Qualitative study exploring general dental practitioners' views of MIH and its management in the UK and Australia.

BACKGROUND: Molar-incisor hypomineralisation (MIH) is a prevalent condition, and how it is managed varies greatly between professional groups. AIM: To explore, and compare, the UK and Australian general dental practitioners' management of MIH in children. DESIGN: Face-to-face (remote) semistructured interviews were undertaken, using country-specific topic guides. Participants were purposively sampled and recruited through national conferences and research networks (eviDent Foundation and Northern Dental Practice Based Research Network). Interviews (from each country) were audio-recorded, transcribed verbatim and independently analysed using thematic analysis. RESULTS: Two major themes arose from the UK interviews: (i) decision-making complexities and understanding of treatment options and (ii) need for specialist input. The main Australian themes were (i) multidisciplinary approach to management supporting decision-making complexities and (ii) economic implications for care. Several difficulties, such as financial implications, multidisciplinary care and clinical decision-making, were identified as barriers to effectively managing MIH by GDPs in primary care. CONCLUSION: There are similarities and differences in the knowledge and management of MIH amongst UK and Australian nonspecialists. The different healthcare systems played a significant role in shaping how GDPs manage MIH with barriers relating to affordability, multidisciplinary care and clinical decision-making.

Dominant Power and the Concept of Caste: Implications for Dentistry and Oral Health Inequality.

This paper explores the issues of caste and casteism in the U.S. as described by Pulitzer Prize winning journalist Isabel Wilkerson in her 2020 book "Caste: The Origin of Our Discontents". Wilkerson argues that a caste system not only exists in the U.S. but operates as a hidden force affecting social inequality. The paper draws on Wilkerson's work to explore caste as an analytical concept. It begins by defining caste and casteism in contrast with racism, the eight pillars of a caste system, the consequences of casteism, and the psychological drivers of casteism. The paper then applies to concept of caste to understanding power, dentistry, and oral health inequality. The paper concludes by emphasizing that the concept of caste and its relationship to oral health inequality must be understood it if we want to create real social change.

Longitudinal relationship of severe periodontitis with cognitive decline in older Japanese.

BACKGROUND AND OBJECTIVE: Epidemiologic data examining the longitudinal relationship between periodontitis and cognitive status are very limited, especially in Asian populations. The present study examined the longitudinal relationship of periodontitis with cognitive decline in 85 Japanese community-dwelling individuals (average age: 79.3 years) for whom data were available from comprehensive health examinations conducted in 2010 and 2013. MATERIAL AND METHODS: Based on a baseline full-mouth periodontal examination, severe periodontitis was defined using a Centers for Disease Control and Prevention/American Academy of Periodontology definition. Cognitive decline during the 3-year study period was defined using the results of the Mini-Mental State Examination (MMSE). Information on age, gender, education, depression, body mass index, smoking status, alcohol use, exercise, hypertension, diabetes, history of cardiovascular disease and stroke, and baseline MMSE scores were obtained and tested as potential confounders in the statistical models. RESULTS: Among 85 study participants, 21 (24.7%) were defined as having severe periodontitis. Multivariable Poisson regression analyses revealed that severe periodontitis was significantly associated with an increased risk of cognitive decline [adjusted relative risk = 2.2; 95% confidence interval (95% CI): 1.1-4.5]. Furthermore, multivariable linear regression analyses revealed that participants with severe periodontitis had a 1.8-point greater decrease (95% CI: -3.3 to -0.2) in MMSE score than those without severe periodontitis. CONCLUSION: Within the limitations related to its small sample size, the findings of the present study suggest that severe periodontitis is significantly associated with future decline in cognitive function among community-dwelling older Japanese subjects.

Maximum bite force at age 70 years predicts all-cause mortality during the following 13 years in Japanese men.

There is limited information on the impact of oral function on mortality among older adults. The aim of this prospective cohort study was to examine whether an objective measure of oral function, maximum bite force (MBF), is associated with mortality in older adults during a 13-year follow-up period. Five hundred and fifty-nine community-dwelling Japanese (282 men and 277 women) aged 70 years at baseline were included in the study. Medical and dental examinations and a questionnaire survey were conducted at baseline. Maximum bite force was measured using an electronic recording device (Occlusal Force-Meter GM10). Follow-up investigation to ascertain vital status was conducted 13 years after baseline examinations. Survival rates among MBF tertiles were compared using Cox proportional hazards regression models stratified by sex. There were a total of 111 deaths (82 events for men and 29 for women). Univariable analysis revealed that male participants in the lower MBF tertile had increased risk of all-cause mortality [hazard ratio (HR) = 1·94, 95% confidence interval (CI) = 1·13-3·34] compared with those in the upper MBF tertile. This association remained significant after adjustment for confounders (adjusted HR = 1·84, 95% CI = 1·07-3·19). Conversely, no association between MBF and all-cause mortality was observed in female participants. Maximum bite force was independently associated with all-cause mortality in older Japanese male adults. These data provide additional evidence for the association between oral function and geriatric health.

Bioarchaeological investigation of individuals with suspected multibacillary leprosy from the mediaeval leprosarium of St Mary Magdalen, Winchester, Hampshire, UK.

Introduction. We have examined four burials from the St Mary Magdalen mediaeval leprosarium cemetery in Winchester, Hampshire, UK. One (Sk.8) was a male child, two (Sk.45 and Sk.52) were adolescent females and the fourth (Sk.512) was an adult male. The cemetery was in use between the 10th and 12th centuries. All showed skeletal lesions of leprosy. Additionally, one of the two females (Sk.45) had lesions suggestive of multi-cystic tuberculosis and the second (Sk.52) of leprogenic odontodysplasia (LO), a rare malformation of the roots of the permanent maxillary incisors.Gap statement. Relatively little is known of the manifestations of lepromatous leprosy (LL) in younger individuals from the archaeological record.Aims and Methodology. To address this, we have used ancient DNA testing and osteological examination of the individuals, supplemented with X-ray and microcomputed tomography (micro-CT) scan as necessary to assess the disease status.Results and Conclusions. The presence of Mycobacterium leprae DNA was confirmed in both females, and genotyping showed SNP type 3I-1 strains but with a clear genotypic variation. We could not confirm Mycobacterium tuberculosis complex DNA in the female individual SK.45. High levels of M. leprae DNA were found within the pulp cavities of four maxillary teeth from the male child (Sk.8) with LO, consistent with the theory that the replication of M. leprae in alveolar bone may interfere with root formation at key stages of development. We report our biomolecular findings in these individuals and review the evidence this site has contributed to our knowledge of mediaeval leprosy.

Fit for Purpose? The Suitability of Oral Health Outcome Measures to Inform Policy.

KNOWLEDGE TRANSFER STATEMENT: Oral health research and program evaluation should consider alternative outcome measures for population oral health other than the DMFT index.

Navigating the Dual Role of Clinician-Researcher in Qualitative Dental Research.

In qualitative research, the researcher is the research instrument. Therefore, a qualitative researcher who is also a clinician must consider how their dual position informs participant consent, data collection, and analysis. This reflexivity is essential in research design to effectively respond to ethical questions around role, authenticity, trust, and transparency around disclosing their clinician status to participants.

An update of treatment modalities in children and adolescents with teeth affected by molar incisor hypomineralisation (MIH): a systematic review.

PURPOSE: To systematically review the treatment modalities for molar-incisor hypomineralisation for children under the age of 18 years. The research question was, 'What are the treatment options for teeth in children affected by molar incisor hypomineralisation?' METHODS: An electronic search of the following electronic databases was completed MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, LILACS, Google Scholar and Open Grey identifying studies from 1980 to 2020. The PRISMA guidelines were followed. The studies were screened, data extracted and calibration was completed by two independent reviewers. RESULTS: Of 6220 potential articles, 34 studies were included. Twenty studies investigated management of molars with fissure sealants, glass ionomer cement, polyacid modified resin composite, composite resin, amalgam, preformed metal crowns, laboratory-manufactured crowns and extractions. In four articles management of incisors with microabrasion, resin-infiltration and a combination of approaches was reported. Eight studies looked at strategies to mineralise MIH-affected teeth and/or reduce hypersensitivity. Two studies investigated patient-centred outcomes following treatment. Due to the heterogeneity between the studies, meta-analysis was not performed. CONCLUSION: The use of resin-based fissure sealants, preformed metal crowns, direct composite resin restorations and laboratory-made restorations can be recommended for MIH-affected molars. There is insufficient evidence to support specific approaches for the management of affected incisors. Products containing CPP-ACP may be beneficial for MIH-affected teeth.

Best clinical practice guidance for clinicians dealing with children presenting with molar-incisor-hypomineralisation (MIH): an updated European Academy of Paediatric Dentistry policy document.

AIM: To update the existing European Academy of Paediatric Dentistry (EAPD) 2010 policy document on the 'Best Clinical Practice guidance for clinicians dealing with children presenting with Molar-Incisor-Hypomineralisation (MIH).' METHODS: Experts, assigned the EAPD, worked on two different topics: (A) Aetiological factors involved in MIH, and (B) Treatment options for the clinical management of MIH. The group prepared two detailed systematic reviews of the existing literature relevant to the topics and following a consensus process produced the updated EAPD policy document on the 'Best Clinical Practice guidance for clinicians dealing with children presenting with molar-incisor-hypomineralisation (MIH).' The GRADE system was used to assess the quality of evidence regarding aetiology and treatment which was judged as HIGH, MODERATE, LOW or VERY LOW, while the GRADE criteria were used to indicate the strength of recommendation regarding treatment options as STRONG or WEAK/CONDITIONAL. RESULTS: (A) Regarding aetiology, it is confirmed that MIH has a multifactorial aetiology with the duration, strength and timing of occurrence of the aetiological factors being responsible for the variable clinical characteristics of the defect. Perinatal hypoxia, prematurity and other hypoxia related perinatal problems, including caesarean section, appear to increase the risk of having MIH, while certain infant and childhood illnesses are also linked with MIH. In addition, genetic predisposition and the role of epigenetic influences are becoming clearer following twin studies and genome and single-nucleotide polymorphisms analyses in patients and families. Missing genetic information might be the final key to truly understand MIH aetiology. (B) Regarding treatment options, composite restorations, preformed metal crowns and laboratory indirect restorations provide high success rates for the posterior teeth in appropriate cases, while scheduled extractions provide an established alternative option in severe cases. There is great need for further clinical and laboratory studies evaluating new materials and non-invasive/micro-invasive techniques for anterior teeth, especially when aesthetic and oral health related quality of life (OHRQoL) issues are concerned. CONCLUSIONS: MIH has been studied more extensively in the last decade. Its aetiology follows the multifactorial model, involving systemic medical and genetic factors. Further focused laboratory research and prospective clinical studies are needed to elucidate any additional factors and refine the model. Successful preventive and treatment options have been studied and established. The appropriate choice depends on the severity of the defects and the age of the patient. EAPD encourages the use of all available treatment options, whilst in severe cases, scheduled extractions should be considered.

An update of the aetiological factors involved in molar incisor hypomineralisation (MIH): a systematic review and meta-analysis.

PURPOSE: To systematically review the aetiological factors associated with molar incisor hypomineralisation (MIH). To this day, the aetiology remains unknown. Determining risk factors would allow risk assessment and enhance early diagnosis of MIH in young patients. The aim was to assess, evaluate and summarise the relationship between MIH and reported aetiological hypotheses. METHODS: Electronic database searches of MEDLINE, EMBASE, EBSCO, LILACS and Cochrane Library were conducted. Authors conformed to PRISMA guidelines. Studies were screened, data extracted, assessment of risk of bias and calibration was completed by two independent reviewers. Meta-analyses with heterogeneity calculations were performed. RESULTS: Of the potential 8949 studies, 64 studies were included in the qualitative analysis whilst 45 were included in the quantitative analysis. Prenatal factors: results are inconclusive as only unspecified maternal illnesses appear to be linked to MIH. Perinatal factors: prematurity (OR 1.45; 95% CI 1.24-1.70; p = 0.0002) and caesarean delivery (OR 1.45; 95% CI 1.09, 1.93; p < 0.00001) are associated with an increased risk of developing MIH. Birth complications are also highlighted. These three factors can lead to hypoxia, and children with perinatal hypoxia are more likely to develop MIH (OR 2.76; 95% CI 2.09-3.64; p < 0.0001). Postnatal factors: measles, urinary tract infection, otitis media, gastric disorders, bronchitis, kidney diseases, pneumonia and asthma are associated with MIH. Fever and antibiotic use, which may be considered as consequences of childhood illnesses, are also associated with MIH. Genetic factors: an increasing number of studies highlight the genetic and epigenetic influences in the development of MIH. CONCLUSION: Several systemic and genetic and/or epigenetic factors acting synergistically or additively are associated with MIH, revealing a multifactorial aetiology model. Peri- and postnatal aetiological factors are more likely to increase the odds of causing MIH than prenatal factors.

The interaction and interference of preformed metal crowns on magnetic resonance imaging: a scoping review with a systematic methodology.

PURPOSE: Preformed metal crowns are widely used to restore primary and permanent teeth. Children may require magnetic resonance imaging (MRI) for diagnosis and monitoring of diseases in the head and neck region. Metallic objects, in the field of view, may compromise the diagnostic value of an MRI. The impact on the diagnostic quality of an MRI in children who have had preformed metal crowns placed has not been assessed. The aim of this systematic review was to evaluate the impact that PFMCs have on MRI imaging quality and thus the overall diagnostic value. METHODS: Electronic searches of the following databases were completed: MEDLINE, EMBASE, Cochrane Library, Web of Science and Open Grey. Primary in vivo studies on children who had at least one preformed metal crown placed and required an MRI investigation were to be included. PRISMA guidelines were followed and screening/data extraction was carried out by two independent calibrated reviewers. RESULTS: A total of 7665 articles were identified. After removing duplicates, 7062 were identified for title and abstract screening. Thirty-four articles underwent full-text review, of which none met the inclusion criteria. Most common reasons for exclusion were not placing preformed metal crowns (n = 16) or in vitro studies (n = 12). CONCLUSION: No in vivo studies were identified to establish the hypothetical impact preformed metal crowns would have on the diagnostic quality of an MRI in the head and neck region. Decision making needs to be guided on a case by case basis. Further high-quality clinical studies are required.

Molecular engineering of antimicrobial peptide (AMP)-polymer conjugates.

As antimicrobial resistance becomes an increasing threat, bringing significant economic and health burdens, innovative antimicrobial treatments are urgently needed. While antimicrobial peptides (AMPs) are promising therapeutics, exhibiting high activity against resistant bacterial strains, limited stability and toxicity to mammalian cells has hindered clinical development. Attaching AMPs to polymers provides opportunities to present AMPs in a way that maximizes bacterial killing while enhancing compatibility with mammalian cells, stability, and solubility. Conjugation of an AMP to a linear hydrophilic polymer yields the desired improvements in stability, mammalian cell compatibility, and solubility, yet often markedly reduces bactericidal effects. Non-linear polymer architectures and supramolecular assemblies that accommodate multiple AMPs per polymer chain afford AMP-polymer conjugates that strike a superior balance of antimicrobial activity, mammalian cell compatibility, stability, and solubility. Therefore, we review the design criteria, building blocks, and synthetic strategies for engineering AMP-polymer conjugates, emphasizing the connection between molecular architecture and antimicrobial performance to inspire and enable further innovation to advance this emerging class of biomaterials.

Shape and volume changes in erythrocyte ghosts and spectrin-actin networks.

In response to changes in electrolyte concentration and pH, erythrocyte ghosts can exhibit some of the characteristic shapes seen in the intact erythrocyte. These shape changes are accompanied by volume changes; both are reversible, not energy dependent, and not inhibited by sulfhydryl reagents. The volume reduction can also be seen in isolated Triton-free spectrin-actin lattices, showing that this network is capable of reversible contraction. The results suggest that reversible changes in size of the underlying cytoskeleton of the erythrocyte membrane can control cell shape.

Scientific knowledge and clinical authority in dentistry: James Sim Wallace and dental caries.

Once the germ theory had become generally accepted within medicine, the importance of experimental science to the improvement of medical practice could no longer be reasonably doubted. However, clinicians still sought to retain control of how knowledge that had originated in the laboratory was interpreted and applied within practical diagnostics and therapeutics. Thus how practitioners incorporated new scientific knowledge into their medical discourse and practice is a matter for careful empirical inquiry. James Sim Wallace, born in Renfrewshire in 1869 and a graduate in medicine from the University of Glasgow, was a leading figure in British dentistry throughout the first half of the twentieth century. Through an examination of his voluminous writings, we explore how the new 'chemico-parasitical' theory of dental caries was accommodated within dentists' understanding of oral hygiene. The paper also looks at the controversies that surrounded the application of the vitamin theory to the problems of rickets and dental caries, focusing on the contentious interaction between Sim Wallace and his colleagues, on the one hand, and the eminent physiologists May and Edward Mellanby, on the other.

Periodontal disease: associations with diabetes, glycemic control and complications.

OBJECTIVE: This report reviews the evidence for adverse effects of diabetes on periodontal health and periodontal disease on glycemic control and complications of diabetes. DESIGN: MEDLINE search of the English language literature identified primary research reports published on (a) relationships between diabetes and periodontal diseases since 2000 and (b) effects of periodontal infection on glycemic control and diabetes complications since 1960. RESULTS: Observational studies provided consistent evidence of greater prevalence, severity, extent, or progression of at least one manifestation of periodontal disease in 13/17 reports reviewed. Treatment and longitudinal observational studies provided evidence to support periodontal infection having an adverse effect on glycemic control, although not all investigations reported an improvement in glycemic control after periodontal treatment. Additionally, evidence from three observational studies supported periodontal disease increasing the risk for diabetes complications and no published reports refuted the findings. CONCLUSION: The evidence reviewed supports diabetes having an adverse effect on periodontal health and periodontal infection having an adverse effect on glycemic control and incidence of diabetes complications. Further rigorous study is necessary to establish unequivocally that treating periodontal infections can contribute to glycemic control management and to the reduction of the burden of diabetes complications.

Leprosy at the edge of Europe-Biomolecular, isotopic and osteoarchaeological findings from medieval Ireland.

Relatively little is known of leprosy in Medieval Ireland; as an island located at the far west of Europe it has the potential to provide interesting insights in relation to the historical epidemiology of the disease. To this end the study focuses on five cases of probable leprosy identified in human skeletal remains excavated from inhumation burials. Three of the individuals derived from the cemetery of St Michael Le Pole, Golden Lane, Dublin, while single examples were also identified from Ardreigh, Co. Kildare, and St Patrick's Church, Armoy, Co. Antrim. The individuals were radiocarbon dated and examined biomolecularly for evidence of either of the causative pathogens, M. leprae or M. lepromatosis. Oxygen and strontium isotopes were measured in tooth enamel and rib samples to determine where the individuals had spent their formative years and to ascertain if they had undertaken any recent migrations. We detected M. leprae DNA in the three Golden Lane cases but not in the probable cases from either Ardreigh Co. Kildare or Armoy, Co. Antrim. M. lepromatosis was not detected in any of the burals. DNA preservation was sufficiently robust to allow genotyping of M. leprae strains in two of the Golden Lane burials, SkCXCV (12-13th century) and SkCCXXX (11-13th century). These strains were found to belong on different lineages of the M. leprae phylogenetic tree, namely branches 3 and 2 respectively. Whole genome sequencing was also attempted on these two isolates with a view to gaining further information but poor genome coverage precluded phylogenetic analysis. Data from the biomolecular study was combined with osteological, isotopic and radiocarbon dating to provide a comprehensive and multidisciplinary study of the Irish cases. Strontium and oxygen isotopic analysis indicate that two of the individuals from Golden Lane (SkCXLVIII (10-11th century) and SkCXCV) were of Scandinavian origin, while SkCCXXX may have spent his childhood in the north of Ireland or central Britain. We propose that the Vikings were responsible for introducing leprosy to Ireland. This work adds to our knowledge of the likely origins of leprosy in Medieval Ireland and will hopefully stimulate further research into the history and spread of this ancient disease across the world.

Does bone quality predict loosening of cemented total hip replacements?

We matched 78 patients with a loose cemented Charnley Elite Plus total hip replacement (THR) by age, gender, race, prosthesis and time from surgery with 49 patients with a well-fixed stable hip replacement, to determine if poor bone quality predisposes to loosening. Clinical, radiological, biomechanical and bone mineral density indicators of bone quality were assessed. Patients with loose replacements had more pain, were more likely to have presented with atrophic arthritis and to have a history of fragility fracture, narrower femoral cortices and lower peri-prosthetic or lumbar spine bone mineral density (all t-test, p < 0.01). They also tended to be smokers (chi-squared test, p = 0.08). Vitamin-D deficiency was common, but not significantly different between the two groups (t-test, p = 0.31) In this series of cemented hip replacements performed between 1994 and 1998, aseptic loosening was associated with poor bone quality. Patients with a THR should be screened for osteoporosis and have regular radiological surveillance.

Investigation of a Medieval Pilgrim Burial Excavated from the Leprosarium of St Mary Magdalen Winchester, UK.

We have examined the remains of a Pilgrim burial from St Mary Magdalen, Winchester. The individual was a young adult male, aged around 18-25 years at the time of death. Radiocarbon dating showed the remains dated to the late 11th-early 12th centuries, a time when pilgrimages were at their height in Europe. Several lines of evidence in connection with the burial suggested this was an individual of some means and prestige. Although buried within the leprosarium cemetery, the skeleton showed only minimal skeletal evidence for leprosy, which was confined to the bones of the feet and legs. Nonetheless, molecular testing of several skeletal elements, including uninvolved bones all showed robust evidence of DNA from Mycobacterium leprae, consistent with the lepromatous or multibacillary form of the disease. We infer that in life, this individual almost certainly suffered with multiple soft tissue lesions. Genotyping of the M.leprae strain showed this belonged to the 2F lineage, today associated with cases from South-Central and Western Asia. During osteological examination it was noted that the cranium and facial features displayed atypical morphology for northern European populations. Subsequently, geochemical isotopic analyses carried out on tooth enamel indicated that this individual was indeed not local to the Winchester region, although it was not possible to be more specific about their geographic origin.

CORRECTIONS ASSOCIATED WITH ON-PHANTOM CALIBRATIONS OF NEUTRON PERSONAL DOSEMETERS.

The response of neutron personal dosemeters as a function of neutron energy and angle of incidence is typically measured by mounting the dosemeters on a slab phantom and exposing them to neutrons from an accelerator-based or radionuclide source. The phantom is placed close to the source (75 cm) so that the effect of scattered neutrons is negligible. It is usual to mount several dosemeters on the phantom together. Because the source is close, the source distance and the neutron incidence angle vary significantly over the phantom face, and each dosemeter may receive a different dose equivalent. This is particularly important when the phantom is angled away from normal incidence. With accelerator-produced neutrons, the neutron energy and fluence vary with emission angle relative to the charged particle beam that produces the neutrons, contributing further to differences in dose equivalent, particularly when the phantom is located at other than the straight-ahead position (0° to the beam). Corrections for these effects are quantified and discussed in this article.

The Evolution of Free Vascularized Bone Transfer: A 40-Year Experience.

BACKGROUND: The first successful free vascularized bone flap was performed on June 1, 1974 (and reported in 1975), using the fibula. This was followed by the iliac crest based on the superficial circumflex iliac artery in 1975 and then the deep circumflex iliac artery in 1978. METHODS: A total of 384 transfers using fibula (n = 198), iliac crest (n = 180), radius (n = 4), rib (n = 1), and metatarsal (n = 1) were used between June of 1974 and June of 2014 for reconstruction of the mandible (n = 267), maxilla (n = 20), clavicle (n = 1), humerus (n = 8), radius and ulna (n = 21), carpus (n = 3), pelvis (n = 2), femur (n = 11), tibia (n = 47), and foot bones (n = 4). Indications were tumor ablation (n = 286), trauma (n = 84), osteomyelitis (n = 2), and the congenital deformities hemifacial microsomia (n = 2) and pseudarthrosis of the tibia (n = 9) and ulna (n = 1). RESULTS: Successful transfer was achieved in 95 percent of patients. Union varied with the recipient bone, from 6 to 8 weeks in the jaw, 2 to 3 months in the upper limb, and 3 to 4 months in the femur and tibia. Union was fastest with iliac crest. The fibula provided easier dissection; it could be raised on either peroneal or anterior tibial vessels; the skin flap could be designed distally; it could be placed centrally in the medullary cavity of long bones; and hairline stress fracture in the lower limb frequently preceded rapid subperiosteal hypertrophy. The fibula lacks sufficient height for osseointegration, whereas iliac crest is ideal. Osteotomies of either bone are possible to straighten or increase curvature. CONCLUSIONS: The fibula is best for long bone or angle-to-angle jaw reconstruction, especially in edentulous patients. Iliac crest is best for hemimandible, curved bones (pelvis, carpus, and metacarpus), and as an alternative for short, straight, 6- to 8-cm-long bone defects.