Bone defects are frequently observed in anterior shoulder instability. Over the last decade, knowledge of the association of bone loss with increased failure rates of soft-tissue repair has shifted the surgical management of chronic shoulder instability. On the glenoid side, there is no controversy about the critical glenoid bone loss being 20%. However, poor outcomes have been described even with a subcritical glenoid bone defect as low as 13.5%. On the humeral side, the Hill-Sachs lesion should be evaluated concomitantly with the glenoid defect as the two sides of the same bipolar lesion which interact in the instability process, as described by the glenoid track concept. We advocate adding remplissage to every Bankart repair in patients with a Hill-Sachs lesion, regardless of the glenoid bone loss. When critical or subcritical glenoid bone loss occurs in active patients (> 15%) or bipolar off-track lesions, we should consider anterior glenoid bone reconstructions. The techniques have evolved significantly over the last two decades, moving from open procedures to arthroscopic, and from screw fixation to metal-free fixation. The new arthroscopic techniques of glenoid bone reconstruction procedures allow precise positioning of the graft, identification, and treatment of concomitant injuries with low morbidity and faster recovery. Given the problems associated with bone resorption and metal hardware protrusion, the new metal-free techniques for Latarjet or free bone block procedures seem a good solution to avoid these complications, although no long-term data are yet available.

Cite this article: Bone Joint J 2024;106-B(10):1100–1110.

Aims

The purpose of this study was to: review the efficacy of the induced membrane technique (IMT), also known as the Masquelet technique; and investigate the relationship between patient factors and technique variations on the outcomes of the IMT.

We hypothesised that cells obtained via a Reamer–Irrigator–Aspirator (RIA) system retain substantial osteogenic potential and are at least equivalent to graft harvested from the iliac crest. Graft was harvested using the RIA in 25 patients (mean age 37.6 years (18 to 68)) and from the iliac crest in 21 patients (mean age 44.6 years (24 to 78)), after which ≥ 1 g of bony particulate graft material was processed from each. Initial cell viability was assessed using Trypan blue exclusion, and initial fluorescence-activated cell sorting (FACS) analysis for cell lineage was performed. After culturing the cells, repeat FACS analysis for cell lineage was performed and enzyme-linked immunosorbent assay (ELISA) for osteocalcin, and Alizarin red staining to determine osteogenic potential. Cells obtained via RIA or from the iliac crest were viable and matured into mesenchymal stem cells, as shown by staining for the specific mesenchymal antigens CD90 and CD105. For samples from both RIA and the iliac crest there was a statistically significant increase in bone production (both p < 0.001), as demonstrated by osteocalcin production after induction.

Medullary autograft cells harvested using RIA are viable and osteogenic. Cell viability and osteogenic potential were similar between bone grafts obtained from both the RIA system and the iliac crest.

Cite this article: Bone Joint J 2013;95-B:1269–74.

Aim of the study. To estimate and compare the cost implications of the first attempt of treatment of tibial fracture non-unions treated with either autologous bone grafting or BMP-7. Materials and methods. Patients who were successfully treated for fracture non-unions between 2001 and 2005 were included. Exclusion criteria included infected non-union, children, malignancy, or chronic debilitating disease. The decision to use BMP-7 or autogenous bone graft was guided by the defect size and the surgeon's preferred method of treatment. Group 1 (n = 12) received iliac crest bone grafting (ICBG) and group 2 (n=15) received recombinant human Bone Morphogenetic Protein-7 (BMP-7). The total costs incurred during treatment including hospital stay, implants, theatre costs, drains, antibiotics, investigations and outpatient appointments were documented and analysed. Results and costs. (Average £ per patient) Average age was 41.4 and 38.52 years in group 1 and 2 respectively. Total follow up was 2.84 and 2.4 years for group 1 and 2 respectively. Average hospital stay was 10.66 and 8.66 days; time to union was 12.3 and 7.6 months; hospitals costs were £2,133.6 and £1,733.33; theatre costs were £2,413.3 and £906.67; implant costs were £696.4 and £592.3; radiology costs were £570 and £270; outpatient costs were £495.8 and £223.33; BMP7 costs were 3002.2; other costs were £451.6 and £566.27; and the total cost of treatment was £6,830.73 and £7,294.1 in group 1 and 2 respectively. Conclusion. In this study, the average cost of treatment of a tibial fracture non-union with autologous bone grafting was 6.7 % higher than the cost incurred with BMP7. Most of the costs incurred (41.1 %) in the BMP7 group were related to the actual price of BMP7. The cost difference between the two groups of patients wasn't statistically significantly higher

Purpose: To estimate and compare the direct medical cost implications of the first attempt of treatment of tibial fracture non-unions treated with either autologous bone grafting or BMP-7. Methods: Patients who were successfully treated for fracture non-unions between 2001 and 2005 were enrolled. Exclusion criteria included a diagnosis of an infected nonunion, children, malignancy, or chronic debilitating disease. The decision to use BMP-7 or autogenous bone graft was guided by the defect size as well as the treating surgeon’s preferred method of treatment. Group 1 received iliac crest bone grafting (ICBG) and Group 2 received recombinant human Bone Morphogenetic Protein-7 (BMP–7) as the first line of treatment. The direct medical costs of treatment – including hospital stay, implants, theatre costs, drains, antibiotics, investigations and outpatient appointments were documented and analysed. Results: The study sample consisted of 27 patients (14 females). Group 1 and Group 2 included 12 patients (4 females) and 15 patients (5 females) respectively. The mean age was 41.4 and 38.5 years respectively. The average hospital stay was 7.66 for the ICBG and 5,66 for the BMP7 patients (p=0.051). The follow-up period for Group 1 was 2.84 and 2.4 years for Group 2. The average time to union was 15.3 and 10.6 weeks respectively and this was statistically significant (p< 0.05). The overall direct medical costs on average reached the sum of £6,830.73 and £7,294.1 respectively. The hospital’s, operating theatre’s and outpatient’s direct medical costs were statistically significant (p< 0.05) more for the ICBG group. The implants costs did not significantly differ between the 2 groups and the second group’s costs were mostly raised due to the actual cost of the BMP7 (£3,002.2). Conclusion and Significance: In this study, the average cost of treatment of a tibial fracture non-union with BMP7 was 6.7% higher than the cost incurred with autologous bone grafting. Most of the costs incurred (41.1%) in the BMP7 group were related to the actual price of BMP7. The direct medical cost difference between the two groups of patients wasn’t statistically significantly higher

Introduction: Autologous bone graft is currently considered the gold standard for anterior cervical discectomy and fusion (ACDF). However, the harvesting of bone graft from the ilac crest is frequently associated with significant patient morbidity. We report on the safety and efficacy of trabecular metal blocks for achieving a stable interbody fusion for ACDF when compared to iliac crest bone graft for a small group of patients. Methods: This is a prospective trial of patients who underwent consecutive ACDFs between September 2004 and September 2007. Patients received one of two materials for their fusion, either trabecular metal blocks or autologous iliac crest bone graft. Each operation was performed by the same spinal surgeon (LT), and all patients had fixation with an anterior titanium plate to enhance interbody arthrodesis. Clinical outcome was assessed with a neck disability score (Vernon and Mior 1991) that was mailed to all participants; bone graft patients were also asked to complete a bone graft morbidity questionnaire (Silber et al. 2003). Radiological followup was assessed with computed tomography and flexion-extension radiographs. A minimum followup time of 3 months was required for inclusion into the study, and unpaired t-tests were used to evaluate statistical differences between relevant sets of data. Results: A total of 31 patients were included into the study, with 15 in the trabecular metal group (TM) and 16 in the iliac crest bone graft group (ICBG). The TM group included 10 males (67%) with a median age of 42 years (range 18–72). Median neck disability score was 18% (2–38) and stable bony ingrowth was observed in all patients (100%) on postoperative scans. Median followup time was 8 months (3–16) for TM patients and 20.3 months (7–36 months) for the ICBG group. In comparison, the ICBG group included 8 males (50%) with a median age of 53.3 years (43–70). Median neck disability score was worse at 30% (4–50), with a significant difference of 12% observed after t-test analysis (p value < 0.02). In addition, there was significant morbidity associated with the harvesting of autologous bone graft, with more than 50% of patients experiencing acute and/or chronic symptoms. Two radiological pseudoarthroses (8%) were observed postoperatively, of which one was manifested clinically. Discussion: These results confirm that, for our population group, trabecular metal implants are both safe and effective for use in ACDF when compared to the gold standard of autologous bone graft. Furthermore, trabecular metal implants avoid the morbidity associated with the harvesting of iliac crest bone graft. We believe the results so far are encouraging for our small group of patients but a larger, randomised control trial is needed to provide definitive results

Despite the widespread use of demineralized bone matrix (DBM) allografts there are few clinical studies comparing DBM to iliac crest bone grafting (ICBG). A comparison of DBM to ICBG is presented in patients who underwent four corner fusions of the wrist by one surgeon using identical operating technique. The senior author’s first fourteen consecutive patients in which DBM was used for four corner fusion were compared with fourteen patients selected from a total of 48 patients in which ICBG was used. The ICBG group was matched for age, indication and healing impairing co-morbidities (mainly smoking). Patient radiographs from the 8th, 12th and 24th postoperative week follow up were digitized and blinded. Three orthopaedic surgeons, not involved in the patients care, rated the degree of bony union in a scale of 0 (no evidence of healing) to 3 (solid bony healing). The operating technique and fixation was identical in all patients. K-wires were removed at a mean of 8.2 weeks for DBM and 7.7 weeks for the ICBG group. All patients had a minimum follow-up of one year. All fusions healed both radiographically and clinically without complications. Review of the radiographs revealed significantly less visible healing at 8 weeks in the DBM group (mean score 1.50 versus 1.74 of the ICBG group, p< .05). Lower scores were also obtained for the DBM group at 12 and 24 weeks but they did not reach statistical significance. In this study both DBM and ICBG were equally effective in achieving solid bone union for intercarpal fusions. However, the statistical power of this series is not adequate to conclude that healing rates are equal between the two graft materials. The radiographic appearance of bridging bone lagged behind in the DBM group. The biological significance of this finding is not clear; it could indicate delayed mineralization at the fusion site. Such a delay may be significant in graft choice for patients with healing impairment

Preliminary results suggest that a new rhBMP-2 formulation may provide an alternative for autologous bone graft in two-level posterolateral fusions. The purpose of this study was to compare the success of instrumented two level fusions using a new rhBMP-2 formulation versus iliac crest bone graft (ICBG). In this formulation, rhBMP-2 was at a concentration of 2mg/cc in a Biphasic Calcium Phosphate (60% hydroxyapatite/40% tricalcium phosphate) ceramic granule carrier. Twenty-nine patients were enrolled in this multicentered, prospective, randomized study. Either 30cc of rhBMP-2/BCP or fresh ICBG were used. Clinical evaluations were done preoperatively, at discharge and 1.5, three, six, twelve and twenty-four months including Oswestry Disability Index SF36, back pain and leg pain questionnaires. CT scan and xrays were independently assessed at six, twelve, and twenty-four months. Fusion criteria included bilateral bridging trabecular bone on each level, less than 3mm translation, less than five degrees angulation . Seventeen patients received ICBG and twelve received rhBMP-2/BCP. With the use of rhBMP-2 average OR time was reduced from 3.8 to 2.9 hours. Twenty-nine patients (100%) have reached twenty-four month followup. Clinical improvements were similar in both groups, however, fusion success was much improved with the use of rhBMP-2. At twenty-four months all patients receiving rhBMP-2/BCP were fused versus 58% of ICBG patients. These results suggest that rhBMP-2/BCP may have improved fusion success in challenging two level posterolateral fusions as compared to ICBG