Assessment of two entry points for S2 alar-iliac screw in a Japanese cohort using three-dimensional computed tomography scan.

BACKGROUND CONTEXT: Lumbosacral fusion supplemented with sacropelvic fusion has recently been increasingly employed for correcting spinal deformity and is associated with lower incidence of pseudarthrosis and implant failure. To date, few studies have evaluated anatomical parameters and technical feasibility between different entry points for S2 alar-iliac screws. PURPOSE: To compare anatomical parameters and technical feasibility of two entry points for the S2 alar-iliac screw (S2AIS) in a Japanese cohort using three-dimensional (3D) computed tomography (CT). STUDY DESIGN/SETTING: Retrospective cohort study. PATIENT SAMPLE: Fifteen men and 15 women aged 50-79 years who underwent pelvic CT at our hospital in 2013. OUTCOME MEASURES: Screw length, lateral angulation, caudal angulation, angle range, distance from the entry point to the sacroiliac joint, distance from the S2AIS to the acetabular roof, distance from the S2AIS to the sciatic notch, and insertion difficulty. METHODS: We used 30 pelvic CT images (15 men and 15 women). We selected two entry points from previous studies: one was 1 mm distal and 1 mm lateral to the S1 dorsal foramen (A group) and the other was the midpoint between the S1 and S2 dorsal foramen (B group). We resliced the plane in which the pelvis was sectioned obliquely from these entry points to the anterior inferior iliac spine in the sagittal plane. We placed the shortest and longest virtual S2AISs bilaterally in this plane using a 4-mm margin. We measured screw length, lateral angulation, caudal angulation, angle range, distance from the entry point to the sacroiliac joint, distance from the S2AIS to the acetabular roof, distance from the S2AIS to the sciatic notch, and insertion difficulty. These measurements were compared between Groups A and B. RESULTS: In group A, the angle in the sagittal plane was significantly smaller and the distance from the entry point to the sciatic notch was significantly longer than in group B. Group B demonstrated a significantly longer screw length, longer distance from the entry point to the sacroiliac joint, and longer distance from the entry point to the acetabular roof than group A. The rate of insertion difficulty of S2AIS was much higher in group A. CONCLUSIONS: Insertion of S2AIS from the midpoint between the S1 and S2 dorsal foramen compared with the entry at distal and lateral to S1 foramen enables insertion of longer screws with low insertion difficulty.

Cost-utility Analysis of Anterior Cervical Discectomy and Fusion for Cervical Spondylosis Patients Comparing Polyetheretherketone Versus Tricortical Iliac Crest Bone Graft.

STUDY DESIGN: Prospective cohort study. OBJECTIVES: To perform a cost-utility analysis and to investigate the clinical outcomes and patient's quality of life after anterior cervical discectomy and fusion (ACDF) to treat cervical spondylosis compared between fusion with polyetheretherketone (PEEK) and fusion with tricortical iliac bone graft (IBG) in Thailand. SUMMARY OF BACKGROUND DATA: ACDF is one of the standard treatments for cervical spondylosis. The fusion material options include PEEK and tricortical IBG. No previous studies have compared the cost-utility between these 2 fusion material options. PATIENTS AND METHODS: Patients with cervical spondylosis who were scheduled for ACDF at Siriraj Hospital (Bangkok, Thailand) during 2019-2020 were prospectively enrolled. Patients were allocated to the PEEK or IBG fusion material group according to the patient's choice of fusion material. EuroQol-5 dimensions 5 levels and relevant costs were collected during the operative and postoperative periods. A cost-utility analysis was performed using a societal perspective. All costs were converted to 2020 United States dollars (USD), and a 3% discount rate was used. The outcome was expressed as the incremental cost-effectiveness ratio. RESULTS: Thirty-six patients (18 ACDF-PEEK and 18 ACDF-IBG) were enrolled. Except for Nurick grading, there was no significant difference in patient baseline characteristics between groups. The average utility at 1 year after ACDF-PEEK and ACDF-IBG were 0.939 ± 0.061 and 0.798 ± 0.081, respectively ( P < 0.001). The total lifetime cost of ACDF-PEEK and ACDF-IBG was 83,572 USD and 73,329 USD, respectively. The incremental cost-effectiveness ratio of ACDF-PEEK when compared with that of ACDF-IBG showed a gain of 4468.52 USD/quality-adjusted life-years, which is considered cost-effective at the Thailand willingness-to-pay threshold of 5115 USD/quality-adjusted life-year gained. CONCLUSIONS: ACDF-PEEK was found to be more cost-effective than ACDF-IBG for treating cervical spondylosis in Thailand. LEVEL OF EVIDENCE: Level II.

Assessment of sacral osseous fixation pathways for same-level dual transiliac-transsacral screw insertion.

INTRODUCTION: The purpose of this study is to (1) describe a pre-operative planning technique using non-reformatted CT images for insertion of multiple transiliac-transsacral (TI-TS) screws at a single sacral level, (2) define the parameters of a sacral osseous fixation pathway (OFP) that will allow for insertion of two TI-TS screws at a single level, and (3) identify the incidence of sacral OFPs large enough for dual-screw insertion in a representative patient population. METHODS: Retrospective review at a level-1 academic trauma center of a cohort of patients with unstable pelvic injuries treated with two TI-TS screws in the same sacral OFP, and a control cohort of patients without pelvic injuries who had CT scans for other reasons. RESULTS: Thirty-nine patients had two TI-TS screws at S1. Eleven patients, all with dysmorphic osteology, had two TI-TS screws at S2. The average pathway size in the sagittal plane at the level the screws were placed was 17.2 mm in S1 vs 14.4 mm in S2 (p = 0.02). Twenty-one patients (42%) had screws that were intraosseous and 29 (58%) had part of a screw that was juxtaforaminal. No screws were extraosseous. The average OFP size of intraosseous screws was 18.1 mm vs. 15.5 mm for juxtaforaminal screws (p = 0.02). Fourteen millimeters was used as a guide for the lower limit of the OFP for safe dual-screw fixation. Overall, 30% of S1 or S2 pathways were ≥ 14 mm in the control group, with 58% of control patients having at least one of the S1 or S2 pathways ≥ 14 mm. CONCLUSIONS: OFPs ≥ 7.5 mm in the axial plane and 14 mm in the sagittal plane on non-reformatted CT images are large enough for dual-screw fixation at a single sacral level. Overall, 30% of S1 and S2 pathways were ≥ 14 mm and 58% of control patients had an available OFP in at least one sacral level.

Intraoperative Assessment of Coronal Balance with Long Cassette Radiographs in Adult Thoracolumbar Deformity Correction.

BACKGROUND: To describe the use of intraoperative anteroposterior long cassette radiographs (APLCRs) to guide kickstand rod application in adult spinal deformity. METHODS: A retrospective chart review was performed to identify patients with adult thoracolumbar and coronal plane deformity undergoing open segmental decompression with spinopelvic fixation and deformity correction between October 2017 and June 2019 who had APLCRs after rod placement. In patients with persistent intraoperative coronal deviations, a kickstand rod was placed. This supplemental rod was anchored to an iliac screw and to the construct via a pair of side-to-side connectors. A distractor was expended between a vice grip plyer on the kickstand and side-to-side connector to apply a lateralizing force to reduce the degree of deviation. RESULTS: Of 15 patients who underwent T3-ilium fusion with spinal deformity correction with intraoperative APLCRs, 7 underwent kickstand placement. Mean preoperative coronal deviation was similar between cohorts (4.3 cm vs. 2.2 cm, P = 0.09), but was greater intraoperatively in the kickstand cohort (4.3 cm vs. 0.6 cm, P < 0.001). Postoperative coronal deviation was similar between groups (2.1 cm vs. 1.8 cm, P = 0.37). Preoperative fractional lumbar curve was significantly greater in patients requiring a kickstand (23° vs. 35°, P = 0.02), but the major thoracolumbar curve was similar between groups (43° vs. 35°, P = 0.14). CONCLUSIONS: Intraoperative APLCRs can help guide application of a kickstand rod in adult thoracolumbar deformity correction. Patients with a greater fractional lumbar curve may derive greater benefit of kickstand usage, independent of major curve magnitude.

Subchondral Bone Changes Following Sacroiliac Joint Arthrodesis - A Morpho-mechanical Assessment of Surgical Treatment of the Painful Joint.

BACKGROUND: Sacroiliac joint arthrodesis is an ultima ratio treatment option for sacroiliac joint dysfunction. Fusion drastically reduces sacroiliac joint movement providing long-lasting pain-relief associated with tension-relief to the innervated sacroiliac joint structures involved in force closure. OBJECTIVES: To display the bone mineralization distribution patterns of the subchondral bone plate in 3 distinct regions (superior, anterior, and inferior) of the sacral and iliac counterparts of the sacroiliac joint pre- and post-sacroiliac joint arthrodesis and compare patterns of sacroiliac joint dysfunction post-sacroiliac joint fusion with sacroiliac joint dysfunction pre- arthrodesis patterns and those from healthy controls. STUDY DESIGN: An observational study. SETTING: The research took place at the University of Basel, Switzerland, where the specific image analysis program (Analyze, v7.4, Biomedical Imaging Resources, Mayo Foundation, Rochester, NY, USA) was made available. METHODS: Mineralization densitograms of 18 sacroiliac joint dysfunction patients pre- and post-sacroiliac joint arthrodesis (>= 6, >= 12, and >= 24 months post-surgery) were obtained using computed tomography osteoabsorptiometry. For each patient, pre- vs. post-surgery statistical comparisons were undertaken, using the Hounsfield unit values derived from the subchondral mineralization of superior, anterior, and inferior regions on the iliac and sacral auricular surfaces. Post-operative values were also compared to those from a healthy control cohort (n = 39). RESULTS: In the pre-operative cohort at all 3 follow-up times, the superior iliac region showed significantly higher Hounsfield unit values than the corresponding sacral region (P < 0.01). Mineralization comparisons were similar for the sacrum and ilium in the anterior and inferior regions at all follow-up points (P > 0.5) with no surgery-related changes. Sacral density increased significantly in the post-operative state; not observed on the ilium. Post-operative sacroiliac joints showed a significantly increased mineralization in the superior sacrum after >= 6 months (P < 0.05), not replicated after >= 12 nor >= 24 months. Further comparison of post-operative scans versus healthy controls revealed significantly increased mineralization in the superior sacral region at (>=) 6, 12, and 24 months (P < 0.01), likely related to bone grafting, and in the anterior and inferior regions in post-operative scans at >= 12 and >= 24 months follow-up (P < 0.05). LIMITATIONS: The given study is limited in sample size. Post-operative computed tomography scans had screws which may have left artifacts or partial volume effects on the surfaces. Healthy controls were different patients to the sacroiliac joint dysfunction and post-operative cohorts. Both cohorts were age-matched but this comparison did not take into account potential population differences. Size differences in the regions may have also been an influencing factor of the results as the regions were based on the size and shape of the articular surface. CONCLUSIONS: Sacroiliac joint arthrodesis results in an increased morpho-mechanical conformity in the anterior and inferior sacrum and reflects variable morpho-mechanical density patterns compared to the healthy state due to permanent alterations in the kinematics of the posterior pelvis.

Assessment of osseous corridor for transiliac-transsacral screws and clinical applications: Computational simulation study.

BACKGROUND: Transiliac-transsacral (TITS) screw fixation might be necessary in some cases involving the vertical shearing injuries with transforaminal fracture and bilateral posterior ring injuries. However, the possibility of S1 TITS screw should be preoperatively assessed because the pelvic ring injuries with sacral dysmorphism had the insufficient osseous corridors. HYPOTHESIS: AxWS2 may predict the possibility of TITS screw fixation and be used as the new indicator to discriminate the sacral dysmorphism. MATERIALS & METHODS: The conventional CT images of eighty-two cadaveric pelvis imported into Mimics® software to reconstruct three-dimensional (3D) models. A 7.0 mm-sized screw was processed into a 3D model using a 3D-sensor at actual size and virtually implanted as S1 and S2 TITS screw using Mimics® software. The cortical violation around screw path was evaluated using 3D biplanar and conventional CT images. The osseous corridor widths around TITS screws were measured in the axial plane images and defined as AxWS1 and AxWS2, respectively. RESULTS: Despite no cortical violation in S2 of all models, cortical violation of S1 TITS screw was found in 20 models. Of them, 14 models (impossible models) were identified in the 3D biplanar images, and all 20 models (CT-violation models) were identified only in CT axial plane images. AxWS1 was<7mm in the impossible models and<9.0mm in the CT-violation models. AxWS2 negatively correlated with AxWS1 (R -0.450, p<0.01). By receiver operating characteristic curve analysis to identify the CT-violation model using AxWS2, the cut-off value of AxWS2 was 13.32mm (sensitivity 0.70, specificity 0.70). DISCUSSION: By using AxWS2, the possibility of S1 TITS screw fixation could be predicted and safely placed without cortical violation, if AxWS2 was less than 13mm. Considering the negative relationship with AxWS1, AxWS2 should be used as a new indicator to predict safe S1 TITS screw fixation. LEVEL OF EVIDENCE: III, controlled laboratory study.

Inguinal and Ilio-inguinal Lymphadenectomy in Management of Palpable Melanoma Lymph Node Metastasis: A Long-Term Prospective Evaluation of Morbidity and Quality of Life.

PURPOSE: Prospective data are lacking on long-term morbidity of inguinal lymphadenectomy including the influence of extent of surgery, use of radiotherapy, and patient factors. The aim of this study is to evaluate the effects of these factors on patient outcome, quality of life (QOL), regional symptoms, and limb volumes after inguinal or ilio-inguinal lymphadenectomy for melanoma. METHODS: Analysis of the subgroup of patients with inguinal lymph node field relapse of melanoma, treated by inguinal or ilio-inguinal lymphadenectomy in the ANZMTG/TROG randomized trial of adjuvant radiotherapy versus observation. RESULTS: Sixty-nine patients, 46 having undergone inguinal and 23 ilio-inguinal lymphadenectomy, with median follow-up of 73 months were analyzed. Mean limb volume increased rapidly after surgery (7% by 3 months) and continued to increase for at least another 18 months. Patients with body mass index (BMI) ≥ 25 kg/m2 had greater limb volume increase than normal-weight patients (13.3% versus 6.9%, P = 0.030). QOL improved over the first 18 months, but despite initial improvement, regional symptoms persisted long term. Type of surgery (inguinal or ilio-inguinal lymphadenectomy) had no demonstrably significant effect on limb volume (9.9% versus 13.4%, P = 0.35), QOL (P = 0.68), or regional symptoms (P = 0.65). There was no difference in overall survival between inguinal and ilio-inguinal lymphadenectomy [hazard ratio (HR) 0.75, 95% confidence interval (CI) 0.40-1.40, P = 0.43]. CONCLUSIONS: Inguinal lymphadenectomy for melanoma is a potentially morbid procedure with significant increases in limb volume. Patients report reasonable QOL but may have ongoing regional symptoms. Overweight/obesity is associated with poorer QOL, increased limb volume, and regional symptoms.

Counting the Cost of Failed Spinal Fusion for Relief of Low Back Pain: Does Primary Fusion With Bone Morphogenetic Protein Make Economic Sense From a Primary Payer Perspective?

STUDY DESIGN: A retrospective cohort study. OBJECTIVES: To investigate the unknown direct costs of failed instrumented lumbar fusion using iliac crest bone graft (ICBG) and subsequent reoperation utilizing recombinant human bone morphogenetic protein-2 (rhBMP-2) from a primary payer perspective. SUMMARY OF BACKGROUND DATA: Recent evidence has demonstrated increased rates of instrumented lumbar fusion and utilization of rhBMP-2 to treat a range of conditions causing lower back pain. For health care providers with finite financial resources, there is an increasing demand to evaluate economic costs of available treatment modalities. The high cost of rhBMP-2 has often been cited as a leading reason for delaying its universal acceptance as a preferred substitute to ICBG. It has been hypothesized that rhBMP-2 may demonstrate cost-effectiveness if pseudarthrosis and reoperation rates are decreased, thus avoiding subsequent expenditure. METHODS: This was a retrospective cohort study of patients who underwent instrumented lumbar fusions utilizing rhBMP-2. Hospital finance records were used to calculate direct total expenditure incurred by the primary payer for the procedure using rhBMP-2. For patients who received rhBMP-2 in a secondary lumbar fusion, additional total expenditure related to the patients' failed primary instrumented fusion with ICBG was also sought. RESULTS: The mean total costs associated with failed instrumented lumbar fusion using ICBG and reoperation using rhBMP-2 totaled £47,734 per patient. The total direct costs of a policy of primary instrumented lumbar fusion with rhBMP-2 were less at £26,923 per patient; however, this was not significant. CONCLUSIONS: To date, this is the first study to report the costs of failed primary instrumented lumbar fusions using ICBG and subsequent secondary fusions using rhBMP-2 from a primary payer perspective. On the basis of this evidence, a policy of using rhBMP-2 in all patients undergoing a primary instrumented lumbar fusion cannot be recommended.

Assessment of Bone Marrow Aspiration Site Pain in Foot and Ankle Surgery.

UNLABELLED: Bone marrow aspiration (BMA) is a validated technique to harvest progenitor cells. BMA has many uses in foot and ankle surgery; however, donor site morbidity is a concern. The purpose of this study was to compare the Visual Analog Scale (VAS) pain scores after BMA at 3 different sites (iliac crest, distal tibia, and calcaneus) over a 12-week postoperative recovery period. This was an institutional review board-approved prospective study of 40 patients who underwent BMA as an adjunct to their primary foot and ankle procedure. Each patient had BMA harvested from the ipsilateral anterior iliac crest, distal tibia, and lateral calcaneus at the time of surgery. Patient follow-up questionnaire forms were filled out at 2, 4, 8, and 12 weeks, with the primary outcome measure being VAS pain scores. Mean VAS scores averaged over the 12-week follow-up period were significantly higher in the calcaneus (20.8 ± 28.6) compared with the distal tibia (7.7 ± 17.6) and the iliac crest (4.2 ± 12.4; P < .05). No significant difference was found between the distal tibia and the iliac crest sites. At 12 weeks, all sites were about equal and without appreciable pain. Our data suggested that donor site selection for BMA affects postoperative pain levels, with BMA from the calcaneus resulting in significantly higher pain scores when compared with the iliac crest or distal tibia. The VAS pain score for the calcaneus was likely confounded by the high number of hindfoot/ankle surgeries performed in the ipsilateral foot. LEVELS OF EVIDENCE: Therapeutic, Level II: Prospective, comparative trial.

Biological substitutes/extenders for spinal arthrodesis: which agents are cost-effective?

STUDY DESIGN: Systematic review. OBJECTIVE: To evaluate the cost-effectiveness of lumbar or cervical spinal arthrodesis using biological substitutes and extenders compared with iliac crest autograft for the treatment of degenerative spinal conditions. SUMMARY OF BACKGROUND DATA: The cost-effectiveness of using bone graft substitutes and extenders for spinal fusion compared with using iliac crest autograft is not yet well established. METHODS: A systematic search of PubMed/MEDLINE, the Cochrane Collaboration Library, EMBASE, the CRD (Centre for Reviews and Dissemination) database, and Tuft's CEA registry for literature published through December 2013 was performed to identify full formal economic analyses comparing the use of biological grafts with iliac crest bone graft in spinal fusion for thoracolumbar or cervical degenerative, deformity, and traumatic spinal conditions. Economic outcomes such as cost per improved outcome or cost per quality-adjusted life year were reported in the context of the model type, analytic perspective clinical comparisons, and sensitivity analyses employed. RESULTS: The search strategy yielded 88 citations, and 6 full economic analyses ultimately met our inclusion criteria. For the comparison of recombinant human bone morphogenetic protein-2 to iliac crest bone graft in the lumbar spine, data from 4 cost-effectiveness studies and 1 cost-utility study provided discordant conclusions that varied with type of data used, cost-measurement methods, and study design. In the cervical spine, one study suggested that from a societal perspective, anterior cervical discectomy and fusion (ACDF) with allograft is similarly cost-effective as ACDF with autograft. CONCLUSION: The results suggest that compared with use of iliac crest bone graft in lumbar spinal fusion, use of recombinant human bone morphogenetic protein is not cost-effective from a payer perspective with higher upfront costs, but it may be cost-effective from a societal perspective due to a decrease in lost productivity. The data in this study also suggest that from a societal perspective, ACDF with allograft is similarly cost-effective to ACDF with autograft. LEVEL OF EVIDENCE: 3.

Avaliação da dor na área doadora de pacientes com fissura labiopalatina submetidos a reparo do defeito ósseo alveolar com enxerto autógeno de crista ilíaca: um estudo prospectivo randomizado comparando dois extratores ósseos / Assessment of donor area pain in patients with cleft lip and palate undergoing alveolar bone defects repairs using iliac crest autogenous grafting: a prospective randomized comparison of two bone extractors

INTRODUÇÃO: Enxerto ósseo autógeno é o padrão no tratamento da falha óssea alveolar. Como a morbidade na área doadora após a obtenção de enxerto ósseo continua sendo um problema relevante em pacientes fissurados, este estudo avaliou a dor na área doadora de pacientes fissurados submetidos ao tratamento de falhas ósseas alveolares com a transferência de enxerto ósseo obtido da crista ilíaca, por meio de um estudo prospectivo randomizado, comparando dois extratores ósseos. MÉTODO: Trinta e seis pacientes com fissura labiopalatina, submetidos ao reparo da falha óssea alveolar com enxerto obtido da crista ilíaca com auxílio do extrator ósseo SOBRAPAR (grupo A) ou extrator ósseo UCLA (grupo B), foram incluídos. A dor na área doadora foi avaliada no período pós-operatório com auxílio da escala numérica unidimensional de dor (0- "sem dor"; 10- "pior dor que se pode imaginar"). RESULTADOS: As médias das mensurações da dor na área doadora não revelaram diferenças significativas (p>0,05 para todas as comparações) nas comparações realizadas entre os grupos A e B, em nenhum dos momentos pós-operatórios avaliados. Houve um maior número (p<0,05) de pacientes do grupo B que não reportaram dor na área doadora, quando comparado ao grupo A. CONCLUSÕES: Este estudo apresentou um maior número de pacientes do grupo B "sem dor", quando comparado aos pacientes do grupo A, não existindo diferenças entre aqueles que reportaram quaisquer notas diferentes de zero.

INTRODUCTION: Autogenous bone grafting is the standard treatment for alveolar bone defects. However, morbidity in the donor area after the bone graft has been obtained continues to be a significant problem in cleft patients. This prospective randomized study compared donor area pain associated with the use of 2 bone extractors in patients with cleft lip and palate, who underwent treatment of alveolar bone defects using a bone graft obtained from the iliac crest. METHOD: Thirty-six patients with cleft lip and palate underwent alveolar bone defect repair using a graft from the iliac crest, harvested with either a SOBRAPAR bone extractor (group A) or UCLA bone extractor (group B). Donor area pain was evaluated in the postoperative period with the aid of a unidimensional numerical pain scale (0, "no pain"; 10, "worst pain imaginable"). RESULTS: Comparison of the mean donor area pain score did not reveal any significant differences (p >0.05 for all comparisons) between the groups A and B, at any of the postoperative times evaluated. A significantly higher number of patients in group B reported no pain in the donor area, compared with group A (p <0.05). CONCLUSIONS: This study showed that a significantly greater number of patients in group B reported "no pain", compared with patients in group A; with regard to patients who reported any level of pain greater than zero, there were no between-group differences.

Cost differences between the anterior and posterior approaches to the iliac crest for alveolar bone grafting in patients with cleft lip/palate.

PURPOSE: There has been debate in the literature regarding the advantages of an anterior versus posterior approach to the iliac crest harvest for alveolar bone grafting (ABG) in patients with cleft lip and palate. The purpose of this study was to add a cost perspective to the discussion. MATERIALS AND METHODS: This was a retrospective microcost analysis for the perioperative period for 2 approaches to graft harvest for ABG in patients with cleft lip and palate. Patient charts and hospital and physician financial databases were searched for detailed cost data in the 30 days before and after ABG for 18 patients who underwent anterior or posterior iliac crest harvest at Children's Hospital Boston. In addition, short-term outcomes for these 18 patients were documented (duration of operation, need for physical therapy services, complications, and hospital length of stay) and compared with the larger study group at the same institution. RESULTS: There was a trend toward lower overall median costs for posterior compared with anterior iliac crest harvest ($18,269 vs $21,801, respectively; P = .15). The differences in cost were seen in inpatient hospital services after the operation, including ward and physical therapy costs, which were significantly lower for the posterior versus the anterior approach. This corresponded with a shorter median length of stay (1 day vs 2 days, respectively; P = .03). There was no significant difference in operating room, recovery room, or outpatient costs. More patients undergoing posterior harvest had bilateral ABG, offsetting the decreased inpatient costs with increased physician costs. CONCLUSIONS: The overall cost for ABG in patients with cleft lip and palate was not significantly different between the anterior and posterior approached to iliac crest harvest. Inpatient cost was lower in the posterior group because of a shorter length of stay.

Iliac crest autogenous bone graft versus alloplastic graft and guided bone regeneration in the reconstruction of atrophic maxillae: a 5-year retrospective study on cost-effectiveness and clinical outcome.

BACKGROUND: Reconstruction of the atrophic maxillae with autogenous bone graft and jawbone-anchored bridges is a well-proven technique. However, the morbidity associated with the concept should not be neglected. Furthermore, the costs for such treatment, including general anesthesia and hospital stay, are significant. Little data are found in the literature with regard to a cost-benefit approach to various treatment alternates. PURPOSE: The aim of this retrospective study was to compare from a health-economical and clinical perspective the reconstruction of the atrophic maxillae prior to oral implant treatment either with autogenous bone grafts harvested from the iliac crest or the use of demineralized freeze-dried bone (DFDB) in combination with a thermoplastic carrier (Regeneration Technologies Inc., Alachua, FL, USA) and guided bone regeneration (GBR). MATERIALS AND METHODS: A total of 26 patients (13 + 13) were selected and matched with regard to indication, sex, and age. The study was performed 5 years after the completion of the treatment. Implant survival, morbidity, and complications were analyzed. Furthermore, a detailed analysis of the total cost for the respective treatment modality was performed, including material, costs for staff, sick leave, etc. RESULTS: The study revealed no statistical difference with regard to implant survival for the respective groups. The average total cost, per patient, for the DFDB group was 22.5% of the total cost for a patient treated with autogenous bone grafting procedures. CONCLUSIONS: The study concluded that reconstruction of atrophic maxillae with a bone substitute material (DFDB) in combination with GBR can be performed with an equal treatment outcome and with less resources and a significant reduced cost in selected cases compared with autogenous bone grafts from the iliac crest.

Intraoperative three-dimensional fluoroscopy assessment of iliosacral screws and lumbopelvic implants stabilizing fractures of the os sacrum.

INTRODUCTION: Percutaneous iliosacral screw fixation of unstable sacrum fractures has gained popularity since its introduction in the 1990s. The combination with lumbopelvic implants allows the application even in situations of higher instability. Both manual and navigated screw insertion in the sacrum and vertebra bodies shows unchanged relevant malpositions. The current standard to control the screw position is postoperative computed tomography. The study presents the results of assessment of these implants by intraoperative three-dimensional fluoroscopy. METHODS: From January 2008 through March 2009, 14 patients had stabilization of the dorsal pelvic ring with iliosacral screws alone or in combination with lumbopelvic implants. Intraoperative 3D fluoroscopy was performed to evaluate the position of the implants stabilizing the posterior pelvic ring. RESULTS: Fourteen iliosacral screws and eight pedicle screws were depicted. In all patients, we were able to adequately evaluate the placement of iliosacral screws, lumbar pedicle screws and iliacal screws. As a consequence of intraoperative 3D scan a lumbar pedicle screw was corrected. The entire scanning procedure required 5 min. The time for analyzing the 3D scan took 3 min. CONCLUSIONS: Intraoperative 3D fluoroscopy is a valuable tool for intraoperative assessment of iliosacral screws and lumbopelvic implants. The technique should help us to detect intraoperative malplacement of the screws more reliably than conventional fluoroscopy and allows an immediate correction of malplaced implants. Therefore, a postoperative computed tomography to control the position of implants is dispensable.

Feline ilial fractures: assessment of screw loosening and pelvic canal narrowing after lateral plating.

OBJECTIVE: To report the incidence of (1) screw loosening and (2) severity of pelvic canal narrowing in cats after repair of ilial fractures by a lateral bone plate. STUDY DESIGN: Case series. ANIMALS: Cats (n=21) with ilial fractures. METHODS: Medical records (June 1994 to February 2004) and radiographs were reviewed. Retrieved data were: signalment, fracture description, screw purchase, screw loosening, complications, and clinical outcome. Sacral index (SI) was used to objectively assess degree of pelvic canal narrowing. Long-term follow-up was by owner telephone interview or postal questionnaire. RESULTS: Screw loosening occurred in 13 cats (62%), with a mean loss of total screw purchase of 13% (range, 0-46%). Pelvic canal narrowing (mean decrease, 25%; range, 5-60%) occurred in all cats. Six cats (28%) had severe pelvic canal narrowing (mean, 52%); 5 of these had signs of recurrent constipation within 12 months postoperatively. Mean loss of total screw purchase in cats with severe pelvic narrowing was 28% compared with 9% for all other cats with narrowing. CONCLUSIONS: Lateral plating of ilial fractures in cats is associated with a high incidence of screw loosening. CLINICAL RELEVANCE: Pelvic canal narrowing >45% is associated with a high risk of recurrent constipation.

Morbidity from anterior iliac crest bone harvesting for secondary alveolar bone grafting: an outcome assessment study.

PURPOSE: To determine the postoperative morbidity of harvesting cancellous bone from the anterior iliac crest for treating secondary cleft alveolus patients. PATIENTS AND METHODS: Twenty-four patients treated for alveolar clefts in the Oral and Maxillofacial Surgery unit at the Jordan University Hospital were included. Medical notes were reviewed for intraoperative and postoperative complications; patients were interviewed to fill a questionnaire on postoperative recovery. The donor site was evaluated for the following factors: chronic pain, neurapraxia of the lateral femoral cutaneous nerve, abnormal gait, altered sensation over the scar, skin tenderness, bone tenderness, deformity of the bony contour, and scar length and width were measured. RESULTS: Age at the time of surgery was 14.0+/-4.1 years (mean +/- SD), and follow-up was 23.2+/-19.3 months. Patients spent a median of 3 days in hospital (range=2-4 days), patients walked normally after 10.4+/-13.2 days and resumed normal activities, including sports, after a mean of 16.0+/-19.6 days. Two patients had neurapraxia of the lateral femoral cutaneous nerve (8%), 2 reported mild residual scar tenderness (8%) and 1 of the latter complained of tenderness on palpating the iliac crest (4%). CONCLUSIONS: Harvesting cancellous bone from the anterior iliac crest in young patients is well-tolerated, allows early resumption of normal activities, has no effect on growth, has minimal morbidity, and a reasonable esthetic outcome.

Quantitative assessment of growth factors in reaming aspirate, iliac crest, and platelet preparation.

Large bony defects and non-unions are still a complication in trauma and orthopedic surgery. Treatment strategies include the use of autogenous materials (iliac crest), allogenic bone, bone substitutes, and currently stimulation with growth factors such as BMP-2, BMP-7 or the growth factors containing platelet-rich plasma (PRP). Another source of bone graft material might be the cuttings produced during intramedullary reaming. The aim of this study was to compare the quantity of various growth factors found within iliac crest, bony reaming debris, reaming irrigation fluid, and platelet-rich plasma. Iliac crest and reaming debris and irrigation samples were harvested during surgery. PRP was prepared from blood. The growth factors in the bony materials (iliac crest or reaming debris) and of the liquid materials (platelet-poor plasma (PPP), platelet-rich plasma (PRP) or reaming irrigation) were compared. Elevated levels of FGFa, PDGF, IGF-I, TGF-beta1 and BMP-2 were measured in the reaming debris as compared to iliac crest curettings. However, VEGF and FGFb were significantly lower in the reaming debris than from iliac crest samples. In comparing PRP and PPP all detectable growth factors, except IGF-I, were enhanced in the platelet-rich plasma. In the reaming irrigation FGFa (no measurable value in the PRP) and FGFb were higher, but VEGF, PDGF, IGF-I, TGF-beta1 and BMP-2 were lower compared to PRP. BMP-4 was not measurable in any sample. The bony reaming debris is a rich source of growth factors with a content comparable to that from iliac crest. The irrigation fluid from the reaming also contains growth factors.

Iliac crest bone graft donor site pain after anterior lumbar interbody fusion: a prospective patient satisfaction outcome assessment.

BACKGROUND: Autogenous iliac crest bone is the gold-standard graft for spinal fusion surgery. Unfortunately, there is a frequent incidence of graft site pain that persists well into the postoperative period with complication rates reported in 2.8-39% of patients. Persistent pain lasting at least 2 years is reported in 15-39% of patients. OBJECTIVE: The objective of this work was to determine the incidence of acute and persistent pain as well as patient assessment of graft site appearance following iliac crest bone graft harvest for anterior lumbar interbody fusion (ALIF). The control arms of four randomized prospective multicenter clinical trials evaluating recombinant human bone morphogenetic protein-2 (rhBMP-2) versus autogenous iliac crest bone graft were combined. Two hundred eight patients underwent iliac crest bone graft harvest for ALIF in threaded cylindrical cages or threaded bone dowels. Patients were assessed at each postoperative visit with questionnaires evaluating graft site pain intensity, duration, and appearance. METHODS: Two hundred eight patients underwent iliac crest bone graft harvest for ALIF as the control group of four randomized prospective multicenter clinical trials evaluating rhBMP-2 versus autogenous iliac crest bone graft in threaded cylindrical cages or threaded bone dowels. Most patients in the control group had anterior iliac crest graft harvest, equally from the right and left side. Three grafts (1.4%) were taken from the posterior crest and six (2.9%) were tricortical. Follow-up was obtained at hospital discharge, 6 weeks, 3, 6, 12, and 24 months. A pain evaluation score was made up of two Visual Analog Scales: one scale measuring intensity, the other frequency of pain. For the intensity scale, a rating of "0" meant no pain and "10" was "as bad as it could be." For the frequency scale, a rating of "0" meant pain was present "none of the time" and "10" meant it was present "all the time." Combining these scales, a total score of 20 indicated the worst pain was present all the time. Patients were also questioned about the graft site appearance. RESULTS: Two hundred eight patients underwent iliac crest harvest, and prospective data were available on 202 patients. At hospital discharge, 2 patients (1%) had no pain; this increased to 34 of 199 (17%) at 6 weeks postoperatively and to 85 of 199 patients (43%) at 3 months. However, 41% of patients reported pain at 6 months postoperatively (79/192), and 33% of 168 reported pain at 1 year. One hundred forty-one of 208 patients completed a survey at 24 months, with 31% reporting some level of pain. At hospital discharge, the graft site pain score ranged from 0 to 20 with a mean of 12.8, decreasing to 7.3 at 6 weeks, to 3.8 at 3 months, and to 2.9, 2.4, and 1.8 at 6, 12, and 24 months, respectively. At all time intervals, P values from t tests comparing the mean with 0 were <0.001. Graft site appearance at discharge was good in 49% of patients, fair in 40%, and poor in 11%. At 6 weeks, appearance was good in 69%, fair in 27%, and poor in 5%; at 3 months, it was good in 75%, fair in 24%, and poor in 2%; at 6 months, it was good in 82%, fair in 15%, and poor in 3%; at 12 months, it was good in 82% and fair or poor in 19%; and at 24 months, it was good in 84% and fair or poor in 16%. There was no significant difference between posterior and anterior harvest sites or bicortical grafts, and all were included in the analysis. Right or left side demonstrated no differences. DISCUSSION: This is the first study known to the authors presenting results of prospective data collected in a multicenter study evaluating iliac crest harvest site pain, both intensity and frequency, as well as graft site appearance. The results demonstrate that 31% of patients had persistent pain at 24 months postoperatively and 16% reported fair or poor appearance of their graft site. CONCLUSIONS: Persistent donor site pain remains a problem with harvest of autogenous iliac crest bone graft for spinal fusion. This prospective study, the first such study reported for ALIF, confirms that donor site pain remains a significant postoperative management problem.

[Calibrated autologous bone grafts--their use in oral implantology. Widening--crest augmentation. Personal technic]. / Greffons osseux autologues calibrés--leur utilisation en implantologie orale. L'élargissement--surélévation crestal. Technique personnelle.

Using special trephines moved by a rotary motor, corticospongy graded-cylindrical grafts can be obtained from the iliac crest. These grafts are used to maintain widened and raised maxillary or mandibular crests. Inserted between type Brane-mark implants is useful to increase the height of the alveolar process when it is impossible to implant. Surgical trauma is limited compared with other Lefort 1 type operations advocated for the same indication. Operative effects resolve quickly and patients are hospitalized less than two days. The entire process is quite economical.