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

Purpose: Performing a labral repair alone in patients with recurrent anterior instability and a large glenoid defect has led to poor outcomes. We present a technique involving the use of iliac crest allograft inserted into the glenoid defect in athletes with recurrent anterior shoulder instability and large bony defects of the glenoid (> 25% of glenoid diameter) We hypothesized that restoring a near-normal glenoid structure would prevent further dislocations and that osseous union would be achieved. Method: All athletes with recurrent anterior shoulder instability and a large glenoid defect who underwent open anterior shoulder stabilization and glenoid reconstruction with iliac crest allograft were prospectively followed over a three year period. Pre-operatively, a detailed history and physical exam was obtained along with radiographs, a CT scan, and magnetic resonance imaging of the affected shoulder. All patients also complete the Simple Shoulder Test (SST) and American Shoulder and Elbow Surgeons (ASES) evaluation forms pre – and post-operatively. A CT scan was again obtained 6 months post-operatively to assess osseous union of the graft, and the patient again when through a physical exam in addition to completing the SST, ASES, and Western Ontario Shoulder Instability Index (WOSI) forms. Results: Nine patients (all male) were followed for an average of 16 months (4 – 36 months) and had a mean age of 24.4 years. All patients exhibited a negative apprehension/ relocation test and full shoulder strength at final follow-up. Eight of nine patients had achieved osseous union at six months (88.9%). ASES scores improved from 64.3 to 96.7, and SST scores improved from 66.7 to 100. Average post-operative WOSI scores were 94%. Conclusion: The use of iliac crest allograft provides a safe and clinically useful alternative compared to previously described procedures for recurrent shoulder instability in the face of glenoid deficiency

When bone graft is harvested during posterior spinal fusion, approaching the posterior iliac crest parallel to the superior cluneal nerves (SCN) can result in vascular, neurological, sacro-iliac joint and other complications. In a previous study, in 30% of adult cadavers I found that branches of the superior cluneal nerves were within the safe zone of 65 mm from the posterior superior iliac spine along the posterior iliac crest. Following posterior spinal fusion, 24 male and 12 female patients, ranging in age from 14 to 55 years, were reviewed. Follow-up ranged from nine months to 15 years. Data collected included personal and social details, surgical indications, neurological status, harvest site and postoperative complications. Patients were excluded if neurological injury affected assessment of the posterior iliac crest. Specifically the harvest site was examined for pain, SCN injury, sacro-iliac joint instability or pain, and any other complications. In 15 patients the incision was parallel to the SCN nerve. One had scar pain and one had scar hypertrophy. Three patients (20%) had SCN damage symptoms in the form of numbness, transient in two and permanent in one. There were no sacro-iliac joint or complex regional pain syndrome (CRPS) problems. Two cases of superficial wound sepsis resolved. The other 21 patients had incisions transverse to the SCN. Six (28%) had persistent scar pain and eight (38%) had symptoms of SCN damage (numbness or hyperaesthesia). None had CRPS, sacro-iliac joint symptoms or sepsis. Incisions parallel to the SCN led to less morbidity than incisions along the posterior iliac crest. Bone graft substitutes are increasingly being used in the developed world, but if thoughtful surgical techniques can minimise graft site morbidity, the posterior iliac crest is a cost-effective source of autologous bone

Purpose. To compare the post-operative morbidity, of a novel vertical approach, with that of the standard transverse one, for procurement of Autologous bone graft from the iliac crest, for the purpose of cervical spine fusions. Methodology. Eighty patients undergoing procurement of bone graft from the iliac crest were prospectively randomised into two groups. The study group (36) underwent the procedure through a novel vertical approach, while the controls (44) had the standard transverse approach. Both groups were evaluated by a blinded observer at 1 month and 6 months post-operatively. The visual analogue pain score, (VAS), use of analgesics, disruption of cutaneous nerve function and local tenderness were recorded. Results. The mean VAS in the study group was 2.5 and 4.4 in the control group one month post-operatively. This was reduced to 2.9 in the control group and 1.8 in the study group six months later (p<0.05). The study group had a lower incidence of local numbness (33.3 %) compared to (72.7%) in the control group one month after surgery. Use of analgesia after 6 months was lower in the study group (11.1%), compared to 50% in the control group (p<0.05). There was no significant difference between the two groups with regards to other parameters. Conclusion. The vertical approach to the iliac crest is associated with lower morbidity and is an effective alternative to the standard approach

Purpose: To compare the post-operative morbidity, of a novel vertical approach, with that of the standard transverse one, for procurement of Autologous bone graft from the iliac crest, for the purpose of cervical spine fusions. Methodology: Patients undergoing procurement of bone graft from the iliac crest were prospectively randomised into two groups. The study group (18) underwent the procedure through a novel vertical approach, while the controls (22) had the standard transverse approach. Both groups were evaluated by a blinded observer at 1 month and 6 months postoperatively. The visual analogue pain score,(VAS), use of analgesics, disruption of cutaneous nerve function and local tenderness were recorded. Results: The mean VAS in the study group was 2.5 and 4.4 in the control group one month postoperatively. This was reduced to 2.9 in the control group and 1.8 in the study group six months later. The study group had a lower incidence of local numbness (33.3 %) compared to (72.7%) in the control group one month after surgery. Use of analgesia after 6 months was lower in the study group (11.1%), compared to 50% in the control group 6 months post operatively. There was no significant difference between the two groups with regards to other parameters. Conclusion: The vertical approach to the iliac crest is associated with lower morbidity and is an effective alternative to the standard approach

A study was undertaken to see the efficacy of backfilling the iliac crest post harvesting on postoperative pain levels and overall functional outcomes. A randomized study was undertaken in which twenty patients were divided into two groups: one received backfilling of the iliac crest with corralline hydroxyapatite and the other did not. All patients underwent posterior instrumented lumbar fusion’s with all evaluated for diagnosis, age, levels fused, and risk factors. Comparisions were made evaluating: postoperative pain, time to mobilization, rehabilitation levels, and incorporation of the corralline. Follow-up was a minimum of two years with patients still being followed. Results revealed a reduction of pain on the analog pain scale in the corralline group compared to the non-backfilled group. This was seen at three days, two weeks, one month, three months, six months, one and two years. Pain levels were reported at one at three months and zero at six months, one and two years in the corralline group compared to five at three months and four at six months and three at one and two years. Time to mobilization was one day sooner in the corralline group. Functional outcomes were seen to be better in the corralline group as well. Incorporation of the corralline hydroxyapatite was seen in all patients. Back-filling the iliac crest has shown to decrease pain, increase functional outcomes and produce a sooner time to mobilization and physical therapy than the non-filled iliac crest

Introduction. Significant donor site morbidity (3–61%) has been associated with tri-cortical iliac crest bone graft harvesting and reconstruction of the defect has been shown to reduce it. Chitra-HABG (Chitra-Hydroxyapatite-Bio-active glass ceramic composite) is an indigenously developed ceramic which has been evaluated as a bone graft substitute. Aim. To prospectively validate the hypothesis that iliac crest donor site morbidity is a structural issue and reconstructing the crest reduces its incidence. The study also evaluates the efficacy of Chitra - HABG as a material for reconstructing the crest. Methods. 26 cases of iliac crest reconstruction with Chitra-HABG blocks were prospectively evaluated. Outcome measures were donor site morbidity as assessed clinically and radiological assessment for ceramic incorporation, dissolution, fragmentation and migration. Results. At the end of one year from surgery, 25 patients (96.15%) had no donor site pain. Radiological evaluation showed that ceramic incorporation was complete in 21 cases, partial in three and absent in two. Partial dissolution of ceramic was noticed in three patients and migration in one. Conclusion. The present study validates our hypothesis that the donor site morbidity following tri-cortical iliac crest graft harvesting is probably a structural issue and it can be reduced by reconstruction of the defect. It also highlights the fact that the Chitra-HABG block is an excellent material for reconstruction of the iliac crest defect, as it gets incorporated into the surrounding bone without adverse effects. Significance. Study describes a simple and effective method to decrease iliac crest donor site morbidity. Level of evidence: IV. Study Design. Prospective study. Summary. Prospectively evaluate the efficacy of Chitra-HABG blocks for iliac crest reconstruction

To improve the accuracy of pinning at the iliac crest during external fixation of the unstable pelvic fracture, an aiming device has been innovated. The device consists of 3 parts: a sleeve, a handle and guide points. The guide points were designed to grasp the iliac crest to allow proper pin fixation. The device has been used in 50 patients who had unstable fractures of their pelvises. All pins were in proper position with out loosening at the time the pins were removed. The use of this device has given encouraging results

Background: There are various sites for pin placement in the pelvis. Recent studies have suggested that the supra acetabular pin placement is mechanically stronger and has been recommended as an alternative. The aim of this study is to analyse the morbidity of the most commonly used pin placement sites namely, conventional pin placement into the anterior iliac crest versus the low pin placement into the supra acetabular region. Methods: Sixty one patients who required pelvic external fixation as part of their management between April 1998 and December 2001 were identified. Three patients died and were excluded from the study. Of the remaining 58 patients, 33 were treated with a supra-acetabular external fixator and 25 had an iliac crest external fixator. The majority of patients sustained the pelvic fracture as a result of road traffic accident. There were no statistically significant differences in the number of patients, mean age, length of stay, ISS or type of fractures for the two patient groups. Results: Fewer complications were noted in the supra-acetabular group versus the iliac crest group (21.2% vs. 56.0%, p< 0.05). In particular, infection rates were significantly lower in the supra-acetabular group (15.1% vs. 36%, p< 0.05). There were no significant differences between the two groups in the number of pin cut-outs or misplacements, injury to the lateral femoral cutaneous nerve or loss of reduction. Conclusion: The supra-acetabular technique of pin insertion for pelvic external fixation has fewer complications and should be utilised if an image intensifier is available. The lower rate of pin tract infection is a favourable outcome when secondary pelvic reconstructive procedures are necessary

We aim to analyze the role of patient-related factors on the yield of progenitor cells in the bone marrow aspiration concentrate (BMAC). We performed a retrospective analysis of patients who underwent autologous iliac crest-based BMAC therapy between Jan 2021–and June 2021. Patient-related factors such as age, sex, and comorbidities and procedure variables such as aspirate volume were analyzed. The yield of the bone marrow aspiration concentrate was assessed with MNC count and CFU assay from the aspirates. 63 patients with a mean age of 51.33±17.98 years were included in the study. There were 31 males and 32 females in the study population with a mean volume of 67.16±17.312 ml being aspirated from the iliac crest for the preparation of BMAC. The final aspirate had a mean MNC count of 20.16±15.73×10^6 cells which yielded a mean of 11±12 CFUs. We noted significant negative correlation between age and MNC count (r=minus;0.671, p<0.001) and CFUs (r=minus;0.688, p<0.001). We did not find the sex to have any significant role in MNC (p=0.082) count or CFUs formed (p=0.348). The presence of comorbidity significantly reduced the MNC count (p=0.003) and CFUs formed (p=0.005). The aspiration volume significantly negatively correlated with MNC count (r=minus;0.731, p<0.001) and CFUs (r=minus;0.618, p<0.001). The MNC count and CFUs formed from the BMAC depend on the patient-specific subjective variables such as age, and comorbid conditions present in them. Sex and volume of aspiration do not alter the MNC count or the CFUs formed from BMAC

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

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

We describe the reconstruction of a defect of the medial malleolus which was the result of an accident in a ten-year-old child. A graft from the iliac crest, with the apophyseal cartilage and perichondrium, was used for reconstruction of the medial malleolus, the growth plate and the adjacent metaphyseal defect, respectively. The soft-tissue defect was covered with a free scapular flap with microvascular anastomosis. Three years after the injury stability of the ankle is excellent with adequate growth of the reconstructed epiphyseal plate

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

Introduction. Augmentation of spinal fusion using bone grafts is largely mediated by the osteoinductive potential of mesenchymal stem cells (MSC) that reside in cancellous bone. Iliac crest (IC) is a common autograft, but its use presents an increased risk for donor-site pain, morbidity and infection. Degenerative facet joints (FJ) harvested during facetectomy might servce as alternative local grafts. In this study, we conducted an intra-individual comparison of the osteogenic potential of MSC from both sources. Methods. IC and degenerative FJ were harvested from 8 consecutive patients undergoing transforaminal lumbar interbody fusion surgery for spinal stenosis. MSC were isolated by collagenase digestion, selected by plastic adherence and minimally expanded for downstream assays. Clonogenic and osteogenic potential was evaluated by colony formation assays in control and osteogenic culture medium. Osteogenic properties, including alkaline phosphatase (ALP) induction, matrix mineralization and type I collagen mRNA and protein expression were characterized using quantitative histochemical staining and reverse transcription PCR. Spontaneous adipogenesis was analysed by adipocyte enumeration and gene expression analysis of adipogenic markers. Results. Average colony-forming efficiency in osteogenic medium was equal between IC (38±12%) and FJ (36±11%). Osteogenic potential at the clonal level was 55±26 and 68±17% for IC and FJ MSC, respectively. Clonogenic and osteogenic potential were significantly negatively associated with donor age. Osteogenic differentiation led to significant induction of ALP activity in IC (6-fold) and FJ (8-fold) MSC. Matrix mineralization quantified by Alizarin red staining was increased by osteogenic differentiation, yet similar between both MSC sources. Protein expression of type I collagen was enhanced during osteogenesis and significantly greater in IC MSC. Correspondingly, COL1A2 mRNA expression was higher in osteogenically differentiated MSC from IC. Adipocyte numbers showed significant differences between IC (63±60) and FJ (18±15) MSC under osteogenic conditions. Negative (GREM1) and positive (FABP4) adipogenic markers were not differentially expressed between sources. Conclusion. MSC from IC and degenerative FJ largely display similar clonogenic and osteogenic properties in vitro. Differences at the molecular level are not likely to impair the osteoinductive capacity of FJ MSC. Facetectomy samples are viable bone autografts for intervertebral spinal fusion

Autogenous iliac bone grafts has been proved to be the most reliable mean to achieve a solid fusion in spine surgery. The purpose of our study is to evaluate that healing process of the ilium after been used as donor site of bone grafts in the treatment of adolescent idiopathic scoliosis. Eighteen patients underwent posterior spinal fusion for progressive adolescent idiopathic scoliosis between 1989 and 1993. Thirteen patients were female and five were male with a mean age at the time of operation of 14.6 years (12–33). The same surgeon performed all procedures with nearly identical technique using the Hart-shill frame as stabilizing instrumentation. The average of the number of levels involved in spinal fusions was 10.3 levels. In all cases the autogenous bone graft used was harvested from the right posterior iliac crest. All patients were reviewed at least fourteen years after surgery. CT scans were performed in all 18 patients in order to evaluate the status of ossification at the donor site. CT scans of the ilium showed that bone deficit was present in 9 cases (50%) and in 9 cases (50%) it was found that both cortical and cancellous bone was fully restored. Using the T-student test we found that bone reformation was independent from the number of levels fused and the amount that was harvested. Our important result is that younger patients with smaller Risser’s line have greater capability to restore bone stock at this area. In conclusion ICBG remains the most effective mean to achieve fusion in spinal surgery. The iliac wing and especially the periosteum of immature patients (Risser 3,4) seem to have great capabilities to regenerate the bone defects

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.

Purpose: The retrospective evaluation of long-term results after reconstructive radial osteotomy for mal-united distal radius fractures.

Material-Method: Twenty-eight patients (21 male and 7 female, average aged 46 years) with 23 dorsal and 5 palmar angulated malunited distal radius fractures were operatively treated during 1994–2002 in our department. The main indications were pain and functional impairment. Dorsal or palmar approach was used in proportion to the site of angulation. The preoperative average radial inclination, radial length and volar or dorsal tilt were 13.5 degrees, 6.3 mm and 23.5 degrees respectively. An open wedge radial osteotomy followed by interposition of trapezoidal iliac crest bone graft and fixation with plate ands crews was performed in all patients four months at least after the initial surgery. An ulnar leveling procedure was considered necessary in 2 patients.

Results: All patients were available in the last follow up evaluation (mean 3.7 years). The functional result according to Mayo wrist score was rated as very good in 15 patients, good in 7 and poor in 6. The average improvement in radial inclination was 14 degrees, in radial length 6.5 mm and in volar or dorsal tilt 21 degrees. The complication rate was 22.7%, including 2 material failures, 1 extensor pollicis longus rupture, 1 nonunion and 3 recurrences of the deformity.

Conclusion: Surgical reconstruction for malunion is technically demanding and may not completely restore the anatomy. Patient satisfaction, however, in terms of increased function, decreased pain and decreased deformity is sufficient high to warrant reconstructive treatment.