Introduction: Anterior cervical discectomy and inter-body fusion (ACDF) is recognised as an effective surgical treatment for cervical degenerative disc disease. The goals of anterior discectomy, interbody graft placement, and subsequent fusion, are to improve and maintain intervertebral height, establish and maintain physiological cervical lordosis, and achieve arthrodesis so as to eliminate pathological motion. Establishing the most clinically effective and cost effective operative approach to achieve these goals while, at the same time, minimising post-operative complications, is currently an evolving process. One view is that the use of anterior cervical plates reduces graft-related complications, maintains the cervical alignment, and leads to a higher incidence of fusion. In addition, there is evidence to suggest that there is a direct cost benefit of earlier return to pre-operative function and employment. Bone graft: Iliac crest autograft would be regarded as the gold standard source of bone for ACDF. However, donor site complications (due to harvesting autograft) are not insignificant and range from 1% to a sizeable 29%. These complications include iliac crest fracture, infection, persisting pain, neural injury, bowel injury, etc. With the advent of bone banks, allograft has become available and eliminates the problem of graft-harvest related complications. There is a theoretical risk of disease transmission and a corresponding difficulty with patients accepting donated tissue. To date, no HIV cases transmission has occurred from ACDF allograft. There are several studies that demonstrate a significant difference in fusion rates when comparing allograft and autograft. The preponderance of data from the literature supports the conclusion that the use of allograft in ACDF can lead to a higher incidence of graft collapse, pseudarthrosis, and possible subsequent revision surgery. Bishop et al., (Spine 1991 16:726–9): have documented a higher increase in pseudarthrosis rate, graft collapse, and interspace angulation in the allograft group compared to the autograft group. Therefore, the dilemma of allograft being preferred as a basis of eliminating graft harvesting complications, while at the same time being associated with a higher incidence of fusion failure and deformity, have led some surgeons to trial the combination of allograft with anterior plate fixation. Shapiro (J Neurosurg 1966 84:161–5) has reported no incidences of fusion failure, graft collapse, progressive kyphosis, or plate-related complications in 82 consecutive single and multiple level ACDF’s using allograft and anterior plating. Treatment failure: The incidence of the following complications have been reported in the literature. (Graham JJ. Spine 1989 14:1046–50). Pseudarthrosis – 3%–36%. Graft collapse – 3%–14%. Graft extrusion – 0.5%–4%. These figures are regardless of the graft source and are significant. Recent studies show that the combination of graft and anterior plate fixation virtually eliminates the complication of graft extrusion, and also decreases the risk of graft collapse and development of pseudarthrosis. There are also studies that contend that plate fixation can maintain proper lordotic alignment of the spine more effectively than can ACDF without plating. I contend that the use of contemporary cervical plates significantly decreases the rate of fusion failure and graft-related complications without imparting significant implant-related complications. As a result, there is decreased overall risk to the patient. The current type of plates which are available are unicortical with locking systems that substantially decrease the risk of screw loosening or hardware migration

Severe glenoid bone loss in patients with osteoarthritis with intact rotator cuff is associated with posterior glenoid bone loss and posterior humeral subluxation. Management of severe glenoid bone loss during shoulder arthroplasty is controversial and technically challenging and options range from humeral hemiarthroplasty, anatomic shoulder replacement with glenoid bone grafting or augmented glenoid component implantation, to reverse replacement with reaming to correct version or structural bone grafting or metallic augmentation of the bone deficiency. Shoulder replacement with severe glenoid bone loss is technically challenging and characterised by higher rates of complications and revisions. Hemiarthroplasty has limited benefit for pain relief and function especially if eccentric glenoid wear exists. Bone loss with >15 degrees of retroversion likely requires version correction include bone-grafting, augmented glenoid components, or reverse total shoulder replacement. Asymmetric reaming may improve version but is limited to 15 degrees of version correction in order to preserve subchondral bone and glenoid bone vault depth. Bone-grafting of glenoid wear and defects has had mixed results with graft-related complications, periprosthetic radiolucent lines, and glenoid component failure of fixation. Implantation of an augmented wedge or step polyethylene glenoid component improves joint version while preserving subchondral bone, but is technically demanding and with minimal short term clinical follow-up. A Mayo study demonstrated roughly 50% of patients with posteriorly augmented polyethylene had radiolucent lines and 1/3 had posterior subluxation. Another wedge polyethylene design had 66% with bone ingrowth around polyethylene fins at 3 years. Long term outcomes are unknown for these new wedge augmented glenoid components. Reverse shoulder arthroplasty avoids many risks of anatomic replacement glenoid component fixation and stability but is associated with a high complication rate (15%) including neurologic and baseplate loosening and often requires structural bone grafting behind the baseplate with suboptimal outcomes or metallic augmented baseplates with limited evidence and short term outcomes. Reverse replacement with baseplate bone grafting or metal augmentation is technically challenging due to limited native glenoid bone stock available for baseplate component ingrowth and long term fixation. Failure to correct glenoid superior inclination and restore neutral version within 10 degrees increases the risks of reverse baseplate failure of fixation, pull out, and failure of reverse replacement. Reverse baseplate failure rates in patients with severe glenoid bone loss and concomitant glenoid bone grafting range from 5–11%. The minimum native glenoid bony contact with the baseplate is unknown but likely is approximately 1cm of native bone contacting a central ingrowth post and a minority (∼15–25%) of native glenoid contacting the backside of the baseplate. Failure to correct posterior bone loss can lead to retroversion of the baseplate, reduced external rotation, posterior scapular notching, and posteromedial polyethylene wear. In summary, shoulder replacement with severe glenoid bone loss is technically challenging and characterised by higher rates of complication and revision

Objectives

The aim of this systematic literature review was to assess the clinical level of evidence of commercially available demineralised bone matrix (DBM) products for their use in trauma and orthopaedic related surgery.