Free iliac crest grafting technology for the management of critical-sized tibial bone defect.

OBJECTIVE: To introduce the method and experience of treating critical-sized tibial bone defect by taking large iliac crest bone graft. METHODS: From January 2020 to January 2022, iliac crest bone grafting was performed in 20 patients (10 men and 10 women) with critical-sized tibial bone defect. The mean length of bone defect was 13.59 ± 3.41. Bilateral iliac crest grafts were harvested, including the inner and outer plates of the iliac crest and iliac spine. The cortical bone screw was used to integrate two iliac bone blocks into one complex. Locking plate was used to fix the graft-host complex, supplemented with reconstruction plate to increase stability when necessary. Bone healing was evaluated by cortical bone fusion on radiographs at follow-up, iliac pain was assessed by VAS score, and lower limb function was assessed by ODI score. Complications were also taken into consideration. RESULTS: The average follow-up time was 27.4 ± 5.6 (Range 24-33 months), the mean VAS score was 8.8 ± 1.9, the mean ODI score was 11.1 ± 1.8, and the number of cortical bone fusion in the bone graft area was 3.5 ± 0.5. Satisfactory fusion was obtained in all cases of iliac bone transplant-host site. No nonunion, shift or fracture was found in all cases. No infection and bone resorption were observed that need secondary surgery. One patient had dorsiflexion weakness of the great toe. Hypoesthesia of the dorsal foot was observed in 2 patients. Ankle stiffness and edema occurred in 3 patients. Complications were significantly improved by physical therapy and rehabilitation training. CONCLUSION: For the cases of critical-sized tibial bone defect, the treatment methods are various. In this paper, we have obtained satisfactory results by using large iliac bone graft to treat bone defect. This approach can not only restore the integrity of the tibia, but also obtain good stability with internal fixation, and operation skills are more acceptable for surgeons. Therefore, it provides an alternative surgical method for clinicians.

The fusion rates at different times of cortical iliac crest autograft or allograft compared with cages after anterior cervical discectomy and fusion: a meta-analysis.

OBJECTIVE: The cortical iliac crest autograft (CICA)/structural allograft (SA) has still been recognized as the gold standard for the ACDF technique for its high degree of histocompatibility and osteoinduction ability though the flourishing and evolving cage development. However, there was no further indication for using CICA/SA in ACDF based on basic information of inpatients. Our operative experience implied that applying CICA/SA has an advantage on faster fusion but not the long-term fusion rate. Therefore, our study aimed to compare the fusion rates between CICA and cage, between SA and cage, and between CICA/CA and cage. METHODS: Based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), a comprehensive literature search of electronic databases including PubMed, Embase, Cochrane Library and Web of Science was conducted to identify these clinical trials that investigated the postoperative 3, 6, 12 and 24 months fusion rates of CICA/structural SA versus cage. Assessment of risk of bias, data extraction and statistical analysis were then carried out by two independent authors with the resolve-by-consensus method. The primary outcome was fusion rate at 3, 6, 12 and 24 months postoperatively. The secondary outcomes were also meta-analyzed such as hardware complications, operative duration and hospitalization time. Our meta-analysis was registered with PROSPERO (Identifier: CRD42022345247). RESULT: A total of 3451 segments (2398 patients) derived from 34 studies were included after the screening of 3366 articles. The segmental fusion rates of CICA were higher than cages at 3 (P = 0.184, I2 = 40.9%) and 6 (P = 0.147, I2 = 38.8%) months postoperatively, but not 12 (P = 0.988, I2 = 0.0%) and 24 (P = 0.055, I2 = 65.6%) months postoperatively. And there was no significant difference in segmental fusion rates between SA and cage at none of 3 (P = 0.047, I2 = 62.2%), 6 (P = 0.179, I2 = 41.9%) and 12 (P = 0.049, I2 = 58.0%) months after operations. As for secondary outcomes, the CICA was inferior to cages in terms of hardware complications, operative time, blood loss, hospitalization time, interbody height, disk height and Odom rating. The hardware complication of using SA was significantly higher than the cage, but not the hospitalization time, disk height, NDI and Odom rating. CONCLUSION: Applying CICA has an advantage on faster fusion than using a cage but not the long-term fusion rate in ACDF. Future high-quality RCTs regarding the hardware complications between CICA and cage in younger patients are warranted for the deduced indication.

Comparison of corticocancellous bone graft from the anterolateral metaphysis of the distal radius versus iliac crest for the treatment of unstable scaphoid nonunion with humpback deformity.

BACKGROUND: Corticocancellous bone grafting from the iliac crest is acceptable treatment for unstable scaphoid nonunion with a viable proximal pole. However, harvesting graft from the iliac crest is associated with donor site morbidity and the requirement of general anesthesia. Thus, bone grafting from the anterolateral metaphysis of the distal radius (DR) can be a treatment option. However, no study has compared the clinical effect between the two grafting techniques. METHODS: From 2014 to 2019, patients with unstable scaphoid nonunion with humpback deformity underwent corticocancellous bone grafting from the anterolateral metaphysis of the DR (group DR) or iliac crest (group IC). Humpback deformity was determined by evaluating the scapholunate angle (SLA) ≥ 60°, intrascaphoid angle (ISA) ≥ 45°, and radiolunate angle (RLA) ≥ 15° from preoperative radiographs and computed tomography scans. The SLA, ISA, and RLA served to gauge carpal alignment. The operative time, grip strength, active range of motion (ROM), the Modified Mayo Wrist score (MMWS), and Disabilities of Arm, Shoulder, and Hand (DASH) score were assessed postoperatively. RESULTS: Thirty-eight patients qualified for the study (group DR, 15; group IC, 23). Union rates did not differ by patient subset (group DR, 100%; group IC, 95.7%; P = .827), and grip strength, ROM, MWS, and DASH score were similar between groups at the last follow-up. The operative time (minutes) was significantly shorter in group DR (median, 98; quartiles, 80, 114) than in group IC (median, 125; quartiles, 105, 150, P < .001). The ISA, RLA, and SLA improved postoperatively in both groups (P < 0.001). The degree of restoring carpal alignment, as evaluated by SLA, showed superior correction capability in group DR (median, 25.3% quartiles, 21.1, 35.3, P < 0.05). Donor site complications were not significantly different between the groups. CONCLUSIONS: Corticocancellous bone graft from the anterolateral metaphysis of the DR for unstable scaphoid nonunion is associated with a shorter operation time and comparable results with that from the iliac crest in regard to union, restoration of carpal alignment, and wrist function. LEVEL OF EVIDENCE: Level III.

Use of autologous iliac crest graft and free anterolateral femoral skin flap in diabetic foot ulcers: a case report.

BACKGROUND: Diabetic foot has a great impact on the life of patients. Its treatment involves a multi-disciplinary and multi-direction approach, which requires not only soft tissue repair, but also bone reconstruction and functional repair. CASE PRESENTATION: A 51-year-old Chinese man with a three-year history of diabetes was diagnosed with ulcers in his left foot. We performed a successful procedure, and the different strategies we adopted helped to avoid serious complications during treatment. The patient was treated with debridement, bone cement, iliac crest graft, and anterolateral femoral skin flap, and recovered well. CONCLUSION: There is a dearth of reports pertaining to treatment of diabetic foot in patients with midfoot bone and soft tissue loss. In this report, we present an effective method that we used to reconstruct the loss of midfoot in a patient with diabetic foot, illustrating a successful therapeutic strategy for saving limbs in this complex medical condition.

Non-vascularised corticocancellous (tricortical) iliac bone graft longer than 3 cm for non-union after failed surgical treatment.

PURPOSE: We hypothesised that traditional iliac tricortical bone grafts (no vascularised) still have a reasonable role in promoting satisfactory bony healing in non-union defects of certain sizes. Here, we report the clinical/radiological outcomes through a retrospective case series. METHODS: We screened 74 patients with definitive non-union in the long bones of the upper extremities who visited the outpatient department from 2008 to 2018. Among these patients, 25 who met our inclusion/exclusion criteria were investigated. RESULTS: The mean age was 51.92 years, and there were 12, 9, 1, and 3 lesions of the radius, ulna, clavicle, and humerus, respectively. The tools for primary fixations were plate and intramedullary nails in 24 and 1 patients, respectively. Six patients presented with atrophic non-union. The mean period from a previous surgery was 6.84 months. The mean defective bone sizes were 1.81 and 3.50 cm pre-debridement and post-debridement, respectively. All devices had locking plates longer than the previous plate, and the graft was concurrently fixed by screws in three patients. At a mean of 15.92 weeks after the revision surgery, all patients experienced union. At the final follow-up, the clinical outcomes were satisfactory. No significant differences in clinical outcomes were found according to the lesion, type of non-union, period from the previous surgery, or harvest length of the iliac bone. CONCLUSIONS: If the proper indications and some technical aspects are considered, a non-vascularised iliac bone graft longer than 3 cm could still be a reasonable option for treating diaphyseal non-union of the upper extremities. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Iliac crest bone graft versus cell-based grafts to augment spinal fusion: a systematic review and meta-analysis.

INTRODUCTION: Despite successful fusion rates with iliac crest bone graft (ICBG), donor-site morbidity and increased operating time remain a considerable limitation and drive the search for alternatives. In this systematic review, grafts with additional cellular supplementation were compared with ICBG for spinal arthrodesis. We compared safety, efficacy and long-term outcomes, thus providing the current and relevant evidence for orthopaedic surgeons to make informed choices regarding this rapidly developing field. METHODS: An electronic literature search was conducted according to the PRISMA guidelines by two independent reviewers for articles published up to 1st March 2023 using PubMed, EMBASE and the Cochrane Central Register of Controlled Trial. Cellular allografts were not included. The following data were extracted: Number of patients, type of graft, fusion assessment method, follow-up duration, fusion rates, clinical outcomes and complications. The methodological quality of evidence (MQOE) was assessed using the Risk of Bias 2 (RoB-2) tool and Risk of Bias In Non-Randomised Studies (ROBINS) tool developed by Cochrane for evaluating bias in randomised and non-randomised studies. RESULTS: Ten studies fulfiled the inclusion criteria, including 465 patients. The mean number of patients per study was 43.8 (std dev. 28.81, range 12-100). Two studies demonstrated cell-based therapy to be significantly more successful in terms of fusion rates compared to ICBG. However, the remaining eight demonstrated equivocal results. No study found that cell-based therapy was inferior. No difference was seen between the two groups in three studies who focused on degenerative cohorts. No difference in functional outcome scores was seen between the groups. A number of different preparation techniques for cell-based grafts were used throughout the studies. CONCLUSION: Cell-based therapy offers a promising alternative to ICBG in spinal fusion surgery, which could help reduce the associated morbidity to patients. This review found that cell-based therapy is non-inferior to iliac crest bone graft and may offer patients an alternative treatment option with fewer complications and reduced post-operative pain. However, the literature to date is limited by heterogeneity of the cell preparation and grafting process. Future research with a unified approach to the cell preparation process is required to fully delineate the potential advantages of this technology.

All-Arthroscopic Glenoid Bone Augmentation Using Iliac Crest Autograft Procedure for Recurrent Anterior Shoulder Instability: Button Fixation Is a Feasible and Satisfactory Alternative to Screw Fixation.

PURPOSE: To investigate the efficacy of all-arthroscopic glenoid bone augmentation surgery using the iliac crest autograft procedure. Furthermore, we sought to compare the clinical and radiographic outcomes of using screw versus button fixation, in patients with recurrent anterior shoulder instability. METHODS: Between 2015 and 2019, 134 shoulders with persistent instability were surgically treated with an arthroscopically placed autologous iliac crest bone graft transfer procedure. Preoperative and postoperative clinical follow-up data were evaluated using the range of motion, and the Walch-Duplay, American Shoulder and Elbow Society, and Rowe scores. Radiologic assessment on 3-dimensional computed tomography scans was performed preoperatively, immediately after surgery, as well as postoperatively, at 3 months, 6 months, 1 year, and at the final follow-up stage. Graft positions, healing, and resorption were evaluated from postoperative images. RESULTS: This study included 102 patients who underwent arthroscopic iliac crest bone grafting procedure with 2 screws fixation (n = 37; group 1) and 2 button fixation (n = 65; group 2). The mean follow-up period was 37 months. There were no significant differences between groups in terms of clinical scores, shoulder motion range, graft healing, or graft positions on computed tomography scans (P>.05). In group 1, 1 patient showed mechanical irritation and persistent pain around the screw insertion site, being treated through the arthroscopic removal of the screws. The average postoperative bony resorption percentages were 20.3% and 11.2% at 6 months, and 32.4% and 19.3% at 12 months, in group 1 and group 2, respectively. A statistically significant difference was detected between the two groups (P<.05). CONCLUSIONS: In the arthroscopic iliac crest bone grafting procedure for the treatment of chronic osseous anterior shoulder instability, excellent functional results were obtained after both button fixation and screw fixation techniques. In addition, less graft resorption and no hardware-related complications were detected with suture button fixation technique. LEVEL OF EVIDENCE: Level III, retrospective comparative therapeutic trial.

Quantitative Volumetric Measurements of Bone Grafting Sites Within the Lower Extremity on Computed Tomography Scans.

The anterior iliac crest is one of the most used options; however, pain and other complications have been reported. Other options for bone harvest in the lower extremity, such as the proximal tibia and calcaneus, can be useful sites for bone grafting. Computed tomography angiography images of the lower extremity were analyzed using 3-D Slicer™ medical imaging software, creating an advanced 3-dimensional model. Bone volume (cm3) and bone mineral density (Hounsfield units) were measured from the cancellous bone in the anterior iliac crest, posterior iliac crest, proximal tibia, and the calcaneus. Fifteen studies were included. The total volume measured it was of 61.88 ± 14.15 cm3, 19.35 ± 4.16 cm3, 32.48 ± 7.49 cm3, 26.40 ± 7.18 cm3, for the proximal tibia, anterior and posterior iliac crest, and calcaneus, respectively. Regarding Hounsfield units, the densities were 116 ± 58.77, 232.4 ± 68.65, 214.4 ± 74.45, 170.5 ± 52.32, for proximal tibia, anterior and posterior iliac crest, and calcaneus. The intraclass correlation coefficients were in average >0.94. In conclusion, the proximal tibia has more cancellous bone than the anterior and posterior iliac crest. The calcaneus has more cancellous bone than the anterior iliac crest. Bone mineral density was highest in the anterior iliac crest and in proximal tibia was the lowest value.

Alveolar cleft reconstruction using bone marrow aspirate concentrate and iliac cancellous bone: A 12-month randomized clinical study.

OBJECTIVE: This study aimed to compare the bone density and volume in patients with alveolar cleft reconstructions utilizing bone marrow aspirate concentrate with iliac graft versus iliac graft alone. MATERIAL AND METHODS: Thirty-six patients with unilateral alveolar cleft were randomly allocated into either an intervention group receiving an iliac bone graft mixed with bone marrow concentrate or a control group receiving an iliac bone graft. Cone beam CT was obtained preoperative, 6 and 12 months postoperatively to assess the bone density of the graft and bone volume of the alveolar defect, and then, the bone loss ratio was calculated. RESULTS: Bone volume and bone density demonstrated a statistically significant increase in the intervention group at 6 and 12 months. In contrast, the bone loss ratio decreased significantly in the intervention group throughout the follow-up period. CONCLUSION: A combination of bone marrow concentrate and iliac cancellous bone in alveolar cleft reconstruction may improve bone densities and volume in addition to decreasing graft loss rate. CLINICAL SIGNIFICANCE: Using of bone marrow aspirate concentrate will decrease the amount of the graft needed and decrease the ratio of bone loss at the grafted site by the time. Trial registration ClinicalTrials.org ( NCT04414423 ) 4/6/2020.

Comparison of two preserved cartilage iliac crest cortical-cancellous bone blocks graft harvesting techniques in children: A prospective, double-blind, randomized clinical trial.

PURPOSE: To compare donor-site morbidity for alveolar bone grafting results following cartilage-preserving outer and inner cortico-cancellous iliac crest (OCIC and ICIC) bone block grafting in children. MATERIALS AND METHODS: Patients were randomly divided into two groups and prospectively reviewed. In the OCIC and ICIC groups, cortico-cancellous bone blocks were harvested at outer and inner iliac crest respectively. Patient characteristics and surgical parameters were compared; pain intensity and duration, lateral femoral cutaneous nerve (LFCN) injury, gait disturbance, scar and contour satisfaction were analysed postoperatively. RESULTS: Forty-nine consecutive patients (OCIC, 24; ICIC, 25) were included. There were no significant differences in patient characteristics or donor-site surgical parameters. The mean pain score on the first post-operative day was significantly lower in the OCIC group (3.75±1.70) than in the ICIC group (5.20±2.08) (p=0.012). The pain duration was similar in the two groups (median: 5 days). Temporary LFCN injury only occurred in 3 patients in the ICIC group. Postoperatively, the duck and circle gaits were observed in the OCIC and ICIC groups, respectively. There were no significant differences in the claudication duration, scar and contour satisfaction between the groups. CONCLUSION: OCIC bone graft harvesting is marginally advantageous in children due to less early postoperative donor-site pain and a lower risk of nerve damage.

The arthroscopic treatment of anterior shoulder instability with glenoid bone loss shows similar clinical results after Latarjet procedure and iliac crest autograft transfer.

PURPOSE: Recurrent anterior shoulder instability caused by critical bone loss of the glenoid is a challenging condition for shoulder surgeons. The purpose of this prospective multicenter trial was to compare the arthroscopic transfer of the coracoid process (Latarjet procedure) with the arthroscopic reconstruction of the glenoid using iliac crest autografts. METHODS: A prospective multi-center trial was performed in nine orthopaedic centres in Austria, Germany and Switzerland between July 2015 and August 2021. Patients were prospectively enrolled and received either an arthroscopic Latarjet procedure or an arthroscopic iliac crest graft transfer. Standardized follow-up after 6 months and mimimum 24 months included range of motion, Western Ontario stability index (WOSI), Rowe score and subjective shoulder value (SSV). All complications were recorded. RESULTS: 177 patients (group Latarjet procedure: n = 110, group iliac crest graft: n = 67) were included in the study. WOSI (n.s.), SSV (n.s.) and Rowe score (n.s.) showed no difference at final follow-up. 10 complications were seen in group Latarjet procedure and 5 in group iliac crest graft; the frequency of complications did not differ between the two groups (n.s.). CONCLUSION: The arthrosopic Latarjet procedure and arthroscopic iliac crest graft transfer lead to comparable results regarding clinical scores, frequency of recurrent dislocations and complication rates. LEVEL OF EVIDENCE: Level II.

Decline in Separate Incision Autograft for Spine Surgery Over the Past Decade: A Fading "gold standard".

BACKGROUND: Spinal fusion is a common procedure for which bone grafting is a critical component. Although iliac crest (separate incision autograft) is typically referred to as the "gold standard" grafting material, it seems to be used less and less frequently. METHODS: The 2010 to Q3 2020 MSpine PearlDiver data set was used to identify patients receiving separate incision autograft versus local autograft/allograft/graft supplement for spinal fusion. Grafting trends over the decade were determined. Patient age, sex, Elixhauser Comorbidity Index, smoking status, insurance plan, region of the country where the surgery was conducted, and surgeon specialty were characterized and compared by the type of bone graft using univariate and multivariate analyses. RESULTS: Of 373,569 spinal bone grafting procedures, separate incision autografts were used for 32,401 (8.67%). A gradual decline was observed from 2010 (10.57% of spinal grafting procedures) to 2020 (4.69%, P -value < 0.00001). Independent predictors of having had a separate incision autograft in order of decreasing odds included surgeon specialty (relative to neurosurgery, orthopaedic odds ratio [OR], 2.45), smoking status (relative to nonsmokers, smokers OR, 1.45), region of the country (relative to Midwest, Northeast OR, 1.11; West OR, 1.42; and South OR, 1.48), insurance (relative to commercial, Medicare OR, 1.14), younger age (OR, 1.04 per decade increase), and lower Elixhauser Comorbidity Index (OR, 0.95 per two-point increase) ( P < 0.0001 for each). CONCLUSION: Iliac crest autograft continues to be referred to as the gold standard grafting material for spine fusions. However, the use of this has faded over the past decade to only 4.69% of spinal fusions in 2020. While some patient factors had an effect on when separate incision autograft was used, nonsurgical factors, including surgeon specialty, geographic region where the surgery was conducted, and insurance factors, suggested that external factors/physician training influence this choice.

Iliac bone graft for the treatment of bone loss and non-union of the distal radius.

Background/Aim of the work: Open distal radius fractures are rare compared to closed ones. They mainly affect young people with high-energy trauma and are burdened with a high number of complications, including non-union. In this case report, we describe the technique used to manage bone loss and non-union of the distal radius of a polytraumatized patient with an open Gustilo IIIB fracture of the wrist. CASE REPORT: 58-year-old man, suffering from head trauma and open right wrist fracture after motorcycle accident, underwent emergency damage control with debridement, antibiotic prophylaxis and stabilization in an external fixator. Then, he developed infection and bone loss, associated with an injury of the median nerve.  Non-union were treated with iliac crest bone graft, open reduction and internal fixation (ORIF). OUTCOMES: At the follow-up 6 months after the bone graft and ORIF procedure and 9 months after the trauma, the patient was clinically healed, with good performance status. CONCLUSIONS: Treatment of non-union in open distal radius fractures with iliac crest bone graft is a viable, safe and easy surgical choice.

Plate fixation using parallelogram prism iliac bone grafts for clavicle oblique nonunion with shortening deformity: a case report.

BACKGROUND: Plate fixation using a tricortical iliac bone graft can provide a high ratio of bone union and restore clavicle length in cases of atrophic nonunion. However, the surgical treatment of clavicle oblique nonunions with marked shortening deformity remains challenging and unresolved. Here, we describe a case of clavicle oblique nonunion with shortening that was treated using plate fixation with parallelogram prism iliac bone grafts. CASE PRESENTATION: A 46-year-old man presented to our hospital with severe medial scapular pain. He had been diagnosed with a right clavicle mid-shaft fracture in a motorcycle accident 9 months earlier. He underwent conservative treatment, but radiographs and computed tomography showed clavicle oblique nonunion with marked shortening. Physical examination revealed no pain at the nonunion site; however, tenderness was noted on the medial side of the right scapula and protrusion of the inferior scapular angle was prominent. His symptoms interfered with daily life and required surgery. After release of the nonunion, we harvested the parallelogram prism bone grafts from the iliac crest. We inserted these bone grafts into the fracture ends and fixed them with lag screws, after which we performed plate fixation. Immediately after surgery, right medial scapular pain and scapula winging subsided. Bone union was achieved, and the length of the clavicle was restored at 9 months postoperatively. CONCLUSIONS: This case report provides new information on the surgical treatment of clavicle oblique nonunion with shortening deformity. The presence of medial scapular pain and winging scapula can be clinically problematic in cases of clavicle nonunion with marked shortening. Our case revealed that reliable bone union and clavicle length recovery can be achieved with plate fixation and iliac bone grafts.

Secondary alveolar cleft grafting using autogenous mineralized plasmatic matrix (MPM) versus cancellous bone particles derived from anterior iliac crest.

OBJECTIVE: The essential concern of alveolar cleft grafting in patients of cleft lip and palate at the mixed dentition phase is to gain bone within the cleft area that provides closure of the oronasal communication with continuous and stable maxilla for future cleft teeth eruption or implantation. This study aimed to compare the effectiveness of mineralized plasmatic matrix (MPM) versus cancellous bone particles harvested from anterior iliac crest in secondary alveolar cleft grafting. PATIENTS AND METHODS: This prospective randomized controlled trial was conducted on ten patients with unilateral complete alveolar cleft requiring cleft reconstruction. Patients were randomly divided into two equal groups; group (1) included 5 patients who received particulate cancellous bone derived from anterior iliac crest (control group) and group (2) included 5 patients who received MPM graft prepared from cancellous bone derived from anterior iliac crest (study group). All patients received CBCT preoperatively, immediately postoperatively and after 6 months. On the CBCT, graft's volume, labio-palatal width, and height were measured and compared. RESULTS: The outcome of the studied patients 6 months postoperatively showed that the control group had significant decrease in the graft volume, labio-palatal width, and height compared to the study group. CONCLUSION: MPM allowed for the integration of bone graft particles inside a fibrin network, which offers positional stability of the bone particles, thus preserving their shape with subsequent "in situ" immobilization of the graft components. This conclusion was reflected positively in terms of maintained graft volume, width, and height compared to that of the control group. CLINICAL RELEVANCE: MPM allowed for maintenance of grafted ridge volume, width, and height.

The corticocancellous press fit iliac crest bone dowel for recalcitrant scaphoid nonunion: analysis of union rate and clinical outcome.

INTRODUCTION: Scaphoid nonunion after failed primary treatment remains challenging particularly when entailed by bone loss, avascular necrosis or deformity. We describe a scaphoid augmentation and fixation technique for cases of recalcitrant nonunion after screw placement by autologous press fit corticocancellous dowel. This study aims to provide reliable data on clinical and radiological outcomes and to contextualize in the face of other treatment options. MATERIAL AND METHODS: The study included 16 patients with recalcitrant nonunion of the scaphoid. All patients received screw removal and scaphoid reconstruction by a dowel shaped non-vascularized corticocancellous bone graft from the iliac crest facilitating packing of the screw channel. Bone union, the scapholunate, radiolunate and intrascaphoidal angles were evaluated on X-ray and CT images, range of motion noted. Additionally grip strength, DASH and Green O'Brien scores were obtained from eight patients. RESULTS: A union rate of 73% was noted after mean follow-up of 54 months. After revisional reconstruction of the scaphoid an extension-flexion rate of 84% of the healthy side was noted while pronation-supination reached 101%. DASH score averaged at 2.9, rest pain on a numeric rating scale was 0.43 with 99% peak grip force of the healthy side. CONCLUSION: In complex cases of revisional scaphoid nonunion after screw placement, the corticocancellous iliac crest pressfit dowel is an option for augmentation and stabilization of the scaphoid by preserving the articular surface. LEVEL OF EVIDENCE: IV, retrospective case series.

Staged Revision Arthrodesis with Interposition of Tricortical Iliac Crest Autograft to Address an Infected Nonunion of the First Metatarsophalangeal Joint: A Case Report.

A 55-year-old woman with a complicated infected nonunion after first metatarsophalangeal joint arthrodesis is presented. The patient initially underwent cross-screw fixation for the treatment of hallux rigidus that resulted in joint infection and hardware loosening. A staged surgical approach was undertaken by means of initial hardware removal with implementation of an antibiotic cement spacer followed by revision arthrodesis with interposition of tricortical iliac crest autograft. This case report aims to highlight an accepted surgical approach to address an infected nonunion at the level of the first metatarsophalangeal joint.

Remodeling process and clinical outcomes following all-arthroscopic modified Eden-Hybinette procedure using iliac crest autograft and 1-tunnel double Endobutton fixation system.

BACKGROUND: Arthroscopically modified Eden-Hybinette procedures for glenohumeral stabilization have been used for a long time. With the advancement of arthroscopic techniques and the development of sophisticated instruments, a double Endobutton fixation system has been used clinically to secure bone graft to the glenoid rim placed through a specifically designed guide. The purpose of this report was to evaluate clinical outcomes and serial glenoid remodeling process following all-arthroscopic anatomical glenoid reconstruction using autologous iliac crest bone grafting technique through 1-tunnel fixation. METHODS: Forty-six patients with recurrent anterior dislocations and significant glenoid defects greater than 20% underwent arthroscopic surgery with a modified Eden-Hybinette technique. Instead of firm fixation, autologous iliac bone graft was fixed to the glenoid by double Endobutton fixation system through 1-tunnel placed in the glenoid surface. Follow-up examinations were performed at 3, 6, 12, and 24 months. The patients were followed up for a minimum of two years using the Rowe score, the Constant score, the Subjective Shoulder Value, and the Walch-Duplay score; patient satisfaction with the procedure outcome was also rated. Graft positions, healing, and absorption were evaluated postoperatively with computed tomography imaging. RESULTS: At a mean follow-up of 28 months, all patients were satisfied and had a stable shoulder. The Constant score improved from 82.9 to 88.9 points (P ＜ .001), the Rowe score, improved from 25.3 to 89.1 points (P < .001), the Subjective Shoulder Value improved from 31% to 87% (P < .001), and the Walch-Duplay score improved from 52.5 to 85.7 points (P ＜ .001). One donor-site fracture occurred during the follow-up period. All grafts were well-positioned and achieved optimal bone healing with zero excessive absorption. The preoperative glenoid surface (72.6% ± 4.5%) increased significantly immediately after surgery to 116.5% ± 9.6% (P ＜ .001). After a physiological remodeling process, the glenoid surface remained significantly increased at the last follow-up (99.2% ± 7.1%) (P ＜ .001). The glenoid surface area appeared to decrease serially when compared between the first 6 months and 12 months postoperatively, while there was no significant interval change between 12 and 24 months postoperatively. CONCLUSION: Patient outcomes were satisfactory following the all-arthroscopic modified Eden-Hybinette procedure using an autologous iliac crest grafting technique through one-tunnel fixation system with double Endobutton. Graft absorption mostly occurred on the edge and outside the ''best-fit'' circle of the glenoid. Glenoid remodeling occurred within the first year after all-arthroscopic glenoid reconstruction with an auto iliac bone graft.

Vascularized Composite Iliac Flap Grafting for Trapezial Metastasectomy in Clear Cell Renal Carcinoma: A Case Report.

CASE: Renal cell carcinoma (RCC) metastases rarely occur in the trapezium. We present the case of a 69-year-old man with clear cell RCC metastasis to the trapezium. After tumor resection, bone and soft-tissue defects were reconstructed with a vascularized osseo-fascio-fat composite iliac flap. Four years later, sorafenib was administered to treat subsequent pulmonary and femoral metastases. CONCLUSION: At the 7-year follow-up, neither local recurrence nor additional metastatic sites were observed. The affected wrist could perform 50° of extension and 40° of flexion. The patient could use his right thumb in daily activities without pain.

The Use of Bone Morphogenetic Protein 2 (BMP-2) in Spine Surgery Is It Valuable?

BACKGROUND: Bone morphogenetic protein 2 (BMP-2) is one of the most widely used biologics in spine surgery. Its osteoinductive properties have been shown since its inception to improve fusion rates. Despite the positive effects on promoting fusion, there remains concerns regarding the significant costs associated with its use. The goal of this review was to investigate the value of BMP-2 in spine surgery. METHODS: A literature search was performed on various studies that report on the cost effectiveness and the value of BMP-2 in spine surgery. The value of BMP-2 was analyzed in two distinct settings: comparison to the gold standard iliac crest autograft and demineralized bone matrix. The value of BMP-2 was further analyzed in the setting of spinal deformity surgery. RESULTS: The findings of our review determined that BMP-2 offers significant improvement in outcomes related to improvement of fusion rates and minimization of pseudoarthrosis and reoperations related to pseudoarthrosis and donor site morbidity from harvesting iliac crest bone graft. However, BMP-2 has been found to be significantly more expensive in comparison to iliac crest bone graft and other bone graft substitutes, which detracts from its positive value. In deformity surgery, BMP-2 is associated with improvement in fusion rates as well as reducing the rate of reoperations and pseudoarthrosis. These positive outcomes, however, are associated with an expensive upfront cost for BMP-2. CONCLUSIONS: In terms of value, BMP-2 is associated with improvement in quality outcomes related to a reduction in pseudoarthrosis and reoperations. It also leads to improved outcomes with a reduction in donor site morbidity associated with iliac crest bone graft harvest. However, the value of BMP-2 is negatively affected because of its significant costs. As a result, higher expense thresholds are needed to increase quality adjusted life years in patients who receive BMP-2. Further research investigating ways to minimize the costs associated with BMP-2 use can further improve its value in spine surgery.