synthetic bone substitute is an attractive option. We aimed to assess the effectiveness of using beta-tricalcium phosphate (ß-TCP) for the treatment of pre-collapse and early post-collapse lesions NONFH. METHODS: From April 2010 to June 2014, 33 patients (47 hips) with NONFH were treated using the afore-mentioned technique. The clinical and radiological outcomes were recorded and compared statistically between pre- and post-operation. Harris hip score (HHS) was used to evaluate the clinical results, and Association Research Circulation Osseous (ARCO) stage was applied to assess the radiological outcomes. RESULTS: The 5-years survival rate of using ß-TCP grafting was accounting for 25.5%. HHS was decreased from 78.47 to 52.87 points, and a very significant worsening of radiological results were revealed (P <  0.05). Two hips collapsed more than 2 mm were awaiting for THA, and 33 of the 47 hips had converted to THAs in an average time to failure of 24.24 months postoperatively. Meanwhile, only 4 hips survived without collapse, and 8 hips collapsed less than 2 mm. After surgery, the time onset of head collapse was 3.65 months on average, and the first conversion to THA was performed at 5 months postoperative. CONCLUSIONS: Our results suggest that "light-bulb" procedure grafting with ß-TCP sticks presented with a high failure rate in the early postoperative period. It is not proposed for the treatment of pre-collapse and early post-collapse lesions NONFH.

Synthetic Blocks for Bone Regeneration: A Systematic Review and Meta-Analysis.

This systematic review is aimed at evaluating the effectiveness of synthetic block materials for bone augmentation in preclinical in vivo studies. An electronic search was performed on Pubmed, Scopus, EMBASE. Articles selected underwent risk-of-bias assessment. The outcomes were: new bone formation and residual graft with histomorphometry, radiographic bone density, soft tissue parameters, complications. Meta-analysis was performed to compare new bone formation in test (synthetic blocks) vs. control group (autogenous blocks or spontaneous healing). The search yielded 214 articles. After screening, 39 studies were included, all performed on animal models: rabbits (n = 18 studies), dogs (n = 4), rats (n = 7), minipigs (n = 4), goats (n = 4), and sheep (n = 2). The meta-analysis on rabbit studies showed significantly higher new bone formation for synthetic blocks with respect to autogenous blocks both at four-week (mean difference (MD): 5.91%, 95% confidence intervals (CI): 1.04, 10.79%, p = 0.02) and at eight-week healing (MD: 4.44%, 95% CI: 0.71, 8.17%, p = 0.02). Other animal models evidenced a trend for better outcomes with synthetic blocks, though only based on qualitative analysis. Synthetic blocks may represent a viable resource in bone regenerative surgery for achieving new bone formation. Differences in the animal models, the design of included studies, and the bone defects treated should be considered when generalizing the results. Clinical studies are needed to confirm the effectiveness of synthetic blocks in bone augmentation procedures.

Maxillary sinus floor elevation using Beta-Tricalcium-Phosphate (beta-TCP) or natural bone: same inflammatory response.

Sinus elevation is a common procedure to increase bone volume in the atrophic maxilla to allow placement of dental implants. Autogenous bone is the gold standard but is limited in quantity and causes morbidity at the donor site. ß-TCP is a synthetic biomaterial commonly used in that purpose. It appears to induce a poor inflammatory response. This study aimed to evaluate the degree of edema of the sinus mucosa after sinus lift surgery according to the type of biomaterial. Forty sinuses (20 patients) were included retrospectively and divided into 2 groups according to the biomaterial that was used: synthetic biomaterial (BTCP group), natural bone (BONE group). A control group (CTRL group) was constituted by the non-grafted maxillary sinuses. Twelve measurements per sinus were realized on pre- and post-operative computed tomography and averaged to provide the sinus membrane thickness value (SM.Th). SM.Th was thicker post-operatively in the BTCP and BONE groups in comparison with the CTRL group and in comparison with pre-operative measurements. No difference was found post operatively between the BTCP and BONE groups. We found that a synthetic biomaterial (ß-TCP) induced the same degree of edema, and thus of inflammation, as natural bone. It constitutes therefore an interesting alternative to autogenous bone for maxillary sinus lifts.

Clinical and radiographic evaluation of bioactive glass in posterior cervical and lumbar spinal fusion.

INTRODUCTION: Spinal surgery of degenerative painful segments is a valuable treatment option in the management of chronic cervical and low back pain. The surgery consists in stabilizing and fusing painful vertebral segment(s). The objective of the study was to report our experience with 45S5 bioactive glass (BAG) to obtain inter-vertebral fusion in the context of posterior spine surgery. MATERIAL AND METHOD: In this retrospective study, 30 patients with a wide range of degenerative and traumatic conditions of the cervical or lumbar spine underwent spinal fusion utilizing a synthetic bone graft substitute of BAG (GlassBone™, Noraker, Lyon-Villeurbanne, France). The pain was evaluated by VAS score, and graft consolidation was assessed on according radiographic images at 1-year post-op. RESULTS: All patients underwent posterior spinal fusion either in the cervical or the thoraco-lumbar spine. Multi-level fusions represented the majority of the cohort (43% of patients with more than seven levels treated). Radiographic imaging demonstrated excellent fusion rates (93%) at final follow-up, equivalent to the outcomes reported in the literature for autogenous bone, with excellent bone bridging and no spinal implant loosening. Only two cases of non-union were encountered. Additionally, 90% of the patients demonstrated recovery at 1 year after surgery with a pain reduction of 60%. CONCLUSION: The results of this retrospective study suggest that the 45S5 BAG may be an interesting alternative option to autologous graft, in terms of safety and bone fusion efficiency. LEVEL OF EVIDENCE: IV Retrospective study.

Biomaterial-induced multinucleated giant cells express proinflammatory signaling molecules: A histological study in humans.

The biomaterials physicochemical characteristics influence their cellular reaction, degradation and regenerative capacities. Macrophages and multinucleated giant cells (MNGCs) are observed in the augmentation area of biomaterials. This study, for the first time, evaluated the polarization pattern of macrophages and MNGCs in response to two different bone substitute materials (synthetic bone substitute material [SBSM] = NanoBone vs. xenogeneic bone substitute material [XBSM] = Bio-Oss) in human bone biopsies compared to non-augmented bone (control). Histomorphometrical analysis of the polarization in proinflammatory (M1) and anti-inflammatory (M2) cells was performed using different immunohistochemical markers: CD-68 = macrophages; CCR-7 and Cox-2 (M1) and CD-206 and CD-163 (M2) and tartrate-resistant acid phosphatase (TRAP). The macrophage polarization pattern in SBSM showed a significantly higher number of M1 cells than did XBSM and non-augmented bone. XBSM induced a significantly higher number of CD-206-positive macrophages than SBSM did. No significant difference was found between XBSM and the non-augmented bone. MNGCs expressed CD-68 and TRAP. In both test-groups, MNGCs showed a high proinflammatory character (CCR-7 and Cox-2-positive) and their number in the SBSM group was significantly higher than that of XBSM. The tissue distribution showed a significantly low percentage of the remaining biomaterial in SBSM compared to XBSM. Within the limitations of this study, these findings show that MNGCs exhibit a rather proinflammatory character and lead to biomaterial degradation, once they are induced in a high number. The premature degradation of bone substitute materials is compensated with a high percentage of connective tissue and not new bone formation. © 2018 Wiley Periodicals, Inc. J Biomed Mater Res Part A: 107A: 780-790, 2019.

[Use of the Peptigel with Nanofibres in the Bone Defects Healing]. / Vyuzití peptigelu s nanovlákny k lécbe defektu kostní tkáne.

INTRODUCTION Traumatic bone injuries or pathological processes may sometimes result in very extensive bone defects. Currently, the standard procedure applied in clinical humane as well as veterinary medicine to fill a bone defect is the autogenous bone graft which, however, necessitates a more invasive procedure for the patient and in the cases of extensive defects it fails to provide adequate amount of graft. Synthetic bone replacements can be used with no further burden for the patient and can simultaneously be used as the carriers for bioactive molecules or therapeutic drugs. For clinical use, an easy and simple application is one of the requirements that have to be taken into consideration. These requirements are best satisfied by preparations in the form of gel, which may be injected into the defects of various shapes even through minimal surgical approach. MATERIAL AND METHODS Synthetic transparent PGD-AlphaProA hydro-peptide-gel was used as a basis to develop a composite hydrogel scaffold. This gel was enriched by cryogenically ground poly- -caprolactone nanofibers (PCL) in a ratio of 1 ml of gel to 16 µg of nanofibres. In experimental animals (laboratory rat Wistar, n=20), a single regular circular defect of 1.5 mm in diameter was drilled by a low speed drill machine across the whole width of distal femur diaphysis, identically in both the hind legs. In the right hindleg, this defect was filled by injection of 0.05 ml of the composite peptide gel with nanofibers (experimental defect). In the contralateral limb a similar defect was left untreated, without filling (control defect), for spontaneous healing. The group of experimental animals was subsequently divided into four sub-groups (A, B, C, D) for the purpose of further follow-up. One week after the surgical implantation, in the first group of experimental animals (Group A; n = 5) lege artis euthanasia was performed, a radiological examination of both the hind legs was carried out and a sample of the bone from both the control and experimental defect was collected for histologic examination. The other groups of experimental animals were evaluated similarly at 2, 4 and 6 weeks after the surgical procedure (Group B, C, D; n = 5). These groups of experimental animals were assessed using various histological techniques by two independent pathologists. RESULTS A difference between the control and the experimental bone defect was observed only at the healing stage at two weeks after the implantation, when a tendency for greater formation of new bone trabeculas was seen in the defect treated with the composite hydro-peptide-gel with PCL nanofibers. The results show a slightly higher angiogenesis and cellularity at the bone defect site with an increase of newly formed bone tissue and faster colonisation of lamellar bone structures by bone marrow cells at early stages of the healing process (1-2 weeks old defect). In the experimental and control groups, at the later stage of healing (4-6 weeks old defect), the process of healing and bone modelling at the defect site shows no detectable morphological differences. CONCLUSIONS The experimental use of hydro-peptide-gel with PCL nanofibers in vivo in laboratory rats shows very good applicability into the defect site and, compared to the untreated defect within two weeks after the implantation, accelerates the bone healing. This fact could be an advantage especially at the early stage of healing, and thus accelerate the healing of more extensive defects. Key words: peptide gel, polycaprolactone, PCL, replacement, bone, healing, scaffold, nanofibers, biomaterial.

Role of the Complement System in the Response to Orthopedic Biomaterials.

Various synthetic biomaterials are used to replace lost or damaged bone tissue that, more or less successfully, osseointegrate into the bone environment. Almost all biomaterials used in orthopedic medicine activate the host-immune system to a certain degree. The complement system, which is a crucial arm of innate immunity, is rapidly activated by an implanted foreign material into the human body, and it is intensely studied regarding blood-contacting medical devices. In contrast, much less is known regarding the role of the complement system in response to implanted bone biomaterials. However, given the increasing knowledge of the complement regulation of bone homeostasis, regeneration, and inflammation, complement involvement in the immune response following biomaterial implantation into bone appears very likely. Moreover, bone cells can produce complement factors and are target cells of activated complement. Therefore, new bone formation or bone resorption around the implant area might be greatly influenced by the complement system. This review aims to summarize the current knowledge on biomaterial-mediated complement activation, with a focus on materials primarily used in orthopedic medicine. In addition, methods to modify the interactions between the complement system and bone biomaterials are discussed, which might favor osseointegration and improve the functionality of the device.

Hydroxyapatite cranioplasty: a retrospective evaluation of osteointegration in 17 cases.

BACKGROUND: Cranial reconstruction with autologous bone is still the gold standard although several biomaterials are available to re-establish the integrity of the cranial vault. Due to their biological and morphological characteristics, hydroxyapatite implants show promising results in small clinical cohort studies, especially within the paediatric population. Its biocompatibility and osteoconductivity should allow the formation of osseous bridging at the skull-prosthesis interface. OBJECTIVE: To examine the possible occurrence of osteointegration and to quantify it. METHODS: A retrospective study of patients with a hydroxyapatite implant from 2010 to 2014 at our neurosurgical department was conducted. Demographic, surgical and radiological data were studied. A senior neuroradiologist, a staff member neurosurgeon and a resident neurosurgeon independently performed the radiological evaluation. A new software analysis technique was developed to objectively quantify the degree of osteointegration. RESULTS: Seventeen implants were evaluated with an average patient age of 39 years and a mean follow-up of 155 weeks. Through radiologic evaluation, osseous bridging was deemed higher than 50% in six prostheses and higher than 75% in three. In five patients, no osteointegration could be seen. The remaining patients exhibited sparse signs of osteointegration, estimated between 10 and 50%. Software analysis showed an average osteointegration ratio of 37.4% with a 400-HU filter and 27.3% with a 700-HU filter. CONCLUSION: In this small retrospective study of cranial hydroxyapatite implants, osteointegration did occur and to a degree of more than 50% in 1/3 of the patients.

Complications with PMMA compared with other materials used in cranioplasty: a systematic review and meta-analysis.

Polymethyl methacrylate (PMMA) has been considered a suitable material for cranioplasty. However, no consensus has been reached concerning the best material for cranioplasty with regard to minimizing complications. Thus, this systematic review and meta-analysis aimed to compare the complication rates of PMMA with those of autologous bone and titanium mesh. This review was registered with PROSPERO (CRD42016042725). Systematic searches were conducted on PubMed/MEDLINE, Scopus, and Web of Science. The focus question was, "Do PMMA prostheses used in cranioplasty have complications rates similar to those of autologous bone and titanium mesh?" A meta-analysis of complication rates was performed on the basis of dichotomous outcomes assessed by risk ratio (RR) with corresponding 95% confidence intervals (CI). From 1014 data sources, 11 articles were selected according to eligibility criteria. These articles involved 1,256 individuals and 1,278 cranioplasties using autologous bone (n = 408), PMMA (n = 379), or titanium (n = 151). The follow-up period ranged from 63 days to 54.3 months. No difference was observed between the complication rates of PMMA and autologous bone (p = 0.94; RR, 0.98; 95%CI, 0.54-1.75) or between PMMA and titanium (p = 0.38; RR, 1.59; 95%CI, 0.57-4.48). Sub-analysis of the reasons for craniotomy (trauma/non-trauma) was conducted, which revealed no significant difference (p = 0.91; RR, 0.95; 95%CI, 0.37-2.42). The meta-analysis indicated that the use of PMMA yields complication rates that are near those of autologous bone and titanium mesh.

Treatment outcomes of the simple bone cyst: A comparative study of 2 surgical techniques using artificial bone substitutes.

Simple bone cysts (SBCs) are benign lesions of unknown etiology. Because of its high relapse rate, they occasionally need a long period of treatment and restriction of activities in children and adolescent. Although various treatment modalities with variable differing outcomes have been described in the literature, no consensus has been reached regarding the standard treatment. The purpose of this study was to evaluate the outcome of a minimally invasive technique that uses a ceramic hydroxyapatite cannulated pin (HA pin) for the treatment of SBCs.Between 1998 and 2015, we have treated 75 patients with SBCs either with continuous decompression by inserting HA pins after curettage and multiple drilling (group 1, n = 39 patients) or with calcium phosphate cement (CPC) filling after curettage (group 2, n = 36 patients). These patients were retrospectively analyzed for recurrence-free survival (RFS) and factors implicated in SBC recurrence.Seventy-five patients (50 man and 25 females) with a mean age of 17.5 ±â€Š11.6 years and a histopathologically confirmed diagnosis of SBCs were included. The mean follow-up period was 33 ±â€Š25.3 months. RFS were 88% at 1 year and 81% at 5 years. Residual or progressing cysts were observed in 12 patients after the surgery and 10 of them underwent additional surgery. Recurrence rate was significantly higher in patients under the age of 10 years (P = .01), in long bone cysts (P = .01), and in active phase cysts (P = .003) (log-rank test). Multivariate analysis results revealed that age less than 10 years was an independent risk factor of recurrence (P = .04). No significant difference in recurrence rate was observed between groups 1 and 2. However, the mean operating time was significantly shorter in group 1. (62.4 ±â€Š25.6 vs 110.5 ±â€Š48.4 minutes in group 2).Continuous decompression using HA pin is a less invasive surgical technique for the treatment of SBCs compared with CPC filling and has a high healing rate. The relapse rate was still high when the cysts were caused in children aged less than 10 years, located in the long bone, or remained adjacent to the epiphysis. LEVEL OF EVIDENCE: Level 3, Retrospective comparative study.

Evaluation of the clinical effectiveness of bioactive glass (S53P4) in the treatment of non-unions of the tibia and femur: study protocol of a randomized controlled non-inferiority trial.

BACKGROUND: Treatment of non-union remains challenging and often necessitates augmentation of the resulting defect with an autologous bone graft (ABG). ABG is limited in quantity and its harvesting incurs an additional surgical intervention leaving the risk for associated complications and morbidities. Therefore, artificial bone graft substitutes that might replace autologous bone are needed. S53P4-type bioactive glass (BaG) is a promising material which might be used as bone graft substitute due to its osteostimulative, conductive and antimicrobial properties. In this study, we plan to examine the clinical effectiveness of BaG as a bone graft substitute in Masquelet therapy in comparison with present standard Masquelet therapy using an ABG with tricalciumphosphate to fill the bone defect. METHODS/DESIGN: This randomized controlled, clinical non-inferiority trial will be carried out at the Department of Orthopedics and Traumatology at Heidelberg University. Patients who suffer from tibial or femoral non-unions with a segmental bone defect of 2-5 cm and who are receiving Masquelet treatment will be included in the study. The resulting bone defect will either be filled with autologous bone and tricalciumphosphate (control group, N = 25) or BaG (S53P4) (study group, N = 25). Subsequent to operative therapy, all patients will receive the same standardized follow-up procedures. The primary endpoint of the study is union achieved 1year after surgery. DISCUSSION: The results from the current study will help evaluate the clinical effectiveness of this promising biomaterial in non-union therapy. In addition, this randomized trial will help to identify potential benefits and limitations regarding the use of BaG in Masquelet therapy. Data from the study will increase the knowledge about BaG as a bone graft substitute as well as identify patients possibly benefiting from Masquelet therapy using BaG and those who are more likely to fail, thereby improving the quality of non-union treatment. TRIAL REGISTRATION: German Clinical Trials Register (DRKS), ID: DRKS00013882 . Registered on 22 January 2018.

Minimally invasive treatment for osteonecrosis of the femoral head with angioconductive bioceramic rod.

PURPOSE: To describe the rationale, the surgical technique, and the short-term follow-up results of a new minimally invasive treatment of osteonecrosis of the femoral head (ONFH) with an angioconductive bioceramic rod (ABR) implant. METHODS: Sixty-two patients (72 hips) with ARCO stage IIA-IIIC ONFH treated with the minimally invasive ABR from January 2012 to December 2016 were reviewed (17 females, 45 males, mean age 44.49). This technique used the angioconductive properties of the porous implant to repair the necrosis by driving vascularization from the trochanter to the necrotic area. Patients had a mean follow-up period of 26.74 months. The outcomes were evaluated by hip joint survival, radiograph, and the Harris Hip Score (HHS). The complications occurred during the treatment period were recorded. RESULTS: No serious post-operative complications occurred during the treatment. The overall joint survival rate was 90.27%, with seven conversions to THA. Improvements were observed in 23 (31.95%) hips, 24 (33.33%) hips remained stable, and 25 (34.72%) hips had worse results according to the radiographic evaluation. The mean HHS at the end follow-up significantly improved compared to the pre-operative mean HHS (82.27 vs 58.14, p < 0.001). In both radiographic evaluation and HHS, the treatment was more effective on patients beneath 44 years old (p < 0.05); ARCO stage II compared to stage III (p < 0.05); and China-Japan Friendship Hospital (CJFH) type C compared to CJFH type L (p < 0.05). CONCLUSIONS: The minimally invasive treatment of ONFH with ABR showed promising results in delaying or even terminating the progression of the necrosis and improving hip function, especially in younger patients and in the early stages of the disease.

Real-time computerised tomography assisted porous tantalum implant in ARCO stage I-II non-traumatic osteonecrosis of the femoral head: minimum five-year follow up.

PURPOSES: This study was established to investigate the medium-term clinical effect of real-time CT assisted porous tantalum implant for the treatment of ARCO stage I-II non-traumatic osteonecrosis of the femoral head (ONFH). METHODS: This study comprised 24 ONFH patients (29 hips) who were treated with intra-operative real-time CT accurate rapid positioning assisted drilling decompression, lesion removal and porous tantalum implant. Harris score, VAS score and imaging in pre-operation and follow-up period were recorded. RESULTS: The average operative time and intra-operative blood loss were 72.6 min and 158.8 ml, respectively. The mean follow-up was 5.4 years. No femoral head penetrating, wound infection, and death occurred. Harris and VAS score improved significantly (73.78 vs. 88.11; 7.13 vs. 2.66) at last follow-up (P < 0.05). The functional improvement and pain relief rate was 100% at six months after operation. The effective rate was 86.21% at 12 months after operation and last follow-up. Five pre-operative ARCO stage I hips had no radiographic progress. Meanwhile, four among the 24 ARCO stage II hips progressed into stage III between eight and 12 months after surgery, among which two progressed into stage IV and two remained in stage III at the last follow-up. The average value of Kerboul combined necrotic angle was 263.24°. There was no progress in Kerboul combined necrotic angle among the grades 2 and 3 patients. However, among the six cases at grade 4, four cases with post-operative progress, two patients converted to THA. CONCLUSIONS: Our technique is safety and effective in the treatment of ARCO stage I-II non-traumatic ONFH.

Complications with PMMA compared with other materials used in cranioplasty: a systematic review and meta-analysis

Abstract Polymethyl methacrylate (PMMA) has been considered a suitable material for cranioplasty. However, no consensus has been reached concerning the best material for cranioplasty with regard to minimizing complications. Thus, this systematic review and meta-analysis aimed to compare the complication rates of PMMA with those of autologous bone and titanium mesh. This review was registered with PROSPERO (CRD42016042725). Systematic searches were conducted on PubMed/MEDLINE, Scopus, and Web of Science. The focus question was, "Do PMMA prostheses used in cranioplasty have complications rates similar to those of autologous bone and titanium mesh?" A meta-analysis of complication rates was performed on the basis of dichotomous outcomes assessed by risk ratio (RR) with corresponding 95% confidence intervals (CI). From 1014 data sources, 11 articles were selected according to eligibility criteria. These articles involved 1,256 individuals and 1,278 cranioplasties using autologous bone (n = 408), PMMA (n = 379), or titanium (n = 151). The follow-up period ranged from 63 days to 54.3 months. No difference was observed between the complication rates of PMMA and autologous bone (p = 0.94; RR, 0.98; 95%CI, 0.54-1.75) or between PMMA and titanium (p = 0.38; RR, 1.59; 95%CI, 0.57-4.48). Sub-analysis of the reasons for craniotomy (trauma/non-trauma) was conducted, which revealed no significant difference (p = 0.91; RR, 0.95; 95%CI, 0.37-2.42). The meta-analysis indicated that the use of PMMA yields complication rates that are near those of autologous bone and titanium mesh.

Concise Review: Biomimetic Functionalization of Biomaterials to Stimulate the Endogenous Healing Process of Cartilage and Bone Tissue.

Musculoskeletal reconstruction is an ongoing challenge for surgeons as it is required for one out of five patients undergoing surgery. In the past three decades, through the close collaboration between clinicians and basic scientists, several regenerative strategies have been proposed. These have emerged from interdisciplinary approaches that bridge tissue engineering with material science, physiology, and cell biology. The paradigm behind tissue engineering is to achieve regeneration and functional recovery using stem cells, bioactive molecules, or supporting materials. Although plenty of preclinical solutions for bone and cartilage have been presented, only a few platforms have been able to move from the bench to the bedside. In this review, we highlight the limitations of musculoskeletal regeneration and summarize the most relevant acellular tissue engineering approaches. We focus on the strategies that could be most effectively translate in clinical practice and reflect on contemporary and cutting-edge regenerative strategies in surgery. Stem Cells Translational Medicine 2017;6:2186-2196.

Efficacy of cortico/cancellous composite allograft in treatment of cervical spondylosis.

This was a prospective comparative study.The aim of this study was to compare the clinical and radiologic outcomes of patients treated with cortico/cancellous composite allograft or autoiliac bone graft in anterior cervical discectomy and fusion.Several methods have been developed to fuse the cervical spine for treatment of cervical spondylosis. Cortico/cancellous composite allograft might be another alternative.A total of 46 patients who underwent surgery for treatment of cervical spondylosis were evaluated between September 2010 and January 2015. The duration of operation, blood loss, perioperative complications, neck disability index (NDI), visual analogue scale (VAS), and fusion rates were compared between the 2 groups.There were no significant differences in clinical or radiologic outcomes between the patients treated with cortico/cancellous composite allograft and those treated with autoiliac bone graft. The 2 groups showed similar improvements in clinical symptoms and fusion rates. Although not statistically significant, the subsidence rate was lower in the cortico/cancellous composite group.Cortico/cancellous composite allograft is an effective alternative to conventional allograft or autograft in anterior cervical discectomy and fusion.