Aims. Hyaline cartilage has a low capacity for regeneration. Untreated osteochondral lesions of the femoral head can lead to progressive and symptomatic osteoarthritis of the hip. The purpose of this study is to analyze the clinical and radiological long-term outcome of patients treated with osteochondral autograft transfer. To our knowledge, this study represents a series of osteochondral autograft transfer of the hip with the longest follow-up. Methods. We retrospectively evaluated 11 hips in 11 patients who underwent osteochondral autograft transfer in our institution between 1996 and 2012. The mean age at the time of surgery was 28.6 years (8 to 45). Outcome measurement included standardized scores and conventional radiographs. Kaplan-Meier survival curve was used to determine the failure of the procedures, with conversion to total hip arthroplasty (THA) defined as the endpoint. Results. The mean follow-up of patients treated with osteochondral autograft transfer was 18.5 years (9.3 to 24.7). Six patients developed osteoarthritis and had a THA at a mean of 10.3 years (1.1 to 17.3). The cumulative survivorship of the native hips was 91% (95% confidence interval (CI) 74 to 100) at five years, 62% (95% CI 33 to 92) at ten years, and 37% (95% CI 6 to 70) at 20 years. Conclusion. This is the first study analyzing the long-term results of osteochondral autograft transfer of the femoral head. Although most patients underwent conversion to THA in the long term, over half of them survived more than ten years. Osteochondral autograft transfer could be a time-saving procedure for young patients with devastating hip conditions who have virtually no other surgical options. A larger series or a similar matched cohort would be necessary to confirm these results which, in view of the heterogeneity of our series, seems difficult to achieve. Cite this article: Bone Jt Open 2023;4(7):523–531

Abstract. Background. The gold standard treatment for Anterior Cruciate Ligament injury is reconstruction (ACL-R). Graft failure is the concern and ensuring a durable initial graft with rapid integration is crucial. Graft augmentation with implantable devices (internal brace reinforcement) is a technique purported to reduce the risk of rupture and hasten recovery. We aim to compare the short-term outcome of ACL-R using augmented hamstring tendon autografts (internally braced with neoligament) and non-augmented hamstring autografts. Methods. This was a retrospective cohort study comparing augmented and non-augmented ACL-R. All procedures were performed in a single centre using the same technique. The Knee injury and Osteoarthritis Outcome Score [KOOS] was used to assess patient-reported outcomes. Results. There were 70 patients in the augmented and 111 patients in the control group. Mean graft diameter in the augmented group was 8.82mm versus 8.44mm in the non-augmented. Six strand graft was achievable in 73.5% of the augmented group compared to 33% in the non-augmented group. Two graft failures were reported in the non-augmented group and none in the augmented group. Patient satisfaction rates were higher in the augmented group. There was a statistically insignificant improvement in the postoperative KOOS in the augmented group compared to the non-augmented group (p 0.6). Irrespective of augmentation status, no correlation was found between the functional score and age, or femoral tunnel width. Conclusion. Augmented ACL-R may achieve superior graft diameters, lower failure rates and better patient reported outcomes when compared to nonaugmented ACL-R. Prospective trials are needed to examine this further

Aims. Reverse total shoulder arthroplasty (rTSA) can be used in complex cases when the glenoid requires reconstruction. In this study, a baseplate with composite bone autograft and a central trabecular titanium peg was implanted, and its migration was assessed for two years postoperatively using radiostereometric analysis (RSA). Methods. A total of 14 patients who underwent a rTSA with an autograft consented to participate. Of these, 11 had a primary rTSA using humeral head autograft and three had a revision rTSA with autograft harvested from the iliac crest. The mean age of the patients was 66 years (39 to 81). Tantalum beads were implanted in the scapula around the glenoid. RSA imaging (stereographic radiographs) was undertaken immediately postoperatively and at three, six, 12, and 24 months. Analysis was completed using model-based RSA software. Outcomes were collected preoperatively and at two years postoperatively, including the Oxford Shoulder Score, the American Shoulder and Elbow Score, and a visual analogue score for pain. A Constant score was also obtained for the assessment of strength and range of motion. Results. RSA analysis showed a small increase in all translation and rotational values up to six months postoperatively, consistent with settling of the implant. The mean values plateaued by 12 months, with no evidence of further migration. In four patients, there was significant variation outside the mean, which corresponded to postoperative complications. There was a significant improvement in the clinical and patient-reported outcomes from the preoperative values to those at two years postoperatively (p < 0.001). Conclusion. These findings show, using RSA, that a glenoid baseplate composite of a trabecular titanium peg with autograft stabilizes within the glenoid about 12 months after surgery, and reinforce findings from a previous study of this implant/graft with CT scans at two years postoperatively, indicating that this type of structural composite results in sound early fixation. Cite this article: Bone Joint J 2023;105-B(8):912–919

Aims. The aim of this study is to provide a detailed description of cases combining bridging patch repair with artificial ligament “internal brace” reinforcement to treat irreparable massive rotator cuff tears, and report the preliminary results. Methods. This is a retrospective review of patients with irreparable massive rotator cuff tears undergoing fascia lata autograft bridging repair with artificial ligament “internal brace” reinforcement technique between January 2017 and May 2018. Inclusion criteria were: patients treated arthroscopically for an incompletely reparable massive rotator cuff tear (dimension > 5 cm or two tendons fully torn), stage 0 to 4 supraspinatus fatty degeneration on MRI according to the Goutallier grading system, and an intact or reparable infraspinatus and/or subscapularis tendon of radiological classification Hamada 0 to 4. The surgical technique comprised two components: first, superior capsular reconstruction using an artificial ligament as an “internal brace” protective device for a fascia lata patch. The second was fascia lata autograft bridging repair for the torn supraspinatus. In all, 26 patients with a mean age 63.4 years (SD 6.2) were included. Results. All patients underwent more than two years of follow-up (mean 33.5 months (24 to 45)). All clinical scores were also improved at two-year follow-up (mean visual analogue scale 0.7 (SD 0.5) vs 6.1 (SD 1.2); p < 0.001; mean American Shoulder and Elbow Surgeons score 93.5 (SD 5.3) vs 42.5 (SD 10.8); p < 0.001; mean University of California, Los Angeles score, 31.7 (SD 3.7) vs 12.0 (SD 3.1); p < 0.001; and mean Constant-Murley score 88.7 (SD 3.5) vs 43.3 (SD 10.9); p < 0.001), and 24 of 26 fascia lata grafts were fully healed on MRI (92%). One patient had haematoma formation at the harvesting side of the fascia lata at two days postoperatively. Conclusion. The fascia lata autograft bridging repair combined with artificial ligament internal brace reinforcement technique achieved good functional outcomes, with a high rate of graft healing at two-year follow-up. Although the short-term results are promising, further studies with a greater number of patients would provide clearer results. Cite this article: Bone Joint J 2021;103-B(10):1619–1626

To document and assess the available evidence regarding single bundle, hamstrings autograft preparation techniques for Anterior Cruciate Ligament reconstruction (ACLR) and provide graft preparation options for different clinical scenarios. Three online databases (Embase, PubMed and Ovid [MEDLINE]) were searched from database inception until April 10, 2021. The inclusion criteria were English language studies, human studies, and operative technique studies for single bundle hamstrings autograft preparation for ACLR. Descriptive characteristics, the number of tendons, number of strands, tendon length, graft length and graft diameter were recorded. The methodological quality was assessed using the Methodological Index for Non-Randomized Studies (MINORS) instrument and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system for non-randomized and randomized studies, respectively. The initial search yielded 5485 studies, 32 met the inclusion criteria. The mean MINORS score across all nonrandomized studies was 8.2 (standard deviation, SD 6.6) indicating an overall low quality of evidence. The mean MINORS score for comparative studies was 17.4 (SD 3.2) indicating a fair quality of evidence. The GRADE assessment for risk of bias in the randomized study included was low. There were 2138 knees in 1881 participants, including 1296 (78.1%) males and 363 (21.9%) females recorded. The mean age was 30.3 years. The mean follow-up time was 43.9 months when reported (range 16-55 months). Eleven studies utilized the semitendinosus tendon alone, while 21 studies used both semitendinosus and gracilis tendons. There were 82 (3.8%) two-strand grafts, 158 (7.4%) three-strand grafts, 1044 (48.8%) four-strand grafts, 546 (25.5%) five-strand grafts, and 308 (14.4%) six-strand grafts included. Overall, 372 (19.7%) participants had a single-tendon ACLR compared to 1509 (80.2%) participants who had a two-tendon ACLR. The mean graft diameter was 9.4mm when reported. The minimum semitendinosus and gracilis tendon lengths necessary ranged from 210-280mm and 160-280mm respectively. The minimum graft length necessary ranged from 63-120mm except for an all-epiphyseal graft in the paediatric population that required a minimum length of 50mm. The minimum femoral, tibial, and intra-articular graft length ranged from 15-25mm, 15-35mm and 20-30mm respectively. Thirteen studies detailed intra-operative strategies to increase graft size such as adding an extra strand or altering the tibial and/or femoral fixation strategies to shorten and widen the graft. Two studies reported ACL reinjury or graft failure rate. One study found no difference in the re-injury rate between four-, five- and six-strand grafts (p = 0.06) and the other found no difference in the failure rate between four- and five- strand grafts (p = 0.55). There was no difference in the post-operative Lysholm score in 3 studies that compared four- and five-strand ACLR. One of the five studies that compared post-operative IKDC scores between graft types found a difference between two- and three- strand grafts, favoring three-strand grafts. There are many single bundle hamstrings autograft preparation techniques for ACLR that have been used successfully with minimal differences in clinical outcomes. There are different configurations that may be utilized interchangeably depending on the number, size and length of tendons harvested to obtain an adequate graft diameter and successful ACLR

Aims. We analyzed the long-term outcomes of patients observed over ten years after resection en bloc and reconstruction with extracorporeal irradiated autografts. Patients and Methods. This retrospective study included 27 patients who underwent resection en bloc and reimplantation of an extracorporeal irradiated autograft. The mean patient age and follow-up period were 31.7 years (9 to 59) and 16.6 years (10.3 to 24.3), respectively. The most common diagnosis was osteosarcoma (n = 10), followed by chondrosarcoma (n = 6). The femur (n = 13) was the most frequently involved site, followed by the tibia (n = 7). There were inlay grafts in five patients, intercalary grafts in 15 patients, and osteoarticular grafts in seven patients. Functional outcome was evaluated with the Musculoskeletal Tumor Society (MSTS) scoring system. Results. There were no recurrences in the irradiated autograft and the autograft survived in 24 patients (88.9%). Major complications included nonunion (n = 9), subchondral bone collapse (n = 4), and deep infection (n = 4). Although 34 revision procedures were performed, 25 (73.5%) and four (11.8%) of these were performed less than five years and ten years after the initial surgery, respectively. The mean MSTS score at the last follow-up was 84.3% (33% to 100%). Conclusion. Considering long-term outcomes, extracorporeal irradiated autograft is an effective method of reconstruction for malignant musculoskeletal tumours. Cite this article: Bone Joint J 2019;101-B:1151–1159

Objectives. Long bone defects often require surgical intervention for functional restoration. The ‘gold standard’ treatment is autologous bone graft (ABG), usually from the patient’s iliac crest. However, autograft is plagued by complications including limited supply, donor site morbidity, and the need for an additional surgery. Thus, alternative therapies are being actively investigated. Autologous bone marrow (BM) is considered as a candidate due to the presence of both endogenous reparative cells and growth factors. We aimed to compare the therapeutic potentials of autologous bone marrow aspirate (BMA) and ABG, which has not previously been done. Methods. We compared the efficacy of coagulated autologous BMA and ABG for the repair of ulnar defects in New Zealand White rabbits. Segmental defects (14 mm) were filled with autologous clotted BM or morcellized autograft, and healing was assessed four and 12 weeks postoperatively. Harvested ulnas were subjected to radiological, micro-CT, histological, and mechanical analyses. Results. Comparable results were obtained with autologous BMA clot and ABG, except for the quantification of new bone by micro-CT. Significantly more bone was found in the ABG-treated ulnar defects than in those treated with autologous BMA clot. This is possibly due to the remnants of necrotic autograft fragments that persisted within the healing defects at week 12 post-surgery. Conclusion. As similar treatment outcomes were achieved by the two strategies, the preferred treatment would be one that is associated with a lower risk of complications. Hence, these results demonstrate that coagulated BMA can be considered as an alternative autogenous therapy for long bone healing. Cite this article: Z. X. H. Lim, B. Rai, T. C. Tan, A. K. Ramruttun, J. H. Hui, V. Nurcombe, S. H. Teoh, S. M. Cool. Autologous bone marrow clot as an alternative to autograft for bone defect healing. Bone Joint Res 2019;8:107–117. DOI: 10.1302/2046-3758.83.BJR-2018-0096.R1

Pseudoarthrosis after spinal fusion is an important complication leading to revision spine surgeries. Iliac Crest Bone Graft is considered the gold standard, but with limited availability and associated co-morbidities, spine surgeons often utilize alternative bone grafts. Determine the non-inferiority of a novel submicron-sized needle-shaped surface biphasic calcium phosphate (BCP<µm) as compared to autograft in instrumented posterolateral spinal fusion. Adult patients indicated for instrumented posterolateral spinal fusion of one to six levels from T10-S2 were enrolled at five participating centers. After instrumentation and preparation of the bone bed, the randomized allocation side of the graft type was disclosed. One side was grafted with 10cc of autograft per level containing a minimum of 50% iliac crest bone. The other side was grafted with 10cc of BCP<µm granules standalone (without autograft or bone marrow aspirate). In total, 71 levels were treated. Prospective follow-up included adverse events, Oswestry Disability Index (ODI), and a fine-cut Computerized Tomography (CT) at one year. Fusion was systematically scored as fused or not fused per level per side by two spine surgeons blinded for the procedure. The first fifty patients enrolled are included in this analysis (mean age: 57 years; 60% female and 40% male). The diagnoses included deformity (56%), structural instability (28%), and instability from decompression (20%). The fusion rate determined by CT for BCP<μm was 76.1%, which compared favorably to the autograft fusion rate of 43.7%. Statistical analysis through binomial modeling showed that the odds of fusion of BCP<μm was 2.54 times higher than that of autograft. 14% of patients experienced a procedure or possible device-related severe adverse event and there were four reoperations. Oswestry Disability Index (ODI) score decreased from a mean of 46.0 (±15.0) to a mean of 31.7 (±16.9), and 52.4% of patients improved with at least 15-point decrease. This data, aiming to determine non-inferiority of standalone BCP<μm as compared to autograft for posterior spinal fusions, is promising. Ongoing studies to increase the power of the statistics with more patients are forthcoming

Aims. MRI has been suggested as an objective method of assessing anterior crucate ligament (ACL) graft “ligamentization” after reconstruction. It has been proposed that the MRI appearances could be used as an indicator of graft maturity and used as part of a return-to-sport assessment. The aim of this study was to evaluate the correlation between MRI graft signal and postoperative functional scores, anterior knee laxity, and patient age at operation. Methods. A consecutive cohort of 149 patients who had undergone semitendinosus autograft ACL reconstruction, using femoral and tibial adjustable loop fixations, were evaluated retrospectively postoperatively at two years. All underwent MRI analysis of the ACL graft, performed using signal-to-noise quotient (SNQ) and the Howell score. Functional outcome scores (Lysholm, Tegner, International Knee Documentation Committee (IKDC) subjective, and IKDC objective) were obtained and all patients underwent instrumented side-to-side anterior laxity differential laxity testing. Results. Two-year postoperative mean outcome scores were: Tegner 6.5 (2 to 10); Lysholm 89.8 (SD 10.4; 52 to 100); and IKDC subjective 86.8 (SD 11.8; 51 to 100). The objective IKDC score was 86% A (128 patients), 13% B (19 patients), and 1% C (two patients). Mean side-to-side anterior laxity difference (134 N force) was 0.6 mm (SD 1.8; -4.1 to 5.6). Mean graft SNQ was 2.0 (SD 3.5; -14 to 17). Graft Howell scores were I (61%, 91 patients), II (25%, 37 patients), III (13%, 19 patients), and IV (1%, two patients). There was no correlation between either Howell score or SNQ with instrumented anterior or Lysholm, Tegner, and IKDC scores, nor was any correlation found between patient age and ACL graft SNQ or Howell score. Conclusion. The two-year postoperative MRI appearances of four-strand, semitendinosus ACL autografts (as measured by SNQ and Howell score) do not appear to have a relationship with postoperative functional scores, instrumented anterior laxity, or patient age at surgery. Other tools for analysis of graft maturity should be developed. Cite this article: Bone Jt Open 2021;2(8):569–575

Autologous bone has been the gold standard for grafting material in foot and ankle arthrodesis. While autograft use has been effective, the harvest procedure does present risks to the patient including readmission, infection, and persistent graft harvest site pain. Previous studies have examined graft harvest site pain, but most have focused on the iliac crest and none have long term follow-up. The purpose of this study was to examine long-term (7–10 year) harvest site pain in subjects undergoing autograft harvest from multiple sites for hindfoot and/or ankle arthrodesis. Sixty (60) subjects underwent hindfoot or ankle arthrodesis supplemented with autograft as part of the control arm of a prospective, randomized trial. The mean subject age was 59.4 years (range, 24.7–76.8) and mean body mass index was 30.6 kg/m2 (range, 22.0–44.0). There were 29 males and 31 female subjects. Subjects had the tibiotalar (37.9%), subtalar (24.1%), talonavicular (10.3%), subtalar/talonavicular (5.1%), or subtalar/calcaneocuboid/talonavicular (22.4%) joints arthrodesed. Autograft was harvested from either the proximal tibia (51.7%), iliac crest (17.2%), calcaneous (15.5%), distal tibia (6.8%), or other location (8.6%). Graft harvest site pain was evaluated using a 100-point visual analog score (VAS), with clinically significant pain being any score greater than 20. Subjects were followed a mean of 9.0 years (range, 7.8–10.5). The percentage of subjects who reported clinically significant pain was 35.7%, 21.4%, 18.2%, 10.5%, 8.9%, and 5.2% at 2, 6, 12, 24, 52 weeks, and final follow-up (7.8–10.5 years), respectively. The mean VAS autograft harvest site pain at final follow-up was 4.4 (range, 0.0–97.0), with 37.9% of subjects reporting at least some pain. For three subjects (5%) with clinically significant pain (VAS >20) at final follow-up, two had proximal tibial harvest sites and one had an iliac crest harvest site. There was no correlation between graft volume and harvest site pain. This study is the first to examine long-term pain following autologous bone graft harvest for hindfoot and/or ankle arthrodesis. Over a third of patients reported having some pain at an average follow-up of nine years, with 5% experiencing clinically significant pain. The results of this study suggest that harvesting autograft bone carries a risk of persistent, long-term pain regardless of the volume of graft that is harvested. This potential for persistent pain should be considered when informing patients of procedure risks and when deciding to use autograft or a bone graft substitute material

Aims. Graft infection following anterior cruciate ligament reconstruction (ACLR) may lead to septic arthritis requiring multiple irrigation and debridement procedures, staged revision operations, and prolonged courses of antibiotics. To our knowledge, there are no previous studies reporting on how gentamicin pre-soaking of hamstring grafts influences infection rates following ACLR. We set out to examine this in our study accordingly. Methods. This retrospective study included 2,000 patients (1,156 males and 844 females) who underwent primary ACLR with hamstring autografts between 2007 to 2017. This included 1,063 patients who received pre-soaked saline hamstring grafts for ACLR followed by 937 patients who received pre-soaked gentamicin hamstring grafts for ACLR. All operative procedures were completed by a single surgeon using a standardized surgical technique. Medical notes were reviewed and data relating to the following outcomes recorded: postoperative infection, clinical progress, causative organisms, management received, and outcomes. Results. Superficial wound infection developed in 14 patients (1.31 %) receiving pre-saline soaked hamstring grafts compared to 13 patients (1.38 %) receiving pre-gentamicin soaked hamstring grafts, and this finding was not statistically significant (p = 0.692). All superficial wound infections were treated with oral antibiotics with no further complications. There were no recorded cases of septic arthritis in patients receiving pre-gentamicin soaked grafts compared to nine patients (0.85%) receiving pre-saline soaked grafts, which was statistically significant (p = 0.004). Conclusion. Pre-soaking hamstring autographs in gentamicin does not affect superficial infection rates but does reduce deep intra-articular infection rates compared to pre-soaking hamstring grafts in saline alone. These findings suggest that pre-soaking hamstring autografts in gentamicin provides an effective surgical technique for reducing intra-articular infection rates following ACLR. Cite this article: Bone Jt Open 2021;2(1):66–71

Abstract

Background of study. Medial patellofemoral ligament (MPFL) reconstructions are often performed using gracilis autografts, this can be associated with donor site morbidity and complications. The use of synthetic material can circumvent a harvest operation and have previously been demonstrated to be effective in other types of reconstructive procedures and may be effective in MPFL reconstruction. We report our experience and clinical results with the use of FiberTape (FT) in MPFL reconstruction and compare it to the same surgical technique using standard autografts. Materials and Methods. Data were collected prospectively in 50 MPFL reconstructions. The first 27 underwent reconstruction using autograft; the following 23 patients were treated with FT. All patients were clinically and radiologically assessed and underwent pre- and post-operative scoring using the Kujala score, Bartlett score, Modified Tegner activity rating scale, SF 12 score and Lysholm score. Statistical significance was tested between groups using ANOVA with repeated measures. Results. There was no significant differences in the pre-operative scores between the FT and GT groups (p>0.05). Both groups showed significant improvement across all scoring modalities between pre- and post-operative periods 12, 24 and 48 months of follow-up (p<0.05). There were no significant differences in knee function scores between the GT and FT groups. Conclusion. The use of FT in MPFL reconstruction is safe and effective, it significantly improved patient's quality of life and related postoperative outcome measures. There were no significant differences in all knee scores compare to GT autografts. Tendon harvesting is unnecessary and FT is a feasible option for MPFL reconstruction

Reverse shoulder arthroplasty (RSA) has an increasing effective use in the treatment of patients with a variety of diagnoses, including rotator cuff deficiency, inflammatory arthritis, or failed shoulder prostheses. Glenoid bone loss is not uncommonly encountered in these cases due to the significant wear. Severe bone loss can compromise glenoid baseplate positioning and fixation, consequently increasing the risk for early component loosening, instability, and scapular notching. To manage severe glenoid bone deficiencies, bone grafts are commonly used. Although, many studies report outcome of bone grafting in revision RSA, the literature on humeral head autograft for glenoid bone loss in primary RSA is less robust. The purpose of this study is to evaluate the clinical and radiographic outcomes of primary RSA with humeral head autograft for glenoid bone loss at our institution. Institutional review board approval was obtained to retrospectively review the records of 22 consecutive primary RTSA surgeries in 21 patients with humeral head autograft for glenoid bone loss between January 2008 and December 2016. Five patients died during follow-up, three were unable to be contacted and one refused to participate, leaving a final study cohort of 12 patients with 13 shoulders that underwent RSA. All patients had a clinical evaluation including detailed ROM and clinical evaluation using the American Shoulder and Elbow Surgeons (ASES) Score, Constant Score, Western Ontario Osteoarthritis of the Shoulder Index (WOOS), and Short Form-12 (SF-12) questionnaires. Preoperative and postoperative plain radiographs and CT scans were assessed for component position, loosening, scapular notching, as well as graft incorporation, resorption, or collapse. There were 6 males and 6 females, with an average age of 74 ± 6.8 years. The average BMI was 31.7 ± 5.3, and the median ASA score was 3. Average follow-up was 3.4 ± 1.1 years. The average postoperative range of motion measurements for the operative arm are: flexion = 120 ± 37, abduction = 106 ± 23, external rotation = 14 ± 12, internal rotation at 90 degrees of abduction = 49 ± 7, external rotation at 90 degrees of abduction = 50 ± 28. Average functional scores are: ASES: 76.9 ± 19.2, WOOS: 456 ± 347, SF12 physical: 34.2 ± 8.2, SF12 mental: 54.1 ± 10.2, Constant Score: 64.6 ± 14. No evidence of hardware loosening or evidence of bone graft resorption were encountered. On CT, the average of pre operative B-angle was 79.3 ± 9.3 while the pre operative reverse shoulder angle was 101.4 ± 28. Glenoid retroversion average on CT was 13.3 ± 16.6. Post operative baseplate inclination average was 82 ± 7.4 while the baseplate version 7.8 ±10. The operative technique was able to achieve up to 30 degrees of inclination correction and up to 50 degrees of version correction. In conclusion, primary reverse shoulder arthroplasty with humeral head autograft for glenoid bone loss provides excellent ROM and functional outcomes at mid-term follow-up. This technique has a high rate of bone incorporation and small risk of bone resorption at mid term follow up

Limited information is published regarding the activity level after gracilis autograft reconstruction, and usually a knee-injury based score is used rather than a specific ankle PROM. The purpose of this study was to investigate the activity level and functional results after lateral ankle gracilis autograft reconstruction in patients with severe lateral ankle instability. The hypothesis was that patients would regain their pre-injury Tegner activity level or one level below and secondary to compare a specific ankle activity score, instability and function score. Finally, donor site and graft complications, clinical stability and range of motion were measured. All 69 patients (50 women, 19 men) recorded at the hospital with severe instability who underwent reconstruction of the anterior talofibular and the calcaneofibular ligament with a gracilis autograft and were minimum 6 months post-operative, were invited to participate in the study. Outcomes measures included the Tegner Activity level (1–10), Ankle Activity Score (0–10) recorded as pre-injury and at follow up. The Karlsson Petterson Ankle Function Score (0–100) and Visual Analog Score (VAS)(0–10) recorded pre-operatively and at follow up. All pre-injury and pre-operative data were recalled retrospectively from memory. Identification of functional ankle instability (IDFAI)(0–37) was recorded at follow up. The clinical tests, Anterior drawer test (0–4), Talar tilt test (0–4) and Range of motion (ROM)(degrees) were compared to the unaffected side at follow up. A difference of 1 in the activity scores was chosen as a clinical relevant difference. Data was tested for normal distribution and for statistical significant difference with a students t-test. study design: Cross sectional clinical study with a retrospective questionnaire. A total of 33 patients (27 women, 6 men), with a mean age on 45 years (range 19–68), were included in this study. Mean follow up was 3.7 years. Mean pre-operative Tegner score was 5.8 vs 5.6 at follow up (p. On average, the patients returned to their pre-injury activity level, with similar specific ankle activity scores to the Tegner. The majority had good functional results and few residual symptoms of functional instability. The response rate was low with few men responding; hence a prospective study is called for to establish the true effect of the surgical technique

Aims. The use of frozen tumour-bearing autograft combined with a vascularized fibular graft (VFG) represents a new technique for biological reconstruction of massive bone defect. We have compared the clinical outcomes between this technique and Capanna reconstruction. Methods. From June 2011 to January 2016 a retrospective study was carried out of patients with primary osteosarcoma of lower limbs who underwent combined biological intercalary reconstruction. Patients were categorized into two groups based on the reconstructive technique: frozen tumour-bearing autograft combined with concurrent VFG (Group 1) and the Capanna method (Group 2). Demographics, operating procedures, oncological outcomes, graft union, limb function, and postoperative complications were compared. Results. A total of 23 patients were identified for analysis: eight in Group 1 and 15 in Group 2. There was no difference in the demographics (age, sex, and affected site) and operating procedures (resection length, duration of surgery, and blood loss) between the two groups. No significant difference was found in local recurrence in Group 1 versus Group 2 (p = 0.585). Mean union time for the frozen autograft-host junction was 8.4 months (7.0 to 11.0), significantly earlier than for the allograft-host junction in Group 2 (mean 14.1 months (10.0 to 28.0); p < 0.001). Mean Musculoskeletal Tumor Society scores in groups 1 and 2 were 90.3% (SD 7.4%) and 88.0% (SD 9.0%), respectively, with no significant statistical difference (p = 0.535). In terms of complications, infection (n = 1, 6.7%) and delayed union (n = 2, 13.3%) occurred in Group 2, but no such complications were observed in Group 1. Conclusion. Frozen tumour-bearing autograft in combination with VFG can be used as an alternative to the Capanna reconstruction in properly selected patients with osteosarcoma. Cite this article: Bone Joint J 2020;102-B(5):646–652

Aims. The primary aim of this study was to determine the morbidity of a tibial strut autograft and characterize the rate of bony union following its use. Patients and Methods. We retrospectively assessed a series of 104 patients from a single centre who were treated with a tibial strut autograft of > 5 cm in length. A total of 30 had a segmental reconstruction with continuity of bone, 27 had a segmental reconstruction without continuity of bone, 29 had an arthrodesis and 18 had a nonunion. Donor-site morbidity was defined as any event that required a modification of the postoperative management. Union was assessed clinically and radiologically at a median of 36 months (IQR, 14 to 74). Results. Donor-site morbidity occurred in four patients (4%; 95% confidence interval (CI) 1 to 10). One patient had a stress fracture of the tibia, which healed with a varus deformity, requiring an osteotomy. Two patients required evacuation of a haematoma and one developed anterior compartment syndrome which required fasciotomies. The cumulative probability of union was 90% (95% CI 80 to 96) at five years. The type of reconstruction (p = 0.018), continuity of bone (p = 0.006) and length of tibial graft (p = 0.037) were associated with the time to union. Conclusion. The tibial strut autograft has a low risk of morbidity and provides adequate bone stock for treating various defects of long bones. Cite this article: Bone Joint J 2018;100-B:667–74

Aims. To compare the structural durability of hydroxyapatite-tricalcium phosphate (HATCP) to autologous iliac crest bone graft in calcaneal lengthening osteotomy (CLO) for pes planovalgus in childhood. Patients and Methods. We present the interim results of ten patients (HATCP, n = 6 and autograft, n = 5) with a mean age of 11.5 years (8.2 to 14.2) from a randomised controlled non-inferiority trial with six months follow-up. The primary outcome was the stability of the osteotomy as measured by radiostereometric analysis. A non-inferiority margin of ≤ 2 mm osteotomy compression was set. Results. At six months the data showed that the osteotomy had been compressed by a mean 1.97 mm (99.8% confidence interval -1.65 to 5.60) more in the HATCP group than in the autograft group. Migration of the CLO grafted with HATCP stabilised at six months rather than at six weeks with autograft. Conclusion. This is the first randomised trial to compare the efficacy of HATCP graft with autograft in terms of stability of CLO in children. Because of problems with the HATCP the trial was stopped. We do not recommend HATCP graft in its current structure for use in unfixed CLOs. Cite this article: Bone Joint J 2016;98-B:1554–62

Abstract. Introduction. The study aims were to demonstrate rates, level, and time taken to RTP in elite sports after ACL reconstruction (ACL-R) and compare football and rugby. Methods. A retrospective review of a consecutive series of ACL-R between 2005 and 2019 was undertaken. Patients were included if they were elite athletes and were a minimum of 2 years post primary autograft ACL-R. The outcomes measured were return to play (RTP), (defined as participation in a professional match or in national/ international level amateur competition), time to RTP after surgery, and RTP level (Tegner score). Results. Three hundred and ninety four elite athletes with 420 ACL-Rs (235 in footballers, 125 in rugby players and 60 in other sports) were included. 95.7% of all athletes returned to competition at a mean of 10.3 months after ACL-R with 90.1% at the same / higher level. There was no difference in RTP rates between rugby and football. Rugby players RTP faster than footballers (9.6 vs 10.6 months, (p=0.027). Overall re-rupture rate within 2 years was 6.4% but not significantly different between football (8.1%) and rugby (7.2%). Footballers were more likely to rupture their ACL during jumping / landing manoeuvres and to receive a PT graft than rugby players. There were no significant differences between football and rugby regarding patient characteristics, intraoperative findings and re-operation rates. Conclusion. Over 95% of all elite athletes RTP after primary ACL-R with 90% able to play at the same level. Rugby players RTP significantly faster than footballers

The purpose of this study was to evaluate the functional and oncological outcome of recycled autograft reconstruction after a wide excision for primary malignant bone tumor around the hip. From 1998 to 2015, 67 patients with a primary malignant bone tumor involving proximal femur or periacetabular zone (P2) were included. There were 36 males and 31 females with a mean age of 34 years (13 to 58). Of these, 29 patients had grade I or II chondrosarcoma, 28 high-grade osteosarcoma, 6 Ewing's sarcoma and 4 undifferentiated pleomorphic sarcoma. Enneking stage of all 67 patients was stage II. Of the resection classification, proximal femur resection was performed in 29 patients, P1+P2 in 15, P2+P3 in 14, P1+P2+P3 in 4, P2 only in 4, and P2+proximal femur in 1. Extracorporeally irradiated recycled autograft and liquid nitrogen frozen autograft were performed in 44 and 23 patients, respectively. At a mean follow-up of 98 months (10 to 239), 48 patients (72%) were continuously disease-free, 12 (18%) died of disease and 7 (10%) were alive with disease. The tumors of these patients who had died of disease were usually located in pelvic bones (10/12). Of these 37 patients with pelvic tumors, 7 patients (22%) had local recurrence, four of them received external hemipelvectomy. Other complications included hip dislocation in 2 patients, nerve injury in 2 and deep infection in 2. However, the above complications were rarely occurred in the patients with proximal femur reconstruction. The mean Musculoskeletal Tumor Society functional score were 77% (53 to 93). Recycled autograft reconstruction for primary malignant bone tumor around the hip is a valid method with acceptable morbidity and a favorable functional outcome

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

Introduction. Patellofemoral instability is one of the most common presentations to a children's orthopaedic clinic. Recurrent patellar dislocations and instability episodes are painful, disabling and increase the risk of irreversible chondral damage. The medial patellofemoral ligament is the primary static stabiliser to prevent lateral dislocation of the patella and is almost always torn or attenuated in these cases. Reconstruction of this ligament is commonly performed using autologous hamstring tendon however there has been some interest recently in use of quadriceps tendon as a graft. Children with patellar instability also present unique challenges due to the small size of the patella and the presence of open growth plates which may require adaptations to the common techniques. Methods. Patients undergoing medial patellofemoral ligament reconstruction using quadriceps tendon autograft were identified using electronic theatre records. Prospectively collected clinical records and imaging findings were reviewed and underlying pathology, additional procedures at time of MPFL reconstruction, current function and need for further revision surgery determined. Results. Between January 2019 and August 2023, 50 MPFL reconstructions were performed in 37 children using partial thickness quadriceps autograft. Patient age at time of surgery ranged from 5 to 17 years (median age 13 years). The technique was utilised for a variety of indications including recurrent traumatic and habitual patellofemoral instability, fixed dislocations, and revision MPFL reconstruction. Conclusion. Partial thickness quadriceps tendon autograft can be used safely to primarily reconstruct the medial patellofemoral ligament in paediatric population, including those children with open growth plates. It also has utility in revision cases following previous failed hamstring MPFL reconstruction. We have noted that the younger the child, the more distal to the physis lies the femoral point of isometricity, rendering this a safe and reproducible treatment in this age group. Use of this technique has increased in our unit as we have observed that patients seem to be satisfied with their clinical and functional outcomes with a low incidence of short- and medium-term complications

Coronoid fractures account for 2 to 15% of the cases with elbow dislocations and usually occur as part of complex injuries. Comminuted fractures and non-unions necessitate coronoid fixation, reconstruction or replacement. The aim of this biomechanical study was to compare the axial stability achieved via an individualized 3D printed prosthesis with curved cemented intramedullary stem to both radial head grafted reconstruction and coronoid fixation with 2 screws. It was hypothesized that the prosthetic replacement will provide superior stability over the grafted reconstruction and screw fixation. Following CT scanning, 18 human cadaveric proximal ulnas were osteotomized at 40% of the coronoid height and randomized to 3 groups (n = 6). The specimens in Group 1 were treated with an individually designed 3D printed stainless steel coronoid prosthesis with curved cemented intramedullary stem, individually designed based on the contralateral coronoid scan. The ulnas in Group 2 were reconstructed with an ipsilateral radial head autograft fixed with two anteroposterior screws, whereas the osteotomized coronoids in Group 3 were fixed in situ with two anteroposterior screws. All specimens were biomechanically tested under ramped quasi-static axial loading to failure at a rate of 10 mm/min. Construct stiffness and failure load were calculated. Statistical analysis was performed at a level of significance set at 0.05. Prosthetic treatment (Group 1) resulted in significantly higher stiffness and failure load compared to both radial head autograft reconstruction (Group 2) and coronoid screw fixation, p ≤ 0.002. Stiffness and failure load did not reveal any significant differences between Group 2 and Group 3, p ≥ 0.846. In cases of coronoid deficiency, replacement of the coronoid process with an anatomically shaped individually designed 3D printed prosthesis with a curved cemented intramedullary stem seems to be an effective method to restore the buttress function of the coronoid under axial loading. This method provides superior stability over both radial head graft reconstruction and coronoid screw fixation, while achieving anatomical articular congruity. Therefore, better load distribution with less stress at the bone-implant interface can be anticipated. In the clinical practice, implementation of this prosthesis type could allow for early patient mobilization with better short- and long-term treatment outcomes and may be beneficial for patients with irreparable comminuted coronoid fractures, severe arthritic changes or non-unions

Abstract. Introduction. Derby technique for posterolateral corner (PLC) reconstruction uses a doubled gracilis autograft to reconstruct the popliteo-fibular ligament (PFL) and a split biceps tendon transfer to reconstruct the lateral collateral ligament (LCL). We report midterm outcomes of a case series who underwent PLC reconstruction. Methodology. A retrospective review of 27 patients who underwent PLC reconstruction from 2012 until 2018 was performed (6 females, 21 males, median age 26). Median time interval from injury to primary procedure was 10 months. Outcomes were recorded as per clinical assessment and outcome scores. Results. All patients had no varus laxity in full knee extension. Similarly, at 30° of knee flexion, 25 patients (92.5%) had no varus laxity and 2 patients (7.5%) had grade 1 laxity. No patients demonstrated abnormal external rotation at final follow up. Outcome scores were obtained from 17 patients who underwent primary ligament reconstruction at a mean follow up of 72 months postoperatively. The mean Lysholm score was 94 +/-5.5 (72–100) and mean subjective IKDC score was 78/87 (89.6%) (51–87). 90% of our patients had gained normal or nearly normal IKDC scores on returning to routine activities of daily living and sports following surgery compared to their pre-injury status. Conclusion. Our technique enables an anatomical LCL & PFL reconstruction in isolation or in combination with ACL/PCL reconstruction or to augment an acute repair without contralateral graft harvest or allograft. The functional knee scores demonstrated in this cohort are comparable and in fact superior to previously published knee scores after PLC reconstruction

In this retrospective study we evaluated the proficiency of shelf autograft in the restoration of bone stock as part of primary total hip replacement (THR) for hip dysplasia, and in the results of revision arthroplasty after failure of the primary arthroplasty. Of 146 dysplastic hips treated by THR and a shelf graft, 43 were revised at an average of 156 months, 34 of which were suitable for this study (seven hips were excluded because of insufficient bone-stock data and two hips were excluded because allograft was used in the primary THR). The acetabular bone stock of the hips was assessed during revision surgery. The mean implant–bone contact was 58% (50% to 70%) at primary THR and 78% (40% to 100%) at the time of the revision, which was a significant improvement (p < 0.001). At primary THR all hips had had a segmental acetabular defect > 30%, whereas only five (15%) had significant segmental bone defects requiring structural support at the time of revision. In 15 hips (44%) no bone graft or metal augments were used during revision. . A total of 30 hips were eligible for the survival study. At a mean follow-up of 103 months (27 to 228), two aseptic and two septic failures had occurred. Kaplan-Meier survival analysis of the revision procedures demonstrated a ten-year survival rate of 93.3% (95% confidence interval (CI) 78 to 107) with clinical or radiological failure as the endpoint. The mean Oxford hip score was 38.7 (26 to 46) for non-revised cases at final follow-up. Our results indicate that the use of shelf autografts during THR for dysplastic hips restores bone stock, contributing to the favourable survival of the revision arthroplasty should the primary procedure fail. Cite this article: Bone Joint J 2013;95-B:777–81

Purpose: This study sought to compare clinical outcomes and return to activity in high-demand patients following ACL reconstruction with either autograft or allograft patellar tendon using a matched-pairs case-control experimental design. Method: Nineteen matched pairs were obtained based on gender (36.8 % female), age (27.9±8.1yrs autograft versus 28.1±9.1 allograft), and length of follow-up (9.1±2.7yrs autograft versus 10.3±2.6 allograft). All patients reported participating in very strenuous (soccer, basketball etc.) or strenuous (skiing, tennis etc.) sporting activity 4–7 times/ week prior to their knee injury. Patient-reported outcomes included the IKDC Subjective Knee Form, Activities of Daily Living (ADLS) and Sports Activity Scales (SAS) of the Knee Outcome Survey and SF-36. Range of motion, laxity, and functional strength were also assessed. Results: There were no significant differences in patient-reported or clinical outcome measures. Sixteen (84.2%) subjects undergoing autograft reconstruction and 12 (63.2%) subjects reconstructed with allograft were able to participate in strenuous or very strenuous sporting activity at follow-up (p=.34). Similar percentages of subjects were able to return to their pre-injury level of sports activity [12 (63.2%) autograft vs. 11 (57.9%) allograft; p=1.0]. Fewer subjects undergoing reconstruction with autograft reported instability with very strenuous activity [5 (26.3%) autograft vs. 12 (63.2%) allograft], but this difference was not significant (p=.07). Conclusion: While autograft and allograft patellar tendon ACL reconstruction exhibit similar clinical outcomes in high-demand individuals, autogenous patellar tendon grafts may be indicated to allow patients to return to very strenuous levels of activity

Between 1996 and 2003, 16 patients (nine female, seven male) were treated for a primary bone sarcoma of the femur by wide local excision of the tumour, extracorporeal irradiation and re-implantation. An additional vascularised fibular graft was used in 13 patients (81%). All patients were free from disease when reviewed at a minimum of two years postoperatively (mean 49.7 months (24 to 96). There were no cases of infection. Primary union was achieved after a median of nine months (interquartile range 7 to 11). Five host-donor junctions (16%) united only after a second procedure. Primary union recurred faster at metaphyseal junctions (94% (15) at a median of 7.5 months (interquartile range 4 to 12)) than at diaphyseal junctions (75% (12) at a median of 11.1 months (interquartile range 5 to 18)). Post-operatively, the median Musculoskeletal Tumour Society score was 85% (interquartile range 75 to 96) and the median Toronto Extremity Salvage score 94% (interquartile range 82 to 99). The Mankin score gave a good or excellent result in 14 patients (88%). The range of movement of the knee was significantly worse when the extracorporeally irradiated autografts were fixed by plates rather than by nails (p = 0.035). A total of 16 (62%) of the junctions of the vascularised fibular grafts underwent hypertrophy, indicating union and loading. Extracorporeal irradiation autografting with supplementary vascularised fibular grafting is a promising biological alternative for intercalary reconstruction after wide resection of malignant bone tumours of the femur

We have evaluated the use of a synthetic porous ceramic (Triosite) as a substitute for bone graft in posterior spinal fusion for idiopathic scoliosis. In a prospective, randomised study 341 patients at five hospitals in the UK and France were randomly allocated either to autograft from the iliac crest or rib segments (171) or to receive Triosite blocks (170). All patients were assessed after operation and at 3, 6, 12 and 18 months. The two groups were similar with regard to all demographic and baseline variables, but the 184 treated in France (54%) had Cotrel-Dubouset instrumentation and the 157 treated in the UK usually had Harrington-Luque implants. In the Triosite group the average Cobb angle of the upper curve was 56°, corrected to 24° (57%). At 18 months, the average was 26° (3% loss). In the autograft group the average preoperative upper curve of 53° was corrected to 21° (60%). At 18 months the mean curve was 25° (8% loss). Pain levels after operation were similar in the two groups, being mild in most cases. In the Triosite group only three patients had problems of wound healing, but in the autograft group, 14 patients had delayed healing, infection or haematoma in the spinal wound. In addition, 15 autograft patients had pain at the donor site at three months. Seven had infections, two had haematoma and four had delayed healing. The haematological and serum biochemistry results showed no abnormal trends and no significant differences between the groups. There were no adverse events related to the graft material and no evidence of allergenicity. Our results suggest that Triosite synthetic porous ceramic is a safe and effective substitute for autograft in these patients. Histological findings on biopsy indicate that Triosite provides a favourable scaffolding for the formation of new bone and is gradually incorporated into the fusion mass

Introduction/purpose: Cementless femoral fixation in TKA varies regarding philosophy of design, materials, and surgical technique. This study evaluates autograft enhancement with AML (porocoated) stems. Impaction autograft (head reamings) enhances cortico-cancellous fit in canals of different geometry, preserves bone, decreases potential for stress shielding and seals the stem from wear particles. Materials/methods: Clinical/radiologic evaluation of 110 AML prostheses (proximal/extensive porous-coated) with 4- to 11-year (mean 6.9) follow-up was performed. Demographics included 68 females, 42 males, age 34–90 (mean 66). Diagnoses included OA (86), RA (16), other (8). Key surgical points included: 1) stem matching/sizing to proximal cortical contact; 2) head/neck reaming with acetabular graters; 3) autograft delivery (distal-lateral) prior to partial stem insertion and proximal-medial prior to prosthetic seating. Results: Femoral stem fixation was successful in 98%. Autograft fill was visualized radiographically within the first 6 weeks. Stem fit-fill ratios were .63 proximally and .73 distally, suggesting that most stems were stabilized via cortico-cancellous bone. The 2 fixation failures (1 stem fracture, 1 aseptic loosening) occurred in large males with undersized stems. Radiologic stability was noted in 95%. There were 6 cases of proximal osteolysis secondary to wear without distal extension, and no lucency > 2mm. Mean subsidence was.6mm. There were 10 acetabular failures secondary to wear/loosening and 1 traumatic neck fracture. There were no infections. Conclusion: The technique of impaction autograft using femoral head reamings is a biological (osteoinductive-osteoconductive), practical, and simple treatment method to accommodate and fill femoral canal voids frequently encountered in THA. Large, stiff stems (with distal fixation) can be avoided with less risk of technical problems and long-term bone loss secondary to stress shielding. The technique can be utilized, with variation, in any current cementless femoral stem

Hip arthroscopy rates continue to increase. As a result, there is growing interest in capsular management techniques. Without careful preservation and surgical techniques, failure of the repair result in capsular deficiency, contributing to iatrogenic instability and persistent post-operative pain. In this setting, capsular reconstruction may be indicated, however there is a paucity of objective evidence comparing surgical techniques to identify the optimal method. Therefore, the objective of this study was to evaluate the biomechanical effect of capsulectomy and two different capsular reconstruction techniques (iliotibial band [ITB] autograft and Achilles tendon allograft) on hip joint kinematics in both rotation and abduction/adduction. Eight paired fresh-frozen hemi-pelvises were dissected of all overlying soft tissue, with the exception of the hip joint capsule. The femur was potted and attached to a load cell connected to a joint-motion simulator, while the pelvis was secured to a custom-designed fixture allowing adjustment of the flexion-extension arc. Optotrak markers were rigidly attached to the femur and pelvis to track motion of the femoral head with respect to the acetabulum. Pairs were divided into ITB or Achilles capsular reconstruction. After specimen preparation, three conditions were tested: (1) intact, (2) after capsulectomy, and (3) capsular reconstruction (ITB or Achilles). All conditions were tested in 0°, 45°, and 90° of flexion. Internal rotation (IR) and external rotation (ER) as well abduction (ABD) and adduction (ADD) moments of 3 N·m were applied to the femur via the load cell at each position. Rotational range of motion and joint kinematics were recorded. When a rotational force was applied the total magnitude of internal/external rotation was significantly affected by the condition of the capsule, independent of the type of reconstruction that was performed (p=0.001). The internal/external rotation increased significantly by approximately 8° following the capsulectomy (p<0.001) and this was not resolved by either of the reconstructions; there remained a significant difference between the intact and reconstruction conditions (p=0.035). The total anterior/posterior translation was significantly affected by the condition of the capsule (p=0.034). There was a significant increase from 6.7 (6.0) mm when the capsule was intact to 9.0 (6.7) mm following the capsulectomy (p=0.002). Both of the reconstructions (8.6 [5.6] mm) reduced the anterior/posterior translation closer to the intact state. There was no difference between the two reconstructions. When an abduction/adduction force was applied there was a significant increase in the medial-lateral translation between the intact and capsulectomy states (p=0.047). Across all three flexion angles the integrity of the native hip capsule played a significant role in rotational stability, where capsulectomy significantly increased rotational ROM. Hip capsule reconstruction did not restore rotational stability and also increased rotational ROM compared to the intact state a statistically significant amount. However, hip capsule reconstruction restored coronal and sagittal plane stability to approach that of the native hip. There was no difference in stability between ITB and Achilles reconstructions across all testing conditions

In 1999, we developed a technique for biological reconstruction after excision of a bone tumour, which involved using autografts of the bone containing the tumour treated with liquid nitrogen. We have previously reported the use of this technique in 28 patients at a mean follow up of 27 months (10 to 54). In this study, we included 72 patients who underwent reconstruction using this technique. A total of 33 patients died and three were lost to follow-up, at a mean of 23 months (2 to 56) post-operatively, leaving 36 patients available for a assessment at a mean of 101 months 16 to 163) post-operatively. The methods of reconstruction included an osteo-articular graft in 16, an intercalary in 13 and, a composite graft with prosthesis in seven. Post-operative function was excellent in 26 patients (72.2%), good in seven (19.4%), and fair in three (8.3%) according to the functional evaluation system of Enneking. No recurrent tumour occurred within the grafts. The autografts survived in 29 patients (80.6%), and the rates of survival at five and ten years were 86.1% and 80.6 %, respectively. Seven of 16 osteo-articular grafts (44%) failed because of fracture or infection, but all the composite and intercalary grafts survived. The long-term outcomes of frozen autografting, particularly using composite and intercalary grafts, are satisfactory and thus represent a good method of treatment for patients with a sarcoma of bone or soft tissue. Cite this article: Bone Joint J 2014;96-B:555–61

Tunnel enlargement after AC reconstruction with a hamstring autograft has been noticed mainly the first 3–6 months postoperatively. Its etiology involves biomechanical and biological factors. The aggressive rehabilitation program is another etiological factor. The aim of this study is to investigate the tunnel enlargement after ACL reconstruction with a Hamstring autograft by the aid of CT-scan. We investigate the tunnel diameter in a series of 25 consecutive patients who operated with a Hamstring autograft 3 months postoperatively. The mean age of the patients was 23.6 years old (18–35). The same femoral fixation system (XObutton) and the same tibial fixation system (bioabsorbable screw) were used in all the patients. All the follow the same rehabilitation program, partial weight bearing from the 1st postoperative day, brace for 3–5 weeks and return to sports activities in 6 months. In 2 patients a meniscal suture was performed and in 3 patients a partial meniscectomy was performed. All patients had excellent clinical result which was demonstrated by the physical examination and by the KT-1000 results. Statistical analysis was performed with the SPSS system. We noticed a tunnel enlargement in the majority of the patients, but this was not statistical significant (P< 0.01). Tunnel enlargement after ACL reconstruction with a hamstring autograft has been noticed the first postoperative months, especially with the use of suspensor fixation systems. However in our study the tunnel enlargement is not correlated with a poor clinical outcome

Between 1983 and 1988 we carried out 45 Charnley low-friction arthroplasties with autografts from the femoral head in 41 patients for developmental dysplasia of the hip. The preoperative radiographs were assessed for the severity of DDH according to the classifications of Crowe et al, Hartofilakidis et al and Sharp. The postoperative and follow-up radiographs were analysed for coverage of the socket by the graft, for loosening and for the outcome of the fixation of the bone graft. Two patients died (two hips) at four and seven years after THR from causes unrelated to the surgery and were excluded from the final radiological analysis. The mean age of the patients at the time of operation was 46 years 3 months. The autograft of the femoral head covered a mean 26% (16 to 35) of the acetabular component. All the grafts united. Some degree of resorption of the bone graft occurred in 27 patients, and always involved the lateral part of the graft, which was beyond the margin of the socket. After a mean follow-up of 11 years there had been no revisions and 38 patients had no pain or only slight discomfort. One socket migrated and four others were fully demarcated. Our findings indicate that the Charnley LFA with an autograft of the femoral head for DDH remains successful at a follow-up of 15 years

Purpose: The use of femural head as an autograft in the reconstruction of dysplastic acetabulum is a fast, convinient and with excellent results throught time. Materlal-method: Since January 1986 until December 2002, 57 total hip replacements had taken place for dysplastic acetabulum. In all of them, the femural head has been used as an autograft. The age of the patients was between 42 to 75 years old (m.a. 63 ñ.Ï.). 45 of them were females and 12 males. 9 patients have been suggested to intertrïchanderic osteotomy in the past. One third of the patients had also the other hip affected. The surgical approach to the hip in all cases was made by the Harding’ s techique. The autograft in received from the femural neck. We prepared the acetabulum until we had bleeding bone. The bone graft is beared with two screws and if any gup exist is filled with cancellous autografts. In 41 operations of total hip replacements the cup was fixed with cement and in the rest 16 without. In our research we have included 43 hips with a follow-up from 3 to 14 years (m.a. 8,5 y.o.). Results: The results were evaluated with the Merle d’Aubigne and Postel scale. 5.6 pain, 4.1 wirdth of mobility. The callousness and the remodeling of the autograft were coplet in x-rays control. Íï case of absorbe of the bone graft. Until now no artrhoplasty has been revised. Conclusions: We consider that this is a satisflng method for filling and supporting the cup and in adittion it offers advantages in case that the artrhoplasty has to be revised

Posterolateral spinal fusion using autograft in adult rabbits has been reported by many groups using the Boden model. Age in general has an adverse effect on skeletal healing; although, its role in posterolateral fusion is not well understood. This study examined the influence of animal age on spinal fusion using a standard model and experimental endpoints. We hypothesised that fusion quality and quantity would be less with increasing age. A single level posterolateral fusion between the fifth and sixth lumbar segments were performed in six-month and two-year-old New Zealand white rabbits (n=6 per group) using morcelized iliac crest autograft. All animals were sacrificed at 12 weeks following surgery. Posteroanterior Faxitron radiographs and CT scans were taken and DICOM data was analysed (MIMICS Version 12, Materialise, Belgium). Axial, sagittal, coronal and three-dimensional models were created to visualise the fusion masses. Bone mineral density (BMD) of the fusion mass was measured using a Lunar DPXL Dexa machine. An MTS Bionix testing machine was then used to assess peak load and stiffness. Sagittal and coronal plane histology was evaluated in a blinded fashion using H&E, Tetrachrome and Pentachrome stains. Assessment included overall bony response on and between the transverse processes. Radiographs and CT confirmed a more robust healing response in younger animals. Radiographic union rates decreased from 83% to 50% in the aged animals. A neo- cortex surrounding the fusion mass was observed in the younger group but absent in the aged animals. Fusion mass BMD and that of the vertebral body was decreased in the older animals (P<0.05). Tensile mechanical data revealed a 30% reduction in peak load (P=0.024) and 34% reduction in stiffness (P=0.073) in the two-year-old animals compared with the six-month-old animals. Histological evaluation demonstrated a reduction in overall biological activity in the two-year-old animals. This reduction in activity was observed in the more challenging intertransverse space as well as adjacent to the transverse processes and vertebral bodies at the decortication sites. Numerous sites of new bone formation was present in the middle of the fusion mass in the six-month-old animals while the bone graft in the two-year- old animals were less viable. Skeletal healing is complex and mediated by both local and systemic factors. This study demonstrated that ageing leads to an impaired and delayed skeletal repair. Where autograft is utilised, diminished graft osteoinductivity and reduced levels of growth factors and nutritional supply in the surrounding milieu explains our observations. The aged rabbit posterolateral spinal fusion model has not been previously described but would be a useful to evaluate new treatment modalities in a more challenging host environment

The primary objective of this study was to establish a safety profile for an all-arthroscopic anatomic glenoid reconstruction via iliac crest autograft augmentation for the treatment of shoulder instability with glenoid bone loss. Short-term clinical and radiological outcomes were also evaluated. This study involved a retrospective analysis of prospectively collected data for 14 patients (male 8, female 6) who were treated for shoulder instability with bone loss using autologous iliac crest bone graft between 2014 and 2018. Of 14 patients, 11 were available for follow-up. The safety profile was established by examining intra-operative and post-operative complications such as neurovascular injuries, infections, major bleeding, and subluxations. Assessment of pre-operative and post-operative Western Ontario Shoulder Instability (WOSI) index, radiographs, and CT scans comprised the evaluation of clinical and radiological outcomes. A good safety profile was observed. There was no occurrence of intraoperative complications, neurovascular injuries, adverse events, or major bleeding. One patient did develop an infection in the neurovascular injuries, adverse events, or major bleeding. One patient did develop an infection in the treated shoulder post-surgery. There were no subluxations or positive apprehension tests on clinical examination post-operatively. Short-term clinical outcomes were seen to be favorable WOSI scores at the most recent follow-up were significantly higher than pre-operative scores, with a mean increase of 39.6 ± 10.60 (p = 0.00055). The average follow-up for CT scan was 4.66 (SD± 2.33) months, where all patients showed bone graft union. Arthroscopic treatment of shoulder instability with bone loss via autologous iliac crest bone graft is shown to be a safe operative procedure that results in favorable short-term clinical and radiological outcomes. Further investigations must be done to evaluate the longevity of these positive health outcomes

The primary purpose of this study was to assess whether patients presenting with clinical graft laxity following primary anatomic anterior cruciate ligament (ACL) reconstruction using hamstring autograft reported a significant difference in disease-specific quality-of-life (QOL) as measured by the ACL-QOL questionnaire. Clinical ACL graft laxity was assessed in a cohort of 1134/1436 (79%) of eligible patients using the Lachman and Pivot-shift tests pre-operatively and at 12- and 24-months following ACL reconstruction. Post-operative ACL laxity was assessed by an orthopaedic surgeon and a physical therapist who were blinded to each other's examination. If there was a discrepancy between the clinical examination findings from these two assessors, then a third impartial examiner assessed the patient to ensure a grading consensus was reached. Patients completed the ACL-QOL questionnaire pre-operatively, and 12- and 24-months post-operatively. Descriptive statistics were used to assess patient demographics, rate of post-operative ACL graft laxity, surgical failures, and ACL-QOL scores. A Spearman rho correlation coefficient was utilised to assess the relationships between ACL-QOL scores and the Lachman and Pivot-shift tests at 24-months post-operative. An independent t-test was used to determine if there were differences in the ACL-QOL scores of subjects who sustained a graft failure compared to the intact graft group. ACL-QOL scores and post-operative laxity were assessed using a one-way analysis of variance (ANOVA). There were 70 graft failures (6.17%) in the 1134 patients assessed at 24-months. A total of 226 patients (19.9%) demonstrated 24-months post-operative ACL graft laxity. An isolated positive Lachman test was assessed in 146 patients (12.9%), an isolated positive Pivot-shift test was apparent in 14 patients (1.2%), and combined positive Lachman and Pivot-shift tests were assessed in 66 patients (5.8%) at 24-months post-operative. There was a statistically significant relationship between 24-month post-operative graft laxity and ACL-QOL scores (p < 0.001). Specifically, there was a significant correlation between the ACL-QOL and the Lachman test (rho = −0.20, p < 0.001) as well as the Pivot-shift test (rho = −0.22, p < 0.001). There was no significant difference between the scores collected from the graft failure group prior to failure occurring (mean = 74.38, SD = 18.61), and the intact graft group (mean = 73.97, SD = 21.51). At 24-months post-operative, the one-way ANOVA demonstrated a statistically significant difference between the ACL-QOL scores of the no laxity group (mean = 79.1, SD = 16.9) and the combined positive Lachman and Pivot-shift group (mean = 68.5, SD = 22.9), (p = 0, mean difference = 10.6). Two-years post ACL reconstruction, 19.9% of patients presented with clinical graft laxity. Post-operative graft laxity was significantly correlated with lower ACL-QOL scores. The difference in ACL-QOL scores for patients with an isolated positive Lachman or Pivot-shift test did not meet the threshold of a clinically meaningful difference. Patients with clinical laxity on both the Lachman and Pivot-shift tests demonstrated the lowest patient-reported ACL-QOL scores, and these results exceeded the minimal clinically important difference

Background: A common problem achieving lumbar spinal fusion is developing a pseudarthrosis. The current gold standard in achieving fusion is the use of autograft from pelvis or posterior elements of the spine. However the potential limitations of insufficient quantity and donor site morbidity have led to the use of bone graft alternatives such as DBM which contains osteoinductive BMPs. Aims & Methods: A prospective randomized control trial comparing the effectiveness of Demineralised Bone Matrix (DBM Putty)/autograft composite with autograft in lumbar postero-lateral or 270 degree spinal fusion. 35 patients were required for the study. They were randomized to have DBM and autograft on one side of the posterior approach and autograft alone on other side of the same approach. Patients were followed up with interval radiographs for total of 24mons. To date 32 patients have been recruited and with an average follow up a15.3 months. The mineralization of fusion mass lateral to the instrumentation on each side was graded as Absent, Mild (< 50%), Moderate (> 50%) or Complete fusion (100%). The assessment was made by independent orthopaedic consultant and a musculoskeletal radiologist who were blinded to graft assignment. Results: The sex distribution was 17:15 male to females with a mean age of 55.2 (21–87years) and an average follow up of 15.3mons (3–24mons). 50% of patients had single level fusion and the remainder had more than one level fusion. At 12months, on the side of DBM 28% had complete fusion, 65% had moderate fusion, and 7% had no fusion mass. During the same period on the other side (non DBM side) approx 25% did not show any sign of fusion. There was no correlation with number of levels, age or sex. Conclusions: Osteoinductive properties of DBM would appear to enhance the consolidation of the lumbar spinal fusion. DBM reduces the amount of harvested autograft graft and also minimises the morbidity of donor site complications

Introduction. In order to prepare hamstring autograft, suture fixation to the tendon is required to secure and handle the tendon during harvest and preparation. We use a simple, grasping suture which doesn't require suture of the tendon, thus saving time and avoiding violation of the graft itself. We present this technique, with results of mechanical testing compared to a standard whip suture, traditionally used to handle hamstring autograft. Methods and materials. Twelve uniform ovine flexor tendons were prepared. A number two braided polyester suture was used in all cases. Six tendons were prepared with a standard, non-locking whip-suture, maintaining uniformity of suture bite and working length between samples. Six tendons were prepared with the utility suture, also taking care to maintain uniformity. The suture was applied by tying the thread around the tendon with a single-throw granny knot then symmetrically wrapping the suture ends from proximal to distal and securing with another single throw, allowing compression of the tendon with longitudinal tension on the suture. All the samples were tested to failure in uniaxial tension in a materials testing machine. Peak load values and load/displacement curves were acquired and results analysed with a two-sample T-test assuming significance at P<0.05. Results. Modes of failure between the groups, as characterised by the load/displacement curves were quite distinct. Peak load to failure was lower in the utility suture group but all failures occurred when the suture snapped. Thus the peak load to failure of the suture/tendon construct exceeded the breaking strain of the suture material. Conclusion. The grasping utility suture described here is sufficiently strong to harvest and handle hamstring autograft without passing a needle through the graft, saving time and avoiding violation of the graft itself. The lower loads at failure, despite failure occurring due to suture snapping, may reflect differing knot orientation between groups

Purpose: The aim of this study is the mid-term analysis of osteochondral autograft transplantation for the repair of focal femoral defects. Methods: We present clinical data based on arthroscopic and MRI appearances of 18 patients, from 2 to 6 years postoperatively, which illustrate growing concern about the progressive deterioration of articular cartilage surrounding the OAT graft. It seems that the osteochondral autograft transfer (OAT) can restore the height and the shape of articulating surface in osteochondral defects with composite autologous material that contains hyaline articular cartilage and a firm carrier. However, limited availability of autologous osteochondral grafts, dead spaces between circular grafts, the lack of integration of donor and recipient hyaline cartilage, and different thickness and mechanical properties of donor and recipient hyaline cartilage are frequent sources of clinical concern. Results: Typically, the OAT graft itself maintains its mechanical and histological integrity over the years, but surrounding articular cartilage continues to deteriorate, leading to a wide area of further chondral damage. Although this is difficult to understand and explain, it seems that the damage to articular cartilage surrounding the defect, and probably most importantly the lack of chondral integration, are the main reason for further chondral damage. Conclusion: Adherence to clear indications, correction of concomitant pathology, precise surgical technique and realistic goals are most important when considering OAT surgery in symptomatic patients with femoral osteochondral lesions. Treatment of focal femoral chondral lesions in active individuals remains a significant challenge with many controversies remaining

AIMS. The aim of this study was to assess the knee function after MPFL reconstruction with single hamstring autograft. METHODS-RESULTS. In this case series 68 patients (69 knees) were treated in total. Clinical and radiological evidence of patellar instability and MPFL rupture or deficiency was documented prior to surgery. The MPFL was reconstructed with semitendinosus autograft. The free end of the graft was rerouted through the most distal part of the medial intermuscular septum proximally to the adductor tubercle, to the superomedial border of the patella, where it was fixed, whereas its distal insertion to the tibia was preserved. Knee function was assessed preoperatively and postoperatively with the use of Kujala, Tegner, Lysholm and International Knee Documentation Committee (IKDC) scores. There were 46 male and 22 female patients with an average age of 25.8 years (median age 23) ranging from 11 to 54 years. The mean follow-up was 19.6 months (range 6-54 months). Ten of the patients had findings of femoral trochlear dysplasia. All knee functional scores significantly improved postoperatively. Kujala score improved from 56 to 84, Tegner score improved from 2 to 6, IKDC score improved from 48 to 75 and Lysholm score improved from 53 to 80. One of the patients required revision of the MPFL reconstruction following traumatic redislocation of the patella. CONCLUSIONS. Rerouting of the semitendinosus tendon for the reconstruction of the MPFL is an effective method for the treatment of patellofemoral instability with very good to excellent functional results

The purpose of our study is to determine if hamstring autograft size can be predicted preoperatively. We will define a relationship between patient body size (BMI, height, and weight) and harvested graft size, as well as define a relationship between the preoperative MRI cross-sectional area (CSA) of hamstring tendons and harvested graft size. This information will be useful as a tool for preoperative planning in graft choice selection. The pre-operative MRIs of one hundred and four patients (62M, 42F) who underwent ACL reconstruction using hamstring autografts were analyzed. Cross-sectional area (CSA) of the ST and G was measured on a single axial MRI image at the level of the knee joint. Combined CSA of both tendons was then compared to the diameter of the four-strand hamstring autograft measured intra-operatively. Patient BMI, height and weight was also compared to intraoperative hamstring autograft size. Linear regression analysis was then performed to define the relationship and predictive value of body size on graft diameter. Mean graft size was 7.4mm (range 6 – 9). Average graft size for men and women, 7.6mm and 7.1mm, respectively. Predicting graft size from BMI: r= 0.29, R2= 0.08. Predicting graft size from height: r= 0.52, R2= 0.27. Predicting graft size from weight: r= 0.5, R2= 0.25. On preoperative MRI, the mean CSA of ST and G was 9.8mm2 (range 5.4 – 17.7) and 4.5mm2 (range 1.8 – 9.4) respectively, with a total CSA of 14.3mm2 (range 8.4 – 25). If the total CSA was greater than 12mm2, a graft of 7.0mm or greater could be predicted 93% of the time, with sensitivity and specificity, 78% and 76%, respectively, and a LR of 3.25. Body size is a poor predictor of hamstring graft size in ACL reconstruction, and therefore a large patient does not always provide a large graft from harvested hamstring tendons. MRI assessment of hamstring tendons can be a useful tool for preoperative planning, providing a strong predictive value of graft size from a simple calculation

Background: The major problem achieving lumbar spinal fusion is developing pseudarthrosis. At present the gold standard in achieving fusion is the use of autograft from pelvis or posterior elements of the spine. However the potential limitations of insuffient quantity and donor site morbidity have led to search for bone graft alternatives like DBM which contains osteinductive BMPs. Aims & Methods: A Prospective Randomized Control trial comparing the effectiveness of demineralised Bone Matrix (DBM Putty)/autograft composite with autograft in lumbar spinal fusion. 35 patients were included in the trial; they were randomized to have DBM and autograft on one side, and autograft alone on other side to side. Patients were followed up with interval radiographs for total of 24mons. To date 20 patients have completed minimum 12mons follow up. The mineralization of fusion mass lateral to the instrumentation on each side was graded Absent, Mild (< 50%), Moderate (> 50%) or Complete fusion (100%). The assessment was made by two orthopaedic consultants and a musculoskeletal radiologist who were blinded to graft assignment. Results: The sex distribution was 11:9 male to females with a mean age of 55.2 (21–87 years) and an average follow up of 18mons (12–24mons). Nine patients had single level fusion and the remainder had more than one level fusion. At 12 months on the side of DBM, 15% (6 of 20) had complete fusion, 80% (16 of 20) had moderate fusion, and 5% had no fusion mass. During the same period on the other side, 25% did not show any sign of fusion. There was no correlation with number of levels, age or sex. Conclusions: Osteoinductive properties of DBM would appear to help in achieving early and higher union rates in lumbar spinal fusion. DBM reduces the amount of harvested autograft graft and also minimises the morbidity of donor site complications

Bone grafts are a useful option to treat large posteromedial defects in tibia which are usually seen in medial condyle of the tibia in severe varus knees and lateral condyle in valgus knees. Contained defects can be treated using cancellous bone chips/graft. Uncontained peripheral defects may be treated using cement with or without screw augmentation for small defects. Large defects > 25 % of tibial plateau and > 5 mm deep may need structural bone graft or impaction bone grafting or metal wedges. The use of bone grafts is a viable alternative for the treatment of massive bone loss. For stable fixation of the components, we performed osseous reconstruction of tibial condyle using autologous structural bone grafts /impaction bone grafting. We used structural bone graft for 62 tibial defects in severe varus knees in 675 primary TKR. Grafts originating from the femoral condyles were fixed with screws. Morselised autograft supported by mesh, fixed with screws, were used in 8 patients. Bilateral bone grafting was done in 28 patients. Goal was to obtain firm seating of the tibial tray on a rim of viable bone along with rigid press fixation of the medullary stem. We observed an average 70-point postoperative increase in knee function according to HSS score. Graft incorporation was seen in all patients at average seven year follow-up. Autologous bone grafts can be successfully used for reconstruction of large osseous defects. It is available then and there, is biological and cost effective

Introduction and Aims: Chronic distal biceps tendon ruptures have traditionally been treated with a biceps to brachialis tenodesis. The use of a semitendinosus autograft to reconstruct the distal biceps tendon for chronic rupture has been described. This study evaluates the functional outcome of a group of patients treated with autograft reconstruction. Method: This retrospective study identified six patients who underwent a late reconstruction of a biceps tendon rupture using a semitendinosis autograft. Functional outcome was evaluated objectively and subjectively. Clinical subjective evaluation included the MAYO elbow score and the outcome questionnaire from the Society of Shoulder and Elbow Surgeons (SSES). Objective outcomes were assessed by measurement of peak torque for both elbow flexion and supination using a Cybex II Isokinetic machine. Comparisons were made with the opposite limb. Results: Six right-handed male patients aged 42±7 yrs (range 34–48 yrs) were evaluated in this study, five of which achieved a good to excellent MAYO performance score (average 87 ±12), and SSES score (average 86±21). Peak torque obtained during maximal elbow flexion was 44±17 Nm (vs. 55 ±16 Nm opposite elbow) during supination was 8±4Nm (vs. 10±2Nm opposite elbow). Conclusion: This study represents a series of patients with autograft reconstruction of the chronic distal biceps rupture. It is the first study to quantitatively measure the recovery of strength of elbow flexion and supination. The semitendinosus autograft provides a strong and reliable reconstructive option in the majority of patients with chronic biceps tendon ruptures. Recovery of elbow flexion and supination power is nearly normal

The aim of this study was to assess a specific protocol for the treatment of patients with a parosteal osteosarcoma of the distal femur with limb salvage involving hemicortical resection and reconstruction using recycled pasteurised autograft and internal fixation. Between January 2000 and January 2010, 13 patients with a mean age of 26.5 years (17 to 39) underwent this procedure. All the tumours were staged according to Enneking’s criteria: there were eight stage IA tumours and five stage IB tumours. The mean follow-up was 101.6 months (58 to 142), and mean post-operative Musculoskeletal Tumour Society functional score was 88.6% (80% to 100%) at the final follow-up. All the patients had achieved bony union; the mean time to union was 11.2 months (6 to 18). Local recurrence occurred in one patient 27 months post-operatively. No patient had a pulmonary metastasis. A hemicortical procedure for the treatment of a parosteal osteosarcoma is safe and effective. Precise pre-operative planning using MRI is essential in order to define the margins of resection. Although it is a technically demanding procedure, gratifying results make it worthwhile for selected patients. Cite this article: Bone Joint J 2013;95-B:1275–9

In this study a combination of autologous chondrocyte implantation (ACI) and the osteochondral autograft transfer system (OATS) was used and evaluated as a treatment option for the repair of large areas of degenerative articular cartilage. We present the results at three years post-operatively. Osteochondral cores were used to restore the contour of articular cartilage in 13 patients with large lesions of the lateral femoral condyle (n = 5), medial femoral condyle (n = 7) and patella (n = 1). Autologous cultured chondrocytes were injected underneath a periosteal patch covering the cores. After one year, the patients had a significant improvement in their symptoms and after three years this level of improvement was maintained in ten of the 13 patients. Arthroscopic examination revealed that the osteochondral cores became well integrated with the surrounding cartilage. We conclude that the hybrid ACI/OATS technique provides a promising surgical approach for the treatment of patients with large degenerative osteochondral defects

Surgical reconstruction of articular surfaces by transplantation of osteochondral autografts has shown considerable promise in the treatment of focal articular lesions. During mosaicplasty, each cylindrical osteochondral graft is centred over the recipient hole and delivered by impacting the articular surface. Impact loading of articular cartilage has been associated with structural damage, loss of the viability of chondrocytes and subsequent degeneration of the articular cartilage. We have examined the relationship between single-impact loading and chondrocyte death for the specific confined-compression boundary conditions of mosaicplasty and the effect of repetitive impact loading which occurs during implantation of the graft on the resulting viability of the chondrocytes. Fresh bovine and porcine femoral condyles were used in this experiment. The percentage of chondrocyte death was found to vary logarithmically with single-impact energy and was predicted more strongly by the mean force of the impact rather than by the number of impacts required during placement of the graft. The significance of these results in regard to the surgical technique and design features of instruments for osteochondral transplantation is discussed

Objective: To determine if a porous, coralline-derived hydroxyapatite block (ProOsteon 500. TM. , Interpore, Irvine, CA) is a suitable substitute for tricortical iliac crest autograft in cervical interbody fusion. Design: A prospective randomised trial with two-year follow-up comparing clinical and radiographic outcomes in patients receiving either iliac crest or hydroxyapatite grafts in cervical interbody fusion. Subjects: Twenty-nine patients undergoing cervical fusion and anterior plating were randomised to receive either iliac crest (Group I) or hydroxyapatite (Group II) interbody grafts. Fourteen patients (19 grafts) in Group I and twelve patients (18 grafts) in Group II were available for final analysis. Both groups were similar with respect to age, sex, diagnosis and levels fused. Outcome Measures: The SF-36 and Oswestry Disability Index were used to measure clinical outcome. Post-op and final follow-up radiographs were analysed for graft fragmentation, loss of height, loss of angular alignment and hardware failure to assess structural integrity of the graft. Computed or plain tomography was used to evaluate fusion. Results: Groups I and II demonstrated improvement in preoperative scores for bodily pain (p=. 016 and. 016 respectively) and physical functioning (p=. 050 and. 016 respectively) at final follow-up. There was no significant difference in SF-36 and Oswestry scores between the two groups. Successful radiographic fusion was similar in both groups (79% in Group I and 76% in Group II). Graft fragmentation occurred in 89% of the hydroxyapatite grafts and 11% of the autografts (p=. 001). Greater than 2mm of graft height and 3° of segmental lordosis were lost in 55% of hydroxyapatite grafts vs. 11% of autografts (p=. 009). One patient in Group II and none in Group I required revision surgery for graft failure. The high rate of early radiographic failure in the hydroxyapatite grafts prompted suspension of further enrolment in the clinical trial. Conclusions: ProOsteon 500 coralline hydroxyapatite blocks do not possess adequate structural integrity to resist axial loading and maintain disc height or segmental lordosis during cervical interbody fusion

We describe a method of reconstruction using tumour-bearing autograft treated by liquid nitrogen in 28 patients. The operative technique consisted of en bloc excision of the tumour, removal of soft tissue, curettage of the tumour, drilling and preparation for internal fixation or prosthetic replacement before incubation for 20 minutes in liquid nitrogen, thawing at room temperature for 15 minutes, thawing in distilled water for ten minutes, and internal fixation with an intramedullary nail, plate or composite use of prosthetic replacement. Bone graft or cement was used to augment bone strength when necessary. The limb function was rated as excellent in 20 patients (71.4%), good in three (10.7%), fair in three (10.7%), and poor in two (7.1%). At the final follow-up six patients had died at a mean of 19.8 months after the operation, while 21 remained free from disease with a mean follow-up of 28.1 months (10 to 54). One patient is alive with disease. Bony union was seen at a mean of 6.7 months after the operation in 26 patients. Complications were encountered in seven patients, including three deep infections, two fractures, and two local recurrences. All were managed successfully. Our results suggest that this is a simple and effective method of biological reconstruction

Aims: The purpose of the study was to assess the mid-term knee functional results after Medial Patellofemoral Ligament (MPFL) reconstruction with single semitendinosus autograft in patients with patellofemoral instability. Methods and Results: Knee function was assessed in 45 patients (46 knees) who underwent MPFL reconstruction with semitendinosus autograft. The tibial insertion of the semitendinosus was preserved whereas the free end, after stripping of the tendon from the musculo-tendinus junction was rerouted through the most distal part of the medial intermuscular septum proximally to the adductor tubercle, to the superomedial border of the patella, where it was fixed. Clinical and radiological evidence of patellar instability and MPFL rupture or deficiency was documented prior to surgery. Knee function was assessed preoperatively and postoperatively with the use of Kujala, Tegner, Lysholm and International Knee Documentation Committee (IKDC) scores. There were 34 male and 11 female patients with an average age of 32.5 years, ranging from 17 to 60 years. The minimum follow up was 2 years with an average of 33.5 months (range 24–54 months). Fourteen patients (30%) presented a degree of patellofemoral dysplasia. All knee functional scores significantly improved postoperatively. Kujala score improved from 57.7 to 77.1, Tegner score improved from 3.06 to 5.26, IKDC score improved from 51.2 to 75.44 and Lysholm score improved from 58.7 to 79.3. One of the patients required revision of the MPFL reconstruction due to traumatic redislocation of the patella. Conclusions: At a midterm follow-up, reconstruction of the MPFL with rerouting of the semitendinosus tendon is an effective method with improved function in all patients. Maximum improvement was achieved within the first six postoperative months. Heterogeneity of our population may have affected some of our results

The aim of the study was to assess the knee function after MPFL reconstruction with single hamstring autograft. In this case series 86 patients (87 knees) were treated in total, from July 2002 till December 2008. Clinical and radiological evidence of patellar instability and MPFL rupture or deficiency were documented prior to surgery. The MPFL was reconstructed with semitendinosus autograft. The tibial insertion of the graft was retained whereas its free end was rerouted through the most distal part of the medial intermuscular septum, to the supero-medial border of the patella, where it was fixed. Knee function was assessed preoperatively and postoperatively with the use of Kujala, Tegner, Lysholm and International Knee Documentation Committee (IKDC) scores. There were 60 male and 26 female patients with an average age of 29.73 years (median age 28) and range 16–54 years. The mean follow-up was 22.4 months (range 6–78 months). All knee functional scores significantly improved postoperatively. Kujala score improved from 61.3 to 84.8, Tegner score improved from 3 to 5.3, IKDC score improved from 52.4 to 73.8 and Lysholm score improved from 58 to 76.5. The comparison was made between the preoperative and the postoperative values at two years after surgery or at the last follow up, if it was shorter than two years. All scores showed significant improvement after the third postoperative month. One of the patients required revision of the MPFL reconstruction following traumatic redislocation of the patella. Rerouting of the semitendinosus tendon for the reconstruction of the MPFL is an effective method for the treatment of patellofemoral instability. Significant functional improvement is achieved between the third and sixth postoperative months

The study describes a technique of tibial autograft to augment posterior instrumented spinal fusion in a population of paediatric patients with severe idiopathic, neuromuscular or syndromic scoliosis who are at a higher risk of postoperative pseudarthrosis and reports patient outcomes in terms of union rate, donor site morbidity and cost. Patients were identified from a review of waiting list and operating room records between 2007–2014. Surgery was performed by the senior author. Information on patient demographics, underlying diagnosis, age at surgery, revision surgery and length of follow-up was obtained from clinic notes. Parents of children were followed up with a structured telephone questionnaire regarding ambulatory status, post-operative pain, infection, further surgery and general satisfaction. Four hundred and nine patients underwent posterior instrumented spinal fusion, during the study period. Forty-two patients’ fusions were augmented with tibial graft, 40 of whom participated in the study. There were no cases of donor site infection, compartment syndrome, tibial fracture or perioperative mortality. In 85% of cases leg pain had resolved within 6 weeks, and 100% within 6 months of surgery. There were 6 cases of revision spinal surgery, 3 for infection, 2 for sacroiliac screw removal and 1 for sacroiliac screw revision. There were no clinical cases of spinal pseudarthrosis in this series. All parents were satisfied by the clinical outcome of both the tibial and spinal surgeries. Spinal fusion utilising tibial autograft is advocated as a simple, safe and cost-effective method of providing significant structural autograft to support fusion for a population of patients with high risk of junctional pseudarthrosis. With the exception of transient post-operative pain, the procedure was without any serious donor site morbidity. The outcomes of this study were as expected and in keeping with previous reports

Purpose. To assess the midterm functional results after Medial Patellofemoral Ligament (MPFL) reconstruction with single semitendinosis autograft in patients with patellofemoral instability. Methods - Results. Forty six knees (45 patients) with patellofemoral instability were treated with surgical stabilisation of the patella with a single semitendinosis autograft and followed up for a minimum of 24 months. The average follow-up was 33.5 months (range 24-54 months). Clinical evidence of patellar instability and radiological (MRI) evidence of MPFL rupture or deficiency was documented prior to surgery. The average post injury interval was 22.3 months. Ipsilateral joint co-morbidities included previous lateral release or distal realignment (n=10), patellofemoral joint (PFJ) dysplasia (n=14) and concurrent ACL, PCL and/or MCL rupture (n=6). Knee function was assessed preoperatively and postoperatively with the use of Kujala, Tegner, Lysholm and International Knee Documentation Committee (IKDC) scores. There were 34 male and 11 female patients with a mean age of 32.5 years (range 17 - 60 years). All measured knee function scores improved postoperatively. Kujala score improved from 58 to 77 (95%CI +/− 9.71). Tegner score improved from 3 to 5 (95%CI+/− 0.65). IKDC score improved from 51 to 75 (95%CI +/− 5.27) and Lysholm score improved from 59 to 79 (95%CI +/− 6.5). Conclusions. MPFL reconstruction with semitendinosis autograft is an effective treatment at a minimum of 24 months (midterm) follow-up in patients with patellofemoral instability even in the presence of heterogeneous knee co-morbidities such as PFJ dysplasia, previous lateral release and failed realignment surgery

Purpose: The management of Dorsal Fracture Dislocations of the PIP joint is challenging, especially for the unstable ones. Complications are common and often lead to functional disability. Many treatment methods have been described in the past, illustrating that no optimal solution has been found. In the Hemi-Hamate autograft technique, introduced by Hastings in 1999, a reconstruction of the volar lip joint surface and stabilization of the joint is achieved. This autograft can be seen as a model of a non vascularised bone-cartilage composite graft. The purpose of the present retrospective study was to evaluate the long term results of the hemi-hamate autograft technique in unstable PIP fracture-dorsal dislocations with special reference to posttraumatic degenerative arthritis common in non vascularized joint transfers. Materials and Methods: We report the results of 9 patients operated between November 2002 and March 2008 and with a minimum follow up of 26 months. The mean follow-up time was 56 months. There were 6 men and 3 women with a mean age at operation of 45 years (23–66). All fractures were unstable with comminution of the volar lip. In 3 patients the dominant hand was involved. The middle finger was injured in 4 patients, the ring finger in 4 and the little finger in 1 patient. All patients were treated with the operation technique described by Hastings and reanalyzed by Williams. The volar base of middle phalanx was debrided and reconstructed by a pre-sized autograft harvested from the dorsal side of the homolateral hamatum, and fixed with mini screws. A standard rehabilitation program was used postoperatively. Clinical (ROM, grip strength), radiographic and subjective outcomes (VAS) were examined in all patients. Results: At the last follow up, the injured finger had an average active ROM at the MCP joints of 97o (90o–115o) at the PIP 69 o (45 o –95 o) and at the DIP 59 o (30 o –90 o). The extension lag in the PIP joints were mean 10 o (0 o –30 o). Grip strength of the injured hand was mean 89% of the uninjured contralateral side. On radiographs, severe arthritis in the treated PIP was found in 2 of 9 patients. Another 2 patients had degenerative arthritis in several PIP. The average subjective score of patient’s satisfaction was 85 (20–100) in a scale 0–100 (100 best). Conclusions: The Hemi-Hamate autograft technique is a technically demanding operation but an alternative to arthrodesis or primary joint arthroplasty in the treatment of Fracture-Dorsal Dislocations of PIP joint. Our results are good and comparable to previously reported results (Williams 2001). Some deterioration will occur regarding joint osteoarthritis but a high degree of subjective patient satisfaction was found. Further studies and methods to decrease the osteoarthritis would be preferential

Background. Medial opening-wedge high tibial osteotomy is one of the common surgical procedures in treatment of knee deformities. Many methods have been proposed to fill the medial side osseous gap. The results of using allograft as void filler compared to iliac crest autograft has not been subject to a randomized clinical trial. The purpose of this study was to examine the results of medial opening-wedge high tibial osteotomy using iliac crest allograft as compared to iliac crest autograft. Materials & Methods. Forty-six patients with genovarum deformity were enrolled based on specific inclusion and exclusion criteria and were randomly assigned into two groups. Medial opening-wedge high tibial osteotomy was done using iliac crest allograft (23 patients) or autograft (23 patients) and the osteotomy site was internally fixed using proximal tibial T-plate. All patients were followed-up to 12 months after surgery. Anatomical indices of proximal tibia, complications of treatment, and functional outcome (using WOMAC osteoarthritis index) were assessed for both groups. Results. The amount of correction (degrees), recurrence of the deformity and loss of correction and time to clinical or radiologic union were similar in both groups with no statistically significant difference. Duration of operation was significantly less in allograft group (66.6±3.6 versus 52.9±5.3 minutes, p<0.001). Incidence of surgical site infection did not significantly differ in two groups. No nonunion or delayed union was encountered in either group. Some patients reported more intense postoperative pain in iliac graft harvest site than tibial osteotomy site. Patients in both groups had statistically significant improvement in WOMAC index postoperatively (with no statistically significant difference between groups). Conclusions. According to the results of this study, iliac crest allograft may be safely used in medial opening-wedge high tibial osteotomy with comparable efficacy to iliac crest autograft in patients who do not accept the morbidity of autograft harvest

We have reviewed 54 patients who had undergone 61 total hip replacements using bulk femoral autografts to augment a congenitally dysplastic acetabulum. There were 52 women and two men with a mean age of 42.4 years (29 to 76) at the time of the index operation. A variety of different prostheses was used: 28 (45.9%) were cemented and 33 (54.1%) uncemented. The graft technique remained unchanged throughout the series. Follow-up was at a mean of 8.3 years (3 to 20). The Hospital for Special Surgery hip score improved from a mean of 10.7 (4 to 18) pre-operatively to a mean of 35 (28 to 38) at follow-up. The position of the acetabular component was anatomical in 37 hips (60.7%), displaced less than 1 cm in 20 (32.7%) and displaced more than 1 cm in four (6.6%). Its cover was between 50% and 75% in 34 hips (55.7%) and less than 50% in 25 (41%). In two cases (3.3%), it was more than 75%. There was no graft resorption in 36 hips (59%), mild resorption in 21 (34%) and severe resorption in four (6%). Six hips (9.8%) were revised for aseptic loosening. The overall rate of loosening and revision was 14.8%. Overall survival at 8.3 years was 93.4%. The only significant factor which predicted failure was the implantation of the acetabular component more than 1 cm from the anatomical centre of rotation of the hip

The rate of nonunion of shaft of humerus ranges from 0 to 15%. The management of this problem becomes difficult when it is complicated by osteoprosis, bone defects and previous surgeries. We treated 24 such cases. There were sixteen males and 8 females. Age ranged from 28 to 65 years and averaged 46 years. Ten fractures were in the middle third and 14 were at the junction of middle and lower thirds. The average duration of nonunion was 8 months. Eight cases were previously treated with plating, 4 were treated with intramedullary nail and 2 with external fixator. Ten cases were treated with slab or cast. All cases were treated with removal of old metalwork (if any), open reduction, placement of fibula autograft in the medullary canal of humerus, plating and cancellous onlay grafting. The length of the fibula autograft in the humerus exceeded the plate length over each fragment. Anterior approach was used in 22 cases. In 2 cases posterior approach was used because of a previously posterior placed plate. U-slab was given in the postoperative period. It was discarded when there was clinical and radiological evidence of union. Physiotherapy was given to all patients after union. 22 humeri united and 2 failed to unite. 21 patients could carry out their daily activities and return to their profession. There was no postoperative radial nerve palsy. 1 case had fibula donor site pain. The follow-up period was 12 to 26 months and averaged 20 months. Conclusion: This method is a very useful way to manage difficult nonunions of shaft of humerus. We conclude that anterior approach to shaft of humerus is easy and physiological; intramedullary fibula helps to improve the screw purchase, abolishes the stress risers, acts as internal splint, substitutes for absent cortex and provides bone graft

Nitric oxide (NO) is a free radical labile gas which has important physiological functions and is synthesised by the action of a group of enzymes called nitric oxide synthases (NOS) on L- arginine. We have shown that nitric oxide modulates fracture healing. 1. Bone morphogenic proteins (BMP) are potent differentiating factors that augment the process of new bone formation. Recombinant human BMP-2 (rhBMP-2) enhances spinal fusion. 2. With progression of fusion there is a remodelling of the fusion mass bone accompanied with a decrease in the fusion mass size. It is not known whether nitric oxide has a role in spinal fusion or rhBMP-2 enhanced spinal fusion. We studied this in a novel rat intertransverse fusion model using a defined volume of bone graft (7 caudal vertebrae) along with 157 mm. 3. of absorbable Type-1 collagen sponge (Helistat®) carrier, which was compacted and delivered using a custom jig for achieving a similar graft density from sample to sample. The control groups consisted of a sham operated group (S, n=20), an autograft + carrier group (AC, n=28) and a group consisting of 43μg of rhBMP-2 (Genetics Institute, Andover, MA) mixed with autograft + carrier (ACB, n=28). Two experimental groups received a nitric oxide syn-thase (NOS) inhibitor, N. G. -nitro L-arginine methyl ester (L-NAME, Sigma Chemicals, St Louis, MO) in a dose of 1mg/ml ad lib in the drinking water (ACL, n=28) and one of these experimental groups had rhBMP-2 added to the graft mixture at the time of surgery (ACLB, n=28). Rats were sacrificed at 22 days and 44 days, spinal columns dissected and subjected to high density radiology (faxitron) and decalcified histology. The faxitrons were subjected to image analysis (MetaMorph). On a radiographic score (0–4) indicating progressive maturation of bone fusion mass, no difference was found between the AC and ACL groups, however, there was a significant enhancement of fusion when rhBMP-2 was added (ACB group,3.3±0.2) when compared to the AC group (1±0) (p< .001). However, on day 44, the ACLB group (3.3±0.2) showed significantly less fusion progression when compared to the ACB group (4±0) (p< 0.01). There was a 25% (p< 0.05) more fusion-mass-area in day 44 of ACLB group (297±26 mm. 3. ) when compared to day 44 of the ACB group (225±16 mm. 3. ) indicating that NOS inhibition delayed the remodelling of the fusion mass. Undecalcified histology demonstrated that there was a delay in graft incorporation whenever NOS was inhibited (ACL and ACLB groups). Our results show that the biology of autograft spinal fusion and rhBMP-2 enhanced spinal fusion can be potentially manipulated by nitric oxide pathways

Nitric oxide (NO) is a free radical labile gas which has important physiological functions and is synthesised by the action of a group of enzymes called nitric oxide synthases (NOS) on L- arginine. We have shown that nitric oxide modulates fracture healing. 1. Bone morphogenic proteins (BMP) are potent differentiating factors that augment the process of new bone formation. Recombinant human BMP-2 (rhBMP-2) enhances spinal fusion. 2. With progression of fusion there is a remodelling of the fusion mass bone accompanied with a decrease in the fusion mass size. It is not known whether nitric oxide has a role in spinal fusion or rhBMP-2 enhanced spinal fusion. We studied this in a novel rat intertransverse fusion model using a defined volume of bone graft (7 caudal vertebrae) along with 157 mm3 of absorbable Type-1 collagen sponge (Helistat®) carrier, which was compacted and delivered using a custom jig for achieving a similar graft density from sample to sample. The control groups consisted of a sham operated group (S, n=20), an autograft + carrier group (AC, n=28) and a group consisting of 43 μg of rhBMP-2 (Genetics Institute, Andover, MA) mixed with autograft + carrier (ACB, n=28). Two experimental groups received a nitric oxide synthase (NOS) inhibitor, N. G. -nitro L-arginine methyl ester (L-NAME, Sigma Chemicals, St Louis, MO) in a dose of 1 mg/ml ad lib in the drinking water (ACL, n=28) and one of these experimental groups had rhBMP-2 added to the graft mixture at the time of surgery (ACLB, n=28). Rats were sacrificed at 22 days and 44 days, spinal columns dissected and subjected to high density radiology (faxitron) and decalcified histology. The faxitrons were subjected to image analysis (MetaMorph). On a radiographic score (0–4) indicating progressive maturation of bone fusion mass, no difference was found between the AC and ACL groups, however, there was a significant enhancement of fusion when rhBMP-2 was added (ACB group, 3.3±0.2) when compared to the AC group (1±0) (p< .001). However, on day 44, the ACLB group (3.3±0.2) showed significantly less fusion progression when compared to the ACB group (4±0) (p< 0.01). There was a 25% (p< 0.05) more fusion-mass-area in day 44 of ACLB group (297±26 mm. 3. ) when compared to day 44 of the ACB group (225±16 mm. 3. ) indicating that NOS inhibition delayed the remodelling of the fusion mass. Undecalcified histology demonstrated that there was a delay in graft incorporation whenever NOS was inhibited (ACL and ACLB groups). Our results show that the biology of autograft spinal fusion and rhBMP-2 enhanced spinal fusion can be potentially manipulated by nitric oxide pathways

Developmental Hip Dysplasia (DDH) presents considerable technical challenges to the primary arthroplasty surgeon. Autogenous bulk grafting using the femoral head has been utilised to achieve anatomic cup placement and superolateral bone coverage in these patients, but reported outcomes on this technique have been mixed with lack of graft integration and subsequent collapse seen as an early cause of failures. Achieving union and incorporation of the autogenous graft have been identified as key determinants of a successful outcome with this technique. The main factors affecting incorporation are stability of the construct and host-graft bone contact. We describe a novel technique combining the use of bulk autograft with an iliac osteotomy, which provides primary stability and optimises direct cancellous-cancellous bone contact. 21 hips in 21 patients with DDH underwent this technique and were followed for a mean 8.1 years. The pre-operative radiographic classification was Crowe type I in 12 hips (57%), type II in 4 hips, and type III in 5 hips, and the mean Sharp angle was 49.6° (range 42–60°). All grafts united by year. At time of follow up, there was no radiographic evidence of graft collapse or loosening. There were no reoperations. Our study has shown that this technique variation combining an iliac osteotomy with bulk autograft in cases of developmental hip dysplasia provides early stability and reliable graft incorporation, together with satisfactory clinical and radiological outcomes in the medium term. Longer term study is necessary to confirm the clinical success of this procedure

We previously reported the result of 45 Charnley LFA’s with femoral head autograft for Developmental Dysplasia of the hip with a minimum follow-up of ten years. After an average follow-up of eleven years there was no revision. One socket migrated and four sockets were fully demarcated. To assess our long-term results we reviewed the clinical and radiological findings in the same group of patients that had been studied previously. To date 5 patients died from causes unrelated to the hip replacement and were excluded from the final radiological analysis. 40 Charnley LFA’s have been followed-up regularly. The average follow-up is now 17 years 1 month / range: 15–21 years/. Three sockets have been revised: two for aseptic loosening and one for infection. Radiographic assessment showed that three sockets migrated and four had full demarcation. Demarcation at the cement-bone interface of the socket was rare in zone one but was common in zone two. We concluded that sound fixation of the autograft and orientations of the acetabular component are essential. We recommend that solid bone graft should be combined with impaction bone grafting in dysplastic cases. We also observed that bone grafting at primary surgery gives better chances for component fixation at the time of revision

To assess the radiological outcome of instrumented posterolateral lumbar fusion in a prospective randomised study comparing the use of allograft (fresh frozen human femoral head) to autologous bone (from the posterior iliac crest), using a validated method. One hundred and twenty four radiographs of patients who had undergone instrumented posterolateral spinal fusion were assessed for fusion or non-fusion by three independent observers using the same criteria, and a second time by one of the observers. The Kappa scores for the inter-observer and intra-observer agreement were calculated. Thirty-three of these patients had fusion status verified by the gold randomised to one of two groups, to receive either allograft bone or autologous bone. The same surgeon using the same surgical technique performed or supervised all cases. The radiological results of the two groups were assessed as well as the quality of fusion. Both the inter-observer and intra-observer kappa scores (k) were 100%. The sensitivity of the method was 87.9% and the specificity was 100%. Thirty-seven patients received allograft and 32 patients received autograft. There was no significant difference in the fusion rate, or the quality and quantity of the graft between the groups. There is no difference in the fusion rates comparing the use of autograft and allograft for posterolateral instrumented lumbar fusion

Study Design: A prospective randomised controlled trial with blind radiological assessment. Objective: To assess the radiological outcome of instrumented posterolateral lumbar fusion in a prospective randomised study comparing the use of allograft (fresh frozen human femoral head) to autologous bone (from the posterior iliac crest) using a validated method. Methods: Sixty-nine patients having instrumented postero-lateral fusion using the Steffee plate were randomised to one of two groups, to receive either allograft bone or autologous bone. The same surgeon using the same surgical technique performed or supervised all cases. The radiological results of the two groups were assessed as well as the quality of fusion. Outcome measures: The radiographs were assessed for fusion or non-fusion by three independent observers using the same criteria, and a second time by one of the observers. The Kappa scores for the inter-observer and intra-observer agreement were calculated. Some of these patients had fusion status verified by the gold standard of surgical exploration and the sensitivity and specificity calculated. The clinical outcome is the subject of a different paper. Results: Both the inter-observer and intra-observer kappa scores (k) were 100%. The sensitivity of the method was 87.9% and the specificity was 100%. Thirty-seven patients received allograft and 32 patients received autograft. There was no significant difference in the fusion rate, or the quality and quantity of the graft between the groups. Conclusions: There is no difference in the fusion rates comparing the use of autograft and allograft for postero-lateral instrumented lumbar fusion

Purpose: This study sought to examine return to sports in athletes younger than 25 following ACL reconstruction with either patellar tendon (PT) or hamstring (HS) autografts using a matched-pairs case-control experimental design. Method: Twenty-three matched pairs were obtained based on gender (56.5% Female), age (18.3±2.5yrs PT vs.17.6±2.6 HS), and length of follow-up (4.7±2.1yrs PT vs. 4.2±1.6 HS). All patients reported participating in very strenuous (soccer, basketball etc.) or strenuous (skiing, tennis etc.) sporting activity 4–7 times/ week prior to their knee injury. Outcomes other than return to play included the IKDC, SAS, ADLS, SF-36, knee range of motion, laxity, and hop/jump testing. Results: Most patients in both groups were able to participate in very strenuous or strenuous sporting activity at follow-up [18 (78.3%) PT vs. 19 (82.6%) HS]. However, only 13 (56.5%) of the patellar tendon subjects and 10 (43.5%) of the hamstrings patients were able to return to pre-injury activity levels in terms of frequency and type of sport (p=.63). Hamstrings patients showed higher ADLS (p< .01) and SAS (p< .01) scores and better restoration of extension (p< 0.05). Conclusion: While autograft and allograft patellar tendon ACL reconstruction exhibit similar clinical outcomes in high-demand individuals, autogenous hamstring grafts may lead to better subjective outcomes in young patients who participate in very strenuous levels of activity. Both graft options only allowed approximately half of the injured athletes to return to their previous level of sporting activity

INTRODUCTION: Posterolateral intertransverse lumbar fusion is a commonly performed procedure for stabilisation of the degenerated lumbar spine. A typical clinical scenario for which such fusions are used is the stabilisation of a degenerative spondylolisthesis after decompression. In a recent large series reported in the literature, this type of fusion was noted to have a pseudarthrosis rate of up to 45% (Fischgrund, Spine 1997). METHODS: A pilot study was designed to evaluate the safety and efficacy of osteoinductive protein-1 (OP-1, also known as recombinant human BMP-7) in lumbar posterolateral fusion. Thirty-six patients with the diagnosis of symptomatic spinal stenosis and single level degenerative spondylolisthesis in the lower lumbar spine (L3–S1) were enrolled. The patients were randomised to either the OP-1 group or the control group. The OP-1 group received 3.5 mg of OP-1 per side in a putty carrier. The control group received iliac crest autograft alone. Outcomes were measured clinically using the Oswestry score and radiographically using dynamic radiographs evaluated independently by two blinded radiologists using digital calipers. Patients were deemed a clinical success if they showed a > 20% improvement in Oswestry score and were deemed a radiographic success if they showed bridging bone and spinal stability on flexion/ extension films. RESULTS: At twelve months, 18/21 (85.7%) patients in the OP-1 group and 8/11 (72.7%) patients in the autograft group were considered clinical successes, while 13/18 (72.2%) of patients in the OP-1 group and 6/10 (60%) patients in the autograft group were considered radiographic successes. No adverse events related to the use of OP-1 were noted. DISCUSSION: Despite the non-statistical number of patients enrolled in this pilot study, these preliminary results suggest that OP-1 appears to be a safe and effective replacement for iliac crest autograft in human pos-terolateral lumbar fusion. The OP-1 group had a higher radiographic fusion rate than the autograft group. This correlated well with the greater clinical success experienced by the OP-1 group, as measured by improvement in the Oswestry score. None of the previously reported device related complications related to the use of BMPs in animal studies, such as exuberant bone growth with subsequent neural impingement, ectopic ossification, or spinal stenosis, was seen in the treatment group. CONCLUSION: OP-1 appears to be a safe and effective replacement for iliac crest autograft in human posterolateral lumbar fusion. The dose, 3.5 mg per side, and the carrier, a biodegradable putty, appear to provide a safe and effective means of delivering the bone morphogenetic protein OP-1 to the human lumbar spine

Purpose: To compare two different techniques of inter-body fusion in treatment for single level degenerative spondylolisthesis with symptomatic spinal stenosis.

Methods: Retrospective review of patients with degenerative spondylolisthesis and spinal stenosis treated with decompression and instrumented posterior interbody fusion with and without cages. Between 1996 and 2003 there were 59 patients with single level degenerative spondylolisthesis and spinal stenosis. Of these 32 were treated with complete laminectomy, interbody grafting and pedicle screw fixation. In the second group of 27 patients, the technique was modified by the incorporation of an interbody cage in an attempt to improve the restoration of lordosis. Both groups were comparable in terms of pathology, age, sex, intraoperative technique and were treated by the same surgeon. All patients were followed up at 6, 12, 26 and 52 weeks with radiographs and were assessed for fusion and maintenance of lordosis at a minimum of 1 year.

Results: There was a statistically significant difference between pre and postoperative lordotic angles in both groups. There was no significant difference in clinical outcomes between the two groups, nor was there a statistical difference in postoperative lordotic angles at the end of 1 year between the two groups. We had 2 deep infections in the cage group. There was one implant failure in the no cage group.

Conclusion: We did not find any advantage in using interbody cages in treating single level degenerative spondylolisthesis.

Introduction: Posterolateral intertransverse lumbar fusion is a commonly performed procedure for stabilization of the degenerated lumbar spine. A typical clinical scenario for which such fusions are used is the stabilization of a degenerative spondylolisthesis after decompression. In a recent large series reported in the literature, this type of fusion was noted to have a pseudarthrosis rate of up to 45% (Fischgrund, Spine 1997). Methods: A pilot study was designed to evaluate the safety and efficacy of osteoinductive protein-1 (OP-1, also known as recombinant human BMP-7) in lumbar posterolateral fusion. Thirty-six patients with the diagnosis of symptomatic spinal stenosis and single level degenerative spondylolisthesis in the lower lumbar spine (L3-S1) were enrolled. The patients were randomized to either the OP-1 group or the control group. The OP-1 group received 3.5 mg of OP-1 per side in a putty carrier. The control group received iliac crest autograft alone. Outcomes were measured clinically using the Oswestry score and radiographically using dynamic radiographs evaluated independently by two blinded radiologists using digital calipers. Patients were deemed a clinical success if they showed a > 20% improvement in Oswestry score and were deemed a radiographic success if they showed bridging bone and spinal stability on flexion/ extension films. Results: At twelve months, 18/21 (85.7%) patients in the OP-1 group and 8/11 (72.7%) patients in the autograft group were considered clinical successes, while 13/18(72.2%) of patients in the OP-1 group and 6/10 (60%) patients in the autograft group were considered radiographic successes. No adverse events related to the use of OP-1 were noted. Discussion: Despite the non-statistical number of patients enrolled in this pilot study, these preliminary results suggest that OP-1 appears to be a safe and effective replacement for iliac crest autograft in human posterolateral lumbar fusion. The OP-1 group had a higher radiographic fusion rate than the autograft group. This correlated well with the greater clinical success experienced by the OP-1 group, as measured by improvement in the Oswestry score. None of the previously reported device related complications related to the use of BMP’s in animal studies, such as exuberant bone growth with subsequent neural impingement, ectopic ossification, or spinal stenosis, were seen in the treatment group. Conclusion: OP-1 appears to be a safe and effective replacement for iliac crest autograft in human posterolateral lumbar fusion. The dose, 3.5mg per side, and the carrier, a biodegradable putty, appear to provide a safe and effective means of delivering the bone morphogenetic protein OP-1 to the human lumbar spine

Aims: The authors report oncological and functional results after 15 acetabular reconstructions, followed tumor resection, with an original technique using homo-lateral proximal femoral autograft and total hip prosthesis. Material and method: The modiþed Musculoskeletal Tumor Society Score (MSTS) and the Toronto Extremity Salvage Score (TESS) were used for functional analysis. Functional results were available for only 10 patients who presented with a minimal of 2 years follow-up. Results: Fifteen consecutive patients, 9 men and 6 women with a median age of 50 years, were managed in our department for acetabular bone malignant tumor. The tumors involved the zones II in 5 patients, the zones II and III in 5 patients. The tumors included 10 chon-drosarcomas, 1 malignant þbrous histiocytoma, 1 radio-induced sarcoma, 1 myeloma and 2 metastasis. The mean follow-up was 31 months (Range, 12 to 50 months). Local recurrence occurred in 1 case and metastases in 3 cases. Three patients died of tumoral disease and one of intercurrent disease. Eight complications were observed: aseptic failure (n=1), obturator nerve damage (n=1), deep infection (n=4), skin necrosis (n=2), pros-thesis dislocations (n=1) and deep venous thrombosis (n=1). Five revision were performed. The mean MTS was 72% (range, 40 to 96%) and the mean TESS was 82.5% (range, 56 to 86%). Fusion occurred in all reconstructions and all patients recovered an active hip abduction and ßexion. Discussion: This original technique, using an autograft and a standard total hip prosthesis, is available for zone II and III acetabular reconstructions

Treatment of segmental bone loss remains a major challenge in orthopaedic surgery. This study evaluated the healing potential of a series of highly porous tissue engineering scaffolds with the current clinical gold standard. We compare healing of collagen-glycosaminoglycan (CG) and collagen micro-hydroxyapatite (CHA) scaffolds, with and without recombinant bone morphogenetic protein-2 (BMP2), with autogenous bone graft (ABG) in the healing of a 15mm rabbit radius defect, which were filled with either CG scaffold, CHA scaffold, CG-BMP2, CHA-BMP2 or ABG. Serial radiographs and micro-computed tomography (µCT) at six week radiographs demonstrated complete defect bridging with callus using CHA and CG-BMP2 while the CHA-BMP2 was already in an advanced state of healing with cortical remodeling. By sixteen weeks CHA, CG-BMP2 and ABG all had advanced healing with cortical remodeling while CHA-BMP2 had complete anatomic healing. Quantitative histomorphometry values demonstrated similarly high healing levels of healing in CHA, CG-BMP2 and ABG with highest overall values in the CHA-BMP2 group. Thus, treatment of a critical sized, weight bearing, rabbit radius defect with a CHA scaffold can result in full cortical bridging with medullary cavity development. In addition, a CHA-BMP2 combination can result in fully mature, anatomic healing. The use of an off-the-shelf CHA scaffold for direct surgical placement into a defect site may be an effective bone graft substitute in the treatment of skeletal defects. The ease of manufacture, storage and peri-operative preparation may offer an alternative to traditional strategies, as well as to more recent BMP2 devices. This study provides clear evidence that CHA scaffolds can perform as well as autogenous bone grafts and supports their use as a viable alternative. Where the use of BMP2 may be desirable, these materials provide an ideal delivery mechanism and using a very low (near physiological) dose, healing superior to autogenous graft may be achieved

The upper three-quarters of the fibula is commonly used as a non-vascularised autograft. Subsequent to this isolated weakness of extensor hallucis longus may occur. We have studied 26 patients in whom the upper and middle thirds of the fibula had been harvested as a graft through Henry’s posterolateral approach. Isolated weakness of extensor hallucis longus was found after operation in ten patients but not in the remainder. EMG and nerve-conduction studies confirmed injury of the nerve to extensor hallucis longus in those with weakness. We dissected 40 cadaver limbs and found that those in which the nerve to extensor hallucis longus ran close to the fibular periosteum were at risk. The injury is mostly incomplete and recovery occurs within four to six months

Increasing expectations from arthroscopic anterior cruciate ligament (ACL) reconstructions require precise knowledge of technical details such as minimum intra-femoral tunnel graft lengths. A common belief of having ≥20mm of grafts within the femoral tunnel is backed mostly by hearsay rather than scientific proof.

We examined clinico-radiological outcomes in patients with intra-femoral tunnel graft lengths <20 and ≥20mm. Primary outcomes were knee scores at 1-year. Secondarily, graft revascularization was compared using magnetic resonance imaging (MRI). We hypothesized that outcomes would be independent of intra-femoral tunnel graft lengths.

This prospective, single-surgeon, cohort study was conducted at a tertiary care teaching centre between 2015–2018 after obtaining ethical clearances and consents. Eligible arthroscopic ACL reconstruction patients were sequentially divided into 2 groups based on the intra-femoral tunnel graft lengths (A: < 20 mm, n = 27; and B: ≥ 20 mm, n = 25). Exclusions were made for those > 45 years of age, with chondral and/or multi-ligamentous injuries and with systemic pathologies. All patients were postoperatively examined and scored (Lysholm and modified Cincinnati scores) at 3, 6 and 12 months. Graft vascularity was assessed by signal-to-noise quotient ratio (SNQR) using MRI. Statistical significance was set at p<0.05.

Age and sex-matched patients of both groups were followed to 1 year (1 dropout in each). Mean femoral and tibial tunnel diameters (P =0.225 and 0.595) were comparable. Groups A (<20mm) and B (≥20mm) had 27 and 25 patients respectively. At 3 months, 2 group A patients and 1 group B patient had grade 1 Lachman (increased at 12 months to 4 and 3 patients respectively). Pivot shift was negative in all patients. Lysholm scores at 3 and 6 months were comparable (P3= 0.195 and P6= 0.133). At 1 year both groups showed comparable Cincinnati scores. Mean ROM was satisfactory (≥130 degrees) in all but 2 patients of each group (125–130 degrees). MRI scans at 3 months and 1 year observed anatomical tunnels in all without any complications. Femoral tunnel signals in both groups showed a fall from 3–12 months indicating onset of maturation of graft at femoral tunnel.

Our hypothesis, clinical and radiological outcomes would be independent of intra-tunnel graft lengths on the femoral aspect, did therefore prove correct. Intra-femoral tunnel graft lengths of <20 mm did not compromise early clinical and functional outcomes of ACL reconstructions. There seems to be no minimum length of graft within the tunnel below which suboptimal results should be expected.

We report intermediate term results of a technique of acetabular augmentation using block femoral head autograft and the uncemented expansion cup for adult hip dysplasia. A retrospective review of one surgeon (BFH) series of consecutive total hip replacements for hip dysplasia using femoral head acetabular augmentation was carried out. The technique involves sectioning the femoral head longitudinally reversing and fixing it to the deficient acetabulum with 6.5mm AO screws. This is then reamed to accept the uncemented expansion cup. Patients were identified from audit databases. Patients completed clinical questionnaires, examination and radiographic evaluation. Fifteen hips were identified in twelve patients (three bilateral). The average at age at surgery was 54 (44–58) years. There were eight females (eleven hips). Three patients (three hips) were unable to be contacted. Average follow up was 8.4 (4.8–11.4) years. Preoperative centre edge angle was 14 (−10–30) degrees. One patient developed a deep infection requiring early staged revision. One patient was not satisfied with her results at follow up. Mean Harris Hip Score was 83 (63–100), mean WOMAC Score was 76 (50–95). Range of motion was well maintained in all patients. Four patients had other co-morbidities affecting their results. Radiological review shows all grafts to have united with no screw breakage and no cup loosening. At eight year follow up there is high satisfaction, good clinical and radiological results. These results demonstrate good intermediate term results using this technique in total hip replacement with acetabular dysplasia

Purpose: Treatment of major bone loss still raises difficult reconstruction problems. For bone tumours, massive resection prostheses allow rapid reconstruction of the architecture and satisfactory function. Several publications have reported the use of autoclave-sterilised cortical autografts for the treatment of bone tumours but only two old publications (1961) have used this method for the treatment of major bone loss in limb traumatology. Case report: A 17-year-old male patient was transported from a neighbouring island after a motorcycle accident. The patient presented Cauchoix stage 2 fracture of the lower end of the femur with bone lose measuring 11 cm. The complete diaphysometaphyseal segment was recovered on the road and was brought in a sack. Emergency debridement was performed followed by complete skin closure and transcalcaneal traction. The femoral cortical fragment was cleaned and sterilised in the autoclave with one cycle at 121°C for 20 minutes at 1.3 bars. Twenty days later, osteosynthesis was performed using a large 95° Muller plate via a lateral approach. The cortical segment was put in position enabling complete recovery of length, alignment and rotation. Rehabilitation was initiated postoperatively. Total weight bearing began at three months and nautical sports (wind surf, surfing) at six months. Complete recovery of motion was achieved (heal-buttocks). Extension was normal and symmetrical both actively and passively with no recurvatum. Results: Successive postoperative x-rays taken at 1.5 and 4 months and 1, 2, 3, 4, 6, and 7 years showed excellent graft incorporation. Healing of the metaphyseal and diaphyseal interfaces was complete at two years. Biopsy of the metaphyseal zone showed a normal bone structure. Discussion: This exceptional case illustrates the capacity of this method to allow total recovery of function, an outcome rarely achieved after such important bone loss

Objectives. Surgical treatment is standard for advanced osteochondritis dissecans (OCD) of the humeral capitellum. When cartilage is seen to be separated or completely detached, this fragment fixation is not usually applied. There have been reports of cases in which advanced OCD of the humeral capitellum progressed to osteoarthritis (Fig), particularly in cases which involved the lateral wall. In these cases, every attempt should be made to reconstruct the lateral wall to avoid osteoarthritis. In this study, we followed up cases with rib osteochondral autograft transplantation technique. Methods. Subjects were 20 cases who were followed up until after they started pitching. The mean age was 13.8 years old and the mean observation period was 2 years and 6 months (from 7 months to 6 year 3 months). Kocher's approach was used to give a good access to the aspect of the radiohumeral joint. The majority of cases suffered from extensive OCD of the elbow. Detached fragment was removed (Fig. 2a) and graft from 5. th. or 6. th. rib with screw fixation was performed on 12 patients and 8 received fixation with no material (Fig. 2b). Follow-up assessment included the range of motion, start time of playing catch and throwing a ball with full power, sports activity, evaluation of radiography, a subjective (including Pain, Swelling, Locking/Catching and Sport activity) and objective (Flexion contracture, Pronation/Supination and sagittal arc of motion) modified elbow rating system by Timmeman et al. We also investigated the details of the arthroscopy observations and the 2nd arthroscopy findings for 4 cases. Results. Preoperative elbow extension increased from −13.5 to −10 degrees and elbow flexion increased from 117 to 123 degrees, but no significant differences were found. All but one patient resumed baseball sporting activity. Catching was started at an average of 3.5 (2 to 5.5 months) months postoperatively and pitching the ball with full power was achieved at 6.7 months. One case was found to have degenerative changes on plain X-ray, and two cases were found to have deviated screws. The mean elbow rating system subjective score improved significantly from 63.9.5 to 89.5 points, as did the overall rating, increasing from 131.6 to 164.8 points. The 2. nd. arthroscopy observations for 4 patients showed that 2 experienced pain due to the loose body, 1 had a limitation in range of motion due to spur formation, and 1 had a screw deviation. Graft survival was observed in two out of four cases. Partial detachment was observed in two cases. Conclusion. Recovery of articular facets with hyaline cartilage were possible using this surgical technique, and in addition, the costal-costochondral grafts, comprising cortical and cancellous bone, were simultaneously transplanted en bloc. This indicates that it is adequate treatment for extensive OCD. All the patients started pitching 3 months postoperatively and returned to full baseball activities after 6 months. Even in cases with extensive OCD, with large osseous and cartilaginous deficits, the surgical technique was useful and showed favorable results

Purpose: To test a CaSO4/CaPO4-TCP composite bone graft substitute in a crtically sized bone defect. Method: Twenty dogs had a contained medullary defect created in the proximal humerus. In ten dogs, the defect was treated with CaSO4/CaPO4-TCP composite graft (PRO-DENSE. ™. , Wright Medical) and studied for 13 weeks (N=5) and 26 weeks (N=5). In the other ten dogs, the defect was treated with autograft and followed for 13 weeks. An additional ten unoperated humeri were used to establish the properties of normal canine bone. The area fraction, ultimate compressive stress and modulus of elasticity of bone in the experimental and normal humeri were quantified using histomorphometric and mechanical methods and analyzed using the Mann-Whitney test. Results: At 13 weeks, the area fraction, compressive stress and modulus of elasticity of new bone in the defects was several-fold greater (p ≤ 0.005) using CaSO4/CaPO4-TCP composite graft compared to defects treated with autograft. The area fraction and compressive stress of new bone using CaSO4/CaPO4-TCP composite graft were also several fold greater (p≤.009) compared to normal bone, but there was no difference in the modulus of elasticity. Although the compressive stress was still greater (p=0.047) at 26 weeks for defects treated with the composite graft compared to normal bone, the regenerated bone had remodeled to a normal cancellous architecture, incorporating minute fragments of residual graft. Conclusion: CaSO4/CaPO4-TCP composite graft produced a several-fold greater amount and strength of bone than autogenous graft bone at 13 weeks. There was no modulus mismatch between the regenerated and native cancellous bone. The composite graft holds promise for non-load bearing applications where dense, strong bone formation at earlier time points would be advantageous, potentially resulting in quicker return to activity

Deficiency of the anterior cruciate ligament (ACL) is a common disorder which can lead to changes in lifestyle. We followed 59 patients who had had arthroscopic reconstruction of the ACL using a central-third patellar-tendon autograft for seven years to assess the long-term effectiveness of recent advances in reconstruction of the ACL. The standard criteria for evaluation of the International Knee Documentation Committee, the Lysholm knee score and measurements using the KT 1000 arthrometer all showed satisfactory results. Deterioration in the clinical performance after seven years was associated with osteoarthritic changes and correlated with chronic ligament injuries and meniscectomy. There were three traumatic and three spontaneous ruptures. We believe that the procedure can be successful, but remain concerned about failure of the graft and osteoarthritis. The results raise questions about the best time to operate and suggest that early surgery may reduce the risk of osteoarthritis

Introduction: We have come across a subset of patients with advanced patellofemoral osteoarthritis who also had well defined full thickness cartilage loss lesions on the weight bearing femoral condyle. In these patients the findings or the symptoms are not severe enough to warrant a total knee replacement. In this select group of patients, a combination of patellofemoral arthroplasty (PFA) and Osteochondral Autograft Transfer System (OATS) can be performed to address this unique problem. Method& Results: Out of 38 PFA procedures performed by the senior author, a concomitant OATS was performed in 6 knees in 5 patients. A retrospective analysis of these patients was carried out with the average follow up being 3.8 years (18 months to 84 months). The average age of the patients in our case study was 48.2 years (36 to 59 years) at the time of surgery. Four of the six knees are doing well in the medium term. One patient had progression of tibiofemoral arthritis and underwent a total knee replacement. The only poor result was a young male, who two years following the PFA, developed a deep infection of the knee. Except for this patient awaiting a second stage revision for an infected knee, all the others have achieved their desired level of activity. Conclusion: The advantage of this combination is that, the donor tubes for the OATS can be harvested from the trochlea or just adjacent to it, which happens to be the bed for the trochlear implant. This area provides good quality thick donor articular cartilage. As the surgical exposure has already been done for the PFA, the operative time is extended by approximately ten minutes for the OATS procedure. This combination procedure offers an alternative to more invasive options such as total knee replacement in younger patients in whom it is preferable to delay such major surgery

Coaxial autografts of skeletal muscle which had been frozen then thawed were used to repair injured digital nerves in eight patients. Assessment from three to 11 months after operation showed recovery to MRC sensory category S3+ in all but one patient, an excellent level of recovery. We conclude that bespoke muscle grafts treated and used in this way may offer significant advantages over conventional nerve grafts or cable grafts especially where large peripheral nerves are involved

Skeletal muscle grafts, when thawed after freezing, can be used to repair peripheral nerves. This method was used after transection of the median nerve in the upper arm in marmosets. Examination at 28 days showed total denervation of flexor carpi radialis; at 150 days electrophysiological evidence of recovery of nerve conduction across the graft and of muscle activation was seen. Sections at this time showed nerve fibres and new functional neuromuscular junctions in the muscle. It is concluded that effective reinnervation of target muscles is possible after peripheral nerve repair using skeletal muscle autografts

A total of 38 patients with leprosy and localised nerve damage (11 median at the wrist and 37 posterior tibial at the ankle) were treated by 48 freeze-thawed skeletal muscle autografts ranging between 2.5 cm and 14 cm in length. Sensory recovery was noted in 34 patients (89%) and was maintained during a mean period of follow-up of 12.6 years (4 to 14). After grafting the median nerve all patients remained free of ulcers and blisters, ten demonstrated perception of texture and eight recognised weighted pins. In the posterior tibial nerve group, 24 of 30 repairs (80%) resulted in improved healing of the ulcers and 26 (87%) demonstrated discrimination of texture. Quality of life and hand and foot questionnaires showed improvement; the activities of daily living scores improved in six of seven after operations on the hand, and in 14 of 22 after procedures on the foot. Another benefit was subjective improvement in the opposite limb, probably because of the protective effect of better function in the operated side. This study demonstrates that nerve/muscle interposition grafting in leprosy results in consistent sensory recovery and high levels of patient satisfaction. Ten of 11 patients with hand operations and 22 of 25 with procedures to the foot showed sensory recovery in at least one modality

Abstract

Resection of the distal femur or proximal tibia en bloc has been performed on twenty-six patients with primary bone tumours. The gap was filled with autogenous bone grafts stabilised with a long intramedullary nail, thus arthrodesing the knee. In two cases temporary stabilisation with a Kuntscher rod and acrylic cement was adopted because of adjuvant chemotherapy. Union was achieved in twenty-four cases (92 per cent). Infection was the main and practically the only major complication, occurring in five (19 per cent) of the cases: it healed with union in three, healed with non-union in one, and led to an above-knee amputation in the fifth case. Follow-up has been from one to eight years with an average of four years

Poly-L-lactic acid (PLLA) is characterized by its biocompatibility and biodegradability, and is used clinically. In our hospital, we started to use PLLA screws instead of metallic or ceramic screws in the fixation of acetabular bone grafts in total hip arthroplasty (THA) in 1990, because there were concerns about the use of rigid and nonbioabsorble screws, which might contribute to the absorption of the grafted bone and induce metallosis or third-body wear when breakage of the screws occurs. The purpose of this study was to review a series of cemented THA for dysplasia, with structural autograft fixed with PLLA screws. We focused on the survival rate of the acetabular component and radiological change of the grafted bone–socket interface. This study included 104 consecutive cemented total hip arthroplasties (80 patients) performed between July 1990 and December 1995 in our hospital. All patients were followed over 10 years and reviewed retrospectively. The grafted bone trimmed from the excised femoral head was fixed rigidly with 1 or 2 PLLA screws (cancellous lag screws 6.5 mm in bore diameter and 4.1 mm in grove diameter) (Fixsorb; Takiron Co., Ltd., Osaka, Japan). X-ray photographs taken just after the primary operation showed an obscure but still visible radiolu-cent region corresponding to the inserted PLLA screws in many cases. However, X-ray photographs at the final follow-up showed an unclear radiolucent zone at the sites of the PLLA screws, and the osteosclerotic line surrounding the site where the radiolucent zone had been found was confirmed in only 4 cases. Bone union was confirmed radiologically at the grafted site in every case, and there were no cases of early collapse or extravasation of the grafted bone. No positive resorption of the grafted bone was observed in any case. Kaplan–Meier survivorship analysis of socket revision, radiological loosening of the socket, and the appearance of a radiolucent line > 1 mm in the graft–socket interface as the endpoints indicated survival rates of 99%, 97.1%, and 63.5% at 10 years, and 96.6%, 90.2%, and 56.1% at 15 years, respectively. The results of this study indicated that PLLA screws are safe and useful for the fixation of acetabular bone graft concomitant to cemented THA with a careful rehabilitation program. However, because of concern about the mechanical insufficiency of the PLLA screws for THA with an early weight-bearing rehabilitation program, we have used mechanically stronger and bioabsorbable screws made of forged composites of hydroxyapatite and PLLA since 2003

We report two patients, each with a giant-cell tumour of the distal radius treated by curettage and bone grafting. Local recurrence of the tumour occurred in the autograft and in the adjacent soft tissues in both patients, and was successfully treated by local excision; one patient also had radiation therapy. Both remain well 20 years and five years later

Aims

Various surgical techniques have been described for total hip arthroplasty (THA) in patients with Crowe type III dislocated hips, who have a large acetabular bone defect. The aim of this study was to evaluate the long-term clinical results of patients in whom anatomical reconstruction of the acetabulum was performed using a cemented acetabular component and autologous bone graft from the femoral neck.

Post traumatic myositisossificans is a benign condition of heterotropic ossification of unknown aetiology which typically is related to trauma from a single blow or repeated episodes of microtrauma. We describe an unusual case of myositis ossificans which developed as a complication at the donor site for hamstring autologous graft used in open anterior and posterior cruciate repair and posterolateral corner reconstruction in a 15 year old girl. Case report: A 15 year old girl sustained a closed traumatic dislocation of her left knee when she fell from a trampoline. She underwent emergency manipulation under anaesthetic and closed reduction followed by MRI scan which showed a complete disruption of the lateral collateral ligament complex, posterolateral corner injury, complete tears of the anterior and posterior cruciate ligaments and a partial tear of the medial collateral ligament. 13 days later she had an open reconstruction of her anterior and posterior cruciate ligaments with allograft and a repair of popliteus and lateral structures with Larson reinforcement with controlateral hamstring autologous graft. Eight months following open reconstruction the patient represented to her primary care practitioner with a painful lump in the postero-medial controlateral right thigh. MRI study showed that there was a lobulated hypervascular appearance with a thin enhancing rim of low signal on all sequences indicating calcification. An xray revealed a calcified mass consistent with the diagnosis of myositis ossificans. Discussion and conclusion: To date we have found no reported cases of myositis ossificans occurring as a result of surgery to harvest hamstring autograft in the setting of ligament reconstruction about the knee. We believe that this is an unusual complication of the donor site which needs awareness amongst clinicians involved in primary and revision cruciate ligament reconstruction. We suggest that a management strategy of surveillance for this lesion is appropriate and excision biopsy should be reserved for specific indications such as malignant features on imaging or mass effect

We describe a new method for reconstructing the patellar tendon following combined injury to the patellar tendon and anterior cruciate ligament (ACL). Combined injuries to the patellar tendon and the ACL represent a rare and potentially serious injury pattern. The injury to the patellar tendon can often go undiagnosed at primary presentation. Reconstructive options for the patellar tendon are described but can be technically difficult, particularly if ipsilateral hamstring has been used for anterior cruciate ligament reconstruction. Evidence suggests combined injuries generally lead to poor long term outcome. We describe a case of a 26 year old male who presented with a reconstructed ACL and a patellar tendon deficient knee. Diagnosis was confirmed on Magnetic Resonance Imaging (MRI). Ipsilateral hamstrings had been used as donor for ACL reconstruction. An Achilles tendon allograft with distal bone block was used in combination with contralateral semitendinosus and gracilis autograft to reconstruct the three bundles of the patellar tendon. The patient experienced no postoperative complications and was followed up radiologically and clinically. Computer Topography imaging performed at 6 months post-operatively showed union of the bony Achilles tendon block. MRI performed 1 year post-operatively showed good incorporation of the tendinous grafts and no evidence of degeneration or tearing. Oxford knee score at 6 months post-operatively was 31/48. One year post-operatively full pre-injury activity level had been achieved. We believe this method to provide adequate strength and integrity, enabling early rehabilitation following this rare injury. It has also been shown to give a good functional outcome

Purpose of the study: We conducted a retrospective study of 66 cases of non-traumatic osteonecrosis of the femoral head by percutaneous drilling and autograft. This technique associated drilling with graft conductor effects and bone marrow inducers. Material and Methods: Forty-six patients (41 male, 5 female) with non-traumatic osteonecrosis were included in this study. Mean age at surgery was 46 years (22–68). The 66 cases involved 32 right hips and 34 left hips (21 bilateral cases), six asymptomatic. Osteonecrosis was related to corticosteroid therapy (n=17), chronic ethylism (n=14), dyslipidaemia (n=7), barotraumatism (n=3), and renal transplantation (n=1). Four were found idiopathic. The preoperative ARCO classification was: 8 stage IIA, 21 stage IIB, 15 stage IIC, 7 stage IIIB, 13 stage IIIC and 2 stage IV. A minimally invasive surgical technique combined simple percutaneous drilling with a cancellous iliac bone graft harvested percutaneously homolaterally. Metaphyseal grafts were excluded from this analysis. Minimum postoperative follow-up was two years. The main outcome was rate of prosthesis conversion at two years. Results: Considering all stages, 38 hips did not have a total prosthesis at two years (58% success) with a mean follow-up of 40 months (25–65). Twenty-eight hips had total prosthesis at two years (42% failure) with mean follow-up of 11 months (3–23). Mean survival was 29 months (3–65) with stabilisation of the initial lesions in 50% of hips. For the 44 stage II hips, success was achieved in 28 (64%). The success rate for stages IIA and IIB was 70% with mean follow-up of 29 months (19–65). For the 20 stage III hips success was achieved in nine (45%), with 30% for stage IIIB and 54% for stage IIIB and mean follow-up of 21 months (12–45). There were no cases of mechanical complications. One superficial skin infection cured favourably. Discusssion and conclusion: Subchondral fracture (stage III) and necrosis volume > 30% appear to be unfavourable factors for outcome with this technique. There are other conservative treatments but all with technical difficulties or cost considerations despite sometimes questionable results. This technique is simple and very attractive. In one hand, it combines the advantages of the decompression-effect for the local vascularization with the bone inducer effect of the marrow auto-graft. And in the other, it is a non-invasive and conservative procedure which does not modify the morphology of the upper extremity of the femur and does not jeopardize a future total hip replacement. This is a reliable technique which merits confirmation with a larger series. The best indication remains stage IIA and IIB

Several methods have been used for proximal humeral reconstruction following tumour resection. None of these modalities allow the patient to regain his normal shoulder range of motion. Moreover, every modality has its advantages and disadvantages. The aim of this study was to compare the functional outcome of 2 reconstructive modalities that we are using in our institution for proximal humeral reconstruction; endoprosthesis and shoulder arthrodesis using a vascularised autograft This study included 48 patients diagnosed with malignant or benign aggressive tumours that required resection of their proximal humerus. They were divided into 2 groups according to the method of reconstruction. Group 1 included 22 patients with an average age of 20 years were reconstructed by shoulder arthrodesis using a free vascularised fibular graft (6) or a pedicled scapular crest graft (16). Group 2 included 26 patients with an average age of 26 years were reconstructed with an endoprosthesis. In group 1 the average follow up period was 88 months (range 12 to 184 months). The average functional outcome (according to the MSTS scoring system) was 25 points (range 19 – 28). The average abduction and forward flexion range of motion (scapulothoracic) was 40 degrees (range 20 -60). Complications included failed fixation (2), non union (1), infection (1) and temporary radial nerve palsy (2). In group 2 the average follow up period was 36 months (range 12 – 110). The average functional outcome was 24 points (range 20 – 27). The average abduction and forward flexion range of motion was 40 (range 30 –70). Complications included sublaxation (2), loosening (1) and infection (1). Reconstruction of the proximal humerus by arthrodesis or endoprosthesis yield similar functional outcome. Although endoprosthesis is a much more expensive modality, it does not provide any superior functional outcome over shoulder arthrodesis

Introduction: In the attempt to improve fusion rates in spondylodesis surgery, focus has been applied on numerous factors, including surgical strategies, instrumentation-devices and –material, technical preparation of the fusion bed, stringency of radiological outcome criteria, patient-related factors such as age, sex, tobacco consumption, and severity of underlying pathology. In recent years the development of new techniques for exploring mechanisms in cellular and molecular biology have further directed focus toward more advanced biological techniques and considerations. To the authors’ knowledge, little or no attention has been focused on one of the basic and important factors in the attempt to achieve fusion, ie the impact of bone graft quantity placed at the fusion bed. The aim of this study was to investigate the influence of autologous bone graft quantity in posterolateral instrumented spinal fusion (PLF) in respect to fusion rates. Methods and results: A prospective clinical study in 76 patients, in which CD-instrumented posterolateral lumbar or lumbosacral spine fusion surgery was performed. The quantity of autologous bone graft applied at the fusion bed was recorded peroperatively. Spinal fusion rates were assessed by AP/lateral radiographs at one-year follow-up by two independent observers, according to our strict classification system. The impact of bone graft quantity, tobacco consumption, age and sex of the patients were analysed in respect to fusion-rates by logistic regression. According to our classification “fusion” was seen in 76% of the patients, “non-union” in 12.7% and “doubtful”fusion in 11.3%. In “fusion” segments, the median amount of bone used was 24.4 (13–53) g and 14.7 (12.5–23.4) g in “non-union” segments. The “non-union” rate was 7.1% for non-smokers in contrast to 21.4% for patients who smoked during the first six post-operative months. The impact on fusion rates by graft quantity and cigarette smoking were significant, p< 0.006 respectively 0.035. Age and gender did not influence fusion rates. Thirty-three percent of patients with “non-union” had a corresponding failure of the implant. Conclusions: The quantity of graft used at the fusion bed is critical for successful fusion. Based on the results presented here, we recommend a minimum of 24 g of autogenous bone graft at each intervention segment in auto-grafted posterolateral spinal spondylodesis surgery. In addition, this study underlines the importance of tobacco arrest, in at least the first six post-operative months. The data presented here strongly support the importance of quantifying or optimally standardising the amount of graft placed at each intervention segment

For 20 years, the cultures of cartilage cells have been giving an important hope in the reconstruction by autografts of the cartilage defects. However, the impossibility until recently to obtain a real cartilaginous tissue did not allow a real graft. The development over 15 years, by the company Bio-Tissue in Freiburg (D) and Dr. Erggelet, has allowed the realization, from an autologous culture, of a real RESISTENT cartilaginous tissue, allowing a real implantation with fixation of the cartilaginous defects. We have been practicing this technique for 18 months and have now the experience of 10 cases. The technique consists in taking, under arthroscopy, from the external trochleocondylar junction, 6 to 8 small “rice grains” of cartilage and in cultivating them for 3 to 4 weeks, which allows to obtain 12 cm2 of graft; more important surfaces are obtained if necessary by extending the culture (18, 24, 30 cm2, etc…). Technically, the not very important defects can be performed under arthroscopy, but as soon as the extent is important we prefer an open-air approach. The intervention begins with the preparation of the sick zone, removing the remainders of damaged cartilage until the subchondral bone with a special sharp curet, realizing rectilinear edges. A “tracing” of the prepared zone is realized, allowing the precise cut-out of the graft; after testing, the graft is fixed by its 4 corners with Dexon passed through the transosseous tunnels, by special pins, blocked by a series of transosseous knots, flattening the graft against the subchondral bone. The technique is relatively simple and quick (pictures). Post-operatively, support is suppressed for 1 month, and the flexion is immediatley started on an electric splint in order to avoid adhesions. Careful walking with support is restarted after one month. Swimming is advised after the 6th week. An MRI control is performed after 3 months and after 6 months, which has always allowed us to visualized well the graft, its good thickness, the continuity with the healthy cartilage and its good adaptation to the subchondral bone. Sport can be restarted after 8 months, as well as carrying charges and physical activities. A biopsy performed 7 months after the implantation, has allowed us to verify that the graft had developed well into HYALIN cartilage (picture). The clinical results are satisfying with the hindsight that we have, which seems to corroborate the results of the longer series of Erggelet. This technique, real BIOSURGERY, is particularly satisfying and if the good results are confirmed in the long-term, it will be a real revolution in orthopedic surgery, all the more since its application to other joints than the knee is possible

Aims

After intercalary resection of a bone tumour from the femur, reconstruction with a vascularized fibular graft (VFG) and massive allograft is considered a reliable method of treatment. However, little is known about the long-term outcome of this procedure. The aims of this study were to determine whether the morbidity of this procedure was comparable to that of other reconstructive techniques, if it was possible to achieve a satisfactory functional result, and whether biological reconstruction with a VFG and massive allograft could achieve a durable, long-lasting reconstruction.

The use of autograft bone is the best option when undertaking a procedure that requires bone graft because it is osteogenic, osteoconductive and osseo-inductive. Pain, morbidity and complications associated with harvesting iliac or non-iliac sites occur in between 6% and 30% of cases. An alternative source of graft with possibly a lower morbidity is the intramedullary canal. In this study, 28 patients undergoing 30 arthrodesis procedures on the hindfoot had a mean of 48 cm³ (43 to 50) of bone harvested locally from the hindfoot or the tibial shaft by antegrade or retrograde reaming. No patient sustained a fracture of the calcaneum, talus or tibia. There was no morbidity except for one complication when the reamer breached the medial tibial cortex. This healed uneventfully.

This method of using the reamer–irrigator–aspirator system is an extension of the standard technique of intramedullary reaming of the lower limb: it produces good-quality bone graft with viable growth factors consistent with that of the iliac crest, and donor site morbidity is low. This is an efficient method of obtaining autologous bone for use in arthrodesis of the ankle or hindfoot.

The treatment of osteochondral lesions of the talus has evolved with the development of improved imaging and arthroscopic techniques. However, the outcome of treatment for large cystic type-V lesions is poor, using conventional grafting, debridement or microfracture techniques.

This retrospective study examined the outcomes of 50 patients with a cystic talar defect who were treated with arthroscopically harvested, cored osteochondral graft taken from the ipsilateral knee.

Of the 50 patients, 45 (90%) had a mean good to excellent score of 80.3 (52 to 90) in the Karlsson-Peterson Ankle Score, at a mean follow-up of 36 months (24 to 83). A malleolar osteotomy for exposure was needed in 26 patients and there were no malleolar mal- or nonunions. One patient had symptoms at the donor site three months after surgery; these resolved after arthroscopic release of scar tissue.

This technique is demanding with or without a malleolar osteotomy, but if properly performed has a high likelihood of success.

Delayed rather than early reconstruction of the anterior cruciate ligament is the current recommended treatment for injury to this ligament since it is thought to give a better functional outcome. We randomised 105 consecutive patients with injury associated with chondral lesions no more severe than grades 1 and 2 and/or meniscal tears which only required trimming, to early (< two weeks) or delayed (> four to six weeks) reconstruction of the anterior cruciate ligament using a quadrupled hamstring graft. All operations were performed by a single surgeon and a standard rehabilitation regime was followed in both groups. The outcomes were assessed using the Lysholm score, the Tegner score and measurement of the range of movement. Stability was assessed by clinical tests and measurements taken with the KT-1000 arthrometer, with all testing performed by a blinded uninvolved experienced observer. A total of six patients were lost to follow-up, with 48 patients assigned to the delayed group and 51 to the early group. None was a competitive athlete. The mean interval between injury and the surgery was seven days (2 to 14) in the early group and 32 days (29 to 42) in the delayed group. The mean follow-up was 32 months (26 to 36).

The results did not show a statistically significant difference for the Lysholm score (p = 0.86), Tegner activity score (p = 0.913) or the range of movement (p = 1). Similarly, no distinction could be made for stability testing by clinical examination (p = 0.56) and measurements with the KT-1000 arthrometer (p = 0.93).

Reconstruction of the anterior cruciate ligament gave a similar clinical and functional outcome whether performed early (< two weeks) or late at four to six weeks after injury.

Purpose: To evaluate the insertion forces required to seat osteochondral plug grafts and the accuracy of plug harvest and seating using three unique instrumentation systems. Our hypothesis was that the systems would have different insertion forces.

Method: The COR (Depuy-Mitek), Mosaicplasty (Smith & Nephew) and OATS (Arthrex.) Instrumentation systems and recommended surgical techniques were used to harvest, transfer, and implant grafts. To simulate the in-vivo surgical setting, multiple-impacts with a mallet were applied to the instruments. Ten tests each were performed for all systems in both rigid polyurethane foam blocks and porcine femur models. Plug length after harvest and final graft position were manually measured. Insertion forces were recorded using a load cell (Omega Engineering) affixed to the insertion tamp. The area under the force curve recorded by the transducer for each blow was then summed to yield the total force required to seat each graft. Means and standard deviations were then calculated and Tukey’s test was used to determine significant differences between the means.

Results: The COR system demonstrated significantly lower mean insertion forces in both polyurethane foam blocks and porcine models when compared with the OATS and Mosaicplasty systems. Graft harvest with Mosiacplasty led to greater harvest length inconsistency than with other systems tested. OATS grafts were more likely to be left proud.

Conclusion: The COR system produced significantly lower insertion forces during graft insertion. COR and OATS yielded consistent harvest lengths. The majority of OATS grafts were left proud which would require additional impaction force to fully seat the graft.

Introduction: We performed cementless total hip arthroplasty (THA) with autogenous bone block grafting on 18 hips in 15 patients with marked acetabular dysplasia and investigated the correlations of clinical results with the placement of the acetabular and femoral components.

Methods: There were 13 women and 2 men who had a mean duration of follow-up of 3.3 years (range, 2 to 4.3 years). According to the classification of Crowe et al, four hips in group I, three hips in group II, one hip in group III and 10 hips in group IV. The resected femoral head was used as a graft for the superior-lateral region of the true acetabulum.

Clinical results were determined according to the hip joint function criteria of the Japanese Orthopaedic Association (JOA).

Results: The mean preoperative JOA hip score was 44 points and that at follow up was 77 points. The distance from the Kohler line to the medial margin of the acetabu-lar component averaged 6.1 mm on the radiograph. Two patients required revision. In both patients, lateral insertion of the acetabular component of 8 and 15 mm respectively from the Kohler line had resulted in loosening of the cup. Of the 18 patients, femoral component had been placed in neutral position in 9, who had better clinical results than those of the others. The grafted bones united in all patients.

Discussion: The present study indicates that lateral insertion of the the acetabular component in THA should be avoided in patients with marked acetabular dysplasia.

Introduction: Until recently adult stem cells were presumed to be committed to differentiation of specific tissues. Adult hematopoietic stem cells (HSCs, CD34+) for example, originally believed to be limited to hematopoiesis are capable of transdifferentiation to generate cells of different lineages. This capability is referred to as stem cell plasticity. Studies in cardiac and peripheral vascular disease and nonunions and osteonecrosis in orthopedics have demonstrated that concentrated bone marrow is an effective and safe method of treatment. The present study evaluated a methodology to concentrate a small sample of bone marrow at point of care to compare with described techniques.

Methods: Sixty or 120 mL of bone marrow was withdrawn from the posterior iliac crest. The concentration process utilized the standard SmartPReP-2/DePuy Symphony Centrifuge (Harvest Technologies, Plymouth, MA). The shape and density of the floating shelf was modified to enhance collection of nuclear cells. The bone marrow was analyzed for cell counts, morphology, and flow cytometry. Hematopoietic stem cells (CD34+) were used as a marker for stem cell concentration. Bone marrow stem cells were cultured using specialized media supplements. The systems were also compared using the hind limb ischemia (HLI) model.

Results: Using the Harvest BMC System™ system, the results for the Colony Forming Unit (CFU’s) Analysis were as follows (Mean ± S.D.): the aspirate volume: 120 mL, CFU’s/cm³: 3040±1251, BMC volume delivered: 20mL, and Progenitor cells delivered: 60,800±29,200.

The cultures demonstrated viable hMSCs that were identical to a commercially available cell line. The cultures were transferred into osteogenic media; after 10 days the bone marrow derived cells and the commercial cell lines were stained with Von Kossa silver stain and for alkaline phosphatase demonstrating osteoblastic differentiation.

Hind limb ischemia studies have demonstrated that laser doppler blood flow was significantly better following BMAC infusion as compared to cells concentrated with Ficoll. These results were confirmed by a Boyden chamber migratory assay.

Discussion: A bone marrow concentrate can be prepared at point of care within 15 minutes of collection. The Harvest BMAC system is capable of producing a concentration of stem cells equivalent to or greater than those used in successful clinical studies. Successful clinical results can be obtained using one-third (1/3) of the aspirate volume required by other methods. Ongoing clinical and animal studies are confirming its clinical application.