Graft Resorption After Posterior Distal Tibial Allograft Augmentation for Posterior Shoulder Instability: A Case Report.

CASE: A 19-year-old man underwent arthroscopic posterior glenoid reconstruction with a distal tibia allograft (DTA) after failing 2 posterior, soft-tissue instability surgeries. Although he experienced near-complete resolution of symptoms and return to sport, graft resorption was noted 7 months postoperatively. The patient underwent revision surgery for screw removal. CONCLUSION: Graft resorption has not previously been reported in the setting of arthroscopic DTA use for posterior instability. It is believed that stress shielding contributed to resorption. In such situations, screw removal may be warranted. Consideration of alternative fixation techniques and additional investigation into the causes, clinical significance, and optimal management of posterior DTA resorption are warranted.

Editorial Commentary: It is Never Wrong to Perform Anterior Cruciate Ligament Revision Reconstruction as a Two-Stage Procedure.

Revision anterior cruciate ligament (ACL) reconstruction can be performed in a single surgery, but in some instances, it requires 2 stages to get it right. The most common reasons for staged reconstruction include dilated bone tunnels on the tibial or femoral side (>13 mm), imperfectly placed bone tunnels that cannot be reused but cannot be avoided, and/or the need to combine the revision ACL reconstruction with meniscus and/or cartilage allograft transplantation. In my practice, we use prefabricated bone dowels, sizing up 0.5 to 1 mm relative to the size of the tunnel (after debridement) for both the femoral side and tibial side. The benefits are efficiency and reproducibility, while the challenges include cost and the potential need for multiple dowels if the prefabricated dowels are not long enough. We will occasionally add demineralized bone matrix, particularly on the tibial side, in the event that there is <5 mm of unfilled tunnel using the bone dowel. We wait ∼3 months before proceeding to the second stage using only plain radiographs to assess healing (advanced imaging such as computed tomography scan is not routinely used). We have also begun to push the limits of single-stage revision reconstruction, using dowels in a single setting. No matter what, it is never wrong to perform ACL revision reconstruction as a 2-stage procedure. When performed for the appropriate indications, outcomes tend to be good, regardless of the chosen technique.

Editorial Commentary: Autologous and Synthetic Bone Fillers for Medial Open-Wedge High Tibial Osteotomy Have No Effect on Clinical Outcomes But Autologous Graft Promotes Complete Bony Union.

In contrast to closed-wedge high tibial osteotomy, medial based open-wedge high tibial osteotomy produces gaps of various sizes. Synthetic bone void fillers are an attractive option to close these gaps, potentially increase bone union, decrease time to union, and improve clinical outcomes. Autologous bone grafts are the accepted standard and result in reliable and reproducible outcomes. However, harvesting of autologous bone requires an additional procedure and is associated with potential complications. The use of synthetic bone void fillers could theoretically avoid these issues and reduce operating times. The current evidence suggests that autologous bone grafting has higher union rates but is not associated with better clinical and functional outcomes. Unfortunately, the certainty of evidence to support the use of bone void fillers is low, and the question of whether bone grafting of the gap should be performed in medial based open-wedge high tibial osteotomies cannot be answered with confidence.

Complications associated using the reamer-irrigator -aspirator (RIA) system: a systematic review and meta-analysis.

INTRODUCTION: Complications associated with the application of the Reamer-irrigator-Aspirator (RIA) system are described in the literature. However, to date a systematic review and meta-analysis to assess prevalence of complications associated with the use of the RIA system have not been conducted. MATERIALS AND METHODS: The review is registered with PROSPERO (CRD42021269982). MEDLINE, the Web of Science Core Collection, and Embase were searched from the inception to 10 August 2021. The primary objective was to assess complications and blood loss associated with the use of the RIA system. RESULTS: Forty-seven studies involving 1834 procedures performed with the RIA system were finally included. A total of 105 complications were reported, with a pooled estimated overall prevalence of 1.7% with a 95% confidence interval (CI) of 0.40 to 3.60, with cortex perforation being the largest reported complication with a total of 34 incidences. A significant subgroup difference was observed (p = 0.02). In subgroup 1 (bone graft harvesting), complication prevalence was 1.4% (95% CI 0.2-3.4); in subgroup 2 (clearance intramedullary canal) it was 0.7% (95% CI 0.00-6.30) and in subgroup 3 (reaming with RIA system prior to nail fixation) 11.9% (95% CI 1.80-26.40). No statistically significant difference for tibia and femur as RIA system application site was observed (CI 0.69-4.19). In studies reporting blood loss, a mean volume of 803.29 ml, a mean drop of hemoglobin of 3.74 g/dl and a necessity of blood transfusion in 9.72% of the patients were observed. CONCLUSIONS: The systematic review and meta-analysis demonstrate a low overall prevalence rate of complications associated with the RIA system. However, especially the risk of cortical perforation and the frequently reported relevant intraoperative blood loss are complications that should be anticipated in perioperative management and ultimately considered when using the RIA system.

[Treatment of severe medial tibial bone defect in primary total knee arthroplasty with autogenous bone graft and plate fixation].

OBJECTIVE: To explore the technique of autogenous bone graft combined with plate fixation in total knee arthroplasty(TKA) with severe proximal medial tibial bone defect. METHODS: From March 2012 to October 2018, 21 patients (9 males and 12 females) with severe bone defects in the proximal medial tibia during primary total knee arthroplasty were treated with autogenous structural bone grafting and steel plate fixation, with an age of 61 to 77 years old with an average of (69.6±9.1) years and a course of 64 to 257 months with an average of (73.6±170.7) months. According to Rand classification, there were 13 cases of type Ⅲb and 8 cases of type Ⅳb. Postoperative complications were observed, and knee joint function was evaluated by the Hospital for Special Surgery (HSS) score and SF-36 quality of life score. RESULTS: All 21 patients were followed up for 37 to 64 months with an average of (49.5±13.7) months. The incisions of all patients healed smoothly, and 2 patients developed lower limb intermuscular venous plexus thrombosis after operation. There were no periprosthetic infection, loosening of prosthesis and other complications. The autogenous bone grafts of all patients achieved bony healing during postoperative X-ray follow-up, and the healing time was 8 to 13 months with an average of (10.1±2.3) months. The HSS score of patients increased significantly from 30 to 48 with an average of (53.4±4.2) before operation to 75 to 92 with an average of (81.2±8.4) at the final follow-up (P<0.05). The SF-36 quality of life score of patients after operation was significantly different from that before operation (P<0.05). CONCLUSION: The technique of autogenous bone graft combined with steel plate fixation can achieve satisfactory osseointegration effect in the treatment of severe proximal tibial bone defects in primary knee arthroplasty, with less complications and obvious improvement in knee function.

La fijación con tornillo de interferencia tibial cuadrante específico permite un constante desplazamiento de los injertos de tejido dentro de tuneles tibiales mal poscionados: análisis cuantitativo de ligamento cruzado anterior en porcinos / Quadrant specific tibial interference screw fixation allows constant displacement of soft tissue grafts inside misplaced tibial tunnels: a porcine anterior cruciate ligament quantitative assessment study

INTRODUCCIÓN El error técnico más común durante la reconstrucción del ligamento cruzado anterior (LCA) es la ubicación incorrecta del túnel. Es incierto si un túnel tibial mal ubicado puede corregirse en el intraoperatorio. OBJETIVO Medir el desplazamiento del injerto de tejido blando con tornillos de interferencia tibial.MATERIALES Y MÉTODOS Estudio experimental ex vivo en 28 rodillas porcinas. Se cosechó el tendón flexor de la extremidad posterior, que fue duplicado y dimensionado para que pasara a través de un túnel tibial mal posicionado. Las muestras se dividieron en 4 grupos según el cuadrante de entrada (anterior [A], posterior [P], medial [M], o lateral [L]) de un tornillo de interferencia tibial de 9 mm con relación al injerto. Se ubicó una regla milimétrica en la meseta tibial, la cual fue fotografiada con una cámara EOS T6 (Canon Inc., Ota, Tokio, Japón), y la imagen fue digitalizada, y puesta en escala a tamaño. La distancia y dirección de los desplazamientos del injerto se midieron con Adobe Photoshop CC 2019 (San José, CA, EEUU). Se analizaron las diferencias medias entre los grupos por análisis de la varianza (analysis of variance, ANOVA, en inglés) unidireccional. El análisis estadístico se realizó con el programa Statistical Package for the Social Sciences (IBM SPSS Statistics for Windows, IBM Corp., Armonk, NY, EEUU), versión 25.0 (p ≤ 0,05)).RESULTADOS La distancias medias de los desplazamientos del injerto fueron similares en todos los grupos: A ­ 4,4 mm; P ­ 4,6 mm; M ­ 4,5 mm; y L ­ 4,3 mm, sin diferencias estadísticamente significativas (p = 0,894). Las direcciones medias de los desplazamientos del injerto también fueron similares entre los 4 grupos: A ­ 176° (desviación estándar [DE]: ± 15,4°); P ­ 165° (DE: ± 16,6°); M ­ 166° (DE: ± 12,1°); y L ­ 169° (DE: ± 10,6°). No se encontraron diferencias estadísticamente significativas (p = 0.42).CONCLUSIONES Independientemente del cuadrante de entrada, se observó un desplazamiento constante del injerto hacia el lado opuesto cuando el tornillo tibial alcanzaba la superficie articular. Relevancia clínica: el tornillo tibial mal posicionado puede corregirse en el intraoperatorio con fijación proximal en cuadrante específico, y debe alcanzar la superficie articular para generar un desplazamiento efectivo del injerto. Sin embargo, no podemos predecir la magnitud de error en todos los túneles mal brocados, que debe ser evaluada caso a caso.

BACKGROUND The most common technical error during anterior cruciate ligament (ACL) reconstruction is incorrect tunnel placement. It remains unclear if a misplaced tibial tunnel may be corrected intraoperatively. AIM To measure the displacement of soft-tissue grafts with tibial interference screws. MATERIALS AND METHODS Ex-vivo experimental study in 28 porcine knees. The flexor tendon of the posterior limb was harvested, doubled and sized to fit through a 9-mm misplaced tibial tunnel. The specimens were divided into 4 groups according to the quadrant of entry (anterior [A], posterior [P], medial [M], or lateral [L]) of a 9-mm tibial interference screw in relation to the graft. A millimetric ruler was placed at the tibial plateau, which was photographed with a an EOS T6 (Canon Inc., Ota, Tokio, Japan) camera, and the image was digitalized and scaled to size. The length and direction of the graft displacements were measured with Adobe Photoshop CC 2019 (San José, CA, US). The mean differences among the groups were analyzed through one-way analysis of variance (ANOVA). The statistical analysis was performed using the Statistical Package for the Social Sciences (IBM SPSS Statistics for Windows, IBM Corp., Armonk, NY, US) software, version 25.0 (p 0.05) RESULTS The mean lengths of the graft displacements were similar among the groups: A ­ 4.4 mm; P ­4.6 mm; M ­ 4.5 mm; and L ­ 4.3 mm, without statistically significant differences (p » 0.894). The mean directions of the graft displacements were also similar among the groups: A ­ 176° (standard deviation [SD]: 15.4°); P ­ 165° (SD: 16.6°); M ­ 166° (SD: 12.1°); and L ­ 169° (SD: 10.6°). No statistically significant differences were found (p » 0.42). CONCLUSIONS Regardless of the entry quadrant, constant graft displacement to the opposite side was observed when the tibial screw reached the articular surface. Clinical relevance: a misplaced tibial tunnel may be corrected intraoperatively with a quadrantspecific screw, which must reach the articular surface to produce an effective graft displacement. Nevertheless, we cannot predict the magnitude of this error in every poorly-drilled tibial tunnel; it should be assessed case by case.

Immune Response to Persistent Staphyloccocus Aureus Periprosthetic Joint Infection in a Mouse Tibial Implant Model.

Staphyloccocus aureus is one of the major pathogens in orthopedic periprosthetic joint infection (PJI), a devastating complication of total joint arthroplasty that often results in chronic and persistent infections that are refractory to antibiotics and require surgical interventions. Biofilm formation has been extensively investigated as a reason for persistent infection. The cellular composition, activation status, cytokine profile, and role of the immune response during persistent S. aureus PJI are incompletely understood. In this study, we used histology, multiparametric flow cytometry, and gene expression analysis to characterize the immune response in a clinically relevant orthopedic PJI model. We tested the hypothesis that persistent S. aureus infection induces feedback mechanisms that suppress immune cell activation, thereby affecting the course of infection. Surprisingly, persistent infection was characterized by strikingly high cytokine gene expression indicative of robust activation of multiple components of innate and adaptive immunity, along with ongoing severe neutrophil-dominated inflammation, in infected joint and bone tissues. Activation and expansion of draining lymph nodes and a bone marrow stress granulopoiesis reaction were also maintained during late phase infection. In parallel, feedback mechanisms involving T-cell inhibitory receptors and exhaustion markers, suppressive cytokines, and regulatory T cells were activated and associated with decreased T-cell proliferation and tissue infiltration during the persistent phase of infection. These results identify the cellular and molecular components of the mouse immune response to persistent S. aureus PJI and indicate that neutrophil infiltration, inflammatory cytokine responses, and ongoing lymph node and bone marrow reactions are insufficient to clear infection and that immune effector mechanisms are suppressed by feedback inhibitory pathways. These immune-suppressive mechanisms are associated with diminished T-cell proliferation and tissue infiltration and can be targeted as part of adjuvant immunotherapeutic strategies in combination with debridement of biofilm, antibiotics, and other therapeutic modalities to promote eradication of infection. © 2021 American Society for Bone and Mineral Research (ASBMR).

Donor site morbidity of calcaneal, distal tibial, and proximal tibial cancellous bone autografts in foot and ankle surgery. A systematic review and meta-analysis of 2296 bone grafts.

PURPOSE: This study aims to report on the safety and donor site morbidity of the distal lower extremity (calcaneal, proximal, and distal tibial) cancellous bone autografts. We summarized the findings in a comprehensive infographic illustration. We are unaware of any similar meta-analyses to date. METHODS: Following the PRISMA guidelines, two independent investigators searched MEDLINE (PubMed), EMBASE, SCOPUS, Google Scholar, and Cochrane databases in December 2020 using the following keywords and their synonyms: ("bone graft", "donor site morbidity", "calcaneal graft", "proximal tibia graft", and "distal tibia graft"). Besides, the reference lists from previous review articles were searched manually for eligible studies. The primary outcomes of interest were (1) chronic pain, (2) fracture, and (3) infection, whereas the secondary outcomes were (1) neurological complications, (2) sensory disturbance and hypertrophic scars, (3) other complications such as shoe-wear difficulties and gait disturbance. Inclusion criteria were: studies on complications and adverse events of lower extremity bone autografts (calcaneal, proximal tibial, and distal tibial bone autografts) reporting at least one of the desired outcomes. Studies not reporting any of the outcomes of interest or if the full text is not available in English were excluded. Studies reporting on bone marrow aspirate or autografts for non-orthopedic indications were also excluded. RESULTS: After the removal of duplicates, a total of 5981 studies were identified. After screening those records, 85 studies remained for full-text assessment. Out of those, 15 studies qualified for the meta-analysis with a total of 2296 bone grafts. Out of those grafts, 1557(67.8%) were calcaneal grafts, 625 (27.2%) were proximal tibial grafts, and 114 (5%) were distal tibial grafts. In calcaneal bone grafts, there were 28 cases of chronic pain [1.97%, CI:1.10-2.50%, I2 = 66%], 5 fractures [0.32%, CI: 0.10-0.60%,I2 = 0%], 20 sural neuritis [1.28%, CI:0.70-1.80%, I2 = 0%), and no wound infections. In proximal tibial grafts there were 13 cases of chronic pain [2.08%, CI: 1.01-3.2%, I2 = 34.5%], 1 fracture [0.16%, CI:0.10-0.50%, I2 = 0%], and 3 superficial wound infections [0.48%, CI: 0.10-1.01, I2 = 0%]. In the distal tibial grafts there were no cases of chronic pain or wound infections, 1 fracture [0.90%, CI: 0.80-2.6%, I2 = 0%], and 5 saphenous neuritis [4.5%, CI: 0.70-8.40%, I2 = 65%]. CONCLUSION: Calcaneal, distal tibial, and proximal tibial bone autografts are safe with a low rate of overall and major complications. We report an overall complication rate of 6.8%, which is less than half of that previously reported for iliac crest grafts. The authors recommend using distal lower extremity grafts for foot and ankle primary surgeries instead of iliac crest grafts when indicated. Clinical trials with a large sample size are required.

Proximal tibia with an inserted nail can be an available donor site for harvesting cancellous bone.

INTRODUCTION: A pre-existing implant at the harvesting site might dissuade the surgeon from considering the site as available for bone harvesting. This study aimed to investigate the quantity of cancellous bone graft that can be harvested from a proximal tibia with an inserted nail and to report the clinical outcomes of this bone graft harvesting technique. HYPOTHESIS: Our hypothesis was that a certain amount of cancellous bone graft could be harvested from a proximal tibia with an inserted nail without compromising the surrounding environment and outcome of nonunion treatment. MATERIAL AND METHODS: Bone grafting from an ipsilateral proximal tibia with an inserted nail was performed in 32 patients for treating defect nonunion. The amount of harvested bone was measured using three parameters (weight, height, and volume). The effects of the proximal locking screw position on the quantity and location of bone graft harvest were analyzed. Clinical outcomes were evaluated by assessing the radiologic healing of the bone graft site and by assessing the donor site complications. RESULTS: The mean bone defect volume in the nonunion site was 31.1±18.3 (range, 10.6-87.0) cm3. The mean quantity of harvested bone from proximal tibias with an inserted nail was 21.2g, height was 3.9cm, and volume was 26.3 cm3. A positive correlation was found between the quantity of harvested bone and the level of the lateral oblique interlocking screw hole in the tibial nail. All grafted bone successfully consolidated in all cases at an average of 5.8 months postoperatively. However, joint penetration during bone harvesting occurred in one case. DISCUSSION: The bony defect, which measured about 14.3 cm3 could be filled with cancellous bone from a PT with an existing IM nail, without additional bone graft requirements. Even if an intramedullary nail exists inside the proximal tibia, harvesting cancellous bone at this site can be a viable option without serious complications. LEVEL OF EVIDENCE: IV; Retrospective descriptive study.

Osteocytes but not osteoblasts directly build mineralized bone structures.

Bone-forming osteoblasts have been a cornerstone of bone biology for more than a century. Most research toward bone biology and bone diseases center on osteoblasts. Overlooked are the 90% of bone cells, called osteocytes. This study aims to test the hypothesis that osteocytes but not osteoblasts directly build mineralized bone structures, and that defects in osteocytes lead to the onset of hypophosphatemia rickets. The hypothesis was tested by developing and modifying multiple imaging techniques, including both in vivo and in vitro models plus two types of hypophosphatemia rickets models (Dmp1-null and Hyp, Phex mutation mice), and Dmp1-Cre induced high level of ß-catenin models. Our key findings were that osteocytes (not osteoblasts) build bone similar to the construction of a high-rise building, with a wire mesh frame (i.e., osteocyte dendrites) and cement (mineral matrices secreted from osteocytes), which is a lengthy and slow process whose mineralization direction is from the inside toward the outside. When osteoblasts fail to differentiate into osteocytes but remain highly active in Dmp-1-null or Hyp mice, aberrant and poor bone mineralization occurs, caused by a sharp increase in Wnt-ß-catenin signaling. Further, the constitutive expression of ß-catenin in osteocytes recaptures a similar osteomalacia phenotype as shown in Dmp1 null or Hyp mice. Thus, we conclude that osteocytes directly build bone, and osteoblasts with a short life span serve as a precursor to osteocytes, which challenges the existing dogma.

Cancellous Tibial Bone Graft for Malunion after Mandibular Reconstruction in Head and Neck Cancer.

OBJECTIVES/HYPOTHESIS: While nonunion after mandibular reconstruction for head and neck surgery is rare, literature exploring management is scarce. Our primary objective was to determine success rates of tibial bone graft (TBG) in achieving mandibular union. Secondary objectives include determining factors that contribute to failure of TBG. STUDY DESIGN: Retrospective Chart Review. METHODS: Retrospective chart review between January 1, 2008 and December 31, 2018. Patients who underwent a mandibulotomy or mandibulectomy with osteocutaneous free flap reconstruction were identified. Patients who were pursuing dental rehabilitation, subsequently diagnosed with mandibular nonunion and received a cancellous TBG were assessed. RESULTS: The 15 patients meeting inclusion criteria were mostly male (67%), white (87%), and nonsmokers (67%) with a median age of 64 (IQR = 60-73). Successful union occurred in 13 of 18 (72%) TBGs and the majority (63%) had a partial union documented at the time of surgery. Five patients (83%) who initially had a mandibulotomy achieved union compared to 78% of those with osteocutaneous reconstruction (P = 1.0). Postoperative radiation did not affect rates of union: 80% for both (P = 1.0). Patients with osteoradionecrosis (ORN) achieved union in 67% of cases compared to 75% of cases who did not have ORN (P = .86). There were similar rates of union for those who required perioperative antibiotics for infection and those without infection (67% vs. 75%, P = .86). Dental rehabilitation was achieved in 55% of patients, most commonly dentures. CONCLUSIONS: This study shows that TBG can be used to achieve union for patients with malunion after head and neck cancer reconstruction. We show its successful use within the reconstructive algorithm for patients regardless of postoperative radiation for very small defects. LEVEL OF EVIDENCE: 3 Laryngoscope, 131:1291-1296, 2021.

The Use of Autologous Iliotibial Band With Gerdy's Tubercle for Irreparable Rotator Cuff Tears.

OBJECTIVE: To determine the radiographic and functional outcomes after autologous iliotibial band with Gerdy's tubercle (ITB-GT) interposition in patients with irreparable rotator cuff tears (IRCTs). METHODS: From December 2015 to March 2017, a total of 16 patients who underwent autologous ITB-GT interposition for IRCTs were identified, including 4 males and 12 females. The mean age was 56.1 ± 10.3 years (range, 44-67 years). Functional assessment consisted of active range of motion (ROM), Visual Analogue scale (VAS), American Shoulder and Elbow Surgeons (ASES) score, Constant-Murley score, and patient satisfaction rate. The tendon integrity and acromiohumeral interval (AHI) were assessed by postoperative magnetic resonance imaging (MRI). RESULTS: The mean duration of follow-up was 25.3 ± 3.5 months. At final follow-up, the patients exhibited significantly improved forward elevation, external rotation, and internal rotation (75.00° ± 13.16° to 159.37° ± 8.51°, t = 26.71, P = 0.001; 17.81° ± 11.54° to 35.31° ± 8.26°, t = 6.57, P = 0.001; 2 to 11, t = 13.10, P = 0.001). Other functional outcomes as measured by VAS score, ASES score, and Constant-Murley score also improved significantly (6.50 ± 1.41 to 1.06 ± 0.93, t = 11.68, P = 0.001; 38.50 ± 8.68 to 81.75 ± 6.80, t = 15.42, P = 0.001; 32.50 ± 8.53 to 77.12 ± 6.72, t = 17.28, P = 0.001). The overall satisfaction rate was 87.5%. The postoperative MRI showed that the tendon integrity was fully intact in 14 patients and partially intact in two patients. The AHI improved significantly from 3.63 ± 1.25 mm preoperatively to 8.37 ± 1.02 mm postoperatively (t = 11.78, P = 0.001). CONCLUSION: Autologous ITB-GT interposition was a useful treatment option for patients with IRCTs, which resulted in significant improvements in active ROM, subjective functional outcomes, and AHI with excellent tendon integrity at a minimum 2-year follow-up.

Preserving the Knee in the Setting of High Segmental Tibial Bone and Massive Soft-Tissue Loss Using Vascularized Distal Tibial Bone Docking and a Foot Fillet Flap: A Case Report.

CASE: We discuss our reconstructive approach to avoid an above-knee amputation in a 33-year-old man presenting after lower extremity crush injury. We used a vascularized tibial bone flap and a foot fillet flap to restore length and joint functionality to the residual limb. The patient ambulates with good prosthetic fit on durable heel pad skin and 100° active knee motion. CONCLUSION: This pairing of intramedullary nail with vascularized bone flap and fillet flap to address soft-tissue coverage and retain limb length is a useful tool in traumatic lower extremity injury management, providing an alternative technique for tibial bone graft stabilization with robust, sensate tissue coverage.

USE OF MEDIAL FEMORAL CONDYLE FLAP AND ANTEROLATERAL THIGH FREE FLAP IN PROXIMAL TIBIAL POSTTRAUMATIC NON-UNION WITH MULTIPLE ANASTOMOSIS - CASE REPORT.

Fractures of the proximal tibia are high energy fractures. According to available literature, 3-4% of all fractures heal problematically with non-union or osteomyelitis. Usage of locking compression plating system as well as usage of hybrid fixator is associated with the risk of compartment syndrome, local infection and subsequent malunion, osteomyelitis or non-union. We present a case of 30-year-old male suffering from posttraumatic non-union. The medial femoral condyle flap was selected due to its favourable properties providing a highly vascularised osteogenic tissue in combination with anterolateral thigh flap and Corlett loop. Our case report describes a reconstruction of a long weight-bearing bone. Despite the amount of anastomoses and usage of vein graft, the selected method of reconstruction seems to be safe and with a long-lasting benefit for the patient.

Do Massive Allograft Reconstructions for Tumors of the Femur and Tibia Survive 10 or More Years after Implantation?

BACKGROUND: Massive bone allografts have been used for limb salvage in patients undergoing bone tumor resections as an alternative to endoprostheses. Although several studies on massive allograft reconstructions for bone tumors reported that most complications occur in the first 3 years after surgery, there are no long-term reports on complications to substantiate this contention. We believe such information is important so that surgeons and patients can make more informed decisions when choosing a reconstructive method after tumor resection. QUESTIONS/PURPOSES: (1) What is the survival of allografts free from removal, amputation, or joint replacement in patients treated for bone tumors in the lower limb with a minimum of 10 years of followup? (2) What complications occur after 10 or more years of followup? (3) Are there factors associated with allograft survival, such as age, sex, the affected bone, reconstruction type (intercalary or osteoarticular allograft), tumor type (malignant or benign), failure type, and chemotherapy use? METHODS: We retrospectively analyzed the records of 398 patients treated in one center with benign or malignant bone tumors in the femur or tibia between 1986 and 2007. During the period in question, our general indications for using allografts (354 patients) included patients with benign or low-grade sarcomas and patients with high-grade sarcomas with clinical and imaging response to neoadjuvant chemotherapy. Other approaches such as endoprostheses (44 patients) were indicated if the patient received radiotherapy, in patients with high-grade sarcomas without clinical and imaging response to neoadjuvant chemotherapy, or with neurovascular tumor involvement. We excluded from the analysis 53 patients treated with allograft-prosthetic composites, 46 with hemicondylar osteoarticular allografts, and 57 with intercalary hemicylindrical allografts. The study was thus performed in 198 patients treated with segmental massive allografts in the long bones of the lower extremity (132 femurs and 66 tibias) after resection of a primary bone tumor, including 120 patients treated with osteoarticular and 78 with segmental intercalary allografts. A total of 32 (16%) of the 198 patients died before 10 years, and graft status was known in all of those patients; these patients were included (mean followup, 192 months; range, 1-370 months). All remaining 166 patients who were not known to have died before 10 years were accounted for at least 10 years after the allograft procedure (mean, 222 months; range, 120-370 months). No patient was lost to followup. The mean age was 22 years (range, 2-55 years); 105 patients were male (53%) and 93 were female. The predominant diagnoses were osteosarcoma (n = 125, 63%), giant cell tumor of bone (n = 27, 14%), and Ewing's sarcoma (n = 19, 10%). In all, 146 patients (74%) underwent chemotherapy. Selected variables were analyzed using multivariate logistic regression analyses to identify risk factors of allograft removal, joint replacement, or amputation. We performed competitive risk analysis with allograft removal, joint replacement, or amputation as the endpoint at 5, 10, and 20 years. Patient function was evaluated using the Musculoskeletal Tumor Society (MSTS)-93 scoring system. RESULTS: The risk of allograft removal, joint replacement, or amputation was 36% at 5 years (95% CI, 30-43), 40% at 10 years (95% CI, 33-47), and 44% at 20 years (95% CI, 37-51). Fractures occurred in 15% (29 patients), infection in 14% (27 patients), nonunion in 12% (23 patients) and tumor recurrence in 7% (13 patients). Thirty-two patients died of disease before 10 years; nine of these patients had a second surgery before death, eight had an amputation, and one underwent graft removal. Of the 166 patients who were still alive 10 years after the allograft procedure, 36 underwent allograft removal, six patients underwent joint replacement, and four had an amputation; however, after 10 years, six more allografts were removed (four due to fractures, one due to infection, and one due to instability), and another patient was amputated due to a second malignancy. After controlling for potentially confounding variables including death, we found that the risk of allograft removal, joint replacement, or amputation in osteoarticular tibial grafts (58% [95% CI, 43-73] at 5, 10, and 20 years) was higher than that of osteoarticular femur allografts (29% [95% CI, 18-39] at 5 years, 30% [95% CI, 19-40] at 10 years, 37% [95% CI, 25-48] at 20 years; p = 0.010) and tibia intercalary allografts (26% [95% CI, 7-45] at 5, 10 and 20 years; p = 0.020). Fractures occurred more frequently in the femur (18% [95% CI, 11-25]) than in the tibia (5% [95% CI, 0-10]; p < 0.010), and infections occurred more frequently in the tibia (24% [95% CI, 14-35]) than in the femur (4% [95% CI, 0-8]; p < 0.001). With the number of patients we had, we found no difference in the proportion of local recurrence in the tibia (12% [95% CI, 4-20]) compared with the femur (5% [95% CI, 1-9]; p < 0.053). CONCLUSIONS: Infections were the most common complications associated with allograft removal in the first 2 to 3 years after reconstruction and were more frequently associated with tibial allograft removal. Fractures were more commonly associated with graft removal with longer term followup and were more frequently associated with femoral allograft removal. Although we cannot directly compare our results with other types of reconstructions, we believe that allografts still have a role in the reconstruction of patients with a benign or low-grade bone tumor. Future studies in femoral allograft with longer followup should be performed to analyze factors that may explain why some grafts fail, such as the percent of the length of the bone resected, type and number of plates and screws used and type of fixation (rods versus plates). There was a higher incidence of graft removal in patients with proximal tibia osteoarticular allografts, which has led us to use this type of reconstruction only in pediatric patients over the last 15 years. LEVEL OF EVIDENCE: Level III, therapeutic study.

Patient-Reported Outcomes After Structural Autograft for Large or Cystic Talar Dome Osteochondral Lesions.

BACKGROUND: While smaller talar dome osteochondral lesions (OCLs) are successfully treated with bone marrow stimulation techniques, the optimal treatment for large or cystic OCLs remains controversial. This study tested the hypothesis that transferring structural autograft bone from the distal tibia to the talus for large or cystic OCLs improves pain and function. METHODS: Thirty-two patients with large or cystic OCLs underwent structural bone grafting from the ipsilateral distal tibia to the talar dome. Patients were assessed with subjective patient-centered tools and objective clinical outcomes. Average age was 48.6 ± 14.9 years, and average follow-up was 19.5 ± 13.3 months. Average lesion area was 86.2 ± 23.5 mm2, and average depth was 8.4 ± 3.0mm. RESULTS: At final follow-up, improvement compared to preoperative scores was seen in American Orthopaedic Foot & Ankle Society (65.4 ± 21.2 to 86.9 ± 15.0, P < .05), Foot Function Index (48.9 ± 20.8 to 21.1 ± 18.9, P < .05), visual analog scale for pain (4.7 ± 3.0 to 1.4 ± 1.5, P < .05), and Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function (40.4 ± 5.4 to 45.5 ± 7.4, P < .05) scores. There was no improvement in PROMIS pain interference (54.7 ± 18.1 to 52.4 ± 7.3, P > .05). Satisfaction with surgery was 8.4 ± 1.3/10, and 96% of patients would have the procedure again. Ninety-four percent of patients returned to work and/or play. One patient had a deep vein thrombosis 6 weeks postoperatively, and 1 patient underwent ankle fusion at 18 months postoperatively. CONCLUSION: This study demonstrates that structural bone graft harvested from the distal tibia transferred to the talus was a safe and effective treatment for large and cystic OCLs. Outcomes compare favorably to other described techniques for treatment of these injuries. LEVEL OF EVIDENCE: Level IV, case series.

Inside-Out Repair of the Meniscus in Concomitant Anterior Cruciate Ligament Reconstruction: Absorbable Versus Nonabsorbable Sutures.

PURPOSE: To compare the clinical and magnetic resonance imaging (MRI) outcomes of meniscal repair using absorbable versus nonabsorbable sutures in patients undergoing concomitant anterior cruciate ligament reconstruction. METHODS: Data of 142 patients who underwent meniscal repair with concomitant anterior cruciate ligament reconstruction using either absorbable or nonabsorbable sutures for longitudinal meniscal tear were retrospectively reviewed. Inside-out suture technique was used for all meniscal repairs. Weight bearing and flexion (>90°) were allowed after 6 weeks postoperatively. Clinical evaluations were assessed by the International Knee Documentation Committee subjective score, Lysholm score, and Tegner activity score preoperatively and at 2-year follow-up. MRI outcomes at 1-year follow-up were compared to identify the successful healing (complete or partial healing) rate and incidence of additional meniscal tears. Subgroup analysis was performed to evaluate the results of medial or lateral meniscus. RESULTS: Eighty patients underwent meniscal repair using absorbable sutures (mean age, 26.3 ± 11.9 years) and 62 patients with nonabsorbable sutures (mean age, 27.2 ± 10.0 years). There were no differences in zone and length of meniscal tears and stability tests between the groups. At a 2-year follow-up, all clinical scores had improved in both groups but did not differ significantly between the groups. Successful healing rate based on 1-year postoperative MRI was not significantly different between the absorbable and nonabsorbable sutures (93.7% vs 96.8%, P = .469). However, the absorbable sutures showed a lower additional tear incidence than the nonabsorbable sutures (2.5% vs 9.6%, P = .031). Subgroup analysis showed that the successful healing rate was not significantly different between the suture materials in both the medial and lateral menisci. CONCLUSIONS: The use of absorbable sutures leads to comparable healing rates to and lower incidence of additional tears than nonabsorbable sutures in patients undergoing meniscal repair with anterior cruciate ligament reconstruction. LEVEL OF EVIDENCE: Level III, retrospective comparative therapeutic trial.

Comparison Matrix-Associated Stem Cell Transplantation (MAST) with Autologous Matrix Induced Chondrogenesis plus Peripheral Blood Concentrate (AMIC+PBC) in chondral lesions at the ankle-A clinical matched-patient analysis.

BACKGROUND: The aim of the study was to compare Matrix-Associated Stem Cell Transplantation (MAST) with Autologous Matrix Induced Chondrogenesis plus Peripheral Blood Concentrate (AMIC+PBC) in chondral lesions at the ankle. METHODS: In a matched-patient clinical follow-up study, patients with chondral lesion at the ankle that were treated with MAST from April 1, 2009 to July 15, 2016, and patients that were treated with AMIC+PBC from July 17, 2016 to May 31, 2017 were included and compared. Size and location of the chondral lesions and the Visual-Analogue-Scale Foot and Ankle (VAS FA) before treatment and at follow-up were analysed. Bone Marrow Aspirate Concentrate (BMAC) was used for MAST and Peripheral Blood Concentrate (PBC) for AMIC+PBC to impregnate a collagen I/III matrix (Chondro-Gide, Wollhusen, Switzerland) that was fixed into the chondral lesion with fibrin glue. RESULTS: One hundred and twenty-nine patients with 136 chondral lesions were included in both groups. The chondral lesions were located as follows (MAST/AMIC+PBC, n (%)), medial talar shoulder only, 59 (43)/62 (46); lateral talar shoulder only, 44 (32)/42 (31); medial and lateral talar shoulder, 7 (10)/7 (10); tibia, 19 (14)/18 (13). The lesion size was 1.6/1.8cm2 on average and VAS FA was 46.9/45.7 (MAST/AMIC+PBC). For MAST/AMIC+PBC groups, 107 (83%)/105 (81%) with 112/110 previous chondral lesions completed the defined 2-year-follow-up after 24.4/23.8 months on average. VAS FA improved to 82.3/79.8 (MAST/AMIC+PBC). No parameter significantly differed between MAST and AMIC+PBC groups. CONCLUSIONS: MAST and AMIC+PBC as part of a complex surgical approach led to improved and high validated outcome scores in 2-year-follow-up. MAST and AMIC+PBC showed similar results.

Donor-Specific Human Leukocyte Antigen Antibody Formation After Distal Tibia Allograft and Subsequent Graft Resorption.

The association between donor-specific human leukocyte antigen (HLA) antibody formation and small bone allograft resorption has not been studied. We present the case of a patient treated for glenoid bone loss using a distal tibial allograft with Bankart repair who formed donor-specific HLA antibodies against the allograft and had subsequent graft resorption. X-ray and computed tomography (CT) scans were performed before and after surgery at standard checkpoints. Patient blood and serum samples were collected before and after surgery for HLA typing and HLA antibody testing. Human leukocyte antigen antibodies against the donor-specific HLA-A2 antigens were identified 6 weeks after surgery and were still detected at 5 months after surgery. At 6 months after surgery, a CT arthrogram revealed significant graft resorption. This case shows a temporal correlation between HLA antibody formation and clinical findings, potentially suggesting an association between HLA antibody formation and graft resorption. Further study is required to confirm this.